Taking care of the ordinary in extraordinary times-delayed routine care means more morbidity and pre-mature mortality.

Individuals with chronic diseases are more susceptible to its grave complications and negative outcomes if infected by COVID-19. Furthermore, mandatory isolation and cancellations of routine healthcare services led to the disruption of the screening and management plans for chronic diseases. Fear of attending health services as well as disruptions to public transport are other factors increasing health risks among persons with chronic conditions during the pandemic. Ensuring access to universal healthcare services, increasing use of digital services, targeted interventions to risk groups are examples of measures that need to be taken when reviewing health systems preparedness for future pandemics and other disasters.

Are normoglycaemic individuals at risk of depression? The depression-dysglycaemic phenotype from a European population-based cross-sectional study.

BACKGROUND: Depression is a chronic non communicable disease. It is a growing public health concern with established links with a number of co-morbidities, including diabetes mellitus. The study aimed to estimate the prevalence of depression at a population level, establish the depression sub-population phenotypic characteristics while exploring for links between depression and a spectrum of glycemic abnormalities. METHODS: A nationally representative cross-sectional study was conducted in Malta between 2014 and 2016. Participants were categorized into different sub-populations according to their glycaemic status. Depression prevalence rates and phenotypic characteristics for each sub-population were established. Multiple regression analysis was performed to identify links with depression. RESULTS: Depression was prevalent in 17.15% (CI 95%: 16.01-18.36) with a female predominance. Those with known (as opposed to newly diagnosed) diabetes had the highest depression prevalence when compared to other glycemic sub-groups. These also exhibited a significant link with self-reported depression. However, at a population level, depression was mostly prevalent within the normoglycaemic sub-population. CONCLUSIONS: The study confirms the strong link between diabetes and depression, especially, in a high risk dysglycaemic population. Of public health concern is the high depression occurrence within the normoglycaemic sub-population, which attributed for the majority of the Maltese population. In order to reduce the impact of mental health on the population, physicians may consider implementing depression screening clinical tools as part of their routine health check-ups at primary care level, irrespective of the glycaemic status of their patients.

Innovative Technologies to Promote Sustainable Recirculating Aquaculture in Eastern Africa-A Case Study of a Nile Tilapia (Oreochromis niloticus) Hatchery in Kisumu, Kenya.

Lake Victoria, regionally important both as a source of food and income, is under pressure due to overfishing and severe pollution. Currently, the vast majority of east African aquaculture is open-pond based. The adoption of modern and sustainable aquaculture technologies and practices-in this case study recirculating aquaculture systems (RAS)-will help the region increase food security and decrease its current reliance on imported fish and stressed wild stock. To this end, VicInAqua, a project under the EU Horizon 2020 program, has developed a pilot Nile Tilapia (Oreochromis niloticus) hatchery in Kisumu, Kenya using RAS adapted to local conditions. The hatchery is designed as a flexible, scalable, and modular system. An online monitoring system enables farmers to access farm data from both fish tanks and the supporting renewable energy systems, allowing around-the-clock monitoring and control. The hatchery is linked to a 14.3 kWp Photovoltaic (PV) system, including a 30 kWh Li-battery storage, to supply sustainable electricity. The water for the RAS, treated by a membrane bioreactor (MBR) and certified for use in aquaculture and agriculture, comes chiefly from Kisumu's municipal sewage, which reduces the farms' reliance on an expensive and occasionally intermittent potable water supply. Combining these technologies represents an industry first and offers a working example for larger-scale future developments. The purpose of the project is to demonstrate the possible technologies and practices in situ as well as provide a template for future development and investment. The hatchery is used by the Department of Livestock, Agriculture and Fisheries, Kisumu County, Kenya, as a training and demonstration facility to promote the aquaculture sector and increase the awareness, knowledge, and skills of fish farmers, as well as provide high quality fingerlings to cage farmers within the lake. Integr Environ Assess Manag 2020;16:934-941. © 2020 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Membrane Bioreactor-Treated Domestic Wastewater for Sustainable Reuse in the Lake Victoria Region.

Lake Victoria is a shared water resource between Kenya, Uganda, and Tanzania, which is the second largest freshwater lake in the world. It has long since suffered from the consequences of overexploitation of its resources, mainly fish stocks, and increasingly high pollution. The closure of 58% of the fish processing plants (FPPs) is attributed to the declining fish stocks due to overfishing and pollution in particular. The installation and operation of a pilot membrane bioreactor (MBR) in Kisumu, Kenya, adopts an integrated approach by providing an integral, sustainable, cost-effective, and robust solution for water sanitation, which also meets the demand for clean water in the fish processing industry, aquaculture, and irrigation. The innovative system comprises a pilot MBR coupled with a recirculation aquaculture system (RAS). The RAS is able to recirculate 90% to 95% of its water volume; only the water loss through evaporation and drum filter back flushing has to be replaced. To compensate for this water deficit, the MBR treats domestic wastewater for further reuse. Additionally, excess purified water is used for irrigating a variety of local vegetables and could also be used in FPPs. The pilot-scale MBR plant with around 6 m2 submerged commercial polyethersulfone (PES) membranes provides treated water in basic agreement with Food and Agriculture Organization (FAO) standards for irrigation and aquaculture, showing no adverse effects on tilapia fingerlings production. A novel membrane module with a low-fouling coating is operating stably but has not yet shown improved performance compared to the commercial one. Integr Environ Assess Manag 2020;16:942-954. © 2020 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Monitoring NDMA precursors throughout membrane-based advanced wastewater treatment processes by organic matter fluorescence.

This study investigates the potential of fluorescence excitation/emission matrices (EEM) measurement as a tool to predict N-Nitrosodimethylamine (NDMA) formation in water reuse applications. In particular, samples from a pilot-scale membrane biological reactor (MBR) followed by nanofiltration (NF) advanced water treatment plant, are used for the study. Concentrations of both, specific NDMA precursors and NDMA formation potential (FP) are correlated with different EEM peaks. The specific precursors investigated are: erythromycin, azithromycin, clarithromycin, venlafaxine, o-desmethylvenlafaxine, ranitidine and citalopram, while the NDMA FP is conventionally measured by the NDMA formation potential test. EEM peaks investigated are obtained by fluorescence regional integration as well as by the peak picking method generating I1, I2, I3, I4, and I5 peaks. Results showed that protein-like materials are correlated with the bulk NDMA FP and specific NDMA precursors. Additionally, selected fluorescence peaks such as I1, I2 and I4 are strongly correlated with NDMA precursors throughout the MBR-NF pilot plant. The removal of NDMA precursors and EEM peaks also correlated well (R2 > 0.8). This data shows that fluorescence EEM can be a promising tool to monitor the concentration of NDMA precursors and their removal in water reuse application.

What is the sex ratio at birth?

INTRODUCTION: The sex ratio at birth (male divided by total births: M/F is often quoted as approximating 0.515. Many factors have been shown to influence this ratio, and these include both acute events and chronic circumstances, both of which may be man-made or natural. This study was carried out in order to attempt to narrow down the range for M/F from a large and internationally recognised dataset of countries reporting live births to the World Health Organisation (WHO). METHODS: Male and female live births were obtained from a WHO (Health for All - HFA) database for the five year period 1996-2000, for all countries reporting to WHO, and for which these values were reported. RESULTS: This study analysed 88,875,750 live births. M/F is estimated at 0.5147 (95% CI: 0.5146-0.5148), quite close to the widely quoted value of 0.515. DISCUSSION: M/F may be less due to female foeticide which cannot be accurately assessed, an unavoidable limitation. Other limitations for M/F estimates such as these are broad, cyclic secular variations, broad demographic population changes, chronic stress and an overall declining M/F in industrialised countries.

The interaction of dyslipidaemia with glycaemia in an adult population study.

PURPOSE: Individuals with dysglycaemic are prone to dyslipidaemia. Understanding the dyslipidaemic status of dysglycaemic individuals is essential for monitoring and early prevention. The aim was to assess the control of lipidaemia by glycaemic status in a representative adult population. METHODS: A retrospective health examination survey was performed on a sample of adults (n = 3947) in Malta in 2014-6. Sociodemographic data, biochemistry blood tests and anthropometric measurements were gathered. Statistical analysis was performed to evaluate the lipidaemic status and its control across the glycaemic spectrum (normoglycemic, impaired fasting glucose individuals, new diabetics and known diabetics). RESULTS: The prevalence of uncontrolled dyslipidaemia was 7.75% (CI 95%: 6.69-8.63), among whom 6.97% (CI 95%: 6.21-7.81) were naïve dyslipidaemic. A progressive elevation in both LDL-C and total cholesterol but not triglycerides was present among uncontrolled dyslipidaemia individuals across the glycaemic spectrum. Global dyslipidaemia was present in 19.26% (CI 95%: 18.05-20.52) of the total general population and in 46.59% (CI 95%: 40.49-52.69%) of known diabetics. Most individuals irrespective of lipid status were normoglycaemic. CONCLUSIONS: Dyslipidaemia occurs in the presence of insulin resistance. Dyslipidaemia predominated in the normoglycaemic state irrespective of statins use, indicating the need to manage dyslipidaemia prior to dysglycaemia.

The Effects of Socioeconomic Determinants on Hypertension in a Cardiometabolic At-Risk European Country.

BACKGROUND: A relationship has been established between socioeconomic status and hypertension. The aim of this study was to determine the prevalence of hypertension and to explore the links between hypertension and socioeconomic factors in the adult population of Malta. METHODS: A national representative cross-sectional health examination study was performed between 2014 and 2016. Sociodemographic and medical history data was gathered by validated questionnaires while blood pressure was measured. Prevalence rates of known hypertension, newly hypertension, and global hypertension were calculated. Associations between sociodemographic characteristics and hypertension were identified through logistic regression models. RESULTS: Hypertension contributed to 30.12% (CI 95%: 28.71-31.57) of the study population, with a male preponderance. The majority was known hypertensive (73.59% CI 95%: 71.01-76.02), with only three-quarters on medication. Multivariant analyses showed that increasing age and body mass index, male gender, and living in Gozo, Western district, and Northern Harbour district were associated with having hypertension. CONCLUSION: Hypertension is a problem in Malta especially in the male population and with increasing age and body mass index. Education did not exhibit any associated risk for having hypertension, which is inconsistent with the literature, while habitat localities played a role in hypertension development.

The effect of age, gender, TG/HDL-C ratio and behavioral lifestyles on the metabolic syndrome in the high risk Mediterranean Island population of Malta.

AIMS: Metabolic syndrome (MetS) is a public health epidemic, typically with female predominance. The aim was to analyse the effect of gender and age on MetS and its components; analyse effects of lifestyle, diabetes mellitus and identify predictors for MetS including TG/HDL ratio, on a national level in a Mediterranean island. Findings will provide evidence-based data for neighboring countries to aid in combat of this epidemic. METHOD: A cross-sectional survey was conducted in Malta (2014-2016) on a randomized adults population sample. Various components of MetS were measured along with lifestyle habits (smoking, alcohol and physical activity) and family history (cardiovascular and diabetes). Both descriptive and statistical analyses were performed. RESULTS: A total of 80,788 Maltese adults estimated to suffer from MetS. Males were predominantly affected with significant difference from females. All MetS components were found to be significant predictors along with alcohol habits but not smoking. Neither physical inactivity nor family history of cardiovascular disease, showed any predictive ability for MetS even after adjustment. Elevated triglyceride levels exhibited highest predictive effect on MetS. TG/HDL ratio showed predictive ability in the Maltese population. CONCLUSIONS: Males were at higher risk for MetS in Malta. A number of predictors were established but not sedentary lifestyle. TG/HDL ratio may provide to be a good indicator for development of MetS.

The diabesity health economic crisis-the size of the crisis in a European island state following a cross-sectional study.

BACKGROUND: Diabetes type 2 and obesity are well-established global epidemics and contributors to clinical, social and economic health burdens. The prevalence rates of these diseases are still on the rise among countries resulting in a corresponding public health burden. The Mediterranean island of Malta, known for it's high diabetes and obesity rates, provides a good fundamental basis to portray the economical health burden of these diseases. METHOD: A recent randomised stratified representative cross-sectional survey conducted in Malta tackling diabetes, obesity and other determinants, was used to work out the population prevalence of these diseases. The cost burden of diabetes and obesity, based on published data, was incorporated to the established population prevalence rates, in order to estimate the Maltese economical burden. Projections to the year 2050 by a bottom-up prevalence based design were performed. RESULTS: One eight of the Maltese adults (25 to 64 years) suffered from diabetes out of which approximately 10,000 adults were unaware of the disease. Alarmingly, more than a third of the Maltese population suffer from obesity. The approximate health care costs (direct and indirect) for the diabetic adult population was of €29,159,217 (€21,994,676 - €38,919,121) annually, amounting to 3.64% (2.75-4.875%) of the total health expenditure in Malta. The obesity cost burden was of €23,732,781 (€21,514,972-€26,049,204) annually contributing for 2.97% (2.69-3.26%) of the total health expenditure. The projected prevalence and costs for 2050 exhibited an estimated cost burden increase of €33,751,487 (€25,458,606-€45,048,473) for the diabetes mellitus population and €46,532,294 (€42,183,889-€51,074,049) for the obese population. These projected cost burdens are expected to increase exponentially the total health care expenditure in Malta by 2050. CONCLUSION: Having an understanding of the prevalence and the economic cost burden of diabetes and obesity within a country, along with projections of the expected burden will enable policy and public health officials to clearly visualize this growing problem. It also helps in establishing effective preventive strategies and screening programs targeting these epidemics.

Getting to grips with the obesity epidemic in Europe.

Obesity is a global epidemic. It is responsible for increased patient morbidity and mortality. Significant related pathologies including diabetes mellitus compound the overall risks. Obesity is a significant financial burden. This includes direct and indirect medical costs, amounting to millions of euros each year. Multiple European studies have outlined a steady incline in obesity prevalence rates. Tackling obesity is no easy task. Policy makers aiming to reduce obesity rates should adopt an evidence-based approach. This entails adopting both micro- and macro-interventions tweaked to each country's individual requirements. The ideal way forward would be to tackle obesity from the individual, population-wide and food industry angles. The key towards a successful intervention is for each country to carry out well-planned health examination studies, in an attempt to pin point local risk factors. Having a correct individualized picture, each country can move forward and draw policies and interventional procedures. The aim should be to primarily improve the quality of life. Second, the country's capital expenditure is also reduced.

Fate of NDMA precursors through an MBR-NF pilot plant for urban wastewater reclamation and the effect of changing aeration conditions.

The removal of N-nitrosodimethylamine (NDMA) formation potential through a membrane bioreactor (MBR) coupled to a nanofiltration (NF) pilot plant that treats urban wastewater is investigated. The results are compared to the fate of the individual NDMA precursors detected: azithromycin, citalopram, erythromycin, clarithromycin, ranitidine, venlafaxine and its metabolite o-desmethylvenlafaxine. Specifically, the effect of dissolved oxygen in the aerobic chamber of the MBR pilot plant on the removal of NDMA formation potential (FP) and individual precursors is studied. During normal aerobic operation, implying a fully nitrifying system, the MBR was able to reduce NDMA precursors above 94%, however this removal percentage was reduced to values as low as 72% when changing the conditions to minimize nitrification. Removal decreased also for azithromycin (68-59%), citalopram (31-17%), venlafaxine (35-15%) and erythromycin (61-16%) on average during nitrifying versus non-nitrifying conditions. The removal of clarithromycin, o-desmethylvenlafaxine and ranitidine could not be correlated with the nitrification inhibition, as it varied greatly during the experiment time. The MBR pilot plant is coupled to a nanofiltration (NF) system and the results on the rejection of both, NDMA FP and individual precursors, through this system was above 90%. Finally, results obtained for the MBR pilot plant are compared to the percentage of removal by a conventional full scale biological wastewater treatment plant (WWTP) fed with the same influent. During aerobic operation, the removal of NDMA FP by the MBR pilot plant was similar to the full scale WWTP.

Determination of 15 N-nitrosodimethylamine precursors in different water matrices by automated on-line solid-phase extraction ultra-high-performance-liquid chromatography tandem mass spectrometry.

A new methodology based on on-line solid-phase extraction (SPE) ultra-high-performance-liquid chromatography coupled to a triple quadrupole mass spectrometer (UHPLC-MS-MS) for the determination of 15 individual anthropogenic N-nitrosodimethylamine (NDMA) precursors was developed. On-line SPE was performed by passing 2mL of the water sample through a Hypersil GOLD aQ column and chromatographic separation was done using a Kinetex Biphenyl column using methanol and 0.1% formic acid aqueous solution as a mobile phase. For unequivocal identification and confirmation, two selected reaction monitoring (SRM) transitions were monitored per compound. Quantification was performed by internal standard approach and matrix match calibration. The main advantages of the developed method are high sensitivity (limits of detection in the sub ng/L range), selectivity due to the use of tandem mass spectrometry, precision and minimum sample manipulation as well as fast analytical response. Process efficiency and recovery were also evaluated for all the target compounds. As part of the validation procedure, the method was applied in a sampling campaign for the analysis of influent and secondary effluent of a wastewater treatment plant (WWTP) in Girona, Spain. Additionally, the effluent from a nanofiltration (NF) membrane system used for water recycling was monitored. The percentage of NDMA formation explained by the measured precursors was also quantified.

Smoking health professional student: an attitudinal challenge for health promotion?

Tobacco is a major preventable cause of premature morbidity and mortality. Health professionals are uniquely positioned to provide targeted interventions and should be empowered to provide cessation counselling that influence patient smoking. A cross-sectional national survey was administered to all third year students in four disciplines at the University of Malta. The Global Health Professional Student Survey (GHPSS) questionnaire was distributed to collect standardised demographic, smoking prevalence, behavioural, and attitudinal data. 81.9% completed the questionnaire (n = 173/211). A positive significant association between tobacco smoke exposure at home and current smoking status was identified. Non-smokers regarded anti-tobacco policies more favourably than smokers, being more likely to agree with banning of tobacco sales to adolescents (OR 3.6; 95% CI: 2.5-5.3; p ≤ 0.001); and with a smoking ban in all public places (OR 8.9; 95% CI: 6.1-13.1; p ≤ 0.001). Non-smokers favoured a role for health professionals in promoting smoking cessation (OR 5.1; 95% CI: 3.1-8.5; p ≤ 0.001). Knowledge of antidepressants as tools for smoking cessation was also associated with a perceived role for skilled health professionals in cessation counselling (OR 4.9; 95% CI: 1.8-13.3; p = 0.002). Smoking negatively influences beliefs and attitudes of students toward tobacco control. There is a need to adopt a standard undergraduate curriculum containing comprehensive tobacco prevention and cessation training to improve their effectiveness as role models.

Invasive meningococcal disease in Malta: an epidemiological overview, 1994-2007.

Since 1996, Malta has experienced an upsurge of invasive meningococcal disease (IMD) following an almost 30 year period with a negligible number of annually reported cases. We reviewed the 233 IMD cases notified during a 14 year period (1994-2007), and analysed epidemiological and laboratory surveillance data. The crude incidence per 100,000 inhabitants peaked in 2000 at 8.1 [95 % confidence interval (CI) 5.7-11.6] and again in 2006 at 8.9 (95 % CI 6.4-12.4), thereby placing Malta amongst the countries with the highest incidence of the disease in Europe. Of the total cases, 137 (59 %) were confirmed and 30 (13 %) were classified as probable. However, 66 cases (28 %) had no laboratory evidence of the disease and were classified as possible. Information on the serogroup was available for 114 cases. Serogroup B formed the largest proportion (76 %, n=87) followed by serogroup C (16 %, n=18). B : 4 : P1.19,15 strains (n=46) predominated throughout the study period since their first identification in 1998. With 28 deaths attributed to IMD, the overall case fatality rate was 12 %. Apart from stressing the importance of maintaining high vigilance for IMD, our findings underscore the importance of enhancing laboratory surveillance of the disease, including characterization of the meningococci. Until vaccines against a broad range of serogroup B meningococci become available for universal use, the main methods of control remain the early treatment of cases and the prevention of secondary cases.