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Objective Dyspnoea is the hallmark progressive symptom in interstitial lung disease (ILD). Breathing retraining in chronic obstructive pulmonary disease (COPD) improves dyspnoea and walking distance (Garrod et al. 2005) but there is a dearth of evidence for ILD. This study aimed to identify whether breathing retraining incorporated during pulmonary rehabilitation (PR), leads to better dyspnoea and functional scores. Design 27 patients with ILD were randomly distributed to a control group (CG) who underwent a 12-week hospital-based PR programme or experimental group (EG), receiving PR with breathing retraining. The 6-minute walk test and dyspnoea scores were assessed at baseline and on completion. Results Statistical improvements in walking distance were recorded in the EG median 416.25; (IQR 368–463) week 0 to 475m (IQR 437–521) week 12; p = 0.017 and dyspnoea post exertion (median 3.00; IQR 1–5) week 0 to 2.50 (IQR 0.3–4) week 12; p = 0.033). The CG obtained a less, but statistically significant improvement 360m (IQR 330–405) week 0 to 412.50m (IQR 394–450) week 12 (p = 0.003). When comparing outcomes at week 12 between groups, superior results in dyspnoea at rest (EG 0 (IQR 0–0); CG 2 (IQR 0–2); p = 0.029), and walking distances (EG 475m (IQR 437–521); CG 412.50 (IQR 394–450; p = 0.015) were recorded for the EG. Conclusion Breathing retraining added to PR, resulted in improvements in dyspnoea scores and functional capacity in patients with ILD.

INTRODUCTION SARS-CoV-2 was identified as the causative agent of the COVID-19 pandemic, which has been the focus of extensive research for over a year. Asthmatics were listed as a high-risk group for susceptibility to SARSCoV-2. Several hypotheses have been proposed regarding protective factors in asthmatics, amongst which were the role of biological agents. One such agent is omalizumab, an IgE inhibitor, which is currently the only biological agent available in Malta for the treatment of severe asthma. METHODS This study aims to evaluate the symptomatology and disease course of SARS-CoV-2 in our cohort of severe asthmatic patients on omalizumab that contracted COVID-19. Molecular diagnostic tests (SARSCoV-2 PCR tests taken, if any, and the PCR result) since March 2020 of all adult patients receiving omalizumab for severe allergic asthma in January 2021, were reviewed from I-soft Clinical Manager (R). Demographic data were collected for those patients who were found to be positive. RESULTS Our cohort included 58 patients, of whom 43 had PCR tests. Of these, 7 patients (12%) tested positive during the study period. Results show a male predominance in the cohort, with fever being the commonest symptom, and a mortality of only 1 patient out of 7. CONCLUSIONS From the small number of our severe asthmatic patients infected with SARS-CoV-2 whilst receiving omalizumab, the majority had only mild symptoms, with minimal effect on asthma-related symptoms and hospitalizations, apart from mortality in one patient.

Background: An association between obstructive sleep apnoea(OSA) and allergic rhinitis(AR), both common conditions with increasing prevalence worldwide, is frequently reported. Aim: To assess the acceptability, feasibility and usefulness of routinely performing allergy testing in patients with suspected OSA. Methodology: Consecutive adult patients referred to an adult sleep clinic over a 10-week period were included. The first visit included a medical history and 36-item Short Form Health Survey for all patients and RQLQ, total-4-nasal symptom score and VAS in patients with AR, physical examination and skin prick testing for common aeroallergens. Patients with uncontrolled AR were prescribed treatment. The sleep study report was reviewed. Results: Our cohort included 95 patients-34.7% were sensitised and diagnosed with AR. The most common perennial aeroallergens were Dermatophagoides pteronyssinus(86.1%) and farinae(75%) and seasonal aeroallergens, tree(19%) and grass pollen(19%). When comparing allergic and non-allergic groups, the former patients were younger(p=0.002), more likely female(p=0.06) and asthmatic(p=0.014), and suffered rhinorrhoea(p=0.02) or other rhino-conjunctivitis symptoms (p Conclusion: Skin prick testing is acceptable, safe and feasible, useful mainly in younger females, asthmatics and those with AR symptoms. Diagnosing AR in patients in whom symptoms may have been mistaken for OSA and in patients with co-existing OSA will improve morbidity and quality of life.

Background/Aims Pulmonary rehabilitation is known to facilitate improvements in chronic obstructive pulmonary disease symptoms, exercise tolerance and quality of life. Despite this, there is no consensus on the ideal programme intensity. This article aims to explore and compare the benefits of a high intensity and low intensity pulmonary rehabilitation programme., Methods A total of 30 patients with a diagnosis of chronic obstructive pulmonary disease were randomly and blindly allocated to either a high intensity or low intensity 12-week pulmonary rehabilitation programme., Results Significant improvements in functional and health-related quality of life measures were obtained in both groups. Most of the significant changes for the high intensity group were achieved by week 8. The low intensity group required a further 4 weeks of rehabilitation in order to reach a significant difference., Conclusions Results show that both low and high intensity pulmonary rehabilitation programmes were beneficial. However, the high intensity programme was more efficient in achieving these improvements than the low intensity group., peer-reviewed

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., peer-reviewed

Background Although there are many asymptomatic patients, one of the problems of COVID-19 is early recognition of the disease. COVID-19 symptoms are polymorphic and may include upper respiratory symptoms. However, COVID-19 symptoms may be mistaken with the common cold or allergic rhinitis. An ARIA-EAACI study group attempted to differentiate upper respiratory symptoms between the three diseases. Methods A modified Delphi process was used. The ARIA members who were seeing COVID-19 patients were asked to fill in a questionnaire on the upper airway symptoms of COVID-19, common cold and allergic rhinitis. Results Among the 192 ARIA members who were invited to respond to the questionnaire, 89 responded and 87 questionnaires were analysed. The consensus was then reported. A two-way ANOVA revealed significant differences in the symptom intensity between the three diseases (p < .001). Conclusions This modified Delphi approach enabled the differentiation of upper respiratory symptoms between COVID-19, the common cold and allergic rhinitis. An electronic algorithm will be devised using the questionnaire.

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPARγ:Peroxisome proliferator-activated receptor, NFκB: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2α:Elongation initiation factor 2α). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT1R axis (AT1R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity.

Background Most patients with malignant pleural mesothelioma (MPM) seek treatment with malignant pleural effusion (MPE). In vitro evidence suggests that MPE may not be a simple bystander of malignancy, but rather potentially has biological properties that improve cancer cell survival and promote cancer progression. If this is the case, MPE management may need to shift from current symptomatic strategies to aggressive fluid removal to impact survival. Research Question Is there an association between pleural fluid exposure and survival in MPM? Study Design and Methods Data from 761 patients who received a diagnosis of MPM between 2008 and 2018 were collected from patient medical records in three UK pleural units. Data included factors previously identified as influencing prognosis in MPM. Medical imaging was reviewed for presence, size, and duration of pleural effusion. Time-dependent covariate analysis of pleural fluid exposure and survival (model included weight loss, serum albumin, hemoglobin, MPM subtype, performance status, chemotherapy, and age) and multivariate Cox regression analysis of pleurodesis and survival were conducted. Results Median overall survival was 278 days (interquartile range, 127-505 days; 95% CI, 253-301 days). Pleural fluid exposure duration showed no association with survival (hazard ratio, 1.0; 95% CI, 1.0-1.0). Median survival was 473, 378, and 258 days with complete, partial, and no pleurodesis (P = .008). Interpretation Pleurodesis success seems to be associated with improved survival; however, it is unclear whether duration of MPM exposure to pleural fluid is associated with survival within the limitations of this retrospective study. Future prospective studies are required to assess this potentially important mechanism.

Malignant pleural mesothelioma(MPM) presents with malignant pleural effusion(MPE) in most patients. There is pre-clinical evidence that MPE may not be a simple bystander of malignancy,but potentially has biological properties increasing cancer cell proliferation.If this is the case,management of MPE may need to shift from current symptomatic strategies to aggressive fluid removal to impact on survival. Aim: to analyse the association of pleural fluid exposure(duration of effusion,& pleurodesis success)with survival in MPM. Method:Data on 761 patients diagnosed with MPM between 2008-2018 was collected from patients’ medical records in 3 UK pleural units.The medical images were reviewed for presence,size & duration of pleural effusion in order to analyse pleural fluid exposure(total number of days pleural effusion was present overall) & pleurodesis effects. Results: The median overall survival was 278 days(IQR 378).Median survival: 473,378,258 days (p 0.0006) with complete, partial,& no pleurodesis respectively.With time-dependent analysis,pleurodesis success remained a significant influencing factor on survival (p 0.002). There was no association between pleural fluid exposure time & survival (p 0.2) with time-dependent covariate analysis(model included serum albumin,MPM subtype,performance status,presence of symptoms at diagnosis,chemotherapy received). Conclusion: Pleurodesis success is associated with improved survival,however given the limitations of this retrospective study,it is unclear whether duration of MPM exposure to pleural fluid correlates with survival.Future prospective studies are required to assess this potentially important mechanism.

School children may be exposed to secondhand smoke (SHS) either at home, in transit or in social gatherings permitting smoking in their presence. Questionnaires about SHS often underestimate prevalence and extent of exposure. A more accurate tool is the use of biomarkers such as cotinine (COT) and trans-3'-hydrocycotinine (3HC) as biomarkers of SHS exposure, alongside 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a reduction product in the body of the tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), both potent carcinogens. We measured urinary COT, 3HC and total NNAL using sensitive and specific high-performance LC-MS/MS methods. The limit of quantification (LOQ) for each assay were 0.05ng/mL, 0.1ng/mL and 0.25pg/mL respectively. The aim of this study was to evaluate the exposure to SHS of school children (9-11 years), from five public schools in the island of Malta, from questionnaire information about smoking at home and verify it by urinary biomarker data of COT, 3HC and NNAL. These biomarkers were measurable in 99.4%, 95.4% and 98.3% of the participating children respectively. From the children reporting smoking at home, 11% had a history of asthma and had COT, 3HC and NNAL geometric mean concentrations double compared to the non-asthmatic group. In has been confirmed that non-smokers exposed to SHS and THS have a higher NNAL/COT ratio than the group identified as smokers according to specific and defined COT threshold levels (despite the fact that a priori, the entire study group was composed of non-smokers). The implication of high measured levels of urinary NNAL in children should be of concern given its potency. A main effects multifactor ANOVA model was developed and the children's house and school locations and the smoking frequency were statistically significant to predict the levels of the three metabolites. For 3HC only, the status of the employment of the mother was also an important predictor.

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

Purpose: Pulmonary rehabilitation is known to lead to improvements in exercise tolerance, health-related quality of life and help reduce symptoms. Exercise, one of the largest components of such an intervention, although of great benefit, can increase the inflammatory response related to chronic obstructive pulmonary disease, depending on intensity and duration. Through this study, the effects of a 12week, high-intensity PR programme on COPD inflammatory-related markers were investigated. Materials and methods: This study is a longitudinal, observational type of study. Sixty COPD patients were enrolled, 49 of which completed the programme. A 2-h high-intensity PR programme was delivered, twice weekly for 12 weeks. The following markers were assessed at baseline, 4, 8 and 12 weeks through rehabilitation – C-reactive protein, erythrocyte sedimentation rate, neutrophil, eosinophil counts, complete blood count, six-minute walk test and St. George’s Respiratory Questionnaire. Serum amyloid A levels were assessed at baseline, week 8 and 12 and exhaled NO at baseline and upon completion of the programme. Results: This 12-week PR programme resulted in no changes in the inflammatory markers but resulted in significant improvements in both the 6MW distance and health quality of life. Conclusions: Beneficial effects on functional and HRQoL measures resulted, which, however, appear unrelated to changes in the systemic inflammatory markers., peer-reviewed

Substantial knowledge is available on the association of the indoor school environment and its effect among schoolchildren. In the same context, the SINPHONIE (School indoor pollution and health: Observatory network in Europe) conducted a study to collect data and determine the distribution of several indoor air pollutants (IAPs), physical and thermal parameters and their association with eye, skin, upper-, lower respiratory and systemic disorder symptoms during the previous three months. Finally, data from 115 schools in 54 European cities from 23 countries were collected and included 5175 schoolchildren using a harmonized and standardized protocol. The association between exposures and the health outcomes were examined using logistic regression models on the environmental stressors assessed in classroom while adjusting for several confounding factors; a VOC (volatile organic compound) score defined as the sum of the number of pollutants to which the children were highly exposed (concentration > median of the distribution) in classroom was also introduced to evaluate the mul tiexposu re - outcome association. Schoolchildren while adjusting for several confounding factors. Schoolchildren exposed to above or equal median concentration of PM2.5, benzene, limonene, ozone and radon were at significantly higher odds of suffering from upper, lower airways, eye and systemic disorders. Increased odds were also observed for any symptom (sick school syndrome) among schoolchildren exposed to concentrations of limonene and ozone above median values. Furthermore, the risks for upper and lower airways and systemic disorders significantly increased with the VOCs score. Results also showed that increased ventilation rate was significantly associated with decreased odds of suffering from eye and skin disorders whereas similar association was observed between temperature and upper airways symptoms. The present study provides evidence that exposure to IAPs in schools is associated with various health problems in children. Further investigations are needed to confirm our findings. (C) 2020 Elsevier B.V. All rights reserved.

EBUS-TBNA at Mater Dei Hospital (MDH), which serves a population of about 432000, was audited over a 2 year period. Our aim was to assess results obtained and factors associated with improved diagnostic yield. All patients who underwent EBUS-TBNA at MDH were included and data was collected retrospectively. 71 EBUS TBNA procedures were performed on 70 patients. Sensitivity for malignancy was 93% (40/43) and sensitivity for granulomatous disease was 72% (16/22). The overall diagnostic sensitivity was 84.5% (60/71). Sampling multiple stations as opposed to a single station was associated with a better histology diagnostic yield (90.3% vs 60% p=0.004) as well as a better yield on cytology (83.9% vs 50% p=0.003). It also led to an improved overall combined diagnostic yield (93.5% vs 77.5%) although this narrowly missed statistical significance (p=0.06). Targeting multiple stations also correlated with obtaining an adequate histology sample (96.8% vs 82.5% p=0.05). This effect was even more pronounced for granulomatous disease with improved diagnostic histology yield (100% vs 43.8% p=0.005) diagnostic cytology yield (89% vs 25% p=0.002) and overall combined diagnostic yield (100% vs 62.5% p=0.035) Increasing lesion size was predictive of obtaining an adequate tissue sample (p=0.03) histology diagnostic yield (p=0.05) and overall diagnostic yield (p=0.04) but there was no correlation between lesion size and yield on cytology (p=0.389). Sampling multiple stations and targeting larger lesions led to an improved diagnostic yield; the effect of targeting multiple stations was even more pronounced in granulomatous disease.

Treatment satisfaction is of utmost importance for ensuring adherence. Omalizumab is administered long-term if effective and well-tolerated in a hospital setting. The aim was to evaluate treatment satisfaction with omalizumab in Malta and to identify factors that may influence patients’ satisfaction. A questionnaire was distributed to all asthmatic adult patients receiving omalizumab for at least one year. The questionnaire included demographic data, dosing regimen, asthma control test and the 14-item English version of the Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4. The TSQM 1.4 domain scores range from 0 to 100. Higher scores represent higher satisfaction. Our cohort included 33 patients (52% males), mean age 53.7 ± 11 years, mean baseline IgE level 510.6IU/ml, mean duration of treatment 3.8 ± 1.98 years and mean number of injections per month 4.6 ± 2.6. Median TSQM scores were as follows: graded effectiveness 78%, graded side effects 100%, graded convenience 74.2% and overall satisfaction 76%. Regression analysis showed that convenience score, effectiveness score and ACT score were significantly associated with global satisfaction. Global satisfaction scored high among the Maltese cohort of patients despite the inconvenience and side effects associated with receiving omalizumab. This is an add-on beneficial effect to the efficacy and effectiveness already been achieved with this medication.

A 62-year-old woman presented with a 3-month history of shortness of breath on exertion and dry cough. On examination, she was noted to have fine end-inspiratory crepitations over the upper zone of the lungs. Pulmonary function tests (PFTs) showed a restrictive defect. Initial chest radiography revealed diffuse reticular interstitial shadowing while high-resolution CT scan of the thorax showed fibrotic changes. Avian precipitins were also highly positive for pigeons, parrots and budgerigars. Taking into account these results, the patient was diagnosed with hypersensitivity pneumonitis. Antigen avoidance, oral glucocorticoids and azathioprine achieved an initial improvement in PFTs and symptoms; however, the patient still deteriorated, requiring long-term oxygen therapy. While working the patient up for lung transplantation, rituximab was given to good effect (acting as a bridging therapy) as it achieved symptomatic relief and stabilisation of her PFTs.

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., peer-reviewed

Systemic to pulmonary fistulas are an unusual entity, even more so in association with Hodgkin’s lymphoma. We herein report a case of a 33-year-old woman that presented with an incidental lung lesion on a chest radiograph with an associated high-frequency continuous murmur over the lesion. The diagnosis of primary pulmonary Hodgkin’s lymphoma, nodular sclerosis type, was obtained by a CT transthoracic biopsy. We achieved an excellent response after polychemotherapy with near-complete disappearance of the mass and a residual faint systolic murmur over the lesion.

Background: It was previously reported that there is a positive correlation between incidence of type 1 diabetes and prevalence of asthma and atopic eczema. A negative correlation between the prevalence of type 1 diabetes and mortality from infectious diseases as well as a positive correlation with antibiotic susceptibility at a country level have also been reported. Objective: The aim of this study was to investigate the association between country prevalence of rhinitis, atopic eczema, rhinoconjunctivitis, and wheezing with mortality from infectious diseases and also with antibiotic susceptibility at a country level. Methods: Data for prevalence of rhinitis, eczema, rhinoconjunctivitis, and wheezing was obtained from the International Study of Asthma and Allergies in Childhood study (ISAAC). ISAAC Phase one was a multicentre multicountry cross sectional study involving over 700,000 children in 2 age groups of school children, 13–14 years old (adolescents) and 6–7 years old (children) in 156 centres from 56 countries. Mortality from infectious diseases was taken from World Health Organisation data. The Alexander project was used to identify antibiotic susceptibilities to common bacteria. Results: There were significant positive correlations between atopic eczema and mortality from all infectious diseases studied, diarrhoeal illness, tropical infections, and childhood infections. A negative correlation exists between the prevalence of rhinitis and Streptococcus pneumoniae susceptibility to penicillin and to erythromycin, rhinitis and Haemophilus influenzae susceptibility to ampicillin and between rhinoconjunctivitis and H. influenzae susceptibility to ampicillin. Conclusion: Th1/Th2 responses might influence the pathogenesis of infectious disease mortality, while antibiotic overprescription could explain the negative association between atopy and antibiotic susceptibility., peer-reviewed

Background: The prevalence of allergic conditions is increasing in most countries. One possible explanation may be childhood nutrition. Objective: The aim of the study was to investigate the relationship between consumption of pre-specified types of food in school-aged children and presence of respiratory and allergic symptoms. Methods: A total of 191 students aged 9–11 years were recruited from 5 schools to geographically cover all of Malta. Data was collected between October 2011 and February 2012. This was part of a bigger study which included clinical and environmental tests besides standardized health questionnaires. For the purposes of this part of the study only the health questionnaires were used. These standardized health questionnaires based on the International Study of Asthma and Allergies in Childhood (ISAAC) were used to identify the presence of respiratory and allergic symptoms and to identify the types of foods and the frequency of consumption of various types of foods. Results: We found that milk, meat, butter, olive oil, and yoghurt consumption had a negative association with allergic symptoms in children, whilst fish consumption had a detrimental effect. These relationships remained significant after correction for paternal level of education. Conclusion: The study highlights the fact that nutrition in early childhood may have a significant effect on the risk of allergic conditions. Our results, taken together with data in the literature, suggest that different types of fish might have had different effects. This is probably related to their different fatty acid constitution thus warranting further studies., peer-reviewed

Background: Eosinophilic gastroenteropathy is an uncommon condition whose causes can be numerous and non-specific. The aim of the study was to characterize the presence of gastrointestinal disorders in the adult Maltese population and assess the degree of association with atopic diseases. Methods: Adult patients with gastrointestinal eosinophilia in the gastrointestinal tract on histology were identified and their clinical case notes were reviewed. Patients were interviewed and asked questions regarding asthma, allergic rhinitis, and eczema. Results: Sixty-six patients (39 female) were recruited. The most common clinical symptoms were diarrhea (42.4%) and abdominal pain (33.3%). The sites involved were stomach (10.6%), colon (56.1%), small bowel (10.6%), small bowel and colon (18.2%), esophagus (1.5%), and esophagus and colon (1.5%). Forty percent had persistent lower gastrointestinal symptoms and a repeat ileocolonoscopy was performed within 12 months. These patients were diagnosed with ulcerative colitis (n=10; 47.6%), Crohn’s disease (n=6; 28.6%), indeterminate colitis (n=1; 4.8%) or microscopic colitis (n=4; 19%). Allergic rhinitis was present in 39.4% of the study group, eczema in 26.1%, and asthma in 19.7%. These findings were compared with local data for atopic conditions and the study group was found to have a significantly higher prevalence of allergic rhinitis (P=0.002), but not of asthma (P=0.62) or eczema (P=0.19). Conclusions: A high proportion of patients with eosinophilic gastrointestinal infiltration were subsequently diagnosed with inflammatory bowel disease. Patients persistently symptomatic or who do not respond to treatment should be reassessed to exclude inflammatory bowel disease, given its high prevalence in this group of patients.

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

Background Omalizumab was introduced in Malta in 2011. To date, no local data have been published. Objective To obtain baseline characteristics of our local cohort, determine effectiveness of omalizumab at 52 weeks, compare clinical outcomes 52 weeks pre- and postomalizumab therapy and to assess its safety and tolerability. Setting The Mater Dei Hospital in Malta. Method All consented adult patients who were eligible to start treatment with omalizumab for asthma were enrolled in this open, prospective observational real-life study. A questionnaire was completed and an Asthma Control Test and spirometry performed. Patients were reviewed on a regular basis. Any undesirable symptoms were recorded. Treatment effectiveness was evaluated at 16 and 52 weeks, during which a decision was taken whether patients were responders. Outcomes were compared 52 weeks pre- and post- treatment initiation. Main outcome measure To determine effectiveness of treatment following 1 year of omalizumab by assessing its impact on the rate of asthma-related exacerbations and health care utilization including hospitalizations. Results Our cohort included 22 patients, all non-smokers (mean age 52.7 ± 11, 64 % males). The mean baseline IgE level was 448.6 ± 444 IU/ml. At week 12, treatment was stopped in one patient due to arthralgias. The drug was stopped in two patients at week 16 due to treatment ineffectiveness. At week 20, treatment was stopped in another patient in view of arthralgias. A significant reduction in the number of asthma exacerbations (p = .03) and number of systemic steroid courses required (p = .03) was identified at 52 weeks. There was a significant improvement in the ACT score (p

The submitted manuscript has not been previously published in any form and is not currently under consideration for publication elsewhere., Asthma is common in children with allergens and mould influencing the development of the disease. Since children spend most of their time outside their homes within the school environment, school indoor air quality can directly influence their respiratory health. This study aims to identify microbiological contaminants in Maltese schools. The association between contaminants, res-piratory health and school characteristics has been analysed. Five primary schools were selected with 9 to 11 years old students participating. Standardised health questionnaires, lung function tests, and school characterisation were performed. Dust samples were analysed for fungi, bacteria and allergens were performed. Penicillium/Aspergillus/Paecilomyces/Variotii (PenAsp) group had the highest median indoor concentration followed by Mycobacterial and Streptomyces species. There was a significant negative correlation between PenAsp and Mycobacterium spp levels in all the participating schools (r = −0.42; p = 0.03). Cat allergen in classroom dust correlated positively with the number of cat owners (r = 0.43; p = 0.041). High exposure to fungi, bacteria and allergens was significantly associated with upper and lower airway atopy. School/classroom characteristics and cleaning protocols were significantly as-sociated with exposure to these pollutants. In conclusion, fungi, bacteria, en-dotoxin, cat and dog allergens have been found to have a direct influence on school indoor air quality in the Maltese Islands. A significant association was observed between these contaminants and upper and lower airway atopy. Specific school, classroom, cleaning and maintenance characteristics have been identified as having a direct impact on indoor air quality., peer-reviewed

The authors would like to thank all the participants who participated in this study and the CEO of the state general hospital for his support., The St. George’s Respiratory Questionnaire (SGRQ) and chronic obstructive pulmonary disease (COPD) assessment test (CAT) are the measures used to assess health status. This study aims to examine the responsiveness of these tools by severity of dyspnoea category in patients with COPD. Forty-nine COPD patients who underwent a 12-week pulmonary rehabilitation (PR) programme were assessed at baseline, 12 weeks and at 28-week follow-up. Patients were categorized into two groups by severity of dyspnoea category (i.e. mild to moderate (modified Medical Research Council (mMRC) 1–2) and severe to very severe (mMRC 3–4)) using the mMRC dyspnoea scale. Effect size (ES) was computed as estimates of responsiveness. The SGRQ demonstrated greater responsiveness by total sample (SGRQ, ES = 0.87; CAT, ES = 0.75) and for the mMRC 3–4 category (SGRQ, ES = 0.91; CAT, ES = 0.76) on completion of PR. At 28-week follow-up, overall comparable responsiveness of the CAT and SGRQ was identified by total sample (SGRQ, ES = 0.75; CAT, ES = 0.74) and by severity of dyspnoea category. The symptom, impact and activity domains of the SGRQ showed good responsiveness, with greater ESs obtained overall for the mMRC 3–4 category. On completion of PR, the SGRQ demonstrates a greater responsiveness with COPD patients, especially in relation to the mMRC 3–4 category, while both the CAT and SGRQ show comparable responsiveness on follow-up., peer-reviewed

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., peer-reviewed

Introduction: Omalizumab is a recombinant monoclonal anti-IgE antibody used in severe IgE-mediated asthma. Few studies include analysis of long-term efficacy beyond 1 year, and most patients do require long-term treatment. Aim: To analyse the long-term efficacy of omalizumab in adult patients following 1 and 3 years of treatment. Method: All adult patients who were started on omalizumab for severe persistent allergic asthma since 2012 were included. Patients were reviewed regularly and outcomes were analysed and compared 1 year before and 1 and 3 years post-initiation of treatment. Outcomes included Asthma Control Test(ACT) scores, FEV 1 , number of exacerbations, hospitalizations, unscheduled health-care visits and number of systemic corticosteroid courses required. Results: 18 patients were included in this study,66% males,mean age 5.2(±9.7) years. The mean IgE level was 413.4(±409) IU/ml. The mean ACT score improved at 1 year( p p p =0.05) and even further at 3 years ( p =0.004). The mean number of unscheduled healthcare visits decreased at 1 year( p =0.09) and at 3 years( p =0.05). The mean number of systemic corticosteroid courses required decreased at 1 year( p =0.02) and at 3 years( p =0.01). There was no significant decline in hospitalisation rate or significant improvement in FEV 1 . Conclusion: Omalizumab in severe asthmatic patients leads to improved ACT scores, decreased exacerbations, unscheduled health-care visits and oral corticosteroid courses. These benefits were noted after 1 year and maintained 3 years later. Further evaluation of our cohort will assess treatment efficacy in the longer term.

Introduction: Both hypoxia and hyperoxia can be harmful, so the correct prescription of oxygen therapy, and it9s use only when it is indicated, is important. Aim: To assess the effect of a hospital oxygen therapy guideline on oxygen prescription and administration at the Emergency Department (ED) and medical wards of Mater Dei Hospital Malta. Methods: Patients attending ED with conditions most likely to require oxygen therapy were recruited over 2 months in 2011, and again in 2015 after a hospital guideline on oxygen therapy was introduced. Data was collected on oxygen therapy. A p value of Results: 248 and 293 patients were recruited in 2011 and 2015 respectively. Oxygen therapy was indicated in 34.3% and 31.4% of patients respectively ( p =0.47). Oxygen saturation on air was not documented in 14.1% (2011) and 4.4% (2015) ( p In patients in whom oxygen therapy was indicated, correct documentation (delivery device and flow rate) of oxygen therapy administered at ED improved from 23.5% to 73.9% ( p p p =0.35). In the medical wards, correct oxygen therapy administration according to prescription improved from 7.1% to 48.9% ( p Oxygen therapy prescription in patients in whom oxygen therapy was not indicated improved from 56.8% to 27.1% ( p Conclusions: Oxygen saturation, oxygen therapy prescription and documentation at the ED and oxygen therapy administration in wards improved significantly after the hospital guideline was introduced.

Background: Chronic Obstructive Lung Disease (COPD) is characterised by persistent and progressive airflow obstruction with enhanced chronic inflammatory responses. This pulmonary inflammation might be localised or it can be an 9over-spill9 of a systemic process. Aims & Objectives : Through this study, the effects of a 12 week, high intensity Pulmonary Rehabilitation programme on markers of systemic inflammation were looked into. Such a programme resulted in improvements in 6 minute walking distance and health related quality of life. Methods: Forty-nine patients were enrolled. The following inflammatory makers were investigated at baseline, 4, 8 and at 12 weeks during rehabilitation - C Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Neutrophil, Eosinophil counts and complete blood count (CBC). Serum Amyloid A (SAA) was measured at baseline, 8th and at the 12th week. Exhaled NO was measured at the start and end of the programme. Results: No statistically significant changes in the inflammatory markers occurred as a result of the exercise intervention. There was a marked peak in CRP, ESR and SAA by the 8th week. The levels declined to baseline values at the 12th week of Pulmonary Rehabilitation. Conclusions : The said programme resulted in improvements in 6 minute walking distance and Health Related Quality of Life. However, systemic inflammatory processes with exercise as a monitor of response to high intensity exercise in COPD is still debatable.

Introduction: Both hyperoxia and hypoxia can be harmful, yet oxygen therapy prescription is often incomplete and with errors. Frequent long work shifts have been shown to increase medical errors (LK Barger et al. PLoS Med. 2006), but evidence of the effect of time, ie day vs night shifts, on oxygen prescription errors is scarce. Aim: To compare oxygen therapy administration and prescription during social and unsocial hours at the emergency department (ED), Mater Dei hospital, Malta, where doctors9 night shifts are usually between 20:00-08:00. Method: 277 patients hospitalised with medical conditions likely to require oxygen therapy were recruited over 2 months. Data was collected on oxygen therapy administered and prescribed at the ED. A p value Results: 138 patients presented between 8:00-19:59 (9Day9 group), 89 between 20:00-07:59 (9Night9 group). Oxygen therapy was indicated in 30.4% in Day, 38.2% in Night ( p =0.2). Oxygen saturation on air was not documented in 2.9% in Day, 6.7% in Night ( p =0.2), so it was not possible to determine whether oxygen was indicated or not. Where oxygen therapy was indicated: administration of oxygen therapy documented in 95.2% in Day, 94.1% in Night ( p =0.8), and the documentation was complete (delivery device and flow rate) in 73.8% in Day, 74.5% in Night ( p =0.9). In patients in whom oxygen therapy was indicated, it was prescribed in the admission plan in 85.7% in Day and 85.3% ( p =0.9) in Night. Prescription was complete in 76.2% in Day and 70.6% ( p =0.6) in Night. Conclusion: Although frequent long work shifts are associated with increased medical errors, the time of day did not influence oxygen prescription errors.

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

An 18-year-old man presented to the local hospital in Malta, with dyspnoea, cough, mild haemoptysis, chest pain and night sweats. CT revealed a right hilar mass. Pleural tap, bronchoscopy and open lung biopsy were inconclusive. Biopsies obtained at repeat bronchoscopy and endobronchial ultrasound (EBUS) revealed a likely diagnosis of inflammatory myofibroblastic tumour (IMT). The patient subsequently underwent right pneumonectomy, and histology revealed the presence of two further nodules apart from the main tumour. Follow-up with positron emission tomography (PET)/CT showed the development of a right basal paracardial lesion due to recurrence and the presence of lymph node, pleural and skeletal disease. Despite radiotherapy to the recurrent nodule and chemotherapy, there was skeletal disease progression. Treatment with an anaplastic lymphoma kinase inhibitor, ceritinib, resulted in very good metabolic response. This case report highlights the importance of keeping IMT in mind when the diagnosis of lung tumours is difficult, as delayed diagnosis may lead to worsened prognosis.