An overview of a problem in Hospitaller naval historiography

The Sovereign Military Hospitaller Order of St. John of Jerusalem of Rhodes and of Malta, frequently referred to as the Religion or the Hospital, is a particular institution. Recognised by Pope Paschal II in 1113, this centuries old Order had a double raison d'etre: To offer hospitality to Christian pilgrims to Jerusalem and to pursue the Holy War against the Infidel. However, the fall of Acre to the Saracens in 1291, made it impossible for the Hospitallers to fulfill their original vocation. After the capture and transformation of Rhodes into their base, they had to find a way of justifying their existence. They quickly came up with a characteristic answer - to wage naval war against Islam. So successful did the Knights become in this new role that the marine branch of the Order's military activities was to come to the greatest prominence, in Rhodes and later in Malta. What were the characteristics of the Order's navy? Small numbers, excellent design and an enviable tradition became the chief qualities of this small but effective nary. What, however, did the Hospitallers do with their galleys? Did they wage war on I slam? Or did their activities degenerate into privateering? This issue is hotly debated by historians of the Order. European Historians have a habit of shuddering away from accusing the Hospitallers of indulging in the corso, as corsairing is known in this context. This paper examines the topic in an attempt to unravel what has become a veritable Gordian knot.peer-reviewe

Surgery and Ulcerative Colitis

The management of ulcerative colitis requires the collaboration of various teams looking after the patient and any decision regarding surgery should involve not only the patient and the surgeons but also various other professionals looking after the patient. Surgery may be needed in the acute setting or in patients with chronic disease and the management in these two scenarios is different. This article will look at the indications for surgery in patients with both acute and chronic colitis and the various options available, together with the results expected. We will also give an overview of the results on 27 cases of chronic colitis with restorative proctocolectomy operated on in our unit.peer-reviewe

Determining the frequency of colton blood group antigens Coa and Cob in the Maltese population

This study aimed at identifying the frequency of two blood group antigens of interest within the Colton (Co) blood group system, Coa and Cob , the higher and lower prevalence antigens respectively. The antigenic frequency was determined using the polymerase chain reaction-allele specific primer extension (PCR-ASPE) technique on a sample size of 68 adult Maltese blood donor samples and 351 neonatal cord blood samples. The aforementioned methodology enabled the molecular typing of the missense variant in the aquaporin 1 (AQP1) gene (NM_198098:c.134C>T; rs28362692), responsible for the single amino acid change of Ala45Val (alanine for Coa and valine for Cob at position 45) (NP_932766:p.Ala45Val) within the AQP1 protein chain. As a result of the missense variant, the Colton phenotypes Co(a+b-), Co(a+b+) and Co(a-b+) could be identified through the stipulated PCR-ASPE technique, and the rare phenotype, Co(a-b+), if detected, would also be subjected to DNA sequencing. Analysis of raw data unveiled that the Co(a+b-) phenotype was the most prevalent in both the donor pool (88.23%) and the cord blood pool (86.04%), whilst the Co(a+b+) phenotype revealed a lower occurrence in the donor pool (5.88%) and the cord blood pool (6.98%). The Co(a-b+) was not encountered in the donor and cord blood samples tested, negating the need for DNA sequencing. The novelty of this study can be seen in the unprecedented determination of the frequency of the Coa and Cob antigens within the Maltese population. Outlining the Colton blood group antigen frequencies is a significant step to understand any susceptibilities to the development of the pertinent antibodies, thus aiding in the reduction of Haemolytic Transfusion Reactions (HTRs) and Haemolytic Disease of the Foetus and Newborn (HDFN). Moreover, research of this calibre would expand the local database of molecular typing of blood group antigens, improving transfusion.peer-reviewe

Excision margins in breast conserving surgery

The ideal excision margin in breast conserving surgery is still a matter of debate. The aim is to see if there is any correlation between increasing excision margin distance and local recurrence rate. Patients who had breast conserving surgery at Mater Dei Hospital in 2009 had their notes reviewed retrospectively. Patient demograpichs, including the excision margins were recorded. Local recurrences within a 3 year follow up period were noted. Chi square was used to compare categorical data and a p value of less than 0.05 was considered statistically significant. 91 patients were recruited into the study. 74 patients (81.5%) had negative margins (>1mm), 10 patients (11%) had close margins (<1mm) while 7 patients (7.5%) had positive margins. 5 patients (5.5%) had local recurrence. The highest recurrence rate (14%) was in patients with positive margins, and no statistical signficant difference in recurrence rates was noted with wider excision margins. As long as the margins are negative, increasing excision margins will not result in a better local recurrence rate.peer-reviewe

Swollen limbs and bone pain : a case report

A 50 year old man presented with peripheral oedema, abdominal distension and a pulmonary opacity on CXR. He subsequently perforated his sigmoid colon as a complication of diverticulitis with pericolic abscess. After colectomy his postoperative period was marked by severe hypokalaemia, metabolic alkalosis, hyperglycaemia and recurrent chest infections. Paraneoplastic Cushing's syndrome was diagnosed after finding elevated serum cortisol and ACTH levels. CT-guided biopsy of the lung lesion revealed small-cell carcinoma. Bone scan disclosed collapse of numerous thoracic vertebrae possibly due to osteoporosis or oncogenic osteomalacia. Treatment with steroid-synthesis blockers was commenced but the patient died before tumour-directed therapy could be started. Ectopic ACTH syndrome and oncogenic osteomalacia are discussed.peer-reviewe

Validation of a Polymerase Chain Reaction technique for Kidd blood group genotyping

The Kidd blood group antigens, Jkª and Jkᵇ , are two of the main surface markers which are found on the membrane of red blood cells. The determination of whether a donor or a recipient has the Jkª and/or the Jkᵇ antigens is crucially important to have a successful transfusion without the development of adverse incompatibility-related reactions. In Malta, routine serological-based tests are applied with the purpose of differentiating between homozygous and heterozygous states for the Jk antigens respectively. Although these tests are highly specific and sensitive, there are particular clinical scenarios where haemagglutination assays are not suitable for determining the individual’s Kidd blood group status. Additionally, the alternative genotyping procedure has never been applied in Malta within the context of blood grouping. The current study was therefore carried out to determine whether a molecular-based technique such as Polymerase Chain Reaction – Restriction Fragment Length Polymorphism analysis (PCR-RFLP) is a suitable alternative procedure for distinguishing amongst the three different Kidd phenotypes. After extracting deoxyribonucleic acid (DNA) from 50 blood samples obtained from serologically-tested healthy blood donors who expressed at least one of the Kidd antigens, PCR-RFLP analyses were carried out. The results of the latter were then compared with those previously obtained with haemagglutination and a complete match was observed between the two. Therefore, this PCR-RFLP method was confirmed as a suitable alternative laboratory technique that can be used to determine efficiently the Kidd blood group of both donors and recipients, in an accurate manner without subjectivity as encountered in the case of haemagglutination. This research further facilitates the introduction of molecular-based techniques in molecular blood transfusion.peer-reviewe

Referral tickets to secondary healthcare : is communication effective?

Communication between primary and secondary health care relies primarily on referral tickets. They determine how patients’ details are conveyed and hence the quality of care. The aim of this study was to assess the quality of referral tickets at the Surgical Outpatients at Mater Dei Hospital in Malta and to develop recommendations for improvement. Consecutive referral tickets between the 7th February and 4th March 2015 were prospectively included in the study and analysed for completeness. The data was entered into a proforma which was revised after the first ten entries. A total of 351 referral tickets were included in the study. Names and surnames were present in all reports and identification number in 99.42% of cases. 44.16% of referrals were inappropriate according to clinical details. The majority of the forms had a history of presenting complaint (98.29%) while the past history, drug history / allergies and examination findings were available in 69.23%, 67.81% and 76.64% respectively. The source of referral was not clear in 56.13%. Only 69.23% of all referral tickets were completely legible while 30.77% were partly legible. This study shows the need for an overhaul in the referral system. Recommendations include the use of electronic referrals and the introduction of feedback letters by hospital specialists.peer-reviewe

Use of Posidonia oceanica as a bioindicator of ecological status for Maltese coastal waters

Data on Posidonia oceanica attributes from Maltese Coastal waters are available from a number of research studies and environmental monitoring programmes. As part of Malta’s obligations for implement- ing the European Union’s Water Framework Directive, the Malta Environment and Planning Authority participated in an intercalibration exercise, involving Mediterranean countries that are also EU member states, aimed at ensuring comparability of different methods for the classification of coastal waters using P. oceanica as bioindicator. Data on P. oceanica attributes (shoot area, shoot biomass and shoot density), collected during the period 1999 to 2004 from 19 sites in Malta and Gozo, were analysed using Analysis of Variance and Principal Component Analysis to identify differences in values of seagrass attributes between the different sites surveyed. The output from the statistical analyses was used to derive values of the Eco- logical Quality Ratio (EQR) for the five status classes (high, good, moderate, poor or bad). Of the 19 sites considered, 2 sites were classified as having ‘high’ status, 14 sites had ‘good’ status, 2 sites had ‘moder- ate’ status, and 1 site had ‘poor’ status. None of the sites were classified as having ‘bad’ status; however, this was attributed to the lack of P. oceanica data from localities that represented highly degraded coastal areas. The results obtained are discussed in the light of knowledge of the environmental characteristics of the sites surveyed, and recommendations for development of a national method for assessing and classifying the ecological status Maltese coastal water, based on a larger data set and inclusion of additional seagrass descriptors, are proposed.peer-reviewe

An audit of the management of diabetic ketoacidosis at St Luke’s Hospital

Aim: To perform an audit of the protocol used in the management of patients with Diabetic Ketoacidosis, in St Lukes Hospital. Methods: Patients admitted with `Diabetes Ketoacidosis', between 14th August 2004 and 14th August 2005, were identified from the Admission book at the Accident and Emergency Department. Data obtained from patients' medical records were collected according to a preset proforma. The criteria assessed by this audit included parameter monitoring, investigations performed, the type and amount of intravenous fluids given, the insulin regime and potassium supplements used. Results: From a total of fifty six patients, forty seven files were traced, of which seventeen satisfied the criteria for Diabetic Ketoacidosis. Two were excluded and fifteen were analysed. In the population studied the mean age was 28 years with a male predominance of 60%. Ten patients suffered from Type 1 Diabetes whilst two patients had Type 2 Diabetes. Three other patients were newly diagnosed. Only one patient had all parameters checked according to protocol. In the majority of patients, fluids given in the first 22 hours, coincided with the amount of fluids stated in the protocol whilst 6/15 (40%) patients were administered the requested amount of insulin via infusion pump. With regards to potassium replacement, 13/15 (87%) patients were started on potassium supplements at a later stage. The factors influencing the total time for conversion to a fixed insulin regime and the duration of stay in hospital were also analysed. Conclusion: Deviations from the protocol were identified in parameter recording, the type of intravenous fluids given and the doses of insulin and potassium supplementation administered. New Diabetic Ketoacidosis guidelines have now been developed.peer-reviewe

A low voltage wide-input-range bulk-input CMOS OTA

The Gm-C technique is extensively used for continuous-time filtering applications because it results in tunable, wideband and compact designs. In this paper, an OTA architecture using a novel bulk-input differential pair without the use of a tail current source is proposed. Good CMRR is still achieved by using the gate terminal to control the total current in the differential pair, via the use of a dummy pair. The OTA also exhibits a wide differential input range and good Gm-tunability. For this design, two standard double-poly double-metal CMOS processes were investigated: a 0.8 μm process having a nominal threshold voltage of around 0.7 V and a 0.35 μm process having a nominal threshold voltage of 0.5 V. Simulation results are presented for both designs while test results are presented, for the OTA, implemented using the 0.8 μm process, used in a second order cochlea low-pass filter.peer-reviewe