Publications by authors named "Neville Calleja"

48 Publications

Cervical cancer and screening: knowledge, awareness and attitudes of women in Malta.

J Prev Med Hyg 2020 Dec 14;61(4):E584-E592. Epub 2021 Jan 14.

University of Malta, Msida, Malta.

Objectives: This study comes at an opportune time due to recent introduction of the National Cervical Cancer Screening programme in Malta. It aims to assess the knowledge of 25-64 year-old females on cervical cancer and attitudes towards screening.

Study Design: A cross-sectional, telephone-based, quantitative survey conducted in 2017.

Methods: The survey tool was based on the Cervical Cancer Awareness Measure questionnaire and was carried out among a random stratified sample of females of 25-64 years, resident in Malta. Multivariate logistic regression models were applied.

Results: 407 females (85% response rate) were interviewed. Knowledge of cervical cancer risk factors and symptoms was found to be significantly higher in women with a higher level of education (p < 0.001). Cervical screening was attended every 3 years by 69% of respondents. Regular attendees were more likely to have children (p = 0.001), have experienced cancer in a close family member (p = 0.002), and were between 35-44 and 45-54 years old (p < 0.001). The main reasons for non-attendance were embarrassment, fear of the test and fear of the result.

Conclusion: This research provides a better understanding of who are the vulnerable groups with respect to cervical cancer knowledge and screening attendance. Improving health literacy and implementing health promotion campaigns will improve early symptom recognition, risk factor knowledge and attendance for screening.
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http://dx.doi.org/10.15167/2421-4248/jpmh2020.61.4.1521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888396PMC
December 2020

GYNOCARE Update: Modern Strategies to Improve Diagnosis and Treatment of Rare Gynecologic Tumors—Current Challenges and Future Directions

Cancers (Basel) 2021 01 27;13(3). Epub 2021 Jan 27.

Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta.

More than 50% of all gynecologic tumors can be classified as rare (defined as an incidence of ≤6 per 100,000 women) and usually have a poor prognosis owing to delayed diagnosis and treatment. In contrast to almost all other common solid tumors, the treatment of rare gynecologic tumors (RGT) is often based on expert opinion, retrospective studies, or extrapolation from other tumor sites with similar histology, leading to difficulty in developing guidelines for clinical practice. Currently, gynecologic cancer research, due to distinct scientific and technological challenges, is lagging behind. Moreover, the overall efforts for addressing these challenges are fragmented across different European countries and indeed, worldwide. The GYNOCARE, COST Action CA18117 (European Network for Gynecological Rare Cancer Research) programme aims to address these challenges through the creation of a unique network between key stakeholders covering distinct domains from concept to cure: basic research on RGT, biobanking, bridging with industry, and setting up the legal and regulatory requirements for international innovative clinical trials. On this basis, members of this COST Action, (Working Group 1, “Basic and Translational Research on Rare Gynecological Cancer”) have decided to focus their future efforts on the development of new approaches to improve the diagnosis and treatment of RGT. Here, we provide a brief overview of the current state-of-the-art and describe the goals of this COST Action and its future challenges with the aim to stimulate discussion and promote synergy across scientists engaged in the fight against this rare cancer worldwide.
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http://dx.doi.org/10.3390/cancers13030493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865420PMC
January 2021

Real-time monitoring shows substantial excess all-cause mortality during second wave of COVID-19 in Europe, October to December 2020.

Euro Surveill 2021 01;26(2)

Department of Veterinary and Animal Science, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark.

The European monitoring of excess mortality for public health action (EuroMOMO) network monitors weekly excess all-cause mortality in 27 European countries or subnational areas. During the first wave of the coronavirus disease (COVID-19) pandemic in Europe in spring 2020, several countries experienced extraordinarily high levels of excess mortality. Europe is currently seeing another upsurge in COVID-19 cases, and EuroMOMO is again witnessing a substantial excess all-cause mortality attributable to COVID-19.
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http://dx.doi.org/10.2807/1560-7917.ES.2021.26.1.2002023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809719PMC
January 2021

Urban-suburban differences in the demographics and clinical profiles of type 2 diabetic patients attending primary healthcare centres in Malta.

Rural Remote Health 2020 11 19;20(4):5666. Epub 2020 Nov 19.

Department of Family Medicine, University of Malta, Tal-Qroqq, Msida, MSD 2080, Malta

Introduction: Social factors might bring about health inequities. Vulnerable population groups, including those suffering from non-communicable diseases such as type 2 diabetes and depression, might be more prone to suffering the effects of such inequities. This study aimed to identify patients with type 2 diabetes with depression in a primary care setting, with the objective of describing health inequities among urban and suburban dwellers.

Methods: A quantitative, retrospective and descriptive study was carried out among patients with diabetes attending public primary healthcare centres in different regions of Malta. Participants completed a self-administered questionnaire to identify patient and disease characteristics. Convenience sampling was used.

Results: The logistic regression model predicting the likelihood of different factors occurring with suburban patients with diabetes as opposed to those residing in urban areas contained five independent variables (severity of depression, monthly income, blood capillary glucose readings, weight and nationality). The full model containing all predictors was statistically significant, c2 (5, n=400), p<0.001, indicating that the model was able to distinguish between urban and suburban areas. The model as a whole explained between 10% (Cox and Snell R2) and 20% (Nagelkerke R2) of the variance in urban and suburban areas, and correctly classified 73.8% of cases. All five of the independent variables made a unique, statistically significant contribution to the model. Elevated blood glucose and obesity tended to be more prevalent in suburban respondents than in urban participants. Conversely, participants with diabetes living in urban areas were more likely to be depressed, non-Maltese and have a higher income.

Conclusion: Despite the small size of the Maltese islands and the expected social homogeneity, health inequities still exist, highlighting the importance of social factors in the epidemiology of disease. This study provides information for healthcare professionals and policy-makers to mitigate the effects of social inequities on vulnerable population groups.
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http://dx.doi.org/10.22605/RRH5666DOI Listing
November 2020

The effect of global warming on mortality.

Early Hum Dev 2020 Oct 6:105222. Epub 2020 Oct 6.

Department of Public Health, Faculty of Medicine and Surgery, University of Malta, Malta.

There is a significant relationship between ambient temperature and mortality. In healthy individuals with no underlying co-morbid conditions, there is an efficient heat regulation system which enables the body to effectively handle thermal stress. However, in vulnerable groups, especially in elderly over the age of 65 years, infants and individuals with co-morbid cardiovascular and/or respiratory conditions, there is a deficiency in thermoregulation. When temperatures exceed a certain limit, being cold winter spells or heat waves, there is an increase in the number of deaths. In particular, it has been shown that at temperatures above 27 °C, the daily mortality rate increases more rapidly per degree rise compared to when it drops below 27 °C. This is especially of relevance with the current emergency of global warming. Besides the direct effect of temperature rises on human health, global warming will have a negative impact on primary producers and livestock, leading to malnutrition, which will in turn lead to a myriad of health related issues. This is further exacerbated by environmental pollution. Public health measures that countries should follow should include not only health-related information strategies aiming to reduce the exposure to heat for vulnerable individuals and the community, but improved urban planning and reduction in energy consumption, among many others. This will reduce the carbon footprint and help avert global warming, thus reducing mortality.
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http://dx.doi.org/10.1016/j.earlhumdev.2020.105222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536190PMC
October 2020

Domestic violence among the elderly during the COVID-19 pandemic.

Rev Esp Geriatr Gerontol 2021 Jan-Feb;56(1):64. Epub 2020 Jun 4.

Faculty of Medicine and Surgery, University of Malta, Malta.

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http://dx.doi.org/10.1016/j.regg.2020.05.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269947PMC
January 2021

Withdrawn: Theoretical novel COVID-19 vaccination risk of rare and severe adverse events versus COVID-19 mortality.

Early Hum Dev 2020 Oct 1:105212. Epub 2020 Oct 1.

Department for Policy in Health - Health Information and Research, Malta. Electronic address:

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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http://dx.doi.org/10.1016/j.earlhumdev.2020.105212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528827PMC
October 2020

Brief tobacco cessation interventions: Practices, opinions, and attitudes of healthcare professionals.

Tob Prev Cessat 2020 26;6:48. Epub 2020 Aug 26.

Department for Policy in Health, Directorate for Health Information and Research, Ministry for Health, Pietà, Malta.

Introduction: Although brief smoking cessation interventions that follow the 5As algorithm (Ask, Advise, Assess, Assist, Arrange) can trigger smokers to quit, routine delivery remains low in Europe. This study aimed to identify the extent of smoking cessation practices of healthcare professionals interested in tobacco cessation, and their opinions and attitudes.

Methods: A quantitative, cross-sectional survey design was adopted. Healthcare professionals (n=133) who attended one of ten training sessions on brief interventions for smoking cessation, held every month between September 2018 and June 2019 in Malta, were recruited. Univariate logistic regression and non-parametric tests were carried out to identify associations by participants' characteristics. Potential confounders were ruled out following multivariate analyses.

Results: Most participants were female nurses who had never smoked. While most professionals reportedly asked (76.3%), advised (83.5%) and assessed (70.5%) patients for cessation, fewer provided assistance (40.9%) and arranged followup (24.2%). Compared to other participants, doctors were more likely to have counselled patients over the previous week. Most professionals were favourably disposed towards counselling patients to quit, however, they claimed they had insufficient time to do so. Although most found it difficult to get clients to quit, former smokers were more likely to disagree when compared to those who never smoked (OR=6.86; 95% CI: 2.17-21.71; p=0.001).

Conclusions: While more initiatives to train healthcare professionals in providing smoking cessation interventions are recommended, lack of sufficient time, being an organisational barrier, requires healthcare management exploration and action. Given that former smokers were more confident in helping patients quit, engaging them in training activities would be of added value.
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http://dx.doi.org/10.18332/tpc/125353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493645PMC
August 2020

Measuring disability-adjusted life years (DALYs) due to low back pain in Malta.

Arch Public Health 2020 23;78:68. Epub 2020 Jul 23.

Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium.

Background: Low back pain (LBP) is a public health concern and a leading cause of ill health. A high prevalence of musculoskeletal complaints has been reported for Malta, a small European state. The aim was to estimate for the first time the burden of LBP at population level in Malta in terms of disability-adjusted life years (DALYs) and compare to estimates obtained by the Global Burden of Disease (GBD) study.

Method: The Maltese European Health Interview Survey dataset for 2015 provided the LBP prevalence data through representative self-reported history of chronic LBP within the past 12 months in combination with limitations to daily activities. Proportions of LBP severity (with and without leg pain - mild, moderate, severe and most severe) and their corresponding disability weights followed values reported in the GBD study. Years lived with disability (YLD) for LBP were estimated for the whole population by age and sex. Since LBP does not carry any mortality, YLD reflected DALYs. The estimated local DALYs per 100,000 were compared to the GBD 2017 study results for Malta for the same year.

Results: LBP with activity limitation gave a point prevalence of 6.4% (95% Uncertainty Interval [UI] 5.7-7.2%) (5.6% males [95% UI 4.6-6.6%]; 7.3% females [95% UI 6.2-8.4%]), contributing to a total of 23,649 (95% UI 20,974-26,463) Maltese suffering from LBP. The LBP DALYs were of 716 (95% UI 558-896) per 100,000. Females experienced higher LBP burden (739 [95% UI 575-927] DALYs per 100,000) than males (693 [95% UI 541-867] DALYs per 100,000). Our DALY estimates were lower than those reported by the GBD 2017 study (i.e., 1829 [95% UI 1300-2466] per 100,000).

Conclusions: LBP imposes a substantial burden on the Maltese population. Differences observed between national estimates and those of the GBD study suggest the integration of updated locally sourced data into the model and encouraging local contributors in order to improve the DALY estimates of each country.
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http://dx.doi.org/10.1186/s13690-020-00451-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7379821PMC
July 2020

Rising Incidence of Glioblastoma Multiforme in a Well-Defined Population.

Cureus 2020 May 19;12(5):e8195. Epub 2020 May 19.

Department of Neurosurgery, Mater Dei Hospital, Msida, MLT.

Background and Objectives The incidence of glioblastoma multiforme (GBM) ranges from 0.59 to 5 per 100,000 persons, and it is on the rise in many countries. The reason for this rise is multifactorial, and possible contributing factors include an aging population, overdiagnosis, ionizing radiation, air pollution and others. The aim of this study is to conduct an epidemiological study of GBM in a well-defined population over a 10-year period and determine its significance, while comparing results with international standards. Materials and Methods All histological diagnoses of GBM in Malta from 2008 to 2017 were identified. Poisson regression was used to determine significance in incidence variation. Log-rank tests were used to compare the survival distributions of each variable. Cox regression for survival analysis with the Breslow method for ties was then performed to consider the overall model. Results A total of 100 patients (61 males; mean age 60.29±10.09 years) were diagnosed with GBM over the period 2008 to 2017. There was a significant increase in incidence from 0.73 to 4.49 per 100,000 over the 10-year period (p≤0.001). The most common presenting complaint was limb paresis (29%). Approximately 65% of patients were treated with maximum safe resection (MSR). Using Cox regression analysis, younger age at presentation and treatment with MSR significantly improved survival (p=0.026 and p≤0.001, respectively). The median survival was 10 months. Conclusions An increasing incidence of GBM is becoming evident, while the median survival remains low. This troubling trend emphasizes the importance of further research into GBM etiology and treatment.
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http://dx.doi.org/10.7759/cureus.8195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302718PMC
May 2020

Framework for Managing the COVID-19 Infodemic: Methods and Results of an Online, Crowdsourced WHO Technical Consultation.

J Med Internet Res 2020 06 26;22(6):e19659. Epub 2020 Jun 26.

Global Infectious Hazards Preparedness, Emergency Preparedness, World Health Organization, Geneva, Switzerland.

Background: An infodemic is an overabundance of information-some accurate and some not-that occurs during an epidemic. In a similar manner to an epidemic, it spreads between humans via digital and physical information systems. It makes it hard for people to find trustworthy sources and reliable guidance when they need it.

Objective: A World Health Organization (WHO) technical consultation on responding to the infodemic related to the coronavirus disease (COVID-19) pandemic was held, entirely online, to crowdsource suggested actions for a framework for infodemic management.

Methods: A group of policy makers, public health professionals, researchers, students, and other concerned stakeholders was joined by representatives of the media, social media platforms, various private sector organizations, and civil society to suggest and discuss actions for all parts of society, and multiple related professional and scientific disciplines, methods, and technologies. A total of 594 ideas for actions were crowdsourced online during the discussions and consolidated into suggestions for an infodemic management framework.

Results: The analysis team distilled the suggestions into a set of 50 proposed actions for a framework for managing infodemics in health emergencies. The consultation revealed six policy implications to consider. First, interventions and messages must be based on science and evidence, and must reach citizens and enable them to make informed decisions on how to protect themselves and their communities in a health emergency. Second, knowledge should be translated into actionable behavior-change messages, presented in ways that are understood by and accessible to all individuals in all parts of all societies. Third, governments should reach out to key communities to ensure their concerns and information needs are understood, tailoring advice and messages to address the audiences they represent. Fourth, to strengthen the analysis and amplification of information impact, strategic partnerships should be formed across all sectors, including but not limited to the social media and technology sectors, academia, and civil society. Fifth, health authorities should ensure that these actions are informed by reliable information that helps them understand the circulating narratives and changes in the flow of information, questions, and misinformation in communities. Sixth, following experiences to date in responding to the COVID-19 infodemic and the lessons from other disease outbreaks, infodemic management approaches should be further developed to support preparedness and response, and to inform risk mitigation, and be enhanced through data science and sociobehavioral and other research.

Conclusions: The first version of this framework proposes five action areas in which WHO Member States and actors within society can apply, according to their mandate, an infodemic management approach adapted to national contexts and practices. Responses to the COVID-19 pandemic and the related infodemic require swift, regular, systematic, and coordinated action from multiple sectors of society and government. It remains crucial that we promote trusted information and fight misinformation, thereby helping save lives.
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http://dx.doi.org/10.2196/19659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332158PMC
June 2020

Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study.

PLoS Med 2020 05 22;17(5):e1003103. Epub 2020 May 22.

Department of Midwifery Science, AVAG, Amsterdam Public Health research institute, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands.

Background: Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics.

Methods And Findings: In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.

Conclusions: Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.
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http://dx.doi.org/10.1371/journal.pmed.1003103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7244098PMC
May 2020

The Finger-Prick Sign of Diabetes: An Observational Study Including Dermatoscopic Features.

Skinmed 2019 1;17(6):374-378. Epub 2019 Nov 1.

Dermatology, Sir Paul Boffa Hospital, Floriana, Malta.

This study aimed to define the clinical features and prevalence of the finger-prick sign in a cohort of persons with diabetes mellitus (DM). One hundred and five consecutive persons with DM attending a hospital diabetes clinic ( = 44) or a dermatology out-patients clinic ( = 61) who performed self-monitoring of blood glucose (SMBG) at least once daily and 105 age- and sex-matched controls were examined for typical prick marks on any of their fingers. The sign was positive (two or more prick marks visible) in 88 participants (84%), with strong positive correlation between the stated daily SMBG frequency and the number of prick marks observed, = 0.723, < 0.0001. Prick mark numbers were highest for the ring followed by the little, middle, and index fingers and lowest for the thumb, and varied significantly between the different fingers ( < 0.0001). Overall, prick marks were commoner on the non-dominant hand compared to the dominant hand ( < 0.0001). None of the controls had any visible finger-prick marks. The finger-prick sign is positive in most persons with DM who perform SMBG, particularly in those who test more frequently. It is a pointer to DM that can be clinically useful, particularly in emergencies when a person's medical history is unobtainable.
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August 2020

Multivariate analysis of the correlation of sex ratio at birth with health and socioeconomic indicators.

Early Hum Dev 2020 02 16;141:104875. Epub 2019 Sep 16.

Academic Department of Paediatrics, Medical School, Mater Dei Hospital, Malta; Department for Policy in Health - Health Information and Research, Malta. Electronic address:

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http://dx.doi.org/10.1016/j.earlhumdev.2019.104875DOI Listing
February 2020

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

J Diabetes Metab Disord 2018 Dec 26;17(2):315-323. Epub 2018 Nov 26.

2Faculty of Medicine and Surgery, University of Malta, Msida, Malta.

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 ( = 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 a 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 a individuals across the glycaemic spectrum. 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.
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http://dx.doi.org/10.1007/s40200-018-0377-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405403PMC
December 2018

WASP (Write a Scientific Paper): The use of bibliographic management software.

Early Hum Dev 2019 01 18;128:118-119. Epub 2018 Sep 18.

Public Health Department, University of Malta, Msida, Malta; Directorate for Health Information and Research, Gwardamanga, Malta. Electronic address:

In the scholarly environment, research findings are disseminated as journal papers which support/dispute extant knowledge or add further to what is already known. The entire manuscript needs to be cited (in-text) and referenced (at the end of article), in order for readers to ascertain the validity of the research claim/s. This must be done in proper and accepted fashion as plagiarism is a serious misdeed and inappropriate referencing mars a paper. Recent advancements in technology have led to the development of bibliographic management software tools. These tools are available as both commercial and open source software, and constitute a database wherein researchers search, store and cite references. Furthermore, authors can not only create personalized databases but also cite stored articles when compiling a manuscript or report or indeed any other form of document. This software obviates human manual inputting errors and inaccurate referencing, while conveniently enabling citation and referencing in any referencing style required, for example, after rejection, when an author must almost perforce resubmit a prepared but rejected paper to a different journal after suitable amendments.
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http://dx.doi.org/10.1016/j.earlhumdev.2018.09.012DOI Listing
January 2019

Relationship of past, present, and passive smoking with sociodemographic, anthropometric, biochemical, and dysglycemic profiles.

J Diabetes 2019 Jan 23;11(1):87-89. Epub 2018 Sep 23.

Department of Public Health, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.

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http://dx.doi.org/10.1111/1753-0407.12844DOI Listing
January 2019

WASP (Write a Scientific Paper): Multivariate analysis.

Early Hum Dev 2018 08 19;123:42-45. Epub 2018 Apr 19.

Department for Policy in Health - Health Information and Research, Malta. Electronic address:

Linear regression is the equation which provides of straight line that best describes the association between two continuous variables, x and y. However, it is often the case that the dependent variable y is influenced by more than one variable and not just a single x variable. Multivariate analysis is a statistical modeling technique wherein multiple x variables are analysed simultaneously for their effect on y, resulting in an additive model (via an equation) that explains the observation/s and corrects for confounding association/s using one dependent and several independent variables, assigning a gradient to each of these independent variables, and with all product terms of gradient and magnitude of the independent variables adding up to estimate 'y'. This paper outlines these various techniques and applications.
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http://dx.doi.org/10.1016/j.earlhumdev.2018.04.012DOI Listing
August 2018

WASP (Write a Scientific Paper): Parametric vs. non-parametric tests.

Early Hum Dev 2018 08 17;123:48-49. Epub 2018 Apr 17.

Department for Policy in Health - Health Information and Research, Malta. Electronic address:

Data may be normally distributed in which case standard and relatively familiar tests may be used for inferential testing. Or data may be non-normally distributed, such as ordinal data, in which case, non-parametric tests are usually advocated. This paper will review current thinking with regard to these tests, and the appropriateness of their application/s.
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http://dx.doi.org/10.1016/j.earlhumdev.2018.04.014DOI Listing
August 2018

WASP (Write a Scientific Paper): Probability - Poisson and binomial distributions.

Early Hum Dev 2018 08 17;123:46-47. Epub 2018 Apr 17.

Department for Policy in Health - Health Information and Research, Malta. Electronic address:

This paper outlines Binomial and Poisson distributions which are both used to measure the occurrence of a number of random events within a certain period.
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http://dx.doi.org/10.1016/j.earlhumdev.2018.04.013DOI Listing
August 2018

Perceptions of first-year medical students towards learning anatomy using cadaveric specimens through peer teaching.

Anat Sci Educ 2018 Jul 7;11(4):346-357. Epub 2017 Nov 7.

Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.

During the last decade, global interest in the multiple benefits of formal peer teaching has increased. This study aimed to explore the perceptions of first-year medical students towards the use of peer teaching to learn anatomy using cadaveric specimens. A descriptive, cross-sectional, retrospective survey was carried out. Data were collected using an online questionnaire which was administered to all medical students who were in their second year of their medical school curriculum and who had participated in sessions taught by their peers during their first year. Peer teaching was perceived as an effective method of learning anatomy by more than half of the participants. Analysis of mean responses revealed that the peer teachers created a positive, non-intimidating learning environment. Overall, participants gave positive feedback on their peer teachers. Six categories emerged from the responses given by participants as to why they would or would not recommend peer teaching. Ways of improvement as suggested by the respondents were also reported. Variables found to be significantly associated with the perceived benefits of the peer teaching program included sex differences, educational level and recommendations for peer teaching. This study brings to light the merits and demerits of peer teaching as viewed through the eyes of the peer learners. Peer teaching provides a sound platform for teaching and learning anatomy. Further discussions at higher levels are encouraged in order to explore the feasibility of introducing formal peer teaching in the medical curriculum. Anat Sci Educ 11: 346-357. © 2017 American Association of Anatomists.
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http://dx.doi.org/10.1002/ase.1751DOI Listing
July 2018

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

Int J Hypertens 2017 28;2017:7107385. Epub 2017 Aug 28.

Department of Public Health, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.

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.
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http://dx.doi.org/10.1155/2017/7107385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592416PMC
August 2017

Psychometric properties of the Belief about Medicines Questionnaire (BMQ) in the Maltese language.

Pharm Pract (Granada) 2017 Jan-Mar;15(1):886. Epub 2017 Mar 15.

BPharm (Hons) (Melit), PhD. Associate Professor. Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine and Surgery, University of Malta, Msida (Malta).

Background: Investigating beliefs about medicines has been of interest over the past years, with studies aiming to better understand theoretical reasons behind development of such beliefs.

Objective: This study aimed to produce a culturally and contextually appropriate version of the Beliefs about Medicines Questionnaire (BMQ) in the Maltese language and to assess its psychometric properties.

Methods: Medication beliefs were evaluated using the BMQ which is divided into two sections: BMQ-General (sub-scales: Overuse and Harm, 4 items per sub-scale) and BMQ-Specific (sub-scales: Necessity and Concerns, 5 items per sub-scale). Following translation/back translation, the Maltese version of the BMQ was applied to patients having asthma, diabetes, cardiovascular disease or depression who attended out-patients' clinics at the main state general hospital in Malta between June and September 2013. Cronbach's alpha coefficient, alpha, was used to determine internal consistency of the BMQ and Principal Component Analysis using Varimax rotation with Kaiser normalisation was carried out to analyse component loading of the items on the respective sub-scales.

Results: The Maltese version of the BMQ showed acceptable internal consistency for the harm scale (alpha=0.56), the necessity scale (alpha=0.73) and the concerns scale (alpha=0.66), however the overuse scale gave poor internal consistency (alpha=0.48) due to the item on natural remedies which posed some difficulty in the Maltese sample. The final solution for Principal Component Analysis yielded a four-factor structure representing the 4 sub-scales of the BMQ, with results being comparable to previous studies out in different languages.

Conclusion: The Maltese version of the BMQ was found to have acceptable psychometric properties for the beliefs about medicines in the Maltese population.
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http://dx.doi.org/10.18549/PharmPract.2017.01.886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5386625PMC
March 2017

Malta: Health System Review.

Health Syst Transit 2017 Jan;19(1):1-137

European Observatory on Health Systems and Policies.

Maltese life expectancy is high, and Maltese people spend on average close to 90% of their lifespan in good health, longer than in any other EU country. Malta has recently increased the proportion of GDP spent on health to above the EU average, though the private part of that remains higher than in many EU countries. The total number of doctors and GPs per capita is at the EU average, but the number of specialists remains relatively low; education and training are being further strengthened in order to retain more specialist skills in Malta. The health care system offers universal coverage to a comprehensive set of services that are free at the point of use for people entitled to statutory provision. The historical pattern of integrated financing and provision is shifting towards a more pluralist approach; people already often choose to visit private primary care providers, and in 2016 a new public-private partnership contract for three existing hospitals was agreed. Important priorities for the coming years include further strengthening of the primary and mental health sectors, as well as strengthening the health information system in order to support improved monitoring and evaluation. The priorities of Malta during its Presidency of the Council of the EU in 2017 include childhood obesity, and Structured Cooperation to enhance access to highly specialized and innovative services, medicines and technologies. Overall, the Maltese health system has made remarkable progress, with improvements in avoidable mortality and low levels of unmet need. The main outstanding challenges include: adapting the health system to an increasingly diverse population; increasing capacity to cope with a growing population; redistributing resources and activity from hospitals to primary care; ensuring access to expensive new medicines whilst still making efficiency improvements; and addressing medium-term financial sustainability challenges from demographic ageing.
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January 2017

Excess all-cause and influenza-attributable mortality in Europe, December 2016 to February 2017.

Euro Surveill 2017 Apr;22(14)

Statens Serum Institut, Copenhagen, Denmark.

Since December 2016, excess all-cause mortality was observed in many European countries, especially among people aged ≥ 65 years. We estimated all-cause and influenza-attributable mortality in 19 European countries/regions. Excess mortality was primarily explained by circulation of influenza virus A(H3N2). Cold weather snaps contributed in some countries. The pattern was similar to the last major influenza A(H3N2) season in 2014/15 in Europe, although starting earlier in line with the early influenza season start.
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http://dx.doi.org/10.2807/1560-7917.ES.2017.22.14.30506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388126PMC
April 2017

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.

Diabetes Metab Syndr 2017 Nov 6;11 Suppl 1:S321-S327. Epub 2017 Mar 6.

Head of Department of Public Health, Faculty of Medicine and Surgery, University of Malta, Msida, Malta. Electronic address:

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.
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http://dx.doi.org/10.1016/j.dsx.2017.03.009DOI Listing
November 2017

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

Arch Public Health 2016 12;74:52. Epub 2016 Dec 12.

Department of Public Health, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.

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.
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http://dx.doi.org/10.1186/s13690-016-0164-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151145PMC
December 2016

The Malta Childhood National Body Mass Index Study: A Population Study.

J Pediatr Gastroenterol Nutr 2017 09;65(3):327-331

*Paediatric Department, Mater Dei Hospital, Tal-Qroqq †EU and International Affairs, Research and Policy Development Directorate, Floriana ‡Malta Association of Physiotherapists §Ministry for Social Dialogue, Consumer Affairs and Civil Liberties, Valletta ||Child Health Services, Primary Health Care, Floriana ¶Department of Health Information and Research, Guardamangia, Malta.

Objectives: Obesity is a chronic disease that often commences in childhood. More than a quarter of Maltese children are overweight or obese. The present study was carried out to measure height and weight (and body mass index) for all school children in Malta to precisely quantify the extent of the problem.

Methods: Schooling in Malta is provided by: free state schools, subsidized Roman Catholic church-run schools, and independent private schools. All were included. Physical education teachers were trained in measurements on identical stadiometers. Bespoke spreadsheets were created using World Health Organization cut-offs for underweight, overweight, and obesity.

Results: The present study included more than 46,027 children in more than 145 schools (ages 4.7-17 years). Less than 10% were unmeasured. Approximately 40% of school-aged children in Malta are overweight or obese. The proportion of obese was greater than that of overweight. Levels of overweight and obesity were significantly different: State>Church>Independent schools. Overall, and for both sexes and for school types, there was a trend for overweight and obesity to peak in years 5 to 8, then decline slightly. Overweight and obesity was secondary>primary schools, and boys>girls. The underweight group was small with no significant difference between the school types.

Conclusions: The present study has confirmed high levels of overweight and obesity in Maltese children. It also provides proof of concept of scalability by demonstrating the feasibility of undertaking a relatively inexpensive study of an entire childhood population. The modus operandi (utilizing physical education teachers) could relatively easily be up scaled for any country.
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http://dx.doi.org/10.1097/MPG.0000000000001430DOI Listing
September 2017

Prognostic indicators and generation of novel risk equations for estimation of 10-year and 20-year mortality following acute coronary syndrome.

Postgrad Med J 2017 May 19;93(1099):245-249. Epub 2016 Aug 19.

University of Malta Medical School, Mater Dei Hospital, Msida, Malta.

Objectives: Although risk assessment is an integral part of management, there are currently no risk calculators of long-term mortality after acute coronary syndrome (ACS). The aim was to provide risk equations for 10-year and 20-year mortality following ACS.

Methods: Patients hospitalised with ACS from December 1990 to June 1994 were recruited and followed up through 31 December 2012.

Results: The study followed 881 patients for 10 years and 712 patients for 20 years. Using Cox regression analysis, 20-year all-cause mortality was associated with myocardial infarction (MI) in the index admission, age and diabetes mellitus (DM). Twenty-year cardiovascular disease (CVD) and cardiac mortality were both associated with MI in the index admission, age, DM and female gender. 10-year all-cause mortality was associated with age and total cholesterol levels; age, DM and total cholesterol levels were found to be independent predictors of 10-year CVD and cardiac mortality. Risk equations were consequently generated for 10-year and 20-year cardiac, cardiovascular and all-cause mortality, with age and DM emerging as the strongest and most consistent predictors of all outcomes studied.

Conclusions: Novel risk equations for all-cause, cardiovascular and cardiac mortality at 10 and 20 years were generated using follow-up data in a large patient population.
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http://dx.doi.org/10.1136/postgradmedj-2016-134129DOI Listing
May 2017

Contribution of Congenital Anomalies to Neonatal Mortality Rates in Malta.

Paediatr Perinat Epidemiol 2015 Sep 30;29(5):401-6. Epub 2015 Jun 30.

Directorate for Health Information and Research, Malta.

Background: Neonatal mortality is a public health concern, and congenital anomalies contribute significantly to this mortality. This paper describes trends in neonatal mortality in Malta separately for congenital anomaly and non-congenital anomaly causes.

Methods: Data for neonatal deaths of 22-week gestation onwards registered between 1994-2013 were obtained from the National Mortality Register. Chi-square tests were used to analyse 5-year time trends and differences in proportions of causes of neonatal deaths. Neonatal mortality was compared with other European countries.

Results: Between 1994 and 2013, 441 neonatal deaths and 84 821 livebirths were registered, giving a neonatal mortality of 5.2 per 1000 livebirths. Congenital anomalies accounted for 36.7% (n = 162) of the neonatal deaths, while the remaining 63.3% (n = 279) were attributed to non-congenital causes. During the 20-year period, neonatal mortality due to non-congenital causes decreased from 4.6 per 1000 livebirths in 1994-98 to 2.5 per 1000 in 2009-13, while that due to congenital anomalies remained stable (2.0 per 1000 livebirths in 1994-98 and 2.2 per 1000 in 2009-13). This has resulted in comparatively higher proportions of neonatal deaths attributed to congenital anomalies in recent years (45.9% in 2009-13 vs. 29.9% in 1994-98). Comparing neonatal mortality reported from European countries, Malta has a high rate most marked for deaths due to congenital anomalies.

Conclusions: During 1994-2013, neonatal mortality has decreased due to a decline of non-congenital causes of death, possibly related to improved health care. The proportionate neonatal mortality attributed to congenital anomalies has increased and is the highest reported from Europe. This may be explained by the fact that termination of pregnancy is illegal in Malta.
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http://dx.doi.org/10.1111/ppe.12206DOI Listing
September 2015