Three-year follow-up mortality rate in Malta

Introduction: Primary osteoporosis is a major factor in fragility hip fractures. The index fracture is loaded with morbidity and increased mortality in these very fragile patients. The aim of the study was to evaluate the mortality rate after 3 months, 1 year and 3 years post hip fracture with possible identification of any relationship between different hip fracture types and mortality. Method: A retrospective analysis of all hip fracture patients admitted to Mater Dei Hospital, from January to December 2011 was performed. Data was gathered from the operating theatre notes, the patient archiving and communication system and the electronic case summary software. The mortality data was achieved from the National Mortality Registry. Statistical analysis was performed. Results: Out of 281 patients with a hip fracture, 47% died (mortality group) within 3 years with a female predominance (68.9%). Within the mortality group, sustaining an intertrochanteric fracture exhibited a statistical difference between the females and males. Within 90 days of a hip fracture, the mortality rate was of 12.8% with the majority of the patients sustaining an intertrochanteric. The median survival period following hip fractures was 190 days for subcapital, 297 days for intertrochanteric and 427 days for subtrochanteric fractures. Conclusion: The mortality rate in our study compares well with the published results of similar studies. A team effort aimed at giving the best possible care and minimize the morbidity and mortality should be endeavored. This should encompass the whole pathway, starting with prevention and finishing with appropriate community care after hospital discharge.peer-reviewe

Outcome of low back pain patients referred to orthopeadic outpatient clinic

Background: Musculoskeletal complaints are the commonest encounters in primary care. Low back pain management is commonly initiated by the family practitioner. Guidelines are limited as to when patients should be referred for specialist treatment by the orthopaedic department. Objectives: Evaluate the justification of low back pain referrals to Orthopedic outpatients (OOP), Mater Dei Hospital, Malta and assess whether these merited specialist consultation. Method: Anonymous data was collected over a 3- month period, where 100 low back pain new case referrals were evaluated during OOP. Data collection was based on routine questions normally brought forward during a consultation and a management plan which was documented in a spreadsheet. Data was analyzed using the same software. Results: Out of the total number of patients reviewed, 57 had been referred for the first time to OOP. Out of these, only 10 required an MRI with a scheduled follow up appointment. The remainder were referred for physiotherapy or pain clinic and discharged to follow-up in the community by the primary care physician. Out of 43 patients who had had previous OOP appointments complaining of lower back pain, 5 patients required an MRI and follow up appointment, remainder were discharged with physiotherapy or pain clinic appointments. Conclusion: The majority of patients seen at OOP could have been managed in primary care. It reflects the importance of developing local management guidelines for low back pain, which would assist general practitioners. It is indicative that referral to OOP should only be triggered when all treatment options available in the primary care are exhausted. This would lead to patients achieving targeted treatment timely within the community, resulting in shorter waiting time for outpatient visits.peer-reviewe

Bisphosphonates : a cost benefit analysis patient

Introduction: Osteoporotic hip fractures are common in elderly. There is increased risk of sustaining other fractures that incur financial burden on the health system. Prescription of bisphosphonates after osteoporotic hip fracture surgery has been shown to reduce the overall incidence of re-fractures. Methods: All osteoporotic hip fractures treated surgically in Mater Dei Hospital in the year 2011 were analysed in this observational retrospective study. The inclusion criteria were all primary osteoporotic hip fractures. The initiation, or not, of anti-osteoporotic treatment upon discharge from hospital was reviewed. The mortality and re-fracture rate of this cohort was reviewed for a period of 3 years. The cost of hospitalization for hip fracture and re-fractures was calculated based on local health services costs and compared to the benefits of providing a free bisphosphonate medication to each patient. Results: The osteoporotic hip fracture care pathway did not include initiation of anti-osteoporotic therapy after operations. A re-fracture rate of 11.7% over three years predominantly in female patients was observed. In the first year following hip fracture, an estimated direct medical health expenditure due to re-fractures was of €37,642.55 - €48,835.19. Conclusion: Prescribing a bisphosphonate has been found to reduce both the re-fracture and mortality rates. In our study, a bisphosphonate prescription could have reduced the all cause mortality rate of 25.3% to 15.18% over the first year of hip fracture, as well as reduced the financial and social burden incurred due to a re-fracture.peer-reviewe

Ankle X-ray use at Mater Dei's accident and emergency department

Aim: To determine the amount of X-rays performed at the Accident and Emergency Department (A&E) at Mater Dei Hospital to investigate ankle injuries. Objectives: A comparison between the X-ray report and the examining physician’s request was also performed. The audit will propose the possibility of implementing a standard protocol of care for ankle injuries namely, based upon the Ottawa Ankle Rules. Methods: A retrospective observational study was carried out between the 20th September and the 20th December 2015. All ankle X-rays performed at A&E during this period were analysed using the Picture and Archiving System (PACS). Results: The commonest reason for requesting an X-ray following a traumatic event was to identify the presence of a fracture. Only 27.8% of these X-ray reports identified a fracture. X-rays were also requested for non-traumatic injuries very often due to swelling. Physicians’ requests often contained minimal clinical details but only one request had no details whatsoever. Conclusion: Ankle X-rays were most commonly performed to identify a fracture but very often no fracture was identified. Fractures were a relatively uncommon finding raising the possibility of inappropriate prescription of X-rays. Use of guidelines or an alternative investigation could be beneficial in order to reduce inappropriate radiography usage. Appropriately filled in request forms including clinical presentation would help the communication between the physician and the radiologist.peer-reviewe

University food environment, an example of health inequality?

Background: Universities provide an influential life structure for students during their transition into adulthood through tuition as well as through the ground’s environment. Ensuring a healthy and safe university environment forms the basis of health equity within such institutions. The objective was to evaluate the food environment through vending machines situated across the grounds of the only state university in Malta, whilst acquiring students’ perspective on these facilities. Method: An audit was conducted on the food and beverage items available within vending machines across university grounds. This was reevaluated a year later. Students’ perceptions and use of such facilities were gathered through electronic-distributed questionnaires. Results: All machines were stocked with identical sugary items. 71.03% of responders purchased from machines due to their easy accessibility, while 61% considered items as “too unhealthy”, with 74.60% showing enthusiasm for healthier choices. 60% reported a willingness to pay more in exchange for healthier options. Conclusion: Limited consumable options leave students without healthier options on campus. Provision of a healthier food environment is a prerequisite in addressing health inequalities. Action is required to tackle this situation urgently especially due to the growing obesity epidemic.peer-reviewe

Vaccine trials with no serious adverse reactions – estimation of upper 95% confidence intervals for likelihood of such events

COVID‑19 remains a pandemic at the time of writing (July 2021) and the ultimate solution appears to be global vaccination. In trials, vaccines did not demonstrate serious side effects and only manifested transient symptoms such as fever and malaise, as well as local reactions such as pain and tenderness at the injection site, effects that continue to be observed even with ongoing mass vaccination. However, it is still possible to have serious rare side effects as millions and even billions are vaccinated. This paper will demonstrate a simple way to estimate such risks based on actual trial data and the on ongoing vaccination. [Excerpt]peer-reviewe

A glimpse into long COVID characteristics and the mental health impact within a highly vaccinated population : a Malta observational study

Background. Post-acute COVID-19 consequences are gaining global recognition. This study explores Long COVID characteristics and associated mental health impact/s among the highly vaccinated adult population of Malta. Methods. A social media survey gathered demographics, vaccination, and COVID-19 data. Generalised Anxiety Disorder and Patient Health Questionnaire-9 assessment tools were used for anxiety and depression. Quantitative analyses were performed. Results. 41% reported Long COVID, mostly female, 30-39 years, absence of chronic disease/s and vaccinated. Shortness of breath commonest persistent symptom among males, and fatigue for females. Significantly higher depression scores were present in Long COVID cohort compared to no persistent symptoms (p=0.001) and never acquiring COVID-19 (p=<0.01). A significant higher anxiety scores was present for Long COVID cohort than never acquiring COVID-19 (p=<0.01). Conclusions. Long COVID occurs even in healthy individuals and vaccinated, while exacerbating mental health burdens. Urgent action is required to manage Long COVID and preventing the sequela.peer-reviewe

Insight into the attitudes and experiences of adults with non-communicable diseases a year into the COVID-19 pandemic : the Malta experience

Introduction: Non-communicable diseases (NCDs) have been a global epidemic long before the advent of COVID-19. Understandably, with the onset of COVID-19, health priorities shifted. The aim of this study was to explore the impact of COVID-19 through attitudes and experiences on the health and well-being of the Malta adult population suffering from NCDs, a year into COVID-19. Methods: An anonymous survey was distributed online between February 1 and 26, 2021 using Google Forms®. This assessed the impact of COVID-19 on medical care, intention to take a COVID-19 vaccine, and whether COVID-19 was acquired. Quantitative and qualitative analyses were performed. Results: Out of the 1,034 participants, 34.82% (95% CI, 31.97–37.77; n = 360) reported to suffer from NCDs (single NCD, n = 276; 2 NCDs, n = 56; 3 NCDs, n = 28) with 6.94% (95% CI, 4.71–10.09) of these reported acquiring COVID-19. Since COVID-19, the NCD population visited the general practitioners less (47%) than those without NCDs (32%) (p ≤ 0.001). With a consensus of concern and fear, “I rather skip check-ups than risk getting COVID-19 in waiting room or clinic.” Postponement and cancellations of medical appointments were reported: “had to do blood tests privately as health centre was not doing them” and “delayed treatment and still awaiting further appointments that were postponed more than once.” The majority intended to take COVID-19 vaccine. Conclusions: It is clear that individuals with NCDs have experienced a general negative effect on their medical care. It’s recommended that a dual action strategy is embraced to ensure that both NCDs and COVID-19 are treated simultaneously, leaving no one behind.peer-reviewe

A cross‐sectional study exploring the Covid‐19 vaccination landscape in Malta through social media : an insight into experiences, attitudes, and perspectives

Background and Aims: Covid‐19 vaccines were disseminated across Europe from the end of 2020. Malta had one of the fastest vaccination rollouts in Europe and by March 2022 most adults had their booster dose. The aim was to investigate adult's perspectives, experiences, and attitudes regarding vaccination in Malta. Methods: An anonymous online survey targeting adult social media users living in Malta was disseminated through social media, with a snowball technique. Demographic information, vaccination uptake, side‐effects, perceptions, and experiences were gathered through quantitative and qualitative means. Participants were sub‐grouped according to their vaccination status and descriptive analysis through frequency was performed. χ 2/Fisher test testing followed by logistic regressions were performed to assess the vaccination perspectives according to vaccination status. Results: Out of 611 participants 79.87% had the booster, 4.91% had two doses awaiting booster, 6.55% refused booster while, 8.67% refused any dose. Booster sub‐group when compared to vaccine hesitant sub‐group exhibited an association with the perception for the need to “continue wearing masks, maintaining physical distance and hand washing following vaccination” (odds ratio [OR]: 5.97 confidence interval [CI] 95%: 1.09–32.36 p = 0.04). Those waiting for the booster dose when compared to those refusing booster, exhibited an association with the perspective that “COVID‐19 vaccine is the solution to returning to normality” (OR: 5.00 CI 95%: 1.12–22.35 p = 0.04). The commonest reason for inoculation was to protect against severe disease (63.08% CI 95%: 58.91–67.07). More pronounced booster adverse effects raised concern about future booster doses uptake. Unwillingness among anti‐booster and vaccine hesitant arose among high socioeconomic background participants, with concern for vaccine safety and adverse effects. Conclusion: Vaccine hesitancy is low yet, vaccination unwillingness even among highly educated may act as a barrier to control the pandemic. Clear, transparent public health communication which targets concerns is crucial, with unified messages from governing bodies optimizing population safety.peer-reviewe

Assessing the impact of the four COVID-19 variants and the vaccine coverage on mortality in Malta over 2 years : an observational case study

Background: Mortality may quantify a population's disease burden. Malta, like other European countries, experienced COVID-19 surges in cases and mortality across the pandemic. This study assesses COVID-19's mortality impact, while exploring the effects of the four dominant COVID-19 variants and that of the vaccination coverage on the Maltese population. Methods: COVID-19 data (cases, mortality, positivity, and vaccination rates) was obtained from the websites of the European Center for Disease Prevention and Control and the Malta Ministry of Health. Data was categorized into the four periods according to reported dominant COVID-19 variant. Years of life lost (YLL) and Case-Fatality-Ratio (CFR) for each period were estimated. CFR was also estimated for the pre-vaccine and post-vaccine periods. Results: The original COVID-19 period (36 weeks) had the highest YLL (4,484), followed by the Omicron variant period (12 weeks; 1,398). The Alpha variant period (7 weeks) had the highest CFR (1.89%) followed by the Original COVID-19 (1.35%). The pre-vaccine (1.59%) period had higher CFR than the post-vaccine period (0.67%). Conclusion: Various factors contributed to mortality, but the variant's infectivity, transmissibility, and the effectiveness of the vaccine against the variant play an important role. Reducing mortality by embracing mass vaccination that targets current variants along with other non-pharmaceutical interventions remains paramount.peer-reviewe