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The second COVID-19 wave is sweeping the globe as restrictions are lifted. Malta, the 'poster child of Europe's COVID-19 first wave success' also fell victim shortly after it welcomed the first tourists on 1st of July 2020. Only four positive cases were reported over the successive 15 days. Stability was disrupted when two major mass events were organized despite various health professional warnings. In a matter of few just days, daily cases rose to two-digit figures, with high community transmission, a drastic rise in active cases, and a rate per hundred thousand in Europe second only to Spain. Frontliners were swamped with swabbing requests while trying to sustain robust case management, contact tracing and follow-up. Indeed, the number of hospitalizations and the need for intensive ventilation increased. Despite the initial cases were among young adults, within weeks a small spill off on the more elderly population was observed. Restrictions were re-introduced including mandatory mask wearing in specific locations and capping of the total number of people in a single gathering. Malta is an island and the potential for containment would have been relatively simple and effective and permitting mass gatherings was unwise. Protecting the health of the population should take centre stage while carrying out extensive testing, contact tracing and surveillance. Containment and mitigation along with public cooperation is the key to curbing resurgences especially with the influenza season around the corner.

The world continues in the grip of COVID-19 with devastated tourism industries and global economies. In a previous paper, it was noted that a country's failure to dampen a first wave of infection or the recurrence of a second wave would serve as disincentives for greatly needed tourists in summer 2020 and would further significantly reduce tourism revenues and potentially accelerate job losses and bankruptcies in affected countries. Countries in the first wave of infection would need to restrain COVID-19 spread swiftly in order to benefit from summer 2020 tourism. Countries that had controlled COVID-19 and who experienced second waves would manifest the same negative effects. In the case of Malta, up to the beginning of July, the country had the lowest COVID-19 numbers in Europe but this ended abruptly when two mass events took place. In a fortnight, the steep escalation of cases led to a downgrade of the country's status to a high-risk destination, with a host of European countries enacting quarantine measures. The Maltese government re-imposed restrictions and COVID-19 numbers slowly started to temporarily decline. As an economy, Malta is highly dependent on the tourism industry, with approximately 17% of GDP reliant on this sector, directly and indirectly. Malta's red listing wrought a heavy toll on the industry. The World Health Organisation has mandated clear criteria for the release of restrictions and this sequence of events should serve as a cautionary tale: heed the advice of our public health colleagues.

Introduction We present an unusual case of sequential right ventricular outflow tract obstruction (RVOTO) caused by pulmonary and subpulmonary stenosis, with formation of aortopulmonary collaterals. Case presentation We report a case of a 47 year old Senegalese man who presented with a three year history of shortness of breath on exertion which worsened over the past week. Cardiovascular examination revealed a parasternal heave, a systolic murmur loudest in the pulmonary area and no evidence of fluid overload. A transthoracic echocardiogram revealed leftward septal deviation during systole due to right ventricular pressure overload, severe right ventricular hypertrophy (RV free wall end-diastolic thickness of 8mm) and normal systolic function (FAC 47%), a dilated right atrium and moderate tricuspid regurgitation with estimated maximum pressures of 112mmHg. On continuous-wave doppler of the right ventricular outflow tract (RVOT), there was a late peaking systolic flow with maximum velocity of 3.8m/s. A cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) was performed which showed sequential stenoses of the RVOT; one at subvalvular level by an infundibular muscular ridge with an area of 0.7 cm2 in mid-systole and one at the level of a dome-shaped pulmonary valve with planimetered valve area of 0.5cm2, severe RV hypertrophy and normal RV ejection fraction. Aortopulmonary collaterals from proximal thoracic descending aorta were seen. The main pulmonary artery was shown to be dilated with no evidence of pulmonary artery branch stenosis. See image: In-plane phase contrast velocity flow mapping of the RVOT using a VENC of 80cm/s, showing aliasing at the level of the pulmonary valve (red arrow) and at the level of the infundibulum (white arrow). Conclusion Congenital pulmonary stenosis (PS) occurs in 8% of congenital heart defects. 80% of pulmonary valve stenosis is typically dome-shaped with commissural fusion whilst the remainder is of the dysplastic type. Congenital PS can be associated with RVOTO at the infundibular level secondary to reactive muscular hypertrophy. In our case, there is a discrete, circumferential muscular ridge at the level of the infundibulum resulting in sequential outflow tract obstruction. PS with intact ventricular septum occurs in conjunction with varying degrees of right ventricular hypertrophy and elevated right ventricular systolic pressures. A dilated pulmonary artery is common in dome-shaped subtype of PS. Survival into adulthood of severe PS is primarily dependent on the adequacy of pulmonary blood flow from systemic-to-pulmonary collateral arteries, which serve as an additive, or the only source of blood supply to the pulmonary arterial vasculature. These collaterals are usually seen in association with cyanotic congenital heart disease such as pulmonary atresia and tetralogy of fallot. Abstract P1691 Figure. Sequential RVOTO

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-hours PM2.5 indoor/outdoor monitoring. PM2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children

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SARS-CoV-2 incidence and mortality in Europe have shown wide variation. Northern Italy in particular the Lombardy region, north-eastern French regions, Switzerland and Belgium were amongst the hardest hit, while the central and southern Italian regions, all the Balkan countries from Slovenia to Greece and the Islands of Malta and Cyprus had much fewer cases and deaths per capita, and deaths per number of cases. Differences in public health measures, and health care delivery, in the author's opinion, can only partly explain the difference. The geographical distribution of Phlebotomus sand-flies and the relative distribution of arthropod borne diseases Leishmaniasis and Phlebovirus infections especially the Sicilian Sandfly fever group corresponds to most areas of low prevalence of SARS-CoV-2. A hypothesis is proposed whereby repeated arthropod or sandfly vector infection of humans by novel viruses of zoonotic origins carrying bat or mammalian RNA/DNA, such as phleboviruses may have resulted in the development of an effective evolutionary immune response to most novel zoonotic viruses such as SARS-CoV-2 by means of survival of the fittest possibly over many generations. This process probably ran in parallel and concurrent with the progressive evolution of novel coronaviruses which spread from one mammalian species to another. Other possible, but less likely mechanisms for the role of sandfly meals within a much shorter time frame may have led to, (i) previous exposure and infection of humans with the SARS-Cov-2 virus itself, or a closely related corona virus in the previous decades, or (ii) exposure of human populations to parts coronavirus protein namely either S or more likely N protein carried mechanically by arthropods, but without clinical disease causing direct immunity or (iii) by causing infection with other arthropod borne viruses which could carry bat DNA/RNA and have similar functional proteins resulting in an immediate cross-reactive immune response rather than by natural selection. The Evidence possibly supporting or disputing this hypothesis is reviewed, however the major problem with the hypothesis is that to date no coronavirus has ever been isolated from arthropods. Such a hypothesis can only be supported by research investigating the possible biological relationship of arthropods and coronaviruses where paradoxically they may be promoting immunity rather than disease.

Background Understanding positive and negative influences on adult immunization status can help healthcare providers to better identify and target patients who are likely to need immunization. Our aim was to assess and compare influenza and pneumococcal (IV/PV) immunisation rates to identify vaccination predictors in Malta. Method One group consisted of all medical patients discharged from Mater Dei Hospital (MDH) over a one week period in February 2013. Patients were administered a phone questionnaire. A second group of patients receiving community-based care at local health centres over a one week period in March 2013 were interviewed, identifying vaccination eligibility as per 2010 WHO recommendations. Results A total of 150 community (Mean age 61.5 SD 15.8, Male 60%) and 149 hospitalised (Mean age 66.8, SD 13.6%, Male 48.3%) patients in whom influenza vaccine was indicated were recruited. In the current year, 44 and 48.3% received the seasonal influenza vaccine, while 32.0, and 49% vaccinated yearly respectively. Pneumococcal vaccination advice was less than 5% in both groups. On stepwise binary regression, vaccination predictors for the current year were regular yearly influenza vaccination (OR 93.62, CI: 31.8–275.5, p

The increasing mobility of patients and healthcare professionals across the countries of Europe has highlighted the wide variations in both medical training, and provision of medical competency and skills. The maintenance of the standards defining competency and skills have national and international implications and have proved challenging for national regulatory bodies. Thus each nation has introduced different types of Continuing Professional Development (CPD), recertification and relicensing systems. At the Symposium entitled: “ ‘Certified … now what?’ On the Challenges of Lifelong Learning” in August 2017 at the Association for Medical Education in Europe (AMEE) annual conference, we reviewed differing European national relicensing systems were reviewed. The review highlighted various lifelong learning and competence assessment approaches using examples from different medical specialties across several European countries.

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM

Introduction: Exposure to airborne allergens was associated to increasing exacerbation of respiratory symptoms and airways inflammation. Fractional exhaled nitric oxide (FeNO) is a non-invasive met...

Background: Correct inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients. Methods: Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical. Results: 23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63–8.54, p = 0.001), male gender 2.70(1.35–5.39, p = 0.004), self-score 1–10 1.21(1.05–1.39, p = 0.007), spacer use 0.38(0.19–0.79, p = 0.007), inhaled steroid 3.71(1.34–10.25, p = 0.01), heart disease 0.31(0.13–0.77, p = 0.01), pneumococcal vaccine 2.48(1.0–6.15, p = 0.043), education level 1–4 1.44(1.00–2.06, p = 0.05) and respiratory physician explained 0–7 times, 1.11(0.99–1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0–4, were: technique self-score 1–10 1.2(1.05–1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1–7.31, p = 0.03) and education level 1–4 1.41(1.02–1.95, p = 0.03 Times respiratory physician explained inhaler technique 0–7 1.1(0.98–1.24, p = 0.1), married status 1.55(0.85–2.82, p= 0.15), hypercholesterolaemia 0.52(0.25–1.01, p = 0.054) and male gender 1.76(0.97–3.18, p = 0.06). Conclusions: Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients’ self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error., peer-reviewed

Introduction. E-learning is a useful tool providing after-hours access to continuous Medical Education and the theoretical component of postgraduate medical trainings. Furthermore, it allows accurate recording of trainee activity. Objective. To observe the pattern of usage by trainees and to assess feedback on e-learning use. Method. A modular object-oriented dynamic learning environment (Moodle) online e-learning management system – including 24 online modules relevant to different medical specialities and 24 quizzes. All 23 (14 Female) medical ‘Commontrunk’ trainees at Mater Dei Hospital, Malta were asked to complete these modules as part of their compulsory academic activities within a 6-week deadline. Data on usage was collected by the learning management system and trainees were asked to fi ll in an online feedback form. Results. All trainees (n=23) completed all modules; however, 36.1% of modules (M=49.8%, F=27.4%) were completed in the last week. Nineteen (n=21) trainees found the e-learning as a useful or very useful tool. 19/21 Students reported presentations as being of good/high quality and 13/21 reported quizzes to be of a good/high quality standard. Selfrating of acquisition of new knowledge was 7.95 (SD 1.75) on a scale of 0–10. The quality of IT work was rated 7.81 (SD 1.86). Forty-three percent (M 36.6%, F 47.0%) of modules were completed from 16:00 hours to 19:59 hours; 16.5% (M=29.3%, F=16.5%); from 20:00 hours to 23:59 hours and 4.5% (M=8.2%, F=2.2%) from 00:00 hours to 03:59 hours. A total of 31.2% of modules were performed during weekends (Sat=13.6%, Sun=17.6%, Average Mon–Fri=13.8%). Average time to complete learning module: F=49.7 minutes, M=76.4 minutes. Conclusion. Overall feedback on e-learning was positive. There was signifi cant after hour and weekend use. Gender diff erences in time of access and total time needed to complete modules were noted. Keywords: Moodle, Online E-Learning, “common trunk” trainees, feedback, medicine (Published: 29 June 2012) DOI: 10.3109/21614083.2012.699440

Intro: Simulation of a real life scenario of an acute ill patient was held for doctors in the foundation year at Mater Dei hospital Malta, using a Gaumard® manikin and simulator equipment with two tutors , in a purpose built facility. Aim: To assess participant response to the simulation sessions. Method: Feedback using a short questionnaire on the simulation was sought from 120 (M=55%) participants. A 1-10 scale was used where 5 was neutral, positive responses higher, and negative lower. Results: Participants were asked if the simulation was “useful” scored 7.8/10 (95%CI 7.4-8.0), and rated “the overall experience” at 7.49 (7.23-7.75) while whether it resulted in a change in “daily practice” at 5.82 (5.4-6.25). The score for the tutor “creating a satisfactory learning environment” was 7.8(7.6-8.1), and 7.7 (7.4-8.0) for “quality of simulator equipment”. Asked how “close was the simulation to real life scenario” 6.2/10 (5.9-6.6). Asked whether the presence of colleagues hindered or helped 50 (41.7%) were neutral, 36 (30%) said it hindered, while only 21 (28.3%) felt it helped. On the contrary how helpful it is to observe colleagues 5(4.2%) stated it was not, 21(17.5%) neutral, and 94(78.33%) useful. Asked on how likely 1-10 was participation in a future voluntary event 7.4(7.0-7.8), with 7 (7.6%) saying it was unlikely, 16(13.4%) maybe, and 94(79%) saying it was likely. Trainees recommended a Median of 3 per year (IQR 2-5). Conclusion: Trainees rated the sessions as useful, and a majority asked for more frequent sessions. However they felt that simulation of reality and effect on daily practice was limited. Rating for equipment and tutors was positive. Most were comfortable observing others and uncomfortable being observed.

Intro: The use of inhalers or other devices is dependent on proper technique. Aim: To evaluate Asthma and COPD patients and determine factors that predict proper inhaler use. Methods: 167 patients (Male 45%, Mean age 57.6, std 15.3 years) were recruited both from hospital outpatients and from the community. Patients had to be on regular inhalers. 41.3% were under the care of a respiratory physician, 25.7% GP, 19.8% both, and 13.2% none. A questionnaire was filled by the patient followed by direct observation of inhaler technique. Results: Self-rating of inhaler technique 0-10 mean 7.91, sd 2.06, with 80.1% >=7/10. 67.7% said use of inhaler was easy or very easy, 93.4% said inhalers were effective or very effective. 164 patients used MDIs, of which 119 utilized a spacer. 32(19.2%) used formoterol aerolizer, and 8 (4.8%) used a turbohaler. MDI use was analysed in 12 steps, and 13 with spacer. Mean score was 82.9% (95%CI 80.7-85.1). Paired T test and Mann whitney test comparing with self rating (p=0.45,0.24). Spearman Correlation p=-0.021. Predictors for score >=80%: demo by other health worker OR 4.39(1.62-11.94,p=0.002), Male Gender 4.13(1.75-9.8 p=0.0001), Influenza vaccine ever 3.7(1.17-11.8, p=0.023), Education level 1-4 1.79(1.15-2.77, p=0.006), number of times explained by doctor 0-4 1.43(1.0-2.47, p=0.048), years of use in decades 1.29(0.98-1.67,p=0.058), self-score 1-10 1.28(1.05-1.56, p=0.012), Use of reliever 0-4 0.74(0.56-0.99, p=0.041), Heart disease 0.25(0.09-0.75, p=0.011). Conclusion: Patients' self-rating, repeated physician demos, health professional demos, longer duration of use, education level and male gender and lower reliever use predicted good technique in a group with high percentage of good technique., N/A

Intro: RESPIRA (EU Funded - Italia-Malta 07-13) indicated that living in Malta is a risk factor for asthma. Aim: To determine the chemical profile of PM2.5 in Malta, and compare with reference values. Methods: Using FAI pumps at 10l/min/48hr, samples were collected on Teflon and Quartz filters from 6 schools and 46 homes in Malta. Total ICP-MS measurement (Residual+extracted), X ray Fluorescence, and thermo-optical methods(TO) were used for analysis by CNR in Rome. Aeroqual IQM60 counters were used for total PM2.5 mass. All data in ng/m3, Mean, (1st to 3rd quartile) of all 48 hour measurements., N/A

The seasonality of asthma exacerbations may reflect varying exposure to triggers. This study retrospectively analyzes the seasonality of asthma hospital admissions, at all ages, in a population-based study. Analysis of the seasonality of asthma admissions and correlation with temperature was carried out in the setting of a regional hospital covering all acute asthma admissions in an island population. Admissions were divided into pediatric (1994-8) and adult (1989-8) cases. Both pediatric (0-14 years; n = 2916) and adult (15-59 years; n = 1269) admissions showed a peak in January and a trough in August. The seasonality in pediatric admissions was far more pronounced than in adults. Both cohorts exhibited a second, smaller peak in spring. In school-aged children, the end of school in June was associated with a sharp (91%) drop in admissions, and restarting school in October was associated with an even sharper rise (165%). A negative correlation was found between admissions and mean monthly ambient temperatures, and this was most pronounced in the pediatric age groups. This marked seasonality may indicate that temperature is a proxy for the total time spent indoors. Both the start and end of school had a profound impact on pediatric admission rates. Prospective studies are necessary to establish the role of viral infections and the influence of indoor and outdoor aeroallergens on the seasonality of hospitalization rates for asthma in the local setting.

Introduction: e-Learning has been shown to be an effective and useful tool in medical education. An e-learning project was part financed through EU funds project ESF1.19 (Malta). Objective: To assess if medical students using e-learning are in front of the screen while using the e-lectures. Method: Eighty-seven finalyear medical students were encouraged to complete an online respiratory course (13 streamed lectures+13 quizzes) on a voluntary basis and were offered a reward on completion. A moodle e-learning management system collected data regarding user activity, in particular the duration of participation. A group of 14 core medical trainees who were forewarned of detection of possible irregular activity was also observed as a reference group. Results: Forty-three medical students completed all modules. Six lectures with corresponding quizzes were analysed; 65.5% (male 66.7%, female 64.1%) of the lectures were completed within the expected time frame; in 19% of lectures, users logged in for a period of 5 minutes less than the duration of the lecture, while 14.7% of users logged in for a duration that was twice as long as the total duration of the lecture. Only 16.3% of students completed all lectures within the established period; 27.9%, 20.9%, and 18.6% missed one, two, and three, lectures respectively; and 16.3% missed more than four lectures. In the other group (the 14 forewarned core medical trainees), 65 modules amongst 12 trainees showed that trainees completed a module in a mean of 113.25% (95% confidence interval 109.72–116.78) of the actual duration of a lecture. Conclusion: The study indicates that in 83.7% of the cases, there was at least one instance per user during which the user was not physically present throughout the presentation of a lecture. The e-learning management systems should be robust so as to detect this kind of behaviour before certification. Keywords: e-learning, web-based learning, undergraduate medical education, learning management system (Published: 23 October 2013) Citation: Journal of European CME 2013, 2 : 22826 - http://dx.doi.org/10.3402/jecme.v2i0.22826

Inhaled corticosteroids have been shown to reduce morbidity and the need for hospitalization from asthma. Despite improvements in the therapy of asthma, epidemiologic data from several countries has shown that the hospital admission rates for asthma among adults at a population level are on the increase. The prevalence rate of hospital admission for asthma among Maltese adults aged 15–59 years was determined retrospectively from 1989 to 1993. Concurrent yearly total dispensal of inhaled corticosteroids for the whole population was also calculated. This study was undertaken amongst a well-defined island population served by a single medical facility offering emergency services, and a possible association between these two trends was investigated by means of logistic regression. The age-specific hospital admission rates for asthma decreased from 96.2 (95% CI: 109·7, 82·7) per 100 000 in 1989 to 38·1 (95% CI: 46·4, 29·8) per 100 000 in 1993. The prevalence rates of admission from asthma decreased from 67·6 (95% CI: 78·9, 56·3) per 100 000 in 1989 to 30·6 (95% CI: 38·0, 23·2) per 100 000 in 1993. The dispensal of inhaled beclomethasone dipropionate (BDP) increased from 0·99 defined daily dose (DDD) per 1000 population in 1989 to 3·28 DDD per 1000 in 1993. Logistic regression showed that increasing dispensal of inhaled BDP by 1 DDD per 1000 decreased the odds of an admission from asthma to 0·71 (95% CI: 0·65, 0·78) times their previous value. Similarly, the odds of an individual being hospitalized because of asthma decreased to 0·75 (95% CI: 0·67, 0·83) times their previous value. This study concludes that there was a progressive decrease in hospital admission rates for asthma in adults, and this trend correlates well with increasing use of inhaled corticosteroids at a community level. This must, however, be interpreted with care in light of the fact that increase in utilization of anti-inflammatory therapy probably also reflected improved general and widespread care for asthma.

Background: Guidelines advise annual influenza vaccination in chronic asthma. The aim of this study was to determine uptake of the influenza vaccine in a group of patients (n = 146) with moderate to severe chronic asthma and establish the main predictors of vaccination. Method: Patients attending a hospital asthma clinic were asked to complete a questionnaire in February 2012 (n = 146). These same patients were contacted a year later via telephone (n = 109 responded), and they were asked to complete the same questionnaire. Results: Vaccination rate was 50.3% in winter 2011/12, and 57.8% in 2012/13. Using binary logistic regression, the predictors for vaccination in 2012 were patient advice (Odds ratio [OR] 15.37 p = 0.001), female gender (OR 2.75, p = 0.028), past side effects (OR 0.21, p = 0.001) and comorbidity (OR 0.39, p = 0.013). Stepwise regression resulted in age as predictor (T value = 3.99, p = 0.001). On analyzing the responses from the second questionnaire at one year after attendance to asthma clinic, predictors changed to compliance to medication (OR 9.52, p= 0.001) and previous exacerbations (OR 4.19, p = 0.026). Out of the 56 patients vaccinated in 2011/12, 33 reported asthma exacerbations before 2012, and 29 reported asthma exacerbations after receiving the influenza vaccine. Out of the 46 unvaccinated patients in 2012, 27 had asthma exacerbations before 2012 and 19 patients had exacerbations in 2013. Patients vaccinated in 2011/12 needed 0.59 courses of steroid/patient/year, and 1.23 visits for nebulizer/patient/year while non-vaccinated patients needed 0.18 courses of steroids/patient/year (p = 0.048), and 0.65 visits for nebulized/patient/year (p = 0.012). Patients’ subjective statements broadly confirmed the predictors. 16/69 (23.1%) received the vaccine in winter 2012/13 despite reporting previous side effects. Conclusions: Advice to patient, female gender and patients’ age predicted vaccination, while past side effects to the influenza vaccine, and presence of comorbidities predicted non vaccination. Symptomatic asthma patients are more likely to be vaccinated. One year after the first contact, treatment compliance and previous asthma exacerbations gained statistical significance as predictors of vaccination., peer-reviewed

Monique Cachia,1 Michael Pace-Bardon,2 Gabriella Balzan,2 Russel Tilney,2 Josef Micallef,2 Martin Balzan2 1Department of Medicine, 2Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta Background: A study evaluating subjective trainee responses to simulation training organized by the Malta Foundation Program in particular whether this changed their clinical practice. Method: Feedback using a standardized questionnaire was obtained from 120 (M=55%) participants. A 0–10 Likert scale was used to evaluate responses. Results: Participants scored the simulation sessions as “useful” at 7.7 (95% confidence interval [CI] 7.4–8.0), rated “the overall experience” at 7.5 (95% CI 7.2–7.8), and thought it made a change in “daily practice” at 5.83 (95% CI 5.4–6.3). The score for the tutor “creating a satisfactory learning environment” and “quality of simulator equipment” was 7.8 (95% CI 7.6–8.1) and 7.7 (95% CI 7.4–8), respectively. Trainees rated “how close was the simulation to a real-life scenario” as 6.24 (95% CI 5.9–6.6). When asked whether the presence of colleagues hindered or helped, the majority were neutral 50 (41.7%), 36 (30%) said it hindered, while only 21 (28.3%) felt it helped. In contrast, 94 (78.33%) stated it was useful to observe colleagues while only 5 (4.2%) stated it was not. Likelihood for future participation was 7.4 (95% CI 7–7.8). Trainees recommended a median of 3 (interquartile range 2–5) simulations per year. Conclusion: Trainees rated the sessions as useful and asked for more sessions possibly at an undergraduate level. Rating for equipment and tutors was positive; however, some felt that the effect on daily practice was limited. Most were comfortable observing others and uncomfortable being observed. The value of increasing sessions to 3–4 per year, timing them before clinical attachments and audiovisual prebriefing for candidates naïve to simulation needs to be evaluated in future studies. Keywords: simulation, foundation, training, acute, medical, mannequin

Summary Inhalation of small amounts of carbon monoxide diminishes the pain threshold in patients with stable angina pectoris. The aim of this study was to identify and describe patients who had been exposed unknowingly to toxic inhalations of this gas and subsequently presented to hospital with a clinical picture of unstable angina. Blood carboxyhaemoglobin levels of 104 patients referred with unstable angina to a coronary care unit were determined on admission. The likely source of carbon monoxide was identified in all patients. Three patients had definite carbon monoxide intoxication. Another five patients had evidence of minor exposure. When the three cases with carbon monoxide poisoning were excluded, the mean carboxyhaemoglobin level was 2.5% (+/- 1.3) for smokers (n = 30) and 0.6% (+/- 0.5) for non-smokers (n = 71). Use of fossil fuel combustion in an enclosed environment was responsible for the three most serious intoxications and one of the minor cases. We suggest that a number of patients admitted for coronary care with unstable angina may have significant carbon monoxide poisoning. This intoxication is often overlooked by attending physicians with the result that high concentration oxygen therapy is not administered, when it is in fact a necessary part of treatment.

Summary A 65 year old patient admitted with carbon monoxide poisoning developed acute pulmonary oedema during treatment with hyperbaric oxygen. After initial recovery he developed extensive intestinal ischaemia which rapidly led to death. It is suggested that intestinal vasoconstriction due to left ventricular failure made the gut much more vulnerable to the hypoxic effects of carbon monoxide than the brain and heart.