Publications by authors named "Stephen Montefort"

41 Publications

Rituximab therapy in a patient with steroid-refractory bird fancier's lung.

BMJ Case Rep 2020 Dec 22;13(12). Epub 2020 Dec 22.

Department of Respiratory Medicine, Mater Dei Hospital, L-Imsida, Malta.

A 62-year-old woman presented with a 3-month history of shortness of breath on exertion and dry cough. On examination, she was noted to have fine end-inspiratory crepitations over the upper zone of the lungs. Pulmonary function tests (PFTs) showed a restrictive defect. Initial chest radiography revealed diffuse reticular interstitial shadowing while high-resolution CT scan of the thorax showed fibrotic changes. Avian precipitins were also highly positive for pigeons, parrots and budgerigars. Taking into account these results, the patient was diagnosed with hypersensitivity pneumonitis. Antigen avoidance, oral glucocorticoids and azathioprine achieved an initial improvement in PFTs and symptoms; however, the patient still deteriorated, requiring long-term oxygen therapy. While working the patient up for lung transplantation, rituximab was given to good effect (acting as a bridging therapy) as it achieved symptomatic relief and stabilisation of her PFTs.
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http://dx.doi.org/10.1136/bcr-2020-237232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757452PMC
December 2020

Self-reported satisfaction of patients receiving omalizumab for severe allergic asthma in Malta.

Biologicals 2019 Jul 18;60:24-27. Epub 2019 Jun 18.

Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta.

Treatment satisfaction is of utmost importance for ensuring adherence. Omalizumab is administered long-term if effective and well-tolerated in a hospital setting. The aim was to evaluate treatment satisfaction with omalizumab in Malta and to identify factors that may influence patients' satisfaction. A questionnaire was distributed to all asthmatic adult patients receiving omalizumab for at least one year. The questionnaire included demographic data, dosing regimen, asthma control test and the 14-item English version of the Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4. The TSQM 1.4 domain scores range from 0 to 100. Higher scores represent higher satisfaction. Our cohort included 33 patients (52% males), mean age 53.7 ± 11 years, mean baseline IgE level 510.6IU/ml, mean duration of treatment 3.8 ± 1.98 years and mean number of injections per month 4.6 ± 2.6. Median TSQM scores were as follows: graded effectiveness 78%, graded side effects 100%, graded convenience 74.2% and overall satisfaction 76%. Regression analysis showed that convenience score, effectiveness score and ACT score were significantly associated with global satisfaction. Global satisfaction scored high among the Maltese cohort of patients despite the inconvenience and side effects associated with receiving omalizumab. This is an add-on beneficial effect to the efficacy and effectiveness already been achieved with this medication.
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http://dx.doi.org/10.1016/j.biologicals.2019.06.004DOI Listing
July 2019

Pulmonary Rehabilitation in patients with Interstitial Lung Disease: The effects of a 12-week programme.

Respir Med 2019 01 23;146:49-56. Epub 2018 Nov 23.

University of Malta, Msida, Malta. Electronic address:

Background: The inclusion of Pulmonary Rehabilitation as part of the management of Interstitial Lung Disease, although being highly recommended in most recent guidelines, still has limited studies exploring the outcomes from such an intervention. The present study aims to contribute to the available literature by investigating the effects of a high intensity, 12 week PR programme on functional and quality of life measures in patients with a diagnosis of Interstitial Lung Disease.

Method: ology: This paper reports outcomes of an observational, prospective, quasi experimental type of study. A total of 120 participants were recruited: 60 patients formed part of the active group, and another 60 patients were enrolled in an inactive group. Each participant was classified according to the modified Medical Research Council dyspnoea scale and placed in one of 5 categories (0-4) according to self-perceived breathlessness during daily activities. The following outcomes were measured: Lung function tests including plethysmography and diffusion capacity of carbon monoxide (DCO), functional tests (6-min walking distance test, Dyspnoea Borg Scale) and health status measures (St George's Respiratory Questionnaire and Hospital Anxiety and Depression Score).

Results: A 12-week PR programme for patients with Interstitial Lung Disease, led to significant improvements in the active group of patients in the 6 min walking distance test, the modified Borg Scale, mMRC scores and in the health status measures. Lung function measures did not show any significant improvement following this intervention.

Conclusion: This 12week Pulmonary Rehabilitation programme resulted in improvements in functional aspects for patients with Interstitial Lung Disease. Further studies are recommended as Pulmonary Rehabilitation for Interstitial Lung Disease may have an impact at both an individual level and at global organisational/financial levels.
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http://dx.doi.org/10.1016/j.rmed.2018.11.007DOI Listing
January 2019

Impact of School Air Quality on Children's Respiratory Health.

Indian J Occup Environ Med 2018 Sep-Dec;22(3):156-162

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

Background: Asthma is common in children with indoor pollutants influencing the development of the disease. Since children spend most of their time outside their homes within the school environment, school indoor air quality can directly influence their respiratory health.

Aims: This study aims to analyze the indoor and outdoor air quality of Maltese schools and if an association exists between indoor pollutants and respiratory health in children.

Settings And Design: Five primary schools were selected with 9- to 11-year-old students participating.

Materials And Methods: Standardized health questionnaires and lung function tests were utilized. Indoor and outdoor air sampling together with traffic counts were carried out.

Statistical Analysis Used: SPSS version 21 was used and the Chi-squared, logistic regression, and Pearson's correlation were used.

Results: The mean indoor PM 2.5 level of 17.78 μg/m and CO (9.11 ppm) exceeded World Health Organization thresholds. Indoor ozone levels exceeded the mean European school's indoor ozone concentration of 8 μg/m. High exposure to formaldehyde, NO, and ozone was associated with atopy in children. Heavy vehicles passing near the schools were associated with current wheezing ( < 0.001) but not nocturnal cough ( = 0.34).

Conclusions: School indoor and outdoor environment has a direct impact on children's respiratory health. This study has identified significant associations between high exposures to indoor air pollutants, school characteristics, and upper and lower airway inflammation.
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http://dx.doi.org/10.4103/ijoem.IJOEM_95_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309359PMC
January 2019

Food consumption and the risk of childhood allergy.

Asia Pac Allergy 2018 Oct 16;8(4):e35. Epub 2018 Oct 16.

Department of Medicine, Mater Dei Hospital, Msida, Malta.

Background: The prevalence of allergic conditions is increasing in most countries. One possible explanation may be childhood nutrition.

Objective: The aim of the study was to investigate the relationship between consumption of pre-specified types of food in school-aged children and presence of respiratory and allergic symptoms.

Methods: A total of 191 students aged 9-11 years were recruited from 5 schools to geographically cover all of Malta. Data was collected between October 2011 and February 2012. This was part of a bigger study which included clinical and environmental tests besides standardized health questionnaires. For the purposes of this part of the study only the health questionnaires were used. These standardized health questionnaires based on the International Study of Asthma and Allergies in Childhood (ISAAC) were used to identify the presence of respiratory and allergic symptoms and to identify the types of foods and the frequency of consumption of various types of foods.

Results: We found that milk, meat, butter, olive oil, and yoghurt consumption had a negative association with allergic symptoms in children, whilst fish consumption had a detrimental effect. These relationships remained significant after correction for paternal level of education.

Conclusion: The study highlights the fact that nutrition in early childhood may have a significant effect on the risk of allergic conditions. Our results, taken together with data in the literature, suggest that different types of fish might have had different effects. This is probably related to their different fatty acid constitution thus warranting further studies.
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http://dx.doi.org/10.5415/apallergy.2018.8.e35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209597PMC
October 2018

Unusual case of primary pulmonary Hodgkin's lymphoma presenting with a continuous murmur.

BMJ Case Rep 2018 Sep 28;2018. Epub 2018 Sep 28.

Respiratory Department, Mater Dei Hospital, Msida, Malta.

Systemic to pulmonary fistulas are an unusual entity, even more so in association with Hodgkin's lymphoma. We herein report a case of a 33-year-old woman that presented with an incidental lung lesion on a chest radiograph with an associated high-frequency continuous murmur over the lesion. The diagnosis of primary pulmonary Hodgkin's lymphoma, nodular sclerosis type, was obtained by a CT transthoracic biopsy. We achieved an excellent response after polychemotherapy with near-complete disappearance of the mass and a residual faint systolic murmur over the lesion.
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http://dx.doi.org/10.1136/bcr-2018-225674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169648PMC
September 2018

Eosinophilic gastrointestinal disorder: is it what it seems to be?

Ann Gastroenterol 2018 Jul-Aug;31(4):475-479. Epub 2018 Apr 27.

Division of Gastroenterology, Department of Medicine (Stefania Chetcuti Zammit, Pierre Ellul), Mater Dei Hospital, Malta.

Background: Eosinophilic gastroenteropathy is an uncommon condition whose causes can be numerous and non-specific. The aim of the study was to characterize the presence of gastrointestinal disorders in the adult Maltese population and assess the degree of association with atopic diseases.

Methods: Adult patients with gastrointestinal eosinophilia in the gastrointestinal tract on histology were identified and their clinical case notes were reviewed. Patients were interviewed and asked questions regarding asthma, allergic rhinitis, and eczema.

Results: Sixty-six patients (39 female) were recruited. The most common clinical symptoms were diarrhea (42.4%) and abdominal pain (33.3%). The sites involved were stomach (10.6%), colon (56.1%), small bowel (10.6%), small bowel and colon (18.2%), esophagus (1.5%), and esophagus and colon (1.5%). Forty percent had persistent lower gastrointestinal symptoms and a repeat ileocolonoscopy was performed within 12 months. These patients were diagnosed with ulcerative colitis (n=10; 47.6%), Crohn's disease (n=6; 28.6%), indeterminate colitis (n=1; 4.8%) or microscopic colitis (n=4; 19%). Allergic rhinitis was present in 39.4% of the study group, eczema in 26.1%, and asthma in 19.7%. These findings were compared with local data for atopic conditions and the study group was found to have a significantly higher prevalence of allergic rhinitis (P=0.002), but not of asthma (P=0.62) or eczema (P=0.19).

Conclusions: A high proportion of patients with eosinophilic gastrointestinal infiltration were subsequently diagnosed with inflammatory bowel disease. Patients persistently symptomatic or who do not respond to treatment should be reassessed to exclude inflammatory bowel disease, given its high prevalence in this group of patients.
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http://dx.doi.org/10.20524/aog.2018.0263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033761PMC
April 2018

Relationship between domestic smoking and metals and rare earth elements concentration in indoor PM.

Environ Res 2018 08 16;165:71-80. Epub 2018 Apr 16.

Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Palermo, Italy.

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-h PM indoor/outdoor monitoring. PM mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children.
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http://dx.doi.org/10.1016/j.envres.2018.03.026DOI Listing
August 2018

Caseous mitral annular calcification mimicking a lung tumor on chest X-ray.

J Family Med Prim Care 2017 Apr-Jun;6(2):442-444

Department of Medicine, Mater Dei Hospital, Msida, Malta.

Mitral annular calcification (MAC) is a common condition of the mitral valve apparatus. A case involving caseous calcification, a rare variant of MAC is presented. This variant which has a benign course can present as an intracardiac mass and needs to be differentiated from more sinister causes of calcified cardiac masses such as tumor, abscess, and infective vegetation. Often, this requires multimodality imaging with echocardiography, computed tomography, and magnetic resonance imaging. Features of caseous calcification of the mitral valve on these imaging modalities are reviewed as the associations and clinical features.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_416_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749103PMC
January 2018

Health status of COPD patients undergoing pulmonary rehabilitation: A comparative responsiveness of the CAT and SGRQ.

Chron Respir Dis 2017 Nov 15;14(4):352-359. Epub 2017 Mar 15.

5 Department of Medicine, Faculty of Medicine and Surgery; University of Malta, Msida, Malta.

The St. George's Respiratory Questionnaire (SGRQ) and chronic obstructive pulmonary disease (COPD) assessment test (CAT) are the measures used to assess health status. This study aims to examine the responsiveness of these tools by severity of dyspnoea category in patients with COPD. Forty-nine COPD patients who underwent a 12-week pulmonary rehabilitation (PR) programme were assessed at baseline, 12 weeks and at 28-week follow-up. Patients were categorized into two groups by severity of dyspnoea category (i.e. mild to moderate (modified Medical Research Council (mMRC) 1-2) and severe to very severe (mMRC 3-4)) using the mMRC dyspnoea scale. Effect size (ES) was computed as estimates of responsiveness. The SGRQ demonstrated greater responsiveness by total sample (SGRQ, ES = 0.87; CAT, ES = 0.75) and for the mMRC 3-4 category (SGRQ, ES = 0.91; CAT, ES = 0.76) on completion of PR. At 28-week follow-up, overall comparable responsiveness of the CAT and SGRQ was identified by total sample (SGRQ, ES = 0.75; CAT, ES = 0.74) and by severity of dyspnoea category. The symptom, impact and activity domains of the SGRQ showed good responsiveness, with greater ESs obtained overall for the mMRC 3-4 category. On completion of PR, the SGRQ demonstrates a greater responsiveness with COPD patients, especially in relation to the mMRC 3-4 category, while both the CAT and SGRQ show comparable responsiveness on follow-up.
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http://dx.doi.org/10.1177/1479972317694622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729730PMC
November 2017

Continuous Positive Airway Pressure: Is it a route for infection in those with Obstructive Sleep Apnoea?

Sleep Sci 2017 Jan-Mar;10(1):28-34

Department of Medicine, Mater Dei Hospital, Msida, Malta.

Introduction: Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients.

Objectives: The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients.

Method: A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers.

Results: 66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively.

Conclusions: This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and micro-organisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users.
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http://dx.doi.org/10.5935/1984-0063.20170005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611769PMC
October 2017

Respiratory medicine training in Malta.

Breathe (Sheff) 2017 Sep;13(3):245-246

Dept of Respiratory Medicine, Mater Dei Hospital, Msida, Malta.

In Malta, respiratory medicine is quite a popular speciality. It is attractive because of the interesting case mix and the interventional element of the speciality.
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http://dx.doi.org/10.1183/20734735.009417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584720PMC
September 2017

Sensitization to dust mite defines different phenotypes of asthma: A multicenter study.

Pediatr Allergy Immunol 2017 Nov 7;28(7):675-682. Epub 2017 Sep 7.

Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy.

Background: Indoor allergens are risk factors for asthma: Thus, the characterization of indoor air quality is important for studying environment-health relationships in children. In particular, Dermatophagoides pteronyssinus is the dominant allergen for asthma. We cross-sectionally investigated the relationships among respiratory symptoms and function, airway inflammation, allergen sensitization, and indoor allergen concentration.

Methods: One hundred and thirty-two children aging 10-14 years and living in a Southern Mediterranean area were evaluated by parental questionnaires. Spirometry, exhaled nitric oxide (FeNO), skin prick tests, total, and specific serum IgE analyses were performed along with the evaluation of home dust samples for the content in Der p 1 allergen. Three clusters were created on the basis of the presence/absence of wheeze in the last 12 months (Wh12m) and Der p 1-specific IgE level.

Results: Cluster 1 (Wh12m+/high Der p 1 IgE) presented higher FeNO and poorer pulmonary function (lower FEV and FEF ), while its symptom score was not different from Cluster 2 (Wh12m+/low Der p 1 IgE). Cluster 3 (Wh12m-/low IgE) showed the lowest FeNO values and pulmonary function similar to Cluster 2. Within Cluster 1, both Der p 1-specific IgE and FeNO were positively correlated with dust Der p 1.

Conclusions: Similar asthma phenotypes may occur in children despite differences in their atopic state. In atopic children, sensitizing allergens in the indoor environment may increase airway inflammation worsening pulmonary function. Moreover, environmental exposures may contribute to the development of asthma-like symptoms also in the absence of atopic sensitization, thus contributing to asthma overdiagnosis.
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http://dx.doi.org/10.1111/pai.12768DOI Listing
November 2017

Sex differences in the efficacy, safety, and tolerability of omalizumab after 1 year in Maltese patients with asthma.

Ann Allergy Asthma Immunol 2017 Apr 7;118(4):513-514. Epub 2017 Mar 7.

Department of Medicine, Mater Dei Hospital, Msida, Malta.

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http://dx.doi.org/10.1016/j.anai.2017.01.019DOI Listing
April 2017

Predictors of correct technique in patients using pressurized metered dose inhalers.

BMC Pulm Med 2017 02 28;17(1):47. Epub 2017 Feb 28.

Mater Dei Hospital, Dun Karm Street, Msida, Malta.

Background: Corret inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients.

Methods: Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical.

Results: 23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63-8.54, p = 0.001), male gender 2.70(1.35-5.39, p = 0.004), self-score 1-10 1.21(1.05-1.39, p = 0.007), spacer use 0.38(0.19-0.79, p = 0.007), inhaled steroid 3.71(1.34-10.25, p = 0.01), heart disease 0.31(0.13-0.77, p = 0.01), pneumococcal vaccine 2.48(1.0-6.15, p = 0.043), education level 1-4 1.44(1.00-2.06, p = 0.05) and respiratory physician explained 0-7 times, 1.11(0.99-1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0-4, were: technique self-score 1-10 1.2(1.05-1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1-7.31, p = 0.03) and education level 1-4 1.41(1.02-1.95, p = 0.03 Times respiratory physician explained inhaler technique 0-7 1.1(0.98-1.24, p = 0.1), married status 1.55(0.85-2.82, p = 0.15), hypercholesterolaemia 0.52(0.25-1.01, p = 0.054) and male gender 1.76(0.97-3.18, p = 0.06).

Conclusions: Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients' self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.
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http://dx.doi.org/10.1186/s12890-017-0386-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331728PMC
February 2017

Association between obstructive sleep apnea and atopy in adult Maltese patients.

Ann Allergy Asthma Immunol 2016 Oct 27;117(4):441-442. Epub 2016 Aug 27.

Department of Medicine, Mater Dei Hospital, Msida, Malta.

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http://dx.doi.org/10.1016/j.anai.2016.07.040DOI Listing
October 2016

A diagnostic dilemma in a case of pulmonary inflammatory myofibroblastic tumour.

BMJ Case Rep 2016 Apr 18;2016:10.1136/bcr-2016-215168. Epub 2016 Apr 18.

Department of Respiratory Medicine, Mater Dei Hospital, Triq Dun Karm Psaila, Tal-Qroqq MSD 2090, Malta.

An 18-year-old man presented to the local hospital in Malta, with dyspnoea, cough, mild haemoptysis, chest pain and night sweats. CT revealed a right hilar mass. Pleural tap, bronchoscopy and open lung biopsy were inconclusive. Biopsies obtained at repeat bronchoscopy and endobronchial ultrasound (EBUS) revealed a likely diagnosis of inflammatory myofibroblastic tumour (IMT). The patient subsequently underwent right pneumonectomy, and histology revealed the presence of two further nodules apart from the main tumour. Follow-up with positron emission tomography (PET)/CT showed the development of a right basal paracardial lesion due to recurrence and the presence of lymph node, pleural and skeletal disease. Despite radiotherapy to the recurrent nodule and chemotherapy, there was skeletal disease progression. Treatment with an anaplastic lymphoma kinase inhibitor, ceritinib, resulted in very good metabolic response. This case report highlights the importance of keeping IMT in mind when the diagnosis of lung tumours is difficult, as delayed diagnosis may lead to worsened prognosis.
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http://dx.doi.org/10.1136/bcr-2016-215168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4840655PMC
April 2016

A rare case of pulmonary alveolar microlithiasis.

BMJ Case Rep 2015 Dec 7;2015. Epub 2015 Dec 7.

Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta.

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http://dx.doi.org/10.1136/bcr-2015-212804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4680284PMC
December 2015

Association of prevalence of rhinitis, atopic eczema, rhinoconjunctivitis and wheezing with mortality from infectious diseases and with antibiotic susceptibility at a country level.

Asia Pac Allergy 2015 Jul 29;5(3):145-55. Epub 2015 Jul 29.

Department of Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta. ; Faculty of Medicine and Surgery, University of Malta, Msida, MSD 2090, Malta.

Background: It was previously reported that there is a positive correlation between incidence of type 1 diabetes and prevalence of asthma and atopic eczema. A negative correlation between the prevalence of type 1 diabetes and mortality from infectious diseases as well as a positive correlation with antibiotic susceptibility at a country level have also been reported.

Objective: The aim of this study was to investigate the association between country prevalence of rhinitis, atopic eczema, rhinoconjunctivitis, and wheezing with mortality from infectious diseases and also with antibiotic susceptibility at a country level.

Methods: Data for prevalence of rhinitis, eczema, rhinoconjunctivitis, and wheezing was obtained from the International Study of Asthma and Allergies in Childhood study (ISAAC). ISAAC Phase one was a multicentre multicountry cross sectional study involving over 700,000 children in 2 age groups of school children, 13-14 years old (adolescents) and 6-7 years old (children) in 156 centres from 56 countries. Mortality from infectious diseases was taken from World Health Organisation data. The Alexander project was used to identify antibiotic susceptibilities to common bacteria.

Results: There were significant positive correlations between atopic eczema and mortality from all infectious diseases studied, diarrhoeal illness, tropical infections, and childhood infections. A negative correlation exists between the prevalence of rhinitis and Streptococcus pneumoniae susceptibility to penicillin and to erythromycin, rhinitis and Haemophilus influenzae susceptibility to ampicillin and between rhinoconjunctivitis and H. influenzae susceptibility to ampicillin.

Conclusion: Th1/Th2 responses might influence the pathogenesis of infectious disease mortality, while antibiotic overprescription could explain the negative association between atopy and antibiotic susceptibility.
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http://dx.doi.org/10.5415/apallergy.2015.5.3.145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521163PMC
July 2015

Systemic and venous thromboembolism: think about paradoxical embolism.

BMJ Case Rep 2015 Jul 28;2015. Epub 2015 Jul 28.

Department of Medicine, Mater Dei Hospital, Msida, Malta.

Patent foramen ovale (PFO) is one of the most important causes of paradoxical embolism; it is found in about 25-30% of the population. In most patients, it is asymptomatic and diagnosis is usually made during routine echocardiography. In a small proportion of patients, PFO is diagnosed after paradoxical embolism is suspected. We present a case of a middle-aged smoker who was admitted with lower limb deep vein thrombosis and pulmonary embolism, who developed acute upper limb ischaemia during his inpatient stay. Since doctors might dismiss such cases as routine, this report highlights the importance of detailed history taking and examination in patients with venous thromboembolism. Paradoxical embolism should always be considered as a possible diagnosis when managing patients with concomitant venous and arterial embolism.
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http://dx.doi.org/10.1136/bcr-2015-211174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521559PMC
July 2015

Outcome of central hypoventilation secondary to childhood pertussis encephalitis in adulthood.

BMJ Case Rep 2015 Jan 23;2015. Epub 2015 Jan 23.

Mater Dei Hospital, Msida, Malta.

We present a rare case of central hypoventilation secondary to pertussis encephalopathy occurring during childhood. The patient was successfully managed by negative pressure ventilation initially until portable non-invasive ventilators became available. The patient was, unfortunately, lost to follow-up. She was reviewed in adulthood following several years of non-compliance to treatment and found asymptomatic despite chronic hypercapnoea.
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http://dx.doi.org/10.1136/bcr-2014-206471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307069PMC
January 2015

The real-life clinical effects of 52 weeks of omalizumab therapy for severe persistent allergic asthma.

Int J Clin Pharm 2015 Feb 14;37(1):36-43. Epub 2014 Nov 14.

Department of Medicine, Mater Dei Hospital, Msida, Malta,

Background: Omalizumab was introduced in Malta in 2011. To date, no local data have been published.

Objective: To obtain baseline characteristics of our local cohort, determine effectiveness of omalizumab at 52 weeks, compare clinical outcomes 52 weeks pre- and postomalizumab therapy and to assess its safety and tolerability.

Setting: The Mater Dei Hospital in Malta.

Method: All consented adult patients who were eligible to start treatment with omalizumab for asthma were enrolled in this open, prospective observational real-life study. A questionnaire was completed and an Asthma Control Test and spirometry performed. Patients were reviewed on a regular basis. Any undesirable symptoms were recorded. Treatment effectiveness was evaluated at 16 and 52 weeks, during which a decision was taken whether patients were responders. Outcomes were compared 52 weeks pre- and post- treatment initiation. Main outcome measure To determine effectiveness of treatment following 1 year of omalizumab by assessing its impact on the rate of asthma-related exacerbations and health care utilization including hospitalizations.

Results: Our cohort included 22 patients, all non-smokers (mean age 52.7 ± 11, 64 % males). The mean baseline IgE level was 448.6 ± 444 IU/ml. At week 12, treatment was stopped in one patient due to arthralgias. The drug was stopped in two patients at week 16 due to treatment ineffectiveness. At week 20, treatment was stopped in another patient in view of arthralgias. A significant reduction in the number of asthma exacerbations (p = .03) and number of systemic steroid courses required (p = .03) was identified at 52 weeks. There was a significant improvement in the ACT score (p < .001) after 52 weeks but no significant improvement in FEV1. There was a non-significant decline in the number of hospitalizations (p = .6), asthma-related healthcare visits (p = .2) and days off work (p = .09). Adverse events occurred in 10 % of patients. Costs related to asthma hospital-stay and medicines administered during hospitalisations were decreased by half following 1 year on omalizumab.

Conclusion: Omalizumab treatment resulted in an improved asthma control, with a significant reduction in asthma exacerbations and systemic steroid courses required and improvement on ACT score. Adverse events were infrequent and the drug was well tolerated.
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http://dx.doi.org/10.1007/s11096-014-0034-7DOI Listing
February 2015

Potential impact of fireworks on respiratory health.

Lung India 2014 Oct;31(4):375-9

Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta.

The world-wide use of fireworks with their consequent detrimental effect on the air quality is widely recognized with elevated ambient air levels of particulate matter and its several metallic components and gases identified in several studies carried out during such events. Exposed individuals may be at risk following inhalation of such produced pollutants. This review focuses on the impact of fireworks on air quality and the potential effect of fireworks on the respiratory system of healthy individuals as well as those suffering from underlying respiratory diseases, particularly asthma and chronic obstructive pulmonary disease (COPD). This applies not only to spectators including children but also to pyrotechnicians themselves. An extensive Medline search revealed that a strong evidence of the impact of fireworks on respiratory health is lacking in susceptible as well as healthy individuals with no formal studies on COPD or asthma, other than a few case reports in the latter. The implementation of global strategies to control the use of fireworks and hence improve air quality could possibly reduce their likely detrimental effect on human respiratory health in exposed individuals, but clearly a more targeted research is needed.
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http://dx.doi.org/10.4103/0970-2113.142124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220320PMC
October 2014

A delayed diagnosis of Mounier-Kuhn syndrome.

BMJ Case Rep 2014 Jun 2;2014. Epub 2014 Jun 2.

Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta.

Following a provisional diagnosis of asthma of several years' duration by his general practitioner, a 43-year-old otherwise healthy man who was a non-smoker was referred to a pulmonologist with worsening productive cough and exertional breathlessness. A thoracic CT scan revealed dilated airways (tracheal diameter 35 mm, left bronchial diameter 20 mm, right bronchial diameter 18 mm). Inflamed and easily collapsible airways were seen on bronchoscopy. The patient remained stable and was followed up with regular spirometry. A follow-up CT scan 7 years later showed tracheobronchomegaly (tracheal diameter 42 mm, left bronchial diameter 25 mm, right bronchial diameter 23 mm) with large cystic spaces consistent with Mounier-Kuhn syndrome. Repeat bronchoscopy showed a massively dilated trachea and generalised collapse on expiration with a dilated thin-walled bronchial tree. He was deemed ineligible for lung transplantation due to the extent of airway involvement making it difficult to anastomose donor lung to native tissue.
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http://dx.doi.org/10.1136/bcr-2014-203674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4054406PMC
June 2014

A local perspective to asthma management in the accident and emergency department in Malta.

Lung India 2013 Oct;30(4):280-5

Department of Medicine, Mater Dei Hospital, B'Kara, Malta, Europe.

Aim: This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma.

Subjects And Methods: Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed.

Results: A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001).

Conclusion: Management of acute asthma in Malta requires optimization in order to compare with international guidelines.
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http://dx.doi.org/10.4103/0970-2113.120601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3841682PMC
October 2013

Aspiration of a speaking valve.

BMJ Case Rep 2013 Jul 16;2013. Epub 2013 Jul 16.

Department of Medicine, Department of Health, Dingli, Malta.

Foreign body aspiration (FBA) is a relatively common and serious condition that can result in a spectrum of presentations ranging from incidental to acutely life-threatening. Described here is a case of aspiration of a tracheo-oesophageal speaking valve through a permanent tracheostomy that went unnoticed for a number of years, and an overview of the technique used for its removal. A 70-year-old ex-heavy smoker with a permanent tracheo-oesophageal fistula presented with a relatively recent history of increasing shortness of breath, sputum purulence and haemoptysis. Further investigation with a CT scan and bronchoscopy revealed the presence of a foreign body within his right lower lobe bronchus which was later removed by advancing a flexible bronchoscope over a rigid one.
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http://dx.doi.org/10.1136/bcr-2013-200066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736530PMC
July 2013

Chronic cough as a complication of treatment with statins: a case report.

Ther Adv Respir Dis 2012 Aug 3;6(4):243-6. Epub 2012 Jul 3.

Mater Dei Hospital, 17, Floreat, Triq il-Kbira, Gharghur, Malta (EU).

Statins are widely used for primary and secondary prevention of cardiovascular disease. For this reason, knowledge of the side effects and interactions pertaining to this class of pharmaceuticals is of utmost importance to all physicians. In this text a case report is presented of an eighty year old gentleman, referred to the respiratory clinic at Mater Dei Hospital Malta after developing dry cough on being treated with simvastatin and fluvastatin. An attempt at switching over to a placebo was made with resolution of symptoms. This is the second described case in the literature of lone cough associated with statin therapy necessitating treatment discontinuation in our patient. Possible hypothesis are discussed as well as suggestions for further research to unravel the underlying mechanisms of this association.
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http://dx.doi.org/10.1177/1753465812452192DOI Listing
August 2012

The association between tobacco and the risk of asthma, rhinoconjunctivitis and eczema in children and adolescents: analyses from Phase Three of the ISAAC programme.

Thorax 2012 Nov 12;67(11):941-9. Epub 2012 Jun 12.

Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Background: Exposure to parental smoking is associated with wheeze in early childhood, but in 2006 the US Surgeon General stated that the evidence is insufficient to infer a causal relationship between exposure and asthma in childhood and adolescents.

Aims: To examine the association between maternal and paternal smoking and symptoms of asthma, eczema and rhinoconjunctivitis.

Methods: Parents or guardians of children aged 6-7 years completed written questionnaires about symptoms of asthma, rhinoconjunctivitis and eczema, and several risk factors, including maternal smoking in the child's first year of life, current maternal smoking (and amount) and paternal smoking. Adolescents aged 13-14 years self completed the questionnaires on these symptoms and whether their parents currently smoked.

Results: In the 6-7-year age group there were 220 407 children from 75 centres in 32 countries. In the 13-14-year age group there were 350 654 adolescents from 118 centres in 53 countries. Maternal and paternal smoking was associated with an increased risk of symptoms of asthma, eczema and rhinoconjunctivitis in both age groups, although the magnitude of the OR is higher for symptoms of asthma than the other outcomes. Maternal smoking is associated with higher ORs than paternal smoking. For asthma symptoms there is a clear dose relationship (1-9 cigarettes/day, OR 1.27; 10-19 cigarettes/day, OR 1.35; and 20+ cigarettes/day, OR 1.56). When maternal smoking in the child's first year of life and current maternal smoking are considered, the main effect is due to maternal smoking in the child's first year of life. There was no interaction between maternal and paternal smoking.

Conclusions: This study has confirmed the importance of maternal smoking, and the separate and additional effect of paternal smoking. The presence of a dose-response effect relationship with asthma symptoms suggests that the relationship is causal, however for eczema and rhinoconjunctivitis causality is less certain.
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http://dx.doi.org/10.1136/thoraxjnl-2011-200901DOI Listing
November 2012

The effect of cigarette smoking on allergic conditions in Maltese children (ISAAC).

Pediatr Allergy Immunol 2012 Aug 22;23(5):472-8. Epub 2012 Mar 22.

Department of Medicine, Mater Dei Hospital and University of Malta, Malta.

Maltese children are frequently exposed to tobacco smoke through passive and personal smoking. In the phase 3 ISAAC study questionnaire, we enquired about passive smoking to the parents of 3816 (80% response rate) 5- to 8-yr-old children and about passive and personal smoking to 4139 (90% response rate) 13- to 15-yr-old participating children. Thirty-one percent of 5- to 8-yr olds were passive smokers with their father more likely to be the smoker (p < 0.0001). Maternal smoking in the first year of the child's life resulted in the children having an increased chance of wheezing 'ever' (p < 0.001), exercise-induced wheezing (p < 0.05) and being diagnosed with asthma (p < 0.0001). Current smoking by the mother also led to the child having current rhinitis (p < 0.001). Fifty-one percent of 13- to 15-yr olds were passive smokers again with the father more likely to be the smoker (p < 0.0001). Maternal (p < 0.0001) and paternal smoking (p < 0.05) resulted in the children having an increased chance of wheezing sometime in their life, exercise-induced wheezing, nocturnal cough, and being diagnosed with asthma. Current smoking by the mother was more common in children having current rhinitis (p < 0.05), while current smoking by both mother and/or father led to itchy/watery eyes accompanying rhinitis (p < 0.05). Recurrent itchy rashes were also more likely in passive smokers (p < 0.001). Personal smoking by the 13- to 15-yr olds (8.15% boys vs. 8.8% girls ns ) resulted in a higher cumulative prevalence of wheezing (p < 0.0001), rhinitis (p < 0.05), and recurrent itchy rash (p < 0.001) but only affected current prevalence of wheezing (p < 0.0001). These smokers were more likely to experience exercise-induced wheezing (p < 0.0001), nocturnal cough (p < 0.0001), and being diagnosed with asthma (p < 0.05) and eczema (p < 0.001). Children smoking more than 10 cigarettes/day persisted with wheezing (p = 0.04) had more frequent episodes of exercise-induced wheeze (p = 0.04), nocturnal cough (p < 0.0001), and rhinoconjunctivitis (p = 0.02) than milder smokers. Smoking seems to be affecting childhood allergies in Maltese children quite significantly.
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http://dx.doi.org/10.1111/j.1399-3038.2012.01276.xDOI Listing
August 2012

Two cases of aspiration of calcium tablets.

Lung India 2011 Oct;28(4):312-4

Department of Respiratory and Internal Medicine, Mater Dei Hospital, Birkirkara, Malta.

Two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet. One of the patients distinctly recalled the choking episode, whereas the other failed to do so making the diagnosis of aspiration difficult. One of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics. The other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion.
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http://dx.doi.org/10.4103/0970-2113.85700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213725PMC
October 2011