Comorbidity in primary care - causal or casual? A longitudinal observational study in family medicine.

BACKGROUND: Comorbidity is increasingly important in the medical literature, with ever-increasing implications for diagnosis, treatment, prognosis, management and health care. The objective of this study is to measure casual versus causal comorbidity in primary care in three family practice populations. METHODS: This is a longitudinal observational study using the Transition Project datasets. Transition Project family doctors in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records and the International Classification of Primary Care, collecting data on all elements of the doctor-patient encounter, including diagnoses (1,178,178 in the Netherlands, 93,606 in Malta, 405,150 in Serbia), observing 158,370 patient years in the Netherlands, 43,577 in Malta, 72,673 in Serbia. Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not, corrected for the prior probability of such co-occurrence, between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Specific associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient. RESULTS: The high frequency of observed comorbidity with low consistency in both clinically and statistically significant odds ratios across populations indicates more casual than causal associations. A causal relationship would be expected to be manifest more consistently across populations. Even in the minority of cases where odds ratios were consistent between countries and numerically larger, those associations were observed to weaken with increasing patient age. CONCLUSION: After applying accepted criteria for testing the causality of associations, most observed primary care comorbidity is due to chance, likely as a result of increasing illness diversity. TRIAL REGISTRATION: This study was performed on electronic patient record datasets made publicly available by the University of Amsterdam Department of General Practice, and did not involve any patient intervention.

Attitudes towards disclosure of familial genetic risk in a Mediterranean island population - A survey of the Maltese population.

Germline genetic testing has implications that extend beyond the individual patient to relatives, particularly for high-penetrance variants implicated in hereditary cancer or neurodegenerative syndromes. Many countries encourage patient-led communication to inform at-risk relatives, although the efficacy and uptake of this approach varies. Alternative scenarios envisage direct contact mediated by clinicians. The familial disclosure of sensitive genetic information is also determined by complex socio-ethnic factors. To date, no study has explored whether relatives would want to be informed of familial genetic risk and their preferences on different methods of communication in Malta. We thus used a published instrument that utilizes hypothetical scenario methodology to survey the attitudes of the Maltese population (n = 334) to receiving genetic information from family members. Two vignettes on Huntington's disease and colorectal cancer were presented. We also explored preferences towards the communication of genetic risk, confidentiality, and disclosure policies. Our preliminary results show that most respondents want to be informed of their increased risk by a family member or a clinician and would opt to receive confirmatory genetic testing. Most respondents preferred being informed of genetic risk by a close relative, but in the case of non-disclosure would want to be informed by a clinician. Most respondents expressed preference in favour of the introduction of registries, legislative change and sharing of contact details to address cases of nondisclosure. Our findings contribute further to evidence that supports, in selected hypothetical scenarios, an envisioned change in disclosure of genetic data policy by the public that is different from current practice to date.

A Good Night's Sleep in Malta in 2023: A Cross-sectional Study Exploring Sleep Quality and its Determinants via Social Media.

BACKGROUND: Sleep quality is affected by a plethora of different factors, although its relationship with chronic diseases is still unclear. This study explored perceived sleep quality and its associated determinants among the adult population of Malta. Study Design: A cross-sectional study. METHODS: An anonymous online survey was distributed through social media targeting adults residing in Malta. Data pertaining to socio-demographic, medical history, lifestyle, well-being, sleep, and daytime sleepiness were gathered, and descriptive, univariant, and multiple binary logistic regression modelling analyses were performed. RESULTS: A total of 855 adults responded, out of whom 35.09% (95% confidence interval [CI]: 31.90, 38.41) reported sleep difficulties, especially females (81.33%; 95% CI: 76.36, 85.49), while 65.33% (95% CI: 59.61, 70.65) reported suffering from chronic disease(s). Sleep problems were positively associated with multimorbidity (odds ratio [OR]: 2.17; 95% CI: 1.38, 3.40; P=0.001), sleeping<6 hours (OR: 3.79; 95% CI: 1.54, 9.30; P=0.040), and the presence of moderate anxiety symptoms (OR: 1.99; 95% CI: 1.10, 3.59; P=0.020). They were also related to the presence of mild (OR: 2.25; 95% CI: 1.46, 3.45; P=0.001), moderate (OR: 2.40; 95% CI: 1.24, 4.64; P=0.010), and moderately severe (OR: 15.35; 95% CI: 4.54, 31.86; P=0.001) depressive symptoms after adjusting for confounders. CONCLUSION: Chronic conditions, including anxiety and depression, along with short sleep duration, appear to contribute to poor sleep quality in Malta. A multifaceted approach is required to deal with the issue holistically and safeguard the health of current and future generations.

An exploratory study of knowledge, attitudes, practice and barriers towards adverse drug reaction reporting among healthcare professionals in Malta.

BACKGROUND: Understanding knowledge and attitudes of health care professionals (HCPs) towards adverse drug reaction (ADR) reporting can inform educational interventions promoting ADR reporting. OBJECTIVE: To explore knowledge, attitudes, practice, and barriers of local HCPs towards ADR reporting. METHODS: Focus groups involving HCPs from different settings were organized to help develop a questionnaire. The questionnaire was validated and disseminated to pharmacists, physicians, dentists and nurses practicing in Malta. A review of ADR reports reported in Malta from 2004 to 2021 was carried out to contextualise questionnaire findings. RESULTS: Overall, HCPs (n = 374) had good knowledge on pharmacovigilance and a positive attitude towards ADR reporting however nurses were found to be less knowledgeable than physicians, dentists, and pharmacists. The main barrier for not reporting ADRs was difficulty to understand whether an adverse event occurred (n = 187). A total of 2581 ADR reports were reported in Malta. Among HCPs, physicians and dentists reported most ADRs (1060 reports), followed by pharmacists (307 reports) and nurses (257 reports). CONCLUSION: Further ADR educational and promotional efforts are needed to increase awareness on the importance of quality ADR reporting and increase the number of ADR reports reported by local HCPs.

Cardiovascular Risk Factors Among First-Degree Relatives of Patients with Premature Cardiovascular Disease in Malta. Baseline Findings from the CRISO Project.

Purpose: A family history of premature atherosclerotic cardiovascular disease (ASCVD) confers a greater risk of developing ASCVD. However, the prevalence of ASCVD risk factors among asymptomatic Maltese adults with parental or fraternal history of premature ASCVD is unknown. The study aimed to evaluate and compare their risk with the general population. Patients and Methods: Posters to market the project were distributed in cardiac rehabilitation areas. Patients with premature cardiovascular disease facilitated recruitment by informing their relatives about the project. Medical doctors and cardiac rehabilitation nurses referred first-degree relatives. Posters were put up in community pharmacies, and an explanatory video clip was shared on social media for interested individuals to contact researchers. Those eligible were enrolled in a preventive cardiology lifestyle intervention. Their data were compared with the risk in the general population. Results: Many first-degree relatives had a suboptimal risk profile, with 60% (N = 89) having a total cholesterol level of >5.0 mmol/L; 54% having a low-density lipoprotein-cholesterol level of >3 mmol/L; 70.5% being overweight/obese, with 62% having a waist circumference greater than the recommended values; 34.8% having hypertension; 56.2% being inadequately adherent to the Mediterranean diet; 62% being underactive, with 18% being sedentary; and 25.8% being smokers. First-degree relatives had significantly higher proportions of underactive lifestyle (p = 0.00016), high body mass index (>25kg/m2) (p = 0.006), and systolic blood pressure (p = 0.001) than the general population, with 30% having metabolic syndrome. Conclusion: This study determined the prevalence of lifestyle, biochemical, physiological, and anthropometric cardiovascular risk factors among asymptomatic first-degree relatives of Maltese patients with premature ASCVD. First-degree relatives had considerable prevalences of an underactive lifestyle, hypertension, and obesity, suggesting better screening and early risk factor intervention are needed to modify their risk of ASCVD.

This study was done to evaluate factors that can increase the risk of heart disease in siblings and offspring of Maltese patients who developed atherosclerotic cardiovascular disease (ASCVD) at a young age. Relatives were invited to meetings during which a risk evaluation was performed. The researchers found that relatives had a high prevalence of cardiometabolic risk factors, meaning they were at increased risk of developing the disease. The researchers have concluded that reducing the risk of ASCVD in individuals at increased risk requires developing and testing potentially sustainable risk factor modification strategies.

Identifying co-morbidities and risk in people with epilepsy: The Maltese experience.

BACKGROUND: People with epilepsy are at increased risk of multiple co-morbidities that may influence risk of adverse outcomes including impact on quality of life and premature mortality. These risk factors include potentially modifiable clinical characteristics associated with sudden unexpected death in epilepsy (SUDEP). For services to tackle risk, the clinical complexity of the target epilepsy population needs to be defined. While this has been comprehensively studied in large, economically developed countries little knowledge of these issues exist in small economically developed countries, like Malta (population: 500,000). METHODS: This was a single centre study focused exclusively on patients attending Gozo General Hospital (GGH) Malta. STROBE guidance for reporting cross sectional studies was used to design and report the study. This was a retrospective review of standard care and SUDEP and seizure risks provided to all adults (over 18 years) with epilepsy attending GGH (2018-2021). RESULTS: The review identified 68 people and 92% were compliant with their anti-seizure medication. A fifth (21%) had an intellectual disability. Despite only one patient having a psychotic illness, 19% were on antipsychotic medication. Only 18% of patients had a specific epilepsy care plan, 6% nocturnal surveillance and none had received advice on SUDEP. DISCUSSION: Patient outcomes may be improved with increasing rates of personalized epilepsy care plans, appropriate nocturnal surveillance and reducing the prescription of antipsychotic medication as it is associated with greater risk of mortality. Issues such as stigma and shame appear to play a significant role in small communities and their access to care.

Genotype-phenotype of autosomal dominant polycystic kidney disease in Malta.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the development of multiple renal cysts causing kidney enlargement and end-stage renal disease (ESRD) in half the patients by 60 years of age. The aim of the study was to determine the genetic aetiology in Maltese patients clinically diagnosed with ADPKD and correlate the clinical features. METHODS: A total of 60 patients over 18 years of age clinically diagnosed with ADPKD were studied using a customized panel of genes that had sufficient evidence of disease diagnosis using next generation sequencing (NGS). The genes studied were PKD1, PKD2, GANAB, DNAJB11, PKHD1 and DZIP1L. Selected variants were confirmed by bidirectional Sanger sequencing with specifically designed primers. Cases where no clinically significant variant was identified by the customized gene panel were then studied by Whole Exome Sequencing (WES). Microsatellite analysis was performed to determine the origin of an identified recurrent variant in the PKD2 gene. Clinical features were studied for statistical correlation with genetic results. RESULTS: Genetic diagnosis was reached in 49 (82%) of cases studied. Pathogenic/likely pathogenic variants PKD1 and PKD2 gene were found in 25 and in 23 cases respectively. The relative proportion of genetically diagnosed PKD1:PKD2 cases was 42:38. A pathogenic variant in the GANAB gene was identified in 1 (2%) case. A potentially significant heterozygous likely pathogenic variant was identified in PKHD1 in 1 (2%) case. Potentially significant variants of uncertain significance were seen in 4 (7%) cases of the study cohort. No variants in DNAJB11 and DZIP1L were observed. Whole exome sequencing (WES) added the diagnostic yield by 10% over the gene panel analysis. Overall no clinically significant variant was detected in 6 (10%) cases of the study population by a customized gene panel and WES. One recurrent variant the PKD2 c.709+1G > A was observed in 19 (32%) cases. Microsatellite analysis showed that all variant cases shared the same haplotype indicating that their families may have originated from a common ancestor and confirmed it to be a founder variant in the Maltese population. The rate of decline in eGFR was steeper and progression to ESRD was earlier in cases with PKD1 variants when compared to cases with PKD2 variants. Cases segregating truncating variants in PKD1 showed a significantly earlier onset of ESRD and this was significantly worse in cases with frameshift variants. Overall extrarenal manifestations were commoner in cases segregating truncating variants in PKD1. CONCLUSIONS: This study helps to show that a customized gene panel is the first-line method of choice for studying patients with ADPKD followed by WES which increased the detection of variants present in the PKD1 pseudogene region. A founder variant in the PKD2 gene was identified in our Maltese cohort with ADPKD. Phenotype of patients with ADPKD is significantly related to the genotype confirming the important role of molecular investigations in the diagnosis and prognosis of polycystic kidney disease. Moreover, the findings also highlight the variability in the clinical phenotype and indicate that other factors including epigenetic and environmental maybe be important determinants in Autosomal Dominant Polycystic Kidney Disease.

Independent clinic-based evaluation of dual POCTs for screening for HIV and syphilis in men who have sex with men in Italy, Malta, Peru, and the United Kingdom.

INTRODUCTION: Globally, the incidence of HIV and syphilis can be reduced by the use of validated point of care tests (POCTs). As part of the WHO PRoSPeRo Network, we aimed to evaluate the performance, acceptability, and operational characteristics of two dual HIV/syphilis POCTs (Bioline HIV/Syphilis Duo (Abbott) and DPP® HIV-Syphilis assay (Chembio) for the screening of HIV and syphilis amongst men who have sex with men (MSM). METHOD AND ANALYSES: A cross sectional study of 2,577 MSM in Italy, Malta, Peru, and the United Kingdom (UK) presenting to seven clinic sites, were enrolled. Finger prick blood was collected to perform POCTs and results compared with standard laboratory investigations on venepuncture blood. Acceptability and operational characteristics were assessed using questionnaires. Diagnostic meta-analysis was used to combine data from the evaluation sites. RESULTS: Based on laboratory tests, 23.46% (n = 598/2549) of participants were confirmed HIV positive, and 35.88% of participants (n = 901/2511) were positive on treponemal reference testing. Of all participants showing evidence of antibodies to Treponema pallidum, 50.56% (n = 455/900) were Rapid Plasma Reagin (RPR) test reactive. Of HIV positive individuals, 60.62% (n = 354/584) had evidence of antibodies to T. pallidum, and of these 60.45% (n = 214/354) exhibited reactive RPR tests indicating probable (co)infection. For Bioline POCT, pooled sensitivities and specificities for HIV were 98.95% and 99.89% respectively, and for syphilis were 73.79% and 99.57%. For Chembio pooled sensitivities and specificities for HIV were 98.66% and 99.55%, and for syphilis were 78.60% and 99.48%. Both tests can detect greater than 90% of probable active syphilis cases, as defined by reactive RPR and treponemal test results. These dual POCTs were preferred by 74.77% (n = 1,926) of participants, due to their convenience, and the operational characteristics made them acceptable to health care providers (HCPs). CONCLUSIONS: Both the Bioline and the Chembio dual POCT for syphilis and HIV had acceptable performance, acceptability and operational characteristics amongst MSM in the PRoSPeRo network. These dual POCTs could serve as a strategic, more cost effective, patient and healthcare provider (HCP) friendly alternative to conventional testing; in clinical and other field settings, especially those in resource-limited settings.

A blueprint for health technology assessment capacity building: lessons learned from Malta.

OBJECTIVES: The development and strengthening of health technology assessment (HTA) capacity on the individual and organizational level and the wider environment is relevant for cooperation on HTAs. Based on the Maltese case, we provide a blueprint for building HTA capacity. METHODS: A set of activities were developed based on Pichler et al.'s framework and the starting HTA capacity in Malta. Individual level activities focused on strengthening epidemiological and health economic skills through online and in-person training. On the organizational level, a new HTA framework was developed which was subsequently utilized in a shadow assessment. Awareness campaign activities raised awareness and support in the wider environment where HTAs are conducted and utilized. RESULTS: The time needed to build HTA capacity exceeded the planned two years accommodating the learning progress of the assessors. In addition to the planned trainings, webinars supplemented the online courses, allowing for more knowledge exchange. The advanced online course was extended over time to facilitate learning next to the assessors' daily tasks. Training sessions were added to implement the new economic evaluation framework, which was utilized in a second shadow assessment. Awareness by decision-makers was achieved with reports, posters, and an article on the current and developing HTA capacity. CONCLUSIONS: It takes time and much (hands-on) training to build skills for conducting complex assessment such as HTAs. Facilitating exchange with knowledgeable parties is crucial for succeeding as well as the buy-in of local managers motivating staff. Decision-makers need to be on-boarded for the continued success of HTA capacity building.

Association between a polygenic lipodystrophy genetic risk score and diabetes risk in the high prevalence Maltese population.

BACKGROUND: Type 2 diabetes (T2DM) is genetically heterogenous, driven by beta cell dysfunction and insulin resistance. Insulin resistance drives the development of cardiometabolic complications and is typically associated with obesity. A group of common variants at eleven loci are associated with insulin resistance and risk of both type 2 diabetes and coronary artery disease. These variants describe a polygenic correlate of lipodystrophy, with a high metabolic disease risk despite a low BMI. OBJECTIVES: In this cross-sectional study, we sought to investigate the association of a polygenic risk score composed of eleven lipodystrophy variants with anthropometric, glycaemic and metabolic traits in an island population characterised by a high prevalence of both obesity and type 2 diabetes. METHODS: 814 unrelated adults (n = 477 controls and n = 337 T2DM cases) of Maltese-Caucasian ethnicity were genotyped and associations with phenotypes explored. RESULTS: A higher polygenic lipodystrophy risk score was correlated with lower adiposity indices (lower waist circumference and body mass index measurements) and higher HOMA-IR, atherogenic dyslipidaemia and visceral fat dysfunction as assessed by the visceral adiposity index in the DM group. In crude and covariate-adjusted models, individuals in the top quartile of polygenic risk had a higher T2DM risk relative to individuals in the first quartile of the risk score distribution. CONCLUSION: This study consolidates the association between polygenic lipodystrophy risk alleles, metabolic syndrome parameters and T2DM risk particularly in normal-weight individuals. Our findings demonstrate that polygenic lipodystrophy risk alleles drive insulin resistance and diabetes risk independent of an increased BMI.

The prevalence of perinatal mental health disorders and psychosocial characteristics of women in Malta: A cross-sectional study.

BACKGROUND: Perinatal mental health disorders (PMHDs) are associated with a myriad of negative outcomes for women, infants, and the rest of the family unit. Understanding the prevalence of these conditions is important to guide prevention and treatment pathways. Indeed, the burden of PMHDs has been studied in many countries, but for Malta, an island with an annual birth rate of 4500 births, this burden is still to be determined. The main objective of this study was to address this gap, determine the prevalence of PMHDs among postpartum women in Malta, and study associated psychosocial determinants for this population. METHODS: A cross-sectional epidemiological study was conducted between March and April 2022 to determine the point prevalence of postpartum PMHDs in Malta. A representative, random sample of 243 postnatal mothers were recruited and screened for mental health issues using a two stage approach incorporating symptom scales and a diagnostic interview. RESULTS: The point prevalence of postnatal PMHDs in Malta, according to a diagnostic interview, was found to be 21.4%. Anxiety disorders were the most prevalent conditions (16.8%), followed by obsessive-compulsive disorder (6.1%) and borderline personality disorder (5.6%), respectively. A higher rate of 32.1% was identified with self-report measures. CONCLUSIONS: PMHDs are highly prevalent, affecting approximately 20% of women in Malta across the first postnatal year. The value of this finding accentuates the need for service availability and the implementation of perinatal mental health screening programs.

The discovery of Moniliformis saudi (Acanthocephala: Moniliformidae) in the Algerian hedgehog Atelerix algirus in Malta: morphological, molecular, and metal analyses.

The acanthocephalan Moniliformis saudi Amin, Heckmann, Mohammed, Evans, 2016 was originally described from the desert hedgehog, Paraechinus aethiopicus (Ehrenberg) in central Saudi Arabia. The distribution of P. aethiopicus extends to North Africa and west to Mauritania. Moniliformis saudi was recently found in the Algerian hedgehog Atelerix algirus (Lereboullet) in Malta. The distribution of A. algirus is restricted to the North African and east Iberian Mediterranean coast and associated islands. Both host species cohabit and share the same feeding grounds in northern Algeria where common infections appear to take place. The morphology of specimens from both acanthocephalan populations was similar, with minor variations mostly related to the relatively larger Maltese specimens especially the trunk and the male reproductive system. Taxonomic features like the cone-shaped anterior trunk, size and formula of proboscis and hooks, the receptacle, size and shape of eggs, anatomy of the apical proboscis sensory pores, and the stellate body wall giant nuclei were, however, practically identical. SEM and microscope images of specimens of the Maltese population emphasize their qualitative characteristics such as the degree of the extreme spiral muscle development and the development of the posterior nucleated pouches of the proboscis receptacle. Proboscis hooks of specimens from both the Maltese and the Saudi populations had similarly high levels (percent weights) of calcium, moderate levels of phosphorus, and minimal levels of sulfur, magnesium and sodium marking the diagnostic value of the Energy Dispersive x-ray analysis in species recognition. Newly generated partial sequences of the 18S ribosomal RNA and cytochrome C oxidase subunit 1 (Cox1) of the mitochondrial gene were generated from M. saudi from Malta. Moniliformis saudi from Malta, when compared with other available sequences of the same species isolates available in the GenBank database, formed a strongly supported clade with other congeners. The comparison of the molecular profiles of specimens from populations in Malta, Spain, and Saudi Arabia shows no or low genetic variation between them. Ultimately, we provide a morphological and molecular description of a new population of M. saudi from a new host species in a new geographical location, vastly exceeding the originally described ones from Saudi Arabia. A Cox 1 haplotype network inferred with 10 sequences revealed the presence of eight haplotypes, one of which was shared between the populations of Malta and Spain of M. saudi.

The epidemiology of CHD in Malta.

BACKGROUND: CHD refers to structural cardiac abnormalities which comprise the commonest group of congenital malformations. Malta is a small island in the central Mediterranean with excellent diagnostic and therapeutic facilities. It is unique in the European population as termination of pregnancy is illegal. This study was carried out to ascertain patterns in CHD prevalence in comparison with EUROCAT data (European Surveillance of Congenital Anomalies). METHODS: Anonymised data were obtained from the EUROCAT website for 1993-2020. RESULTS: There were a total of 22,833,032 births from all EUROCAT Registries, of which 121,697 were from Malta. The prevalence rate for Malta CHD was 32.38/10,000 births (at the higher end of the range). Malta had a significant excess of commoner, comparatively non-severe CHDs. For most of the severe lesions analysed rates reported were higher than EUROCAT average, however, apart from Ebstein's anomaly, they all fell within the ranges reported from the different registries. DISCUSSION: Wide variations in reported CHD prevalence are known, and the Malta rates may be higher for milder defects due to quicker pickup prior to spontaneous resolution. There may also be a higher pickup of milder forms of more severe conditions. For the more severe conditions, lack of termination may be the explanation. These factors may result in the higher neonatal mortality observed in Malta.

Transfusion in hemoglobinopathies and red blood cell alloimmunization: data from Sicily, Sardinia and Malta.

BACKGROUND: Hemoglobinopathies are a group of diseases that include those due to globin gene mutations, such as thalassemia major (TM) and thalassemia intermedia (TI) or due to alteration of hemoglobin structure such as sickle cell disease (SCD), as well as a combination of these conditions such as thalasso-drepanocytosis (TD). They constitute the most frequent hereditary anemias requiring blood transfusion. MATERIALS AND METHODS: In April 2022, a questionnaire was sent to the Transfusion Services (TS) of Sicily, Sardinia and the Maltese National Blood Transfusion (MNBT) service. The questionnaire was divided into a generic part including the number of patients followed and the type of hemoglobinopathy, and a section relating to transfusion therapy, including the number of units transfused, whether red blood cells (RBC) were washed and, finally, a section relating to the presence or absence of alloantibodies and their identification. RESULTS: Data was retrieved for 2,574 patients: 68.6% TM, 15.4% TI, 10.3% TD, 4.1% SCD, and 1.6% other hemoglobinopathies (OHA). The number of RBC units transfused was 76,974, equivalent to 24.5% of all the RBCU transfused from the total number of patients followed. The number of washed RBCU was 21.1% of all the units used; 337 patients (37%) were diagnosed with alloantibodies, the majority of which were patients with SCD (20.6%). Of the 485 alloantibodies found, 90.3% were identified. The antibodies found most frequently were related to the Kell system (41.7%) followed by antibodies to the Rhesus system (37.9%); 29.7% of patients had more than one antibody. DISCUSSION: From our study, certain indications can be formulated: complete the National Registry for patients with hemoglobinopathies; create a Registry of alloimmunized patients to ensure transfusion therapy is as safe as possible, considering antibody evanescence; and 3) increase the recruitment of blood donors of diverse ethnicities.

Case study: the development of specialist nurse roles in Malta.

Specialist nurses play a significant role in healthcare. This study investigated and evaluated the primary and extended roles and the development of specialist nurses in Malta. METHODS: A qualitative case study design and purposive sampling techniques were used to gain a deep understanding of the complex issues surrounding specialist nurses from multiple data sets. A survey of the total specialist nurse population in 2013 (n=27), in-depth interviews with a group of specialist nurses (n=9) and four focus groups with key professionals and policy stakeholders (total n=28) were carried out. Data were collected between 2013 and 2015 and analysed using thematic analysis. FINDINGS: Three themes emerged: the roles and attributes of specialist nurses in Malta; the development of specialist nurses; and the influences on the advancement of specialist nursing practice in Malta. Although these data are nearly a decade old, no further research has been carried out. CONCLUSIONS: A legally accepted set of definitions as well as preparation and evaluation of the specialist nurse role from a national policy perspective is needed. Attitudes and systems that limit specialist nurses need to be challenged.

Addressing childhood obesity through policy: A cross-sectional study in Malta.

Introduction: Childhood overweight and obesity are major public health challenges, with Malta having one of the highest prevalences among European countries. The COVID-19 pandemic may further worsen this epidemic. The food and physical activity environments impact children's behaviours. This study looks at barriers to maintain a healthy weight, responsibility to address obesity, and assesses parental support for 22 policies aimed at addressing childhood obesity. Public support for policy is key because it influences which policies are adopted and their success. Methods: A cross-sectional, paper-based, quantitative survey was conducted amongst parents of primary school-aged children in Malta in 2018-2019. Ethical approval was obtained. Statistical analysis was performed using SPSS. Results: 1,169 parents participated. The food environment was more commonly identified as a barrier to maintain a healthy weight than the physical activity environment. Parents were least supportive of taxation policies, and most in favour of increasing spaces available for safe physical activity (94.0%), followed by providing free weight management services for children (90.8%). The level of support varied significantly by various socio-demographic/economic characteristics; parents with a higher educational level were significantly more supportive of most policies. Most findings were consistent with the international literature. Conclusions: Most policies supported are trans-sectoral; a health-in-all policies approach is needed to address the obesogenic environment. The strong public support identified for several policies should embolden policymakers to consider policy options that were not previously considered.

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

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

Rehabilitation Nurses' Knowledge About Pain in Older Adults in Malta.

PURPOSE: Rehabilitation nurses require adequate knowledge about pain to improve patient experience and quality of care. We explored nurses' knowledge and attitudes towards pain in older adults in a large rehabilitation hospital in Malta. DESIGN: A cross-sectional study. METHODS: In total, 130 nurses received a short survey, which gathered sociodemographic data, information regarding usual pain management, and prior education on pain. A modified version of the Knowledge and Attitudes Survey Regarding Pain (KASRP) with 18 questions was used, alongside the 24-item Pain in the Older Adults' Knowledge Survey (POAKS). Non-parametric tests identified factors associated with KASRP and POAKS scores. RESULTS: Overall, 89 nurses completed the survey (response rate 68%). The median modified KASRP score was 50% (IQR 3.00), with only two nurses achieving the proposed "adequate" score of >80%. The median POAKS score was 79% (IQR 4.00). The only determinant of performance was nationality, with Maltese nurses performing better in POAKS than non-Maltese nurses (median 20.00 (3.00) vs. 16.50 (5.00); p = .003), indicating a possible language-related performance issue. Nurses scored poorly in some questions relating to analgesia administration, particularly opioids, as well as pain indicators and pain assessment. CONCLUSIONS: Rehabilitation nurses have fair knowledge of pain management in older people but require further education, particularly in opioid indications for pain management, pain expression, and assessment.