Prosthetic joint infections

Objectives: To review the available literature on prosthetic joint infections and provide recommendations on management particularly the importance of identifying the causative organism and starting the most appropriate antimicrobial therapy. Methods: The medical literature was searched using PubMed, employing the key words prosthetic joint infections. There appears to be no UK consensus guidelines on the management of prosthetic joint infections or the use of prophylactic antibiotics to prevent them. There is however a number of key documents and trust policies which deal with the subject extensively. We also made use of ‘The Sanford Guide to Antimicrobial therapy 2012’ for the latest recommendations on the correct antimicrobial therapy. Conclusion: Although diagnosis is often difficult, there are a number of investigations which can help us identify the organism. We recommend that the local prevalence of such infections is studied together with identification of the commonest organisms. Work is already underway between the infectious disease team and orthopaedic surgeons to devise locally adapted protocols for the identification and management of such infections. They should work in close liaison to implement the correct treatment which often involves a combination of both surgical and antimicrobial therapy.peer-reviewe

School indoor air quality and allergen exposure

There is growing concern about the association of school indoor air quality (SIAQ) with asthma, rhinitis and rhinoconjunctivitis. The most commonly studied allergens are cat (Fel d 1), dog (Can f 1) and dust mite (Der f 1, Der p 1). Very few studies have analysed the significance of cockroach (Bla g 1 and 2) and mould allergens in schools and not much is known about SIAQ in island nations such as Malta. Schools with high allergen levels have an increased incidence of atopic disease resulting in a negative impact on the childrens’ health and performance. An acceptable SIAQ can be achieved by adopting published recommendations regarding the control and prevention of indoor allergens. The absence of a European SIAQ monitoring programme highlights the urgent need for more research in this field so as to issue the necessary evidence based recommendations specific to the individual countries.peer-reviewe

The impact of microbiological pollutants on school indoor air quality

The submitted manuscript has not been previously published in any form and is not currently under consideration for publication elsewhere.Asthma is common in children with allergens and mould influencing the development of the disease. Since children spend most of their time outside their homes within the school environment, school indoor air quality can directly influence their respiratory health. This study aims to identify microbiological contaminants in Maltese schools. The association between contaminants, res-piratory health and school characteristics has been analysed. Five primary schools were selected with 9 to 11 years old students participating. Standardised health questionnaires, lung function tests, and school characterisation were performed. Dust samples were analysed for fungi, bacteria and allergens were performed. Penicillium/Aspergillus/Paecilomyces/Variotii (PenAsp) group had the highest median indoor concentration followed by Mycobacterial and Streptomyces species. There was a significant negative correlation between PenAsp and Mycobacterium spp levels in all the participating schools (r = −0.42; p = 0.03). Cat allergen in classroom dust correlated positively with the number of cat owners (r = 0.43; p = 0.041). High exposure to fungi, bacteria and allergens was significantly associated with upper and lower airway atopy. School/classroom characteristics and cleaning protocols were significantly as-sociated with exposure to these pollutants. In conclusion, fungi, bacteria, en-dotoxin, cat and dog allergens have been found to have a direct influence on school indoor air quality in the Maltese Islands. A significant association was observed between these contaminants and upper and lower airway atopy. Specific school, classroom, cleaning and maintenance characteristics have been identified as having a direct impact on indoor air quality.peer-reviewe

Indoor climate and its impact on atopic conditions in Maltese school children

Several studies on the prevalence of allergic conditions have identified that allergic conditions are on the increase worldwide. The aim of this study was to study the effect of classroom humidity and temperature levels on schoolchildren in Malta. Our cohort included 191 children. Standardised ISAAC health questionnaires were answered by the children’s parents. Lung function tests, acoustic rhinometry, exhaled NO, exhaled CO and nasal lavage were performed on the participating children. School building characteristics were also studied. A significant association was noted between a high relative humidity exposure and nasal cross-sectional areas (p=0.003), and doctor diagnosed allergic rhinitis (p=0.002), indicating the presence of allergic rhinitis, as was increased indoor temperature (p=0.003). Increased indoor temperature was also associated with increased exhaled nitric oxide (FeNO) (p<0.001) indicating uncontrolled asthma. In conclusion, increased classroom temperatures and humidity, both linked to decreased classroom ventilation, were associated with increased incidence of allergic conditions in schoolchildren in Malta. These results emphasize the important need for the introduction of climate control and dehumidifying systems in our schools with the aim of decreasing the prevalence and severity of such conditions in this cohort of patients.peer-reviewe

Food consumption and the risk of childhood allergy

Background: The prevalence of allergic conditions is increasing in most countries. One possible explanation may be childhood nutrition. Objective: The aim of the study was to investigate the relationship between consumption of pre-specified types of food in school-aged children and presence of respiratory and allergic symptoms. Methods: A total of 191 students aged 9–11 years were recruited from 5 schools to geographically cover all of Malta. Data was collected between October 2011 and February 2012. This was part of a bigger study which included clinical and environmental tests besides standardized health questionnaires. For the purposes of this part of the study only the health questionnaires were used. These standardized health questionnaires based on the International Study of Asthma and Allergies in Childhood (ISAAC) were used to identify the presence of respiratory and allergic symptoms and to identify the types of foods and the frequency of consumption of various types of foods. Results: We found that milk, meat, butter, olive oil, and yoghurt consumption had a negative association with allergic symptoms in children, whilst fish consumption had a detrimental effect. These relationships remained significant after correction for paternal level of education. Conclusion: The study highlights the fact that nutrition in early childhood may have a significant effect on the risk of allergic conditions. Our results, taken together with data in the literature, suggest that different types of fish might have had different effects. This is probably related to their different fatty acid constitution thus warranting further studies.peer-reviewe

The impact of school environment on children’s respiratory health

The study was done as part of the European Union SINPHONIE Study commissioned by DG SANCO. The authors received some funding from SINPHONIE (European Commission service contract of the DG Sanco).Abstract Background/Aims: School indoor air quality is important because children spend most of their time outside home within the school environment. This study aimed to investigate the school environment and its impact on the respiratory health of the children. Methods: A total of 191 pupils in the 9- to 11-year age group were selected from 5 primary state schools. Validated school and health questionnaires, spirometry, acoustic rhinometry, nasal lavage, urine for environmental tobacco smoke biomarkers and traffic counts were used. Results: Cumulative (32.98%) and current wheezing (17.8%) were in keeping with the International Study of Asthma and Allergies in Childhood Malta data. Southern schools had the highest prevalence of current wheezers (OR 3.77; p = 0.012), rhinoconjunctivitis (OR 3.59; p = 0.003) and nasal eosinophilic cationic protein levels (p < 0.001). Small openable window areas increased rhinitic symptoms (OR 3.14; p = 0.016). Classes facing roads had increased current wheezers (OR 2.27; p = 0.03) and exhaled carbon monoxide (eCO) levels (p < 0.001). Current wheezing was significantly associated with the number of light and heavy vehicles passing near the school (p < 0.001). The presence of smokers at home was significantly associated with urinary cotinine and 3HC (p < 0.001). Proximity to power plants increased the current wheezers (OR 5.89; p = 0.001) who had impaired spirometry (p = 0.003). Asthma symptoms (OR 5.25; p = 0.001) and elevated eCO levels (p < 0.001) were associated with fuel storage facilities near schools. The accumulation of dust on flat surfaces within classrooms was related to wheezing (OR 5.23; p = 0.001). Conclusions: The school environment had a direct impact on the respiratory health of children, with several factors having a direct impact on the children's health.peer-reviewe

Plethysmography and its relationship with biochemical parameters in the Maltese population

Plethysmography is an ever increasing test being performed at Mater Dei Hospital. The aim of the study was to obtain descriptive data regarding plethysmography in the Maltese population as well as to investigate the association of these lung function tests to various biochemical parameters. 282 patients who had plethysmography between June 2015 and March 2016 at Mater Dei Hospital were enrolled in the study. The indications for referral, demographic data, lung function parameters, white cell count (WCC), urea, potassium and fasting blood glucose were noted. The mean BMI of the population cohort was 29.06. BMI was found to be negatively correlated to serum potassium levels (r value: -0.14) and residual volume (r value: -0.2). DLCO, total lung capacity and forced expiratory flow in one second were negatively correlated to the WCC (r value: -0.2, -0.17 and -0.12 respectively) in the population. The current study confirms a significant association between lung function testing, diabetes, BMI and total serum white cell count after correcting for confounding factors. This highlights the need for clinicians to be more aware of the possibility of underlying lung disease in these patients. A good clinical evaluation using history and examination of such patients is essential so as to identify which patients should be referred for lung function testing. Such early referrals could potentially avoid progression of undiagnosed lung disease thus reducing the burden on the health care service with particular emphasis on acute hospital admissions and respiratory outpatient clinics.peer-reviewe

Diagnosing lung malignancy from bronchoscopy in Malta : an update

Introduction: A previous local study by Agius et al. published in MMJ in 20091 identified a rise in lung adenocarcinoma over a decade, as well as an increasing number of females diagnosed with lung malignancy. Aims and Objectives: The aim of this retrospective study was to further compare trends in lung malignancy diagnosis made from bronchoscopy in Malta to previous local data. Materials and Methods: All bronchoscopies performed by one respiratory firm at Mater Dei Hospital in 2014-2015 were analysed, excluding those performed in intensive care. Cytology and histology results were retrieved and compared to those obtained from previously studied timeframes. Patients who had a post-bronchoscopy diagnosis via other means, were noted in order to calculate the bronchoscopy pick-up rate. Results: 118 bronchoscopies were performed, 101 of which were done for suspected malignancy. 48 patients were diagnosed with lung malignancy from bronchoscopy in 2014-2015 by this respiratory firm. When compared to 2006-2007, 83.3% were males (vs 75%) and 16.7% were females (vs 25%). The overall bronchoscopy pick-up rate for malignancy was 81.4%. The most common histological diagnoses, when compared to 8 years previously, were adenocarcinoma 35.4% vs 27.8% (males 37.5% vs 31%; females 25% vs 14.3%), squamous cell 35.4% vs 44.4% (males 37.5% vs 44.8%; females 25% vs 42.9%), and small cell 14.6% vs 13.9%. Conclusion: Adenocarcinoma has shown an upward trend in both gender groups, having now reached a similar prevalence to squamous cell carcinoma, which appears to be decreasing in both males and females in the Maltese population.peer-reviewe

Pulmonary rehabilitation in chronic obstructive pulmonary disease : outcomes in a 12 week programme

Objective. The optimal time-frame for pulmonary rehabilitation (PR) in patients diagnosed with chronic obstructive pulmonary disease (COPD) is still debated. A 12 week programme was designed looking at whether the benefits were reached at or before a 12 week period of PR for COPD patients. Method. Seventy-five patients (59 males, 16 females) aged 40 75 years were referred from the local general hospital in Malta. Baseline assessments were carried out on all patients 2 weeks before initiation of the programme. Sixty patients were eligible to start a twice-weekly, 12 week multidisciplinary programme delivered after the screening process. The Six-Minute Walk Test (6MWT), dyspnoea score using the Borg scale, spirometry testing, plethysmography, COPD Assessment Tool (CAT) score, St George's Respiratory Questionnaire (SGRQ) and Hospital and Anxiety scale score were monitored at 4 weekly intervals throughout the 12 weeks of PR for these COPD patients. Results. The 6MWT distance increased by a mean total of 132.45 m (p < 0.001) by 12 weeks, with the highest change recorded in the first 4 weeks for the milder COPD patients. Lung function test improvements were marginal. Borg scale readings at rest and following exertion decreased significantly from weeks 0 to 4 but remained fairly constant thereafter. The Body mass index, airway Obstruction, Dyspnoea, and Exercise capacity (BODE) index, SGRQ and CAT score values decreased significantly throughout the weeks irrespective of the initial Medical Research Council score. Anxiety scoring decreased significantly by 12 weeks, while the depression rating improved by 8 weeks. Conclusion. These findings show that 12 weeks of PR in this cohort of COPD patients resulted in clinically significant changes in functional outcome measures which are supported by statistically significant changes in health-related quality of life measures. In milder COPD cases, by 4 weeks of PR gains in exercise tolerance had already resulted. The more severe group required more time to obtain improvements. Therefore, hospitals could organize shorter PR programmes for larger numbers of patients with milder COPD.peer-reviewe

A rare case of congenital pulmonary airway malformation presenting with chest pain and dyspnoea in an adult

A healthy 19-year-old man, who was a non-smoker, presented with a first episode of sudden onset, unprovoked dyspnoea and pleuritic chest pain. Chest X-ray showed a cystic abnormality in the right lung (Figure 1). Subsequently, a computed tomography scan of the thorax revealed large cysts in the right lower lobe (Figure 2), in keeping with a diagnosis of congenital pulmonary airway malformation (Stocker, 1994, 2002). The patient underwent a right lower lobectomy.peer-reviewe