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Background: Allergic rhinitis (AR) is a highly prevalent disease. We aimed to assess the symptoms that physicians who see patients with AR perceive as the most bothersome in their patients. Methods: We performed a cross-sectional study based on an online questionnaire sent to all members of the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative. The survey included questions on the physicians' perceptions of patients’ AR symptoms as well as of their own AR symptoms. Results: Among 401 respondents, 155 (38.7%) reported having AR. ARIA members reported nasal symptoms to be the most frequent (89.7%) and bothersome (80.0%) symptoms experienced by themselves. Likewise, nasal symptoms were reported by ARIA members as the most frequent (94.8% in members with AR vs 96.0% in members without AR) and bothersome (57.0% in members with AR vs 67.9% in members without AR) in their patients. We found a significant association (p = 0.001) between physicians’ own symptoms and those perceived as the most bothersome in their patients. Conclusion: Physicians perceive nasal symptoms to be the most frequent and the most bothersome symptoms in AR patients. The physicians' personal experiences with AR may influence their perception of patients’ symptoms.

ObjectivesPatients with malignant pleural mesothelioma (MPM) or pleural metastases often present with malignant pleural effusion (MPE). This study aimed to analyze the effect of pleural fluid on cancer cells.Materials and MethodsEstablished patient-derived cancer cell cultures derived from MPE (MPM, breast carcinoma, lung adenocarcinoma) were seeded in 100% pleural fluid (exudate MPM MPE, transudate MPE, non-MPE transudate fluid) and proliferation was monitored. In addition, the establishment of new MPM cell cultures, derived from MPE specimens, was attempted by seeding the cells in 100% MPE fluid.ResultsAll established cancer cell cultures proliferated with similar growth rates in the different types of pleural fluid. Primary MPM cell culture success was similar with MPE fluid as with full culture medium.ConclusionsPleural fluid alone is adequate for cancer cell proliferation in vitro, regardless of the source of pleural fluid. These results support the hypothesis that pleural fluid has important pro-growth biological properties, but the mechanisms for this effect are unclear and likely not malignant effusion specific.

Introduction and Aims. The first COVID-19 case in Malta was confirmed on the 7th of March 2020. This study is aimed at investigating a significant difference between the number of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) admissions and their inpatient outcome at Mater Dei Hospital during the COVID-19 pandemic when compared to the same period in 2019. Furthermore, we aim to determine predictors of mortality in AECOPD inpatients. Method. Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020. Results. There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n=119 in 2020 vs. n=259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p≤0.001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p=0.006). There was a significant increase in inpatient mortality in 2020 (19.3% [n=23] and 8.4% [n=22] for 2020 and 2019, respectively, p=0.003). Year was found to be the best predictor of mortality outcome (p=0.001). The lack of use of SABA pre-admission treatment (p=0.002), active malignancy (p=0.003), and increased length of hospital stay (p=0.046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality. Conclusions. There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study.

The global prevalence of allergic diseases have increased considerably and are a major socio-economic burden. Asthma is a complex disease and understanding asthma phenotypes and endotypes could eventually lead to individualised management, and offer better symptom control and quality of life. In this review, we first summarise the pathogenesis of atopic asthma and delve into the assessment of sensitisation to aeroallergens through skin prick testing and serological testing with total and specific immunoglobulin E testing. We will then analyse the distribution of aeroallergen sensitisation patterns in the United States and Europe and its effect on the population. This review gives a comprehensive overview on atopy and it compares the prevalence and effect of atopy within various regions of both continents using data from large multicentre studies. We will conclude this review by discussing the efficacy of add-on treatments in the most prevalent severe asthma phenotypes and endotypes.

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Abstract: Exposure to outdoor air pollution has been shown to increase asthma symptoms. We assessed the potential role of particulate matter with aerodynamic diameter 2.5) on respiratory condition in schoolchildren in the south Mediterranean area. A total of 2400 children aged 11–14 years were recruited, and data on their symptoms were collected through an ISAAC (International Study of Asthma and Allergies in Childhood)-based questionnaire. Outdoor PM2.5 was collected for 48 consecutive hours in the schoolyards of their schools and selected residential outdoor areas. The levels of PM2.5 were measured, along with its elemental composition. The incidence of an acute respiratory illness within the first 2 years of life was higher amongst Sicilian children when compared to Maltese children (29.7% vs. 13.5% respectively, p < 0.0001). Malta had a significantly higher prevalence of doctor‐diagnosed asthma, when compared to Sicily (18.0% Malta vs. 7.5% Sicily, p p < 0.0001) and use of asthma medication in the last 12 months (12.1% vs. 4.9%, p < 0.0001) were more frequent amongst Maltese children. Total median PM2.5 was 12.9 μg/m3 in Sicily and 17.9 μg/m3 in Malta. PM2.5 levels were highest in the Maltese urban town of Hamrun (23.6 μg/m3), while lowest in the rural Sicilian town of Niscemi (10.9 μg/m3, p < 0.0001). Hamrun also exhibited the highest levels of nickel, vanadium, lead, zinc, antimony, and manganese, whilst the Sicilian city of Gela had the highest levels of cadmium, and the highest level of PM2.5 when compared to rural Sicily. Elevated levels of PM2.5 were positively associated with the prevalence of doctor diagnosed asthma (odds ratio (OR) 1.05), current asthma (OR 1.06), and use of asthma medication (OR 1.06). All elements in PM2.5 showed increased OR for doctor diagnosed asthma, while higher concentrations of Cd and Mn were associated with higher prevalence of rhinitis.

Mitral annular calcification (MAC) is a common condition of the mitral valve apparatus. A case involving caseous calcification, a rare variant of MAC is presented. This variant which has a benign course can present as an intracardiac mass and needs to be differentiated from more sinister causes of calcified cardiac masses such as tumor, abscess, and infective vegetation. Often, this requires multimodality imaging with echocardiography, computed tomography, and magnetic resonance imaging. Features of caseous calcification of the mitral valve on these imaging modalities are reviewed as the associations and clinical features.

The world-wide use of fireworks with their consequent detrimental effect on the air quality is widely recognized with elevated ambient air levels of particulate matter and its several metallic components and gases identified in several studies carried out during such events. Exposed individuals may be at risk following inhalation of such produced pollutants. This review focuses on the impact of fireworks on air quality and the potential effect of fireworks on the respiratory system of healthy individuals as well as those suffering from underlying respiratory diseases, particularly asthma and chronic obstructive pulmonary disease (COPD). This applies not only to spectators including children but also to pyrotechnicians themselves. An extensive Medline search revealed that a strong evidence of the impact of fireworks on respiratory health is lacking in susceptible as well as healthy individuals with no formal studies on COPD or asthma, other than a few case reports in the latter. The implementation of global strategies to control the use of fireworks and hence improve air quality could possibly reduce their likely detrimental effect on human respiratory health in exposed individuals, but clearly a more targeted research is needed.

Aim: This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma. Subjects and Methods: Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed. Results: A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001). Conclusion: Management of acute asthma in Malta requires optimization in order to compare with international guidelines.

Two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet. One of the patients distinctly recalled the choking episode, whereas the other failed to do so making the diagnosis of aspiration difficult. One of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics. The other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion.

Statins are widely used for primary and secondary prevention of cardiovascular disease. For this reason, knowledge of the side effects and interactions pertaining to this class of pharmaceuticals is of utmost importance to all physicians. In this text a case report is presented of an eighty year old gentleman, referred to the respiratory clinic at Mater Dei Hospital Malta after developing dry cough on being treated with simvastatin and fluvastatin. An attempt at switching over to a placebo was made with resolution of symptoms. This is the second described case in the literature of lone cough associated with statin therapy necessitating treatment discontinuation in our patient. Possible hypothesis are discussed as well as suggestions for further research to unravel the underlying mechanisms of this association.

Introduction: Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients. Objectives: The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients. Method: A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers. Results: 66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively. Conclusions: This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and micro-organisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users.