Evolutionary and spatiotemporal analyses reveal multiple introductions and cryptic transmission of SARS-CoV-2 VOC/VOI in Malta

IMPORTANCE

Our study provides insights into the evolution of the coronavirus disease 2019 (COVID-19) pandemic in Malta, a highly connected and understudied country. We combined epidemiological and phylodynamic analyses to analyze trends in the number of new cases, deaths, tests, positivity rates, and evolutionary and dispersal patterns from August 2020 to January 2022. Our reconstructions inferred 173 independent severe acute respiratory syndrome coronavirus 2 introductions into Malta from various global regions. Our study demonstrates that characterizing epidemiological trends coupled with phylodynamic modeling can inform the implementation of public health interventions to help control COVID-19 transmission in the community.

English in Valletta's Linguistic Landscape: a case of instrumental rationality?

Cities are the natural homes for linguistic and cultural diversity. Valletta, Malta's capital city and the smallest city in the European Union, is no different. When its foundation stone was laid in 1566 by Grandmaster Jean Parisot de Vallette, it was given the formal title of Humillima Civitas Valettae, but ‘there is little that is humble about the appearance of Valletta, that city “built by gentlemen for gentlemen”’ (Luke, 1968: 65).

P337 SPORTS CARDIOLOGY NURSE IMPORTANCE IN YOUNG SPORTSMEN SUFFERING FROM ACUTE HEART DISEASE PREVENTION AND REHABILITATION. PILOT EXPERIENCE: REMOTE MONITORING DURING THE SARSCOV–2 PANDEMIC

This is because it is difficult to understand that a “well trained” heart is not necessarily a “healthy” heart, and many malignant arrhythmias are triggered by physical activity. A project on diagnosis and prevention aimed at recognizing acute cardiac pathologies in young sportsmen has been launched using professional nursing figures, who in addition to having acquired relevant skills in the critical, interventional and clinical cardiology area, have also acquired additional skills in the field of the Biomedical and Neuromotor Sciences. The “sport cardiology nurse” can represent a relevant support for athletes’ acute cardiac pathologies prevention and rehabilitation. It takes the young patient throughout the process together with the Doctor: – Outpatient activity (recognition of ECG alterations, preparation of the patient for drug tests, Tilt test, management of complications) – Interventional cardiology activities: implantation of loop recorders and implantable defibrillators. – Rehabilitation and physical, nutritional and psychological education. With the SARS–CoV–2 pandemic, our work has undergone a drastic change. We have worked with telemedicine and activated remote monitoring for implanted cardiac devices. Our experience from January 2020 to today counts the enrolment of 80 patients undergoing ICD implantation, of which 8 subcutaneous, in young athletes. With the video visiting service it was possible to follow young patients who had been diagnosed with acute heart disease, to monitor and identify the onset of symptoms and / or arrhythmias. Remote monitoring is managed by the Sports Cardiology Nurse and the Doctor in charge. Given the results obtained, the project also aims to expand its skills in the environments most attended by young people, such as schools and sports centres in association with local companies in a not too far future. This “Sport Cardiology” aims to train more nursing professionals, to plan interventions aimed at reducing mortality and to spread the basic concepts of health education in the field of prevention.

Impact of the environment on the health: From theory to practice

The Erice 56 Charter titled "Impact of the environment on the health: from theory to practice" was unanimously approved at the end of the 56th course of the "International School of Epidemiology and Preventive Medicine G. D'Alessandro" held from 3rd to November 7, 2019 in Erice - Sicily (Italy) and promoted by the Study Group of "Environment and Health" of the Italian Society of Hygiene, Preventive Medicine and Public Health. The course, that included lectures, open discussions and guided working groups, was aimed to provide a general training on epidemiological and toxicological aspects of the environmental health impact, to be used by public health professionals for risk assessment, without forgetting the risk communications. At the end of the course 12 key points were agreed among teachers and students: they underlined the need of specific training and research, in the perspective of "One Health" and "Global Health", also facing emerging scientific and methodological issues and focusing on communication towards stakeholders. This Discussion highlight the need to improve knowledge of Health and Environment topic in all sectors of health and environmental prevention and management.

Patients with Covid-19 exhibit different immunological profiles according to their clinical presentation

OBJECTIVES

A novel beta coronavirus has been identified as responsible for the 2019 coronavirus infection (Covid-19). Clinical presentations range from asymptomatic cases to acute respiratory distress syndrome with fatal outcome. Such a broad spectrum of disease expression calls for an investigation of immune response characteristics.

METHODS

We identified subjects admitted for Covid-19 in whom a large panel of immunological markers were measured, including B- and T- and NK-lymphocyte phenotypes, T-lymphocyte subpopulation cells and plasma cytokines. Patients were divided according to symptom severity during hospitalisation, in those with uncomplicated and complicated infection. Differences between groups were analyzed.

RESULTS

Seventeen patients were included (mean age: 83 years; 9 women; mean delay of symptoms onset: 4 days). Six had uncomplicated infection, while 11 developed complicated forms during hospitalization. CD10 + B lymphocyte levels were inversely correlated with clinical severity (5.8% vs 2.0%, p = 0.04) and CD10+ levels above 3% were independently associated with uncomplicated forms [Odds Ratio 0.04 (CI 0.002-0.795, p = 0.034)]. TNF-alpha, IL-1, Il-6 and Il-8 measurements upon admission differed between patients who died and those who survived (p < 0.01 for all comparisons).

CONCLUSIONS

In a population of elderly patients recently infected with Covid-19, CD10 + B cell levels were inversely correlated with clinical severity. Cytokine values upon admission were highly predictive of fatal outcome during hospitalisation. These findings could explain differences in the clinical presentation and allow rapid identification of patients at risk for complications.

Fibrinogen measurement in liver disease: validation of the functional fibrinogen thromboelastography assay and a novel mathematical predictive model

BACKGROUND

Fibrinogen is produced in the liver and tends to be reduced in liver cirrhosis. Quantitative and qualitative tests exist to measure fibrinogen. We aimed to validate the functional fibrinogen thromboelastography assay (FF-TEG) and propose a new model to estimate fibrinogen levels via the Clauss method (Clauss) using data from a prothrombin time-derived fibrinogen assay (PT-Fg) in patients with liver cirrhosis.

MATERIALS AND METHODS

Clauss, PT-Fg, fibrinogen antigen (Fib-Ag) and FF-TEG were studied in 55 patients with liver cirrhosis (26 with Child-Turcotte-Pugh [CTP]-A disease, 14 with CTP-B and 15 CTP-C) and 20 healthy individuals.

RESULTS

The results of all four assays correlated strongly with each other, but gave significantly different mean levels in all cohorts. PT-Fg gave the highest levels whereas the Clauss gave the lowest levels. The FF-TEG performed well with results which were in between the Clauss and the PT-Fg. Significant differences were only observed between CTP-A and CTP-C for the Clauss, PT-Fg and Fib-Ag but not functional fibrinogen level. We devised a simple linear regression model in order to estimate Clauss from the PT-Fg.

DISCUSSION

The results of the FF-TEG correlate well with those of routine fibrinogen assays in patients with liver cirrhosis. However, the FF-TEG assay does not discriminate between early and late stages of disease, pointing to a preserved fibrin clot strength in cirrhosis. Through linear regression models, fibrinogen levels can be accurately estimated using the Clauss method based on fibrinogen levels obtained in the cheaper PT-Fg.

The pulmonary rehabilitation regimen: a treatment for frailty and 'inflammaging'?

Pulmonary rehabilitation is an exercise-based intervention that improves walking endurance, strength, functional independence, wellbeing and the risk of re-admission to hospital. It was developed for patients recovering from acute exacerbations of chronic obstructive pulmonary disease, and sometimes other long-term inflammatory lung diseases. Many other conditions have a chronic inflammatory component, including type 2 diabetes, obesity, osteoarthritis and old age. Such background inflammation is linked to a range of adverse outcomes, including all-cause mortality, sarcopenia and other markers of frailty. Exercise, including pulmonary rehabilitation, has an anti-inflammatory effect on innate immune chemistry, and improves outcomes in a variety of conditions, although for most diagnostic groups there is no consistent structured programme similar to pulmonary rehabilitation. The authors contend that the pulmonary rehabilitation model could be used generically to treat other chronic and post-acute inflammatory states and thereby reduce the risk of frailty and other adverse outcomes.

Phenotyping of subjects for large scale studies on patients with IBS

BACKGROUND

Irritable bowel syndrome (IBS) is a complex condition with multiple factors contributing to its aetiology and pathophysiology. Aetiologically these include genetics, life-time events and environment, and physiologically, changes in motility, central processing, visceral sensitivity, immunity, epithelial permeability and gastrointestinal microflora. Such complexity means there is currently no specific reliable biomarker for IBS, and thus IBS continues to be diagnosed and classified according to symptom based criteria, the Rome Criteria. Carefully phenotyping and characterisation of a 'large' pool of IBS patients across Europe and even the world however, might help identify sub-populations with accuracy and consistency. This will not only aid future research but improve tailoring of treatment and health care of IBS patients.

PURPOSE

The aim of this position paper is to discuss the requirements necessary to standardize the process of selecting and phenotyping IBS patients and how to organise the collection and storage of patient information/samples in such a large multi-centre pan European/global study. We include information on general demographics, gastrointestinal symptom assessment, psychological factors, quality of life, physiological evaluation, genetic/epigenetic and microbiota analysis, biopsy/blood sampling, together with discussion on the organisational, ethical and language issues associated with implementing such a study. The proposed approach and documents selected to be used in such a study was the result of a thoughtful and thorough four-year dialogue amongst experts associated with the European COST action BM1106 GENIEUR (www.GENIEUR.eu).

Antimicrobial stewardship policy: time to revisit the strategy?

Recent data indicate that both the overall numbers of antibiotic prescription and the frequency of multidrug-resistant bacteria are increasing significantly. These threatening features are observed, despite national antimicrobial stewardship (AMS) policies aimed at decreasing antibiotic use. AMS should also focus on the initial steps leading to antibiotic prescription. Physicians and their patients should benefit from the structured clinical pathways, the latter being adapted to regional epidemiological data and resources. Continuous evaluation of these predefined clinical paths through a computerized medical dashboard will allow a critical review and finally the optimization of medical practices. These innovative behavioural approaches for clinicians will supply precise information on the relationship among the diagnosis, therapeutics and outcome. This changing environment will carry out the adapted therapeutic procedures, and appropriate antibiotic use will inherently improve.

Virologically suppressed patients with asymptomatic and symptomatic HIV-associated neurocognitive disorders do not display the same pattern of immune activation

OBJECTIVES

Inversion of the CD4:CD8 ratio is a marker of immune activation and age-associated disease. We measured the CD4:CD8 ratio as a marker of cognitive impairment in HIV-infected patients and explored differences according to clinical severity.

METHODS

Post hoc analysis of data from two prospective cohorts of HIV-infected patients randomly selected to undergo neuropsychological tests was performed. Test scores were adjusted for age, gender and education. Inclusion criteria were undetectable viral load and stable treatment for at least 6 months. Subjects with HIV-associated dementia were excluded. Patients were divided into an unimpaired group, a group with asymptomatic neurocognitive disorder (ANI) and a group with symptomatic HIV-associated neurocognitive disorder (sHAND), represented by mild neurocognitive disorder (MND). Demographic and background parameters, immune activation markers and the CD4:CD8 ratio were recorded.

RESULTS

Two hundred patients were included in the study. The mean age was 52 years, 78% were male, the mean CD4 count was 624 cells/μL, the mean nadir CD4 count was 240 cells/μL, 27% were hepatitis C virus (HCV)-coinfected, the mean duration of HIV infection was 16 years, and the mean time on current combination antiretroviral therapy (cART) was 2.9 years. Twenty-nine per cent of subjects had HAND (21% had ANI and 8% had MND). In multivariate analysis, a CD4:CD8 ratio < 1 was associated with a nadir CD4 count < 200 cells/μL [odds ratio (OR) 3.68] and with the presence of CD4(+) CD38(+) HLA(+) cells (OR 1.23). Multinominal logistic regression showed that, in comparison with the unimpaired group, diagnosis of sHAND was associated with a CD4:CD8 ratio < 1 (OR 10.62), longer HIV infection (OR 1.15) and longer current cART (OR 1.34), while the ANI group differed from the unimpaired group only for education level.

CONCLUSIONS

Aviraemic patients with sHAND did not display the same pattern of immune activation as subjects with ANI, suggesting that the underlying pathophysiological mechanisms could be different.

Evaluation of the probiotic properties of new Lactobacillus and Bifidobacterium strains and their in vitro effect

Probiotic ingestion is recommended as a preventive approach to maintain the balance of the intestinal microbiota and to enhance the human well-being. During the whole life of each individual, the gut microbiota composition could be altered by lifestyle, diet, antibiotic therapies and other stress conditions, which may lead to acute and chronic disorders. Hence, probiotics can be administered for the prevention or treatment of some disorders, including lactose malabsorption, acute diarrhoea, irritable bowel syndrome, necrotizing enterocolitis and mild forms of inflammatory bowel disease. The probiotic-mediated effect is an important issue that needs to be addressed in relation to strain-specific probiotic properties. In this work, the probiotic properties of new Lactobacillus and Bifidobacterium strains were screened, and their effects in vitro were evaluated. They were screened for probiotic properties by determining their tolerance to low pH and to bile salts, antibiotic sensitivity, antimicrobial activity and vitamin B8, B9 and B12 production, and by considering their ability to increase the antioxidant potential and to modulate the inflammatory status of systemic-miming cell lines in vitro. Three out of the examined strains presenting the most performant probiotic properties, as Lactobacillus plantarum PBS067, Lactobacillus rhamnosus PBS070 and Bifidobacterium animalis subsp. lactis PBSO75, were evaluated for their effects also on human intestinal HT-29 cell line. The obtained results support the possibility to move to another level of study, that is, the oral administration of these probiotical strains to patients with acute and chronic gut disorders, by in vivo experiments.

How does cognitive impairment impact on functional improvement following the rehabilitation of elderly patients?

AIMS

It has been suggested that patients with cognitive impairment do not benefit from rehabilitation or that rehabilitation gains are reduced. Most studies focus on absolute gain rather than gains in individual functional areas. The Barthel activities of daily living (ADL) score is a tool, which is used widely and comprises 10 functional domains. This study aimed to assess the response to rehabilitation based on improvement or deterioration on the Barthel ADL score for patients with different cognitive abilities

METHODS

This independence measure was assessed at specific time periods in an observational study of 241 patients undergoing in-patient rehabilitation. Therapy was delivered formally by physiotherapists and occupational therapists and also informally by nursing staff. Patients were divided into four groups according to cognition. Group 1 (MMSE, mini-mental state examination 27-30), normal cognition, Group 2 (MMSE 21-26) mild impairment, Group 3 (MMSE 11-20) moderate impairmentand Group 4 (MMSE 0-10) severe impairment.

RESULTS

Statistically significant improvement was made in most of the functional domains by patients with normal cognition and mild cognitive impairment (p < 0.0025). The exception to this for both groups was in the areas of feeding and bowels because of the fact that most patients were independent with these aspects on admission. Group 3 patients made improvements in the domains of grooming, dressing, toileting, transferring and mobility. Group 4 patients did not demonstrate statistically significant improvement in any domain although there were trends for improvement in mobility and transferring.

CONCLUSIONS

This study demonstrated that cognitive impairment did have an impact on the ADL that patients improved in following rehabilitation. However, even patients with moderate cognitive impairment made significant gains with many ADL.

Diarrhoeal episodes in travellers suffering from IBD

BACKGROUND AND AIMS

There is limited data on the risk of developing diarrhoea in travelling patients with inflammatory bowel disease (IBD). We analysed the rate of developing diarrhoea among travellers suffering from IBD and their healthy controls.

METHODS

We performed a retrospective case-controlled study among 78 patients with IBD and their healthy travelling companion controls, thus matching both groups to the same environmental conditions. Data was retrieved through a structured questionnaire, interview and clinical case notes review.

RESULTS

Sixteen (20.5%) patients with IBD developed diarrhoea while abroad (p -0.0001) Statistical analysis using a χ² test for independence (with Yates Continuity Correction). Prior to travelling, they were in clinical remission. Only one healthy control (1.3%) developed diarrhoea while abroad. In 11 patients (14.1%), the duration of diarrhoea was 3 days or less, and resolved on its own without antibiotics, any increase in their IBD medications and without a medical consultation. The other five patients had a flare-up of their disease and needed medications to put them back into remission. There was no statistically significant difference between patients having immunomodulator medications versus those having aminosalicylates only in developing diarrhoea when abroad.

CONCLUSIONS

Patients with IBD have a higher rate of developing diarrhoea compared with controls when travelling. Thus, such patients must always seek a pretravel medical consultation.

Normal and abnormal development of the fetal anterior fontanelle: a three-dimensional ultrasound study

OBJECTIVES

To describe the methodology for correct visualization of the anterior fontanelle using three-dimensional ultrasound, to report its normal development during gestation, and to compare this with abnormal development.

METHODS

This was a cross-sectional prospective evaluation of development of the anterior fontanelle in a series of 78 normal fetuses and 47 fetuses with congenital anomalies between 12 and 38 weeks of gestation. The anterior fontanelle was visualized in a mid-sagittal view of the fetal head, preferably with a pocket of fluid between the fetal head and the uterine wall, to ensure an optimal acoustic window. Visualization using volume contrast imaging mode in the coronal plane (VCI-C) was preferred to static acquisition of three-dimensional (3D) volumes, as the former allows real-time evaluation of the 3D image. Anteroposterior and laterolateral diameters, perimeter and area of the fontanelle were measured offline, with the diameters normalized for biparietal diameter and the perimeter and area normalized for head circumference. The variables were then regressed against gestational age.

RESULTS

The best fitting regression model to describe the relationships between the fontanelle anteroposterior diameter and area and gestational age was a quadratic one, whereas a simple linear model fitted all remaining variables. All variables showed a positive or biphasic correlation with advancing gestational age, but a negative one after normalization for biparietal diameter or head circumference. Twenty of the 47 fetuses with abnormalities had abnormal (18 enlarged and two reduced) fontanelle dimensions, particularly those with chromosomal or non-chromosomal syndromes, primary or secondary cardiac overload, primary skeletal dysplasias or central nervous system malformations. Hydrops was not associated with abnormal fontanelle dimensions.

CONCLUSIONS

We have described the methodology to obtain correct visualization of the fetal anterior fontanelle. The actual size of the fontanelle increases during gestation, while its size in relation to the volume of the fetal head diminishes, possibly due to the rapid development of the brain hemispheres and the consequent outward growth of the calvarial bones. The fact that enlarged fontanelle dimensions may be associated with certain fetal abnormalities may be employed advantageously in the differential diagnosis of some syndromic conditions in utero.

Incidence of inflammatory bowel disease in Malta between 1993 and 2005: a retrospective study

BACKGROUND

The primary aim of the study was to estimate the incidence of Crohn's disease (CD) and ulcerative colitis (UC), collectively known as inflammatory bowel disease (IBD), in Malta in a well-defined population during a 13-year study period.

METHODS

Diagnostic criteria for CD and UC were defined. A diagnosis of IBD was obtained from the histopathology reports at St. Luke's Hospital, Malta, between January 1993 and December 2005. The date of diagnosis was defined as the date of the first histopathology report revealing signs of IBD.

RESULTS

Incidence rates were standardized using the direct method on the European Standard Population. The mean incidence of UC in males was 8.16 per 100,000 per year and for females was 7.59 per 100,000 per year, while that for CD in males was 0.96 per 100,000 per year and for females 1.622 per 100,000 per year. Using linear regression, in UC there is an almost significant (P = 0.069) increasing trend with time but no difference by gender (P = 0.591). On the other hand, in CD there is no significant trend with time (P = 0.555) but almost a significant difference by gender (P = 0.078).

CONCLUSIONS

This is the first Maltese study in which the incidence of IBD has been recorded. In Malta the incidence of UC is similar to the overall incidence of other European countries while the incidence of CD is lower. In fact, the incidence rates of CD are among the lowest in Europe, similar to other southern European countries.

Transposition of the great arteries in the fetus: assessment of the spatial relationships of the arterial trunks by four-dimensional echocardiography

OBJECTIVE

Coronary arterial abnormalities can be one of the few negative prognostic indicators in transposition of the great arteries (TGA), and their occurrence is related to the type of spatial relationship of the great arteries. The main objective of this study was to assess whether the use of the reconstructed en-face view with color Doppler imaging of the four cardiac valves can demonstrate the different types of spatial relationship of the arterial trunks in fetuses with TGA, in order to derive the risk of coronary abnormalities. A secondary end-point was the evaluation of the type of coronary arterial branching pattern.

METHODS

Twenty-three fetuses with a confirmed diagnosis of TGA underwent four-dimensional (4D) echocardiography at 19-33 gestational weeks. The en-face view of the four cardiac valves and color Doppler with high persistence were employed to assess the spatial relationships of the great arteries. In all cases, confirmation of the vessels' arrangement and coronary arterial distribution was obtained at neonatal echocardiography and/or surgery.

RESULTS

The spatial relationships of the great vessels was identified correctly in 20/23 (87%) cases. The aorta was found to be located anterior to and to the right of the pulmonary trunk in 13/23 (56.5%) cases and just anterior to the pulmonary artery in 6/23 (26.1%) cases; in the remaining four (17.4%) cases, the two vessels were side by side. With respect to the association between the spatial relationship of the great arteries and the occurrence of an unusual pattern of coronary arterial branching, five of the TGA fetuses had abnormal coronary arterial distribution.

CONCLUSIONS

Using 4D echocardiography with color Doppler, it is possible to define the spatial relationships of the great arteries in fetuses with TGA with a high degree of accuracy. This information can be used during counseling to predict the likelihood of abnormal coronary arterial distribution.

Comparison of elicitation methods for moral and affective beliefs in the theory of planned behaviour

Although the theory of planned behaviour (TPB) has been applied successfully in the area of food choice, it has been criticized for its pure utilitarian approach to the factors determining behaviour. Despite the increase in predictive power of the model with added components such as affective attitude and moral and ethical concerns, in most studies the elicitation process still only addresses people's utilitarian beliefs about the behaviour with little attention paid to other aspects. This study compares the traditional method of elicitation of advantages and disadvantages with two other methods (word association and open-ended) in the elicitations of beliefs, attitudes and moral concerns in relation to the consumption of organic foods. Results show the traditional method to be best for eliciting cognitive beliefs, open-ended emotion task for eliciting emotional beliefs and open-ended beliefs task best for moral concerns. The advantages and disadvantages of each method are discussed.