Reducing meat consumption for a more sustainable lifestyle

Meat consumption has sky-rocketed over the past 50 years. An increase in one's standard of living (mostly in developed countries) along with the fact that meat has become cheaper and more affordable, has led to an increase in meat consumption. Furthermore, a human population of more than 7.8 billion people has inevitably created more demand for meat and poultry consumption.

Unfortunately, this demand and supply system is functioning at the cost of our Earth and its natural resources. The truth is, with a human population this large, the Earth simply cannot meet such great demands to feed the amount of cattle we eat nowadays. Animal agriculture requires acres and acres of land for cattle to feed on, resulting in the fall of millions of trees and forests which are cleared in the process.

So, what can you do to help?

1) Engage in meatless Mondays - if you're a meat-lover, or is struggling with cutting down on your meat consumption, this is a great starting point! As the name implies, 'Meatless Monday' is an international campaign that encourages people not to eat meat on Mondays for the benefit of both their health and the planet's.

2) When eating out at a restaurant, opt for vegetarian or vegan alternative s- there are SO many delicious dishes on the menu that are plant-based and that are much healthier for you that do not involve meat.

3) Try a plant-based home-cooked meal - with more time on our hands this Christmas season, now would be a perfect opportunity to experiment with veggies and make some really hearty meals. From soups, to salads, to curries and casseroles, the floor is yours to create a multitude of yummy vegetarian meals!

4) Watch some documentaries or read books to better inform yourself on the link between meat consumption and environmental degradation, and how, with simply eating more plant-based meals you can contribute towards a more sustainable world.Some documentaries that can help are: Cowspiricy, Forks over Knives, What the Health, and David Attenborough: A Life on our Planet

Written by: Miriana Fenech Caruana

A Step in the Right Direction

The average person walks about 10,000 steps daily, carrying 4-6 times of the body weight whilst climbing up stairs or walking up steep inclines.  Feet may take the backseat when it comes to our health, however healthy feet are a must for an active lifestyle. Here are some things to keep in mind to safeguard foot health:

Skin: The skin is an active organ, continuously regenerating itself. It is important that our feet are kept adequately hydrated and clean. After washing, it is important that the interdigital spaces are thoroughly dried so that the chances of contracting fungal infections or wounds is diminished. Common lesions like corns and callosities occur mainly due to excess pressure from ill-fitting shoes or biomechanical issues. It is important that one consults a podiatrist for their in-clinic and home management, as these could lead to the development of wounds and ulcers. When in public pools, saunas or even in a hotel room it always advised to wear flipflops so as to reduce the likelihood of contracting infections such as viral warts.  Further, it is essential to talk to a podiatrist or a dermatologist if skin abnormalities such as redness, rashes, fissuring, and abnormal odours are identified.

Nails: It is important to cut nails straight across. It is important that the corner of the nail is still visible above the skin, to prevent any ingrown toenails. These can also occur due to excessive sweating, tight hosiery, and ill-fitting footwear. Thickened nails are also to be filed regularly with an emery board. Additionally, conservative treatments should never be attempted at home as this could lead to serious problems and infections.

Exercise: It is advisable to do at least 30 minutes of exercise every day, which as well as inducing endorphin production, also induces blood flow to the lower limbs, improving cardiovascular health. It is important to wear adequate footwear so to stabilise the foot and prevent injuries. If there is pain on exercise, it is extremely important to consult with a podiatrist as this can be a sign of more serious problems.

Shoes: Everyday shoes are ideally lace-ups or hook-and-loop fasteners since the foot can be controlled and held in place. It is important that shoes are wide from the front so that the toes are in a comfortable position. Narrow toe-boxes can give rise to conditions like bunions and overriding toes. It is also not advisable to wear high heels regularly, in fact a high heel of about 6cm can increase the load on the forefoot by 75%, whilst simultaneously shortening calf and sole muscle. It is also very important that cotton socks are worn with closed shoes, so that they absorb any sweat, as well as protect the foot from shear and friction forces within the shoe. Footwear should never be shared to prevent the spread of any infections and biomechanical issues. Furthermore, one should regularly check for wear marks on the inside and outside of the sole and replace shoes when necessary.

Smoking: Even though we may not often associate smoking with foot health, the two are very much related. Peripheral arterial disease (PAD) is a condition that occurs when plaque builds up in arteries, causing them to narrow and harden, consequently reducing blood flow to limbs. Smokers are 4 times more likely to develop PAD than non-smokers, since the nicotine present in cigarettes causes the arterial walls to constrict. Smoking can also even affect the nerves, leading to peripheral neuropathy (loss of skin sensation), which can cause to more serious complications

Diabetes: It is important that patients living with diabetes visit a podiatrist at least once a year so that their vascular and neurological foot status can be assessed, together with their general foot health and footwear. Keeping a stable blood glucose level within the range of 4-7 mmol/L is of utmost importance, as is checking the level regularly. No one should be walking around barefoot especially diabetics, who could be suffering from peripheral neuropathy. Doing so could impede diabetics from feeling pain when stepping on sharp objects, leading to poorly healing wounds and ulcers due to the reduced blood supply. It is vital that diabetic patients dry their feet well and look out for any abnormalities on their foot by using a mirror or otherwise.

As one can see, there are multiple factors that facilitate the upkeep of healthy feet. It is suggested to constantly be on alert for any changes that may be going on, and not to hesitate to talk to a podiatrist when seeking help in resolving such problems and forwarding queries.

Written by: Maria Abela and Federica Bartolo

Heart Attack: Signs, Symptoms & Prevention

Cardiovascular Diseases (CVDs) are a group of heart and blood vessel disorders. They are the main cause of death globally, being the cause of an estimated 17.9 million deaths in 2016, and representing 31% of all global deaths. 85% of these were due to heart attacks and strokes.  

Strokes and heart attacks, also known as myocardial infarctions, are acute events usually caused by a blockage that decreases blood flow to the brain and heart, respectively. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels. 

Early Signs of Heart Attacks

As in all illnesses, early detection can considerably increase the probability of surviving a heart attack, as the amount of damage to the heart muscle is significantly reduced. 

Common early signs that may lead up to the event of a myocardial infarction are shortness of breath with or without chest discomfort, and chest pain that is often described as a sudden heart-clutching pain. This is most commonly located at the centre of the chest and lasts more than a few minutes, or comes and goes, usually starting slowly with mild pain or discomfort. 

Signs & Symptoms in Men

Symptoms exhibited by men include breaking out in a cold sweat, sudden chest pain, nausea, dizziness, and lightheadedness. Discomfort in the upper limb, mainly in the left arm is also present. 

Signs & Symptoms in Women

Women can experience any of the symptoms exhibited by men but there are some specific symptoms that are characteristic to women. These include shortness of breath, nausea and vomiting, unexplained fatigue, sleep disturbances, anxiety, indigestion and gassiness, and the sense of impending doom.

Experiencing menopause increases the risk of a heart attack drastically as it is known to cause vasculitis or thinning of blood vessels. It is therefore recommended that women going through this period contact their cardiologist to take the necessary steps to prevent cardiovascular disease and hence the risk of heart attacks.

The difference in symptoms between gender 

While a male and female’s heart is anatomically very similar, there are actually physiological differences that affect the symptoms when a heart attack arises. These differences make heart attacks harder to diagnose, especially in women.   

Endometriosis, polycystic ovary syndrome, and pregnancy-related hypertension all increase the risk of having a heart attack. Research suggests that women with endometriosis are up to 3 times more likely to have a heart attack, experience chest pain, or need treatment for blocked arteries due to the chronic inflammation that accompanies endometriosis, also inflaming the arteries.

Suffering from hypertension, diabetes, and depression is common in both genders. However, according to the American Heart Association, a female suffering from these conditions has a greater risk for heart attacks.

Women tend to suffer from heart attacks later on in life than men. Experts believe that women’s exposure to oestrogen through most of their reproductive life provides some extra protection against heart attacks. With this being said, younger females are having more heart attacks. The reason behind this is unknown, but experts speculate that teenagers are less healthy nowadays.

Heart attack symptoms develop rapidly in males. The plaque suddenly ruptures or breaks apart, and the body’s response to this is to form a protective blood clot that can block the artery, resulting in a heart attack. This is when men are more likely to experience crushing chest pain and heaviness. It was found that this is the reason behind 75% of all heart attacks in males but only 55% in females. 

Plaque erosions are more common in females; bits of plaque wear away, and smaller blood clots form in response. This takes place over a longer period of time which is why the symptoms usually come on gradually.

Reducing Heart Attack Risk

While there are certainly ways to reduce the chances of a myocardial infarction, our biological makeup plays a role in determining the risk of a heart attack. Therefore, the most important line of defence against a heart attack is awareness of the different signs and symptoms. 

It is also a known fact that awareness regarding symptoms of heart attacks is lower in women than in men, and that women are less likely to seek medical attention if they experience early symptoms. Therefore, over the years the lack of awareness in women and their reluctance to seek help has reduced their chances of surviving a heart attack.

What to do if someone is having  a heart attack

If you or someone around you is showing any signs or symptoms of a heart attack, call 112 immediately. The emergency medical staff will then begin treatment upon arrival.

If unsure whether you’re experiencing symptoms of a heart attack, check it out! Minutes matter and fast action can save lives.

Written by: Gail Bonnici and Stella Sammut

Aircon and my Health

Aircon and my Health

The thought of surviving the Maltese Summer without the use of air conditioner seems inhumane to most. The glorious ‘on’ button provides immediate relief from the scorching summer heat. However, as air conditioners seem to be a blessing, few know about the health risks involved.

Air conditioners draw moisture from the air and body. This can manifest in the skin, making it dry and itchy. Dehydration of the eyes can in turn cause irritation, a burning sensation, blurred vision, and itchiness.

The influence of air conditioners on our  respiratory system can also be quite significant. They may cause drying out of the nasal passage and mucous membrane, that acts as a protective layer against infections. Therefore, making one more prone to a disturbance in the proper functioning of the nose, throat, and lungs.

The vast amount of moisture that builds up from the condensation produced in the air conditioner provides a breeding ground for black mould, bacteria, and fungi. Irregular cleaning of the filters allows these micro-organisms to accumulate, potentially leading to respiratory problems. To reduce such casualties, the unit must be cleaned and the filter must be changed every couple of months. Furthermore, such maintenance is even more so important for those suffering from respiratory conditions such as asthma.

Surprising to some, air conditioners blasting air at a very low temperature can elevate one's blood pressure. The arteries constrict to avoid loss of body heat, which in turn creates resistance of blood flow, and hence an increase in blood pressure.

Sudden changes in temperature “shocks the system”. Combined with cranial hypertension, this may result in a headache. Turning the temperature up or going out for some fresh air allows the body temperature to return back to normal and often subsides the headache.

With this being said, air conditioners bring about various benefits as long as they are not used at a strong intensity and very low temperatures. It is advised to stay hydrated, and keep the room temperature between 21-25°C. Furthermore, in periods of prolonged exposure one could also place a bowl of water which offers an alternative source for moisture withdrawal.

References:

Hozawa A., S. Kuriyama, T. Shimazu, K. Ohmori-Matsuda, I. Tsuji. Seasonal variation in home blood pressure measurements and relation to outside temperature in Japan. Clin Exp Hypertens, vol. 33, no. 3, pp. 153-8, 2011.

Mark J Mendell. Commentary: Air conditioning as a risk for increased use of health services. International Journal of Epidemiology, vol. 33, issue 5, pp. 1123-6, 2004

Yong-Han Lee, Sanghyuk Bae, Seung-sik Hwang, Jong-Hun Kim, Kyoung-Nam Kim, Youn-Hee Lim, Miji Kim, Sohwa Jung, & Ho-Jang Kwon.  Association Between Air Conditioning Use and Self-reported Symptoms During the 2018 Heat Wave in Korea. J Prev Med Public Health, vol. 53, issue 1, pp. 15-25, 2020

Written by: Gail Bonnici

The Experience of a First Time Blood Donor

The Experience of a First Time Blood Donor

This article commemorates “MHSA’s Every Drop Counts”, MHSA’s first public event for the term 2020/2021. Raquel Zerafa, a first-time blood donor who donated through this initiative, was interviewed for the purpose of this article.

The National Blood Transfusion Service provides donors with digital information on their website, this can be accessed through the following: https://bit.ly/Bbipq7 . The website can aid the donor prepare for donation and help in understanding whether one can potentially donate. Zerafa mentioned that she had gone through the guidelines and as a vegetarian, sought out iron and Vitamin C rich foods, to ensure a good haemoglobin level. She also tried to prepare herself mentally and although she felt nervous and excited, during the donating process she relaxed through the sense of security and reassurance provided by the staff. Furthermore, she read the guidelines regarding age, weight, health, and medication consumption, amongst others, and these indicated that she would potentially be able to donate. Zerafa also commented that the criteria included was informative enough; it does not include information which is too specific and irrelevant to most, but also not too general that it is impossible to predict if one can actually donate.

Once at the Guardamangia institution, the temperature is noted due to COVID-19 measures and as her temperature was in the safe range, she proceeded with the donation process. After registration, first-time donors are provided with a comprehensive pamphlet describing said process, but due to Zerafa’s previous attempt this resource was not needed.

This is proceeded by testing, where weight and haemoglobin readings are taken, followed by a medical questionnaire regarding one’s health. Zerafa expressed that she understood the need for such tests as her blood would potentially be transfused into another person. The staff made sure to accommodate her by explaining what they were doing, and during the medical exam the door was closed to maximise confidentiality.

After medical clearance, one would progress to the donation. In addition to the standard hygiene measures, social distancing was promoted between donors by only allowing three donors in the room, and both donors and staff wore facemasks or visors due to COVID-19 measures. Zerafa remarked how the phlebotomists were very hospitable and professional in their work; they asked her if she was afraid of needles before insertion and asked how she felt multiple times during the donation. When asked if the experience was painful, she answered that it was not but rather she felt that “The needle was annoying.”

Immediately after donating, while she was having a complimentary sandwich and some refreshing water, she felt that the discomfort of donating was worth the deed. Later on in the day she reported that although she did not experience any bruising, she developed weakness in her right arm and hand. This, together with the tiredness of donating a pint of blood challenged her, but nonetheless she continued her day normally.

When asked what were her favourite and least favourite parts of the donation, she answered with the staff, their smiles, and their hospitality, followed by the anticipation previous to the medical clearance, respectively. In a previous attempt she had been refused due to her weight, but through a healthier lifestyle she managed to achieve a suitable weight.

Zerafa’s advice for first time donors is to not be afraid, she remarked that it is a comprehensively explained yet simple process, with a high reward as with one pint one can potentially save three lives. Questions asked to the staff were answered, in fact when Zerafa asked if 7minutes of blood donation was normal the phlebotomist confirmed that it is, and explained further that temporal variations occur due to a multitude of factors including blood vessel length and diameter, and how nervous the person is. Her concluding remarks were that the overall experience was “Phenomenal” and she was glad to share that by the end of the week she had already set up a reminder on her calendar, marking her next donation attempt in four months’ time.

Written by: Malcolm Camilleri

Combined Oral Contraceptive Pill

Combined oral contraceptive pill, more typically referred to as “the pill”, can be used as a form of birth control to prevent pregnancy. This is not to be confused with the morning after pill which is considered to be an emergency contraceptive.

 There are two types of this drug, combination pills containing both oestrogen and progestin, and progestin-only pills also called the minipil as it only contains progestin.

 Why take it?

Although its primary use is to act as a form of contraception, which is to be taken daily, some women also take the pill for other reasons. Being a combination pill, it can be used to help prevent acne and correct any hormone imbalances. Women who suffer from heavy or imbalanced periods can also benefit from “being on the pill” as it helps to regulate the menstrual cycle. Apart from this, studies have shown that taking the pill can also have other benefits, such as the prevention of cysts in the breasts or ovaries and ease symptoms of endometriosis when using pills with high levels of progestin as well as easing conditions such as Polycystic Ovarian Syndrome (PCOS).

 Although very efficient, like most drugs, the pill does not come without its side-effects. This can range from nausea to having a decreased sex drive and breast tenderness. However, such symptoms could ease after a few months of using the pill, so it is recommended to wait the time directed to you by your clinician before switching to a new pill.

 Different pill brands generally tend to differ in the ratio of hormones; the amount of oestrogen and progestin in them. Therefore, the correct pill can be administered for its desired effect on the body. Changing pills to find the preferred effect can be relatively low risk, however changing pills regularly can lead to many undesired effects on the body as well as the change in behaviour (mood swings) because of the severe imbalance of hormones in the body.

 Contraception and Malta

Conversation on topics such as contraception have always been hot topics filled with controversy and, rather frequently, not talked about well enough. Discussions are held during times of crisis however conversation typically stops there, with little to no payoff. What's worrying is that girls often feel like they do not have the adequate information regarding contraception and often resort to researching online. Schools should be at the forefront of such matters and should educate young girls on the different types of contraception and their effectiveness.  Currently the world is going through the Covid-19 pandemic and this has shed light on many inequalities in our society. Covid – 19 is changing our mentality and our lifestyle and surely brings about a change in how we view our sexual and reproductive health.

 In countries such as the UK, women are finding it difficult to find contraception, as many are out of stock or have been stopped due to manufacturing issues. In Malta things are no different, as women are having trouble finding their prescribed pill during this Covid - 19 crisis. However, this seems to be a recurrent issue as women have been dealing with out of stock medication well before Covid. In fact, some women have been prescribed medication, for it to only go out of stock and then have to constantly change medication again. This is increasingly harmful not to mention the effects this has on a person’s mental health. 

What’s troubling is that during the start of the pandemic, the government stocked up on essential medications. However, oral contraceptives, medicines that as stated can not only be prescribed as a form of contraception but also as a form of medication, is not considered to be essential. Moreover, the criminalisation and banning of abortion in Malta makes the access to contraceptives more eminent. This decision has affected many women and will continue if nothing is changed. The decision to make the pill free will benefit many, however the obstacle we need to overcome is having it readily available and in stock. 

Written by: Nicholas Aquilina

Mask the Virus

With the new regulations in place, it is mandatory to be heading out with a face mask. But are they as effective as perceived to be? Are they actually being worn properly to protect us against this COVID-19 pandemic?

Face masks have been utilized for over a century, initially developed for the safeguard of the surgical team whilst being exposed to the operating theatre environment (Oberg & Brosseau, 2008). They are however used today in a variety of health care settings, and in many ways. 

How is Corona Virus transmitted?

The World Health Organisation (WHO) explains that it spreads from person to person via tiny droplets from the nose and mouth. They end up on surfaces, and when making contact with the latter, and then touching the eyes, nose or mouth, the virus has reached a new target. 

With this being said, wearing a mask that covers the nose, and mouth seems to be promising in the fight against the virus. Offeddu et al. (2017) suggest that wearing masks and respirators is an efficient way of having infection control thus limiting spread of a disease.

Types and uses of masks

There exist four types of masks: the homemade cloth face mask, surgical mask, N95 respirator, and one-use cotton or paper masks. 

Surgical masks allow for easy breathing whilst also obstructing the entry of any contaminated droplets from making their way into the nose and mouth. It can also aid in limiting exposure of saliva and secretions from other people.  

N95 respirators are said to be more efficient in providing protection than the surgical masks as it is said to obstruct 95% of particles. However, due to their shortage, the Centres for Disease Control and Prevention advise that they should only be used by individuals in hospital environments or in health care institutions. 

Makison Booth et al. (2013) concluded that the live virus is detectable in the breathing zone that is covered by the surgical mask, allowing the particles to penetrate it. They also found that masks adapted with a visor further block the entry of foreign particles, acting as a shield to prevent entry of large droplets, while providing further protection since it disallows an individual from touching the eyes.

There is mixed evidence on the effectiveness of homemade face masks. Research has found that although protection is given, other masks are favourable. It is also advised that paper masks wouldn’t be used as airborne particles holding the virus may still be able to penetrate. 

Making the mask effective

Although evidence does not clearly indicate that these face masks do prevent the transmission of Coronavirus, there is some evidence for a degree of protection. An effective mask should fit well around the nose, mouth, and chin. No air should enter from the sides, and there must not be any space between the face and the mask.

A mask can easily provide one with a false sense of security - if it is reused or touched, the virus, if present, can still be transmitted. In a published document, the WHO explains that masks are only effective with frequent hand washing with alcohol-based hand rub or soap and water. 

The mask must be removed from behind - the front must not be touched, and must be discarded immediately in a closed bin. Its disposal is very important and should be followed, as otherwise its purpose would be rendered useless. Hands must be washed appropriately afterwards. 

In conclusion, wearing a mask and going out for no particular reason should not be done, as we should safeguard, and respect the community. Although masks are an effective way of protecting ourselves, we should not rely solely on them. Whilst abiding to Malta’s regulations, it is up to the individual to decide whether to wear a face mask or not. 

References

Coronavirus disease (COVID-19) advice for the public: When and how to use masks. Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks?fbclid=IwAR3vAQabEaOc3QMaI2LjPUJcHmVbh7EfaRbfnpCoRk8gQNV6qbw30ImGLZE

Makison Booth, C., Clayton, M., Crook, B., & Gawn, J. M. (2013). Effectiveness of surgical masks against influenza bioaerosols. Journal of Hospital Infection, 84(1), 22-26. doi:10.1016/j.jhin.2013.02.007

Oberg, T., MS, & Brosseau, L. M., ScD. (2008). Surgical mask filter and fit performance. AJIC: American Journal of Infection Control, 36(4), 276-282. doi:10.1016/j.ajic.2007.07.008

Offeddu, V., Yung, C. F., Low, M. S. F., & Tam, C. C. (2017). Effectiveness of masks and respirators against respiratory infections in healthcare workers: A systematic review and meta-analysis. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 65(11), 1934-1942. doi:10.1093/cid/cix681

Written by Gail Bonnici and Nikita Schembri

What is Posture?

“Fix your posture, you’re slouching”, “Sit up straight”, they say!

Posture is the overall position of the body maintained against gravity. It can be referred to as dynamic, during movement, or static, when at rest. When thinking about posture, the spine is often thought of first. The vertebral column is composed of natural lordotic and kyphotic curves from the neck to lower back.

How we should sit and stand has been reiterated for a while, but each and every one of us assume different comfortable positions.  Recently there have been numerous debates of whether an ideal posture exists and whether there truly are incorrect postures. 

Studies have shown that maintaining a poor position can increase unwanted forces on the spine and joints. In turn this can produce pain in the shoulder, neck, or back, and may cause tension headaches and migraines. Faulty postures have been identified, namely; flat-back, sway-back, excessive kyphosis and lordosis. However, it is important to note that many studies have found no correlation with altered postures contributing to pain and negatively affecting one’s health. 

Varied postures may also be adopted, relating  work to an increased risk of pain. Text neck, for example, may occur when hunched over your phone or keyboard, or when looking up towards a screen which is too high. This is where ergonomics comes to play. It involves improving the surrounding work environment to enhance well-being and performance by reducing discomfort. Adjusting the height of the chair and screen are easy methods to go about this. Again, when looked at closely, some studies have found no evidence on these negative effects of posture.  

A common phrase that you might have heard of is ‘imagining a string attached to the top of your head that is pulling upwards.’ Generally, when trying to improve posture we are taught to engage our abdominals, pull our shoulders backwards and maintain an upright position. Exercise is key to strengthen and maintain flexibility of the muscles to prevent any imbalances. One can engage themselves in exercise classes such as pilates or back muscle training (planks, pull ups or back extensions may help). 

So what have we learnt? Posture is a complex topic and has been debated for a while. Ideal and stereotypical postures are evident amongst the community, as well as different opinions on how to manage it.  More evidence-based research is required to determine and identify, if existent, an ideal posture.

Exercising and keeping active is always beneficial. So if you are reading this while working at your desk or binge watching Netflix, take a break and give your circulation a boost. Go for a walk, or do that 15 minute workout you have been planning to do for weeks! 

In the meantime check out our video on our Facebook page by Seven Steps by Sarah Jane Zrinzo, which contains great exercises on posture!

Written by Gail Bonnici

Is Sitting the new Smoking?

How often do you find yourself stuck in an awkward sitting position and can’t seem get yourself up? This has happened to every single one of us, and now, even more than ever! The current COVID-19 pandemic has forced us to spend all our time at home, obviously resulting in prolonged sitting hours. 

Sitting is very much part of our everyday life; usually at our workplace, transportation and advances in domestic technology have made us more sedentary (Owen et al., 2010). However, this does not only mean that we are getting lazier, and let’s face it - plumper, there are other effects that would take us by surprise. Over the past decade, media coverage of sitting research has been widespread, and the hard truth is that health consequences of sitting are being compared to those of smoking!

Sitting is detrimental for our wellbeing, physiological, and musculoskeletal health. Levels of obesity, diabetes, and cardiovascular disease are on the rise, because we are mainly sitting on the sofa watching Netflix and binge eating. A higher risk of both depression and mortality are also caused by prolonged sitting (Heneghan et al., 2018). 

Long hours of sitting and doing less than 150 minutes of physical activity a week are associated with increased neck, shoulder and lower back pain. It is correlated to posture and an increased stiffness of the spine, especially the thoracic part (the spinal region that is attached to your ribs).

Stiffness of the thoracic region contributes to pain surrounding the neck as it is responsible for about 33% of functional neck movement and 21% of neck rotation. It is also reasonable that dysfunction of the adjacent spinal regions would occur, resulting in lower back pain. Evidence suggests that as sedentary lifestyles are increasingly becoming the norm, and sitting for even just an hour leads to increased spinal stiffness (Beach et al., 2005).

With all this being said, prolonged sitting is a means of getting through to the detrimental effects of smoking on your health. Although there are negative effects of sitting, the effects of smoking are so much worse including dementia, pulmonary diseases, asthma, adverse reproductive outcomes, and cancers (Courtney, 2015).

If smoking causes one billion deaths in the 21st century (Eriksen et al., 2012), why do we still smoke? And with all the adverse effects of prolonged sitting and lack of exercise, why are we still sedentary? You’re probably sat reading this - get up, stretch and make sure you walk for at least 2 minutes every 30 minutes! 

References

Heneghan, N., Baker, G., Thomas, K., Falla, D. and Rushton, A., 2018. What is the effect of prolonged sitting and physical activity on thoracic spine mobility? An observational study of young adults in a UK university setting. BMJ Open, 8(5), p.e019371.

Vallance, J., Gardiner, P., Lynch, B., D’Silva, A., Boyle, T., Taylor, L., Johnson, S., Buman, M. and Owen, N., 2018. Evaluating the Evidence on Sitting, Smoking, and Health: Is Sitting Really the New Smoking?. American Journal of Public Health, 108(11), pp.1478-1482.

Beach TA, Parkinson RJ, Stothart JP, et al. Effects of prolonged sitting on the passive flexion stiffness of the in vivo lumbar spine. Spine J 2005;5:145–54.

Chau JY, Reyes-Marcelino G, Burnett AC, Bauman AE, Freeman B. Hyping health effects: a news analysis of the “new smoking” and the role of sitting. Br J Sports Med. 2018;bjsports-2018-099432.

Courtney, R., 2015. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General, 2014Us Department of Health and Human Services Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for. Drug and Alcohol Review, 34(6), pp.694-695.

World Medical & Health Policy, 2013. Michael Eriksen, Judith Mackay, and Hana Ross. 2012. The Tobacco Atlas, 4th ed. Atlanta, GA: World Lung Foundation. Downloadable pdf, available at http://tobaccoatlas.org/. 5(3), pp.274-275.

Owen, N., Sparling, P., Healy, G., Dunstan, D. and Matthews, C., 2010. Sedentary Behavior: Emerging Evidence for a New Health Risk. Mayo Clinic Proceedings, 85(12), pp.1138-1141.

Written by: Bernard Von Brockdorff

Radiotherapy in Cancer Treatment

Radiotherapy

In Malta, cancer represents a significant burden of disease, with 1 in 4 individuals being diagnosed with cancer by the age of 80 years. In 2016, 27% of all deaths locally were attributed to cancer (World Health Organisation, 2018). Approximately 50% of all patients diagnosed with cancer will receive radiotherapy as part of their treatment (Delaney, Jacob, Featherstone, & Barton, 2005). Therefore, radiotherapy represents a crucial part of cancer treatment, in conjunction with other therapies such as surgery and chemotherapy.

The discovery of X-rays over 100 years ago has allowed for numerous advances in technology and in the treatment of diseases. The use of radiation in medicine is not a new concept, however, only relatively recently has radiotherapy become an accepted, well-established therapy in the treatment of diseases such as cancer (Martins, 2018). Radiotherapy may be defined as the delivery of ionising radiation to a target in order to treat disease. It encompasses a wide range of treatment types and techniques, which have gradually developed throughout history with the advancement of new technologies (Martins, 2018).

Types of Radiotherapy Treatments

Briefly, radiotherapy treatments may be classified as external beam radiotherapy (EBRT), which is the most frequently utilised type, or internal radiotherapy. In EBRT the source of ionising radiation is located outside the patient’s body, typically delivered through a linear accelerator (LINAC) or similar units. Conversely, in internal radiotherapy, the source of ionising radiation is placed inside the patient’s body. The type of ionising radiation used is most commonly x-ray photons, where these particles are accelerated and targeted to the localised disease. However, other particles such as electrons or protons may be used to achieve the therapeutic effect. The radiotherapy technique used is dependent on the tumour site, disease characteristics (i.e. stage, grade and histology) and the patient’s overall fitness to receive the treatment. Treatment intent may be curative or palliative, which focuses on reducing the disease burden for the patient.

Radiobiology

Irrespective of the radiotherapy technique used, ionising radiation is utilised to damage diseased cells, while minimising the damage to the healthy tissues. Damage to healthy tissues will lead to the development of radiation associated side effects, such as skin erythema, dry desquamation, and fatigue (Beyzadeoglu, Ozyigit, & Ebruli, 2010).

Two pathways are responsible for the therapeutic effect of radiotherapy. The direct pathway occurs by directly depositing the energy from the ionising radiation, thereby resulting in cellular damage through ionisation. Conversely, the indirect pathway generates free radicals, most frequently from the water. This in turn leads to cellular damage and is responsible for the majority of the cellular damage in radiotherapy treatments. (Cherry & Duxbury, 2019), (Figure 1) In order for ionisation to lead to cell death, the damage must occur within the deoxyribonucleic acid (DNA) macromolecule of the cell. Moreover, several types of DNA damage may occur, which may be repaired by the cell. However, one type of damage termed “double-strand break” is frequently irreparable, thereby leading to apoptosis or mitotic catastrophe of the affected cell. (Cherry & Duxbury, 2019)

Illustration of DNA radiation damage (Retrieved from: Pocket Dentistry, 2015)

Overview of the Treatment Pathway

In Malta, all radiotherapy treatments take place at the Sir Anthony Mamo Oncology Centre (SAMOC). The treatment pathway may vary between centres; however most follow a standardised procedure. Figure 2 illustrates the key stages of radiotherapy treatments (The Society and College of Radiographers, 2020).

Radiotherapy Pathway

Prior to the localisation scan, which is performed using a dedicated computed tomography (CT) scanner, the patient is first provided an overview of the process and what he/she should expect. Similarly, this is done prior to starting the first radiotherapy treatment. The immobilisation is primarily used to minimise patient motion during irradiation and to allow for reproducible setups. In addition, throughout the radiotherapy treatment period, the patient is scheduled to meet with radiotherapy specialised nurses and the oncologist. During these sessions, any side-effects and issues may be addressed. The radiotherapy treatments are delivered on one of three LINACs present at SAMOC. Treatments are led by radiographers; however, radiotherapy requires a multidisciplinary approach, including without limitation: psychologists, occupational therapists and physiotherapists.

Radiotherapy Contraindications

Although radiotherapy treatments are widely used for several cancer types, the use of radiotherapy may be contraindicated in certain clinical scenarios. This may be due to the treatment being inappropriate for the disease characteristics or as it may compromise patient safety. The following are the most frequent relative contraindications for radiotherapy (Beyzadeoglu et al., 2010):

• Treatment of radiation-insensitive lesions, such as soft tissue sarcomas;

• Poor performance status prior to initiation radiotherapy;

• Severe weight changes and/or cachexia associated with the lesion;

• Development of complications associated with the lesion, such as large-volume ascites, plural effusions or bowel perforation;

• Development of severe radiation-associated toxicities.

Nonetheless, in specific cases radiotherapy may still be used in the presence of these contraindications, with alterations in the treatment plan and appropriate precautions. Radiotherapy may also be stopped should such factors develop, since they may compromise the patient’s safety and quality of life.

Furthermore, radiotherapy is a loco-regional treatment, where the therapeutic effect is focused on the target area. This is as opposed to other cancer treatments such as chemotherapy or immunotherapy, which are systemic therapies. Therefore, although metastasis is routinely treated using radiotherapy, the intent of treatment is palliation and not curative.

Future Developments

The development of novel radiotherapy techniques allows for greater treatment accuracy, shorter treatment times and fewer radiation-associated side-effects. This thereby improves the efficacy of treatments and quality of life. At SAMOC, such new techniques are gradually being introduced. One such example is volume modulated arc therapy (VMAT), which was adopted locally in February 2017. Currently, VMAT has become the standard technique for several cancers, such as prostate cancer. Another recent advancement is the implementation of 4D CT scanning, which allows respiratory motion to be taken into account when planning treatments.

In conclusion, radiotherapy has a significant role in cancer treatment, where techniques may be utilised for treatment delivery depending on the clinical scenario. In Malta, radiotherapy is well established, with future advancements allowing local treatments to be improved further.

References

Beyzadeoglu, M., Ozyigit, G., & Ebruli, C. (2010). Radiobiology - chapter 2. In Springer (Ed.), Basic radiation oncology (2010th ed., ) Springer.

Cherry, P., & Duxbury, A., M. (2019). In Cherry P., Duxbury A. (Eds.), Practical radiotherapy physics and equipment (Third ed.). London: John Wiley & Sons.

Delaney, G., Jacob, S., Featherstone, C., & Barton, M. (2005). The role of radiotherapy in cancer treatment estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer, 104(6), 1129-1137.

Martins, P., Nuno. (2018). A brief history about radiotherapy. International Journal of Latest Research in Engineering and Technology, 4(2), 8-11.

Pocket Dentistry. (2015). The biological effects associated with X-rays, risk and practical radiation protection. Retrieved 04/04, 2020, from https://pocketdentistry.com/5-the-biological-effects-associated-with-x-rays-risk-and-practical-radiation-protection/

The Society and College of Radiographers. (2020). An overview of radiotherapy. Retrieved 04/04, 2020, from https://www.sor.org/public-and-patient/overview-radiotherapy

World Health Organisation. (2018). Noncommunicable diseases country profiles 2018 No. 3)World Health Organisation.

Written by: Robert Pisani

A Multidisciplinary Approach to the Treatment and Management of Dyspareunia.

Authors: Karen Louise Stoner, Michaela Briscoe, Nicholas Aquilina

Organisation: Malta Health Student’s Association

University of Malta - Faculty of Health Sciences.

Dyspareunia:

Dyspareunia originally stems from an Ancient Greek phrase translating into ‘difficult mating’. Medically, it is a sexual condition with the presentation of genital pain during intercourse or sexual related activities. Although quite common amongst women of reproductive age, it presents an oftentimes neglected and overlooked area of women’s health, particularly sexual. 

Pathology and Etiology 

Pathology has been defined as "that branch of medicine which treats of the essential nature of disease" and etiology is the study of causation, or origin. (MedicineNet, 2020)

When treating dyspareunia, it is vital to narrow down the initial and dispersing factors to arrive at the correct understanding of the condition. The various conclusions of the pathophysiology of presenting dyspareunia include vaginismus, lack of lubrication, atrophy and vulvodynia (vulvar vestibulitis). Other less quoted, yet still valid conclusions are endometriosis, pelvic congestion, adhesions or infections, and adnexal pathology. Disorders of the urethral, cystitis and interstitial cystitis may also result in the presentation of dyspareunia symptoms. Studies have shown, however, that this lack of a narrowed down etiology, due to the multifaceted dimensions of the conditions, can lead to delayed and difficult diagnosis. (Heim, Lutz., 2001) 

Practitioners will sometimes aim to stimulate or recreate the pain experienced by patients to try and decipher the cause or main concern. An example of this can be seen in the instance of vulvar vestibulitis. This presents when the vagina is felt with a cotton swab or spontaneous spasms of the vaginismus occurs on examination with a finger or speculum. Examination of the lateral vaginal wall, uterus, adnexa and structures of the urethral may assist in identifying the root or trigger of the problem. A holistic understanding of the current organic diagnosis in conjunction with the psychological perspective and anticipated malice brought about by the pain needs to be addressed. (Heim, Lutz., 2001)

Prevalence: 

The prevalence of dyspareunia can alter depending on the population and size of population being sampled. Post-partum patients tend to have higher rates of experiencing dyspareunia when compared to nonparous women. This is the same with those who have experienced sexual assault versus those who have not had any trauma to the vagina. There are many studies that have gone into these specific situations, however, not many of high validity have portrayed the image of the general public. A survey carried out by the authors of this paper, attempted to get a general idea of the Maltese public. However, due to small sample size, this can not be deemed reliable.

 The Maltese Population:

A survey was created and distributed amongst the Maltese population by sharing it via the Malta Health Student’s Association social media page. The survey had a total of 65 participants. Results reveal that the majority of people (64.6%) who participated in the survey did not know the meaning of the term ‘dyspareunia’. 

This predicts that there is a lack of knowledge about this pathology and substantiates the need for more education (assumed based on the small sample side. Further research is required to explore this further). When asked if they had ever experienced dyspareunia or had been with someone who underwent such an experience, the response generated showed that 50.8% of participants answered ‘no’ whilst 41.8% answered ‘yes’. Given such a small sample size, it was surprising to find that such a large percentage admitted to having or have been with someone who has experienced dyspareunia when compared to similar studies. 7.7% of participants claimed that they were not aware if they had experienced or been with someone who experienced it. 

Another question focused on, should the situation arise, would the person disclaim that they were in pain to their partner? The greater part of the respondents claimed that they would. The vast majority of the remainder (41.5%) stated that it would depend on the partner. This might be predictive of the anxiety certain patients feel towards their sexuality, pain, or lack of addressing the issue, which is later addressed in the Occupational Therapy portion of this paper. 

Finally, the survey looked into the medical aspect of the condition. Although there were a variety of causes reported for this sexual dysfunction when asked, the vast majority reported anxiety, vaginismus, vaginitis, postpartum trauma and vaginal trauma as what they thought were the main causes of dyspareunia. When asked which medical professional they would most likely consult for this condition, participants replied that they would consult with a general practitioner, gynecologist and midwife in this order. This is further delved into in the ‘multidisciplinary approach’ section of the paper. 

The Multidisciplinary Team:

With so many women having experienced dyspareunia, it is ideal that healthcare professionals, across the multidisciplinary team, should be prepared with the appropriate knowledge and advice to patients they may come across. Whether the healthcare professional is taking a history, noting reactions to treatments, or by the patient informing the practitioner of the dyspareunia, this paper aims to show that it is fundamental for the practitioner to understand how to; note the symptoms and indicators of dyspareunia, educate, and treat the patient. (Abraham et al., 2019)Such signs may include unilateral or bilateral pelvic pain, gluteal region pain, internal vaginal, peripheral vaginal, and labial pain. Decreasing pain is often a main outcome measure, particularly in physiotherapy and occupational therapy (Enderby et al., 2006). Therefore, pain from dyspareunia should not be neglected.

As previously discussed, the etiology of dyspareunia is multifactorial and it is precisely this reason that a multidisciplinary approach is required to treat and manage it. (Ghaderi et al., 2019)

Chronic pelvic pain affects both quality of life and functionality of patients. It has been shown to negatively impact work activities, sometimes ability to sit for prolonged periods, ability to exercise, sexual function; and by result; self-esteem, intimacy, and relationships. As previously mentioned, it is often difficult to identify the precise etiology of pain and thus, this may prove frustrating for the patient and left with many unanswered questions. A question is posed; do women experiencing dyspareunia know, or are fully informed, on where to turn for medical advice and the array of treatment options offered? 

To quote Frank, Robert in 1948;  ‘Most frequently the family physician is the first to be consulted, particularly by newlyweds whom he has known since childhood or adolescence. Too often the general practitioner, because he has not been instructed in medical school, proves ill qualified to be a useful counselor. Moreover, he will find little useful guidance in the textbooks’.

Although this is not recent evidence, there is still some truth in this statement. Referring back to the survey distributed around on our social media platforms, the question ‘Which medical personnel would you seek should you experience dyspareunia?’ was asked.

As shown in the chart, the replies were the following:

• GP

• Gynecologist/ genital specialist

• Midwife

• Sex therapist

• Nurse

• Emergency Room

• Physiotherapist

• ‘I don’t know’

With the vast majority opting for gynecologist. Whilst a gynecologist does occupy a vital role within the team, only three people mentioned physiotherapist, with just one specifically mentioning a women’s health physiotherapist. This alludes that the general public is not educated on the different professions that deal with dyspareunia. However, with this small sample size, further research is required. 

Treatment:

Healthcare practitioners strive for a non-pharmaceutical approach where possible. Studies have shown that prescription of medicine, can sometimes have adverse effects to the condition in which the patient feels disregarded, and thus, disregards the pharmaceutical prescription guidelines. (Chiatti et al., 2012). In the case of physiotherapy, dyspareunia can be addressed in a number of ways. Musculoskeletal factors play an important role in the diagnosis, treatment, and management modalities of dyspareunia. Rehabilitating the pelvic floor muscles, for this reason, is fundamental to treat this dysfunction. (Ghaderi et al., 2019) One of which is addressing muscle flexibility in the form of stretching (with particular focus on adductors, obturator internus, piriformis, hamstrings, and iliopsoas muscles). The patient may also attempt to use a vaginal dilator to help manually stretch internally. This may result in pain for the patient since penetration happens, and thus, the practitioner should receive carefully and regular feedback from the patient. Myofascial release and deep, intravaginal, soft-tissue manipulation may be performed to restore connective tissue pliability, particularly in the case of scar tissue formation. This can then be transferable and taught for the patient to perform self-treatment. This is an extremely intimate procedure and may also result in pain and spasm, if the patient is not made comfortable. (Abraham et al., 2019) It is fundamental that the professional treats dyspareunia as any other condition, and does not shy away from the topic of sex. If they do not feel able to treat it themselves, they are still to handle the situation with ease and refer accordingly. (Lee et al., 2018). 

In a study by Ghaderi et al, 64 women with dyspareunia participated in being allocated randomly into two groups; an experimental/treatment group and a control group. The treatment group included electrotherapy, manual therapy, and pelvic floor muscle exercises. Prior to the treatment, which lasted three months, an evaluation on pelvic floor muscle strength [and endurance], pain, and sexual dysfunction was taken. This was also taken three months follow-up. Results showed improvement in the treatment group when compared to the control. Using the Oxford Scale, there was a mean increase of 2.01 in muscle power, a mean difference in pain (VAS score) of 7.32. By using the Sexual Functional Index score, there was a mean difference of 51.05. This proves, with need for further research and similar studies, the statistical significance of such a treatment programme on dyspareunia. 

Education:

Cross-comparing multiple studies on the topic, a common thread has been educating the woman on her pelvic floor anatomy and physiology(Abraham et al., 2019)(Fisher, 2007). Explaining the funnel-shaped structure of the pelvic floor anatomy and the three main components consisting of the 

• Levator ani muscles (puborectalis; U-shaped sling) (pubococcygeus) (iliococcygeus; the actual ‘levator’ of the three)

• Coccygeus muscle (the smaller, most posterior pelvic floor component

• And the fascia covering the muscles is fundamental. 

Studies have shown that by taking the time to explain this, the woman is able to visualise her anatomy better and isolate the muscles more leading to more effective and selective targeting during treatment(Fisher, 2007) (Bo et al.). When patients think of their pelvic floor muscles, due to media and uninformed information from practitioners, ‘Kegel's’ are often what come to mind. Kegel’s, in fact, cause increased tension in the pelvic floor muscles which could result in the potential increase of pain, and thus, adverse treatment. Exercise prescription by the physiotherapist should focus on relaxation of the pelvic floor muscles. This can be done via, diaphragmatic breathing, and as explained above, imagery. The following is an example of an image that can be shown to a patient whilst demonstrating the exercise.

(Fisher, 2007)

This shows a seated position with flat feet on the ground with intent on the ‘sit bones’. On inhalation, the patient is guided to image the sit bones moving away from each other. On exhalation, the bones are to glide inwards gently whilst avoiding contraction. The hands in the picture depict the movement of the pelvic floor. Evidence shows that this is effective with targeting pelvic floor muscles using terminology and descriptive wording as well as actual imagery.  

Evidence also shows that women are not always able to immediately locate their pelvic floor muscles. Unlike the hamstrings or biceps, which are oftentimes visible and palpable, the pelvic floor muscles are intimately positioned within the anatomy. (Kiyosaki et al., 2012). In a study from Loyola University Chicago; school of nursing, they quote ‘Centuries of yoga practice have provided a guide to help practitioners of yoga reconnect to the power of the pelvis.’ In healthcare and exercise prescription, the modalities of relaxation, meditation, and muscle mind connection offered by yoga techniques, does indeed, help the patient focus on isolating their pelvic floor muscles. This is a tool often used in the treatment/ management of dyspareunia. (Tenfelde, 2014). 

Occupational therapy:

Occupational Therapy can be defined as “the art and science of helping people do the day-to-day activities that are important and meaningful to their health and well-being through engagement in valued occupations.” (Willard and Spackman’s,. 2019). This is important as occupational therapists value the importance of one's desire to participate in occupations. Occupations give meaning and purpose to the client and differ from person to person. This can be called occupational need, and gives people the opportunity and ability to freely choose their own desired occupations. 

However, if these needs are not met, the person may feel imbalanced and without fulfilment. Research has gone into the exclusion of sex and treating sexual dysfunctions within occupational therapy. This goes against the client-centred approach practitioners strive towards. Holistically, sex can be considered an occupation and is, of course, a healthy expression of one’s sexuality. To quote Couldrick: ‘sexual expression may be of higher priority to an individual than other activities of daily living’, The lack of attention and treatment towards such a condition as dyspareunia might indeed lead to habitual precarious occupations as a form of venting away from their sexual needs. (Pollard and Sakellariou, 2007)

Occupational Therapists, take on a holistic view of the person. The relation between the environment, social, cultural and spiritual needs of the person is regarded with importance. It therefore, seems unwarranted, for the exclusion of addressing sex within treatment and why it was felt to be included in this paper. Research has gone into the occupational therapist promoting sexual aids or helping/ finding ways for client’s with sexual dysfunction to masturbate. This, however, was frowned upon by other professionals and the general public. Sometimes, even the patient themselves would see this type of treatment as unprofessional. Thus, this presents the practitioner with ethical dilemmas that cannot be ignored. Penna and Sheehy 2000, Earle 2001) (Stoner 1999). The findings of this study are rather old and there is an apparent gap in research regarding contemporary views on such an approach. 

When looking at dysfunction, occupational therapists may not only examine the physical aspect, but also play a key role in the mental health of the client. Adopting theories and approaches from psychology, occupational therapists found an important link between occupations and mental health. This is due to the fact that someone's emotional state can drastically affect one's ability to participate in occupations. 

Women who suffer from Dyspareunia often demonstrate signs of anxiety and depression due to their condition. The problems faced by these women may affect their day to day lives , participation in other occupations, self-esteem, and outlook towards sex. (Landry and Bergeron, 2010)

Anxiety often presents when faced with new and uncertain complications. In the case of dyspareunia, some women may almost develop a fear of intercourse due to the overriding anxiety and guilt towards the occupation.  Some may also find difficulty in disclosing the pain they feel during intercourse for fear that they would be judged and believe it would have a negative impact on their relationship. It has also been found that some women do not disclose pain during intercourse as they feel it is their duty to please their partner. This lack of being able to have sex has also been linked to cases of depression. (Khandker et al., 2011). Without this volition, - as described by Kielhofner in the Model of Human Occupation, is the sense that guides individuals to choose and experience occupations which are meaningful to them and that allows them to be self competent in them leading to occupational justice. Without it, different aspects of daily life which are integral to Occupational therapy, such as productivity, leisure and self-care are affected. Moreover, aspects of one's cognition may be impacted greatly and so problems with decision making and solving memory and attention can be affected. 

It is this which outlines the role of the occupational therapist within the multidisciplinary approach to treatment and management of dyspareunia. 

Examples in Practice:

Endometriosis

Endometriosis is a condition that affects 10% of the female reproductive population. It is often painful. Endometriosis occurs when the endometrium or similar tissue grows outside of the uterus. It usually spreads to pelvic organs and can, but rarely, spread beyond. The symptoms of this condition are severe dysmenorrhea, pain on urination or defecation, heavy bleeding during menstruation, sometimes infertility, and dyspareunia. This has a negative effect on the women’s overall quality of life. Studies have shown that the sex-life aspect of endometriosis is often neglected. (Lukic et al., 2015) Looking at sex as a whole, its many physiological aspects include vascular supply, hormones, nervous supply, and immune systems. Imbalances or pathologies amongst these leads to dysfunction. It is a disruption amongst these that can account for the pathogenesis of dyspareunia. 

67 women with endometriosis who experienced deep dyspareunia underwent laparoscopic surgery. After this surgery, a significant decrease in VAS score (pain outcome measure) was noted six months post-op. Laparoscopies are invasive and not readily available for everyone. It is for this reason, treatment (as mentioned above), from the multidisciplinary team is fundamental to treat the multifaceted dimensions of sex and its dysfunctions. (Lukic et al., 2015) 

Postpartum: 

After birth, especially if complications such as tears in the vagina arise, sutures are rather common to be done on the patient. Dyspareunia can be the result of scarring and scar tissue forming in the vicinity of the sutures. In such cases reassurance and appropriate referral to a multidisciplinary team has to be the course of action. (Fitzpatrick and O'Herlihy, 2007)

A particular study found that 8% of women had persistent perineal pain at one year following vaginal delivery (Kainu et al ., 2001).  Another study shows that, when comparing an episiotomy to spontaneous tears, the risk and prevalence of dyspareunia did not increase. This comments on the generality of sexual dysfunction and thus enhances the previous statement that due to varied etiology, diagnosis is taxing. (Signorello er al., 2001). On the other hand operative vaginal delivery (forceps/vacuum) and third and fourth degree tears increase the risk of dyspareunia (Leeman et al., 2016 ; Fodstad et al.,2016). This correlates with findings of increased scar tissue and increased trauma to the vagina enhancing symptoms of dyspareunia.

It is to be noted that superficial dyspareunia can be secondary to scar tissue formation, poor anatomical reconstruction following perineal trauma or vaginal dryness and atrophy. Until this point, midwives are equipped with general techniques of how to manage dyspareunia. If perineal pain and dyspareunia persists at 3 months postpartum, with completely healing sutures, a referral to a women’s health physiotherapist is advisable. (Manresa et al., 2019)

Painful intercourse post partum can often be linked to the following physiological sources; painful stitches after childbirth, pressure on spinal nerves in the pelvis [such as the pudendal nerve], hormonal changes accounting for the vaginal dryness, narrowing of the vaginal entrance, and tight muscles of the pelvic floor, amongst others.

Conclusion:

Outlining the major symptoms, pathologies, scenarios, and different effects on life, it is evident through research that the multidisciplinary team is fundamental in treatment and management of dyspareunia. Further research is suggested to look at the public’s perception towards professionals such as occupational or physiotherapists and their treatment methods. Improvements to the survey carried out would be a larger sample size and perhaps individual outlooks of male and female. 

References:

Abraham, A., Scott, K., Christie, A., Morita-Nagai, P., Chhabra, A. and Zimmern, P. (2019). Outcomes Following Multidisciplinary Management of Women With Residual Pelvic Pain and Dyspareunia Following Synthetic Vaginal Mesh and/or Mesh Sling Removal. Journal of Womenʼs Health Physical Therapy, 43(4), pp.171-179.

Bergeron, S., Binik, Y. M., Khalifé, S., Pagidas, K., Glazer, H. I., Meana, M., et al. (2001). A randomized comparison of group cognitive–behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain, 91, 297–306.

Chiatti, C., Bustacchini, S., Furneri, G., Mantovani, L., Cristiani, M., Misuraca, C. and Lattanzio, F. (2012). 

The Economic Burden of Inappropriate Drug Prescribing, Lack of Adherence and Compliance, Adverse Drug Events in Older People. Drug Safety, 35(S1), pp.73-87.

Enderby, P., John, A., Petheram, B. and Enderby, P. (2006). Therapy outcome measures for the rehabilitation professions. Chichester, West Sussex, England: Whurr.

Fisher, K. (2007). Management of Dyspareunia and Associated Levator Ani Muscle Overactivity. Physical Therapy, 87(7), pp.935-941.

Fitzpatrick, M. and O'Herlihy, C. (2007). Postpartum care of the perineum. The Obstetrician & Gynaecologist, 9(3), pp.164-170.

Ghaderi, F., Bastani, P., Hajebrahimi, S., Jafarabadi, M. and Berghmans, B. (2019). Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. International Urogynecology Journal, 30(11), pp.1849-1855.

Heim, L. (2001). Evaluation and Differential Diagnosis of Dyspareunia. [online] Aafp.org. Available at: https://www.aafp.org/afp/2001/0415/p1535.html [Accessed 1 Mar. 2020].

Khandker, M., Brady, S., Vitonis, A., MacLehose, R., Stewart, E. and Harlow, B. (2011). The Influence of Depression and Anxiety on Risk of Adult Onset Vulvodynia. Journal of Women's Health, 20(10), pp.1445-1451.

Kiyosaki, K., Ackerman, A., Histed, S., Sevilla, C., Eilber, K., Maliski, S., Rogers, R. and Anger, J. (2012). Patients’ Understanding of Pelvic Floor Disorders. Female Pelvic Medicine & Reconstructive Surgery, 18(3), pp.137-142.

Landry, T. and Bergeron, S. (2010). Biopsychosocial Factors Associated with Dyspareunia in a Community Sample of Adolescent Girls. Archives of Sexual Behavior, 40(5), pp.877-889.

Lee, N., Jakes, A., Lloyd, J. and Frodsham, L. (2018). Dyspareunia. BMJ, p.k2341.

 Lukic, A., Di Properzio, M., De Carlo, S., Nobili, F., Schimberni, M., Bianchi, P., Prestigiacomo, C., Moscarini, M. and Caserta, D. (2015). 

 Manresa, M., Pereda, A., Bataller, E., Terre-Rull, C., Ismail, K. and Webb, S. (2019). Incidence of perineal pain and dyspareunia following spontaneous vaginal birth: a systematic review and meta-analysis. International Urogynecology Journal, 30(6), pp.853-868.

MedicineNet. (2020). Definition of Pathology. [online] Available at: https://www.medicinenet.com/script/main/art.asp?articlekey=6387 [Accessed 1 Mar. 2020].

Quality of sex life in endometriosis patients with deep dyspareunia before and after laparoscopic treatment. Archives of Gynecology and Obstetrics, 293(3), pp.583-590.

Pollard, N. and Sakellariou, D. (2007). Sex and Occupational Therapy: Contradictions or Contraindications?. British Journal of Occupational Therapy, 70(8), pp.362-365.

Stoner K (1999) Sex and disability: whose job should it be to help disabledpeople make love? Eye Weekly,08.12.99. Available at:www.eye.net/issue/issue 08.12.99/news/sex.html Accessed on 07.07.06

How to be your own Valentine : The MHSA Guide

Two terms that we have heard about perhaps several times this past decade or so, are body positivity and self-love. But what do these terms mean exactly?

Body positivity refers to the assertion that all people deserve to have a positive body image, regardless of how society and popular culture view ideal shape, size, race, gender, sexuality, disability, and general appearance. In contrast, self love is something one can work on internally and encourage others to practice. It is really about honouring one’s feelings, taking time for one’s self, and caring for one’s self as is done for others.

The importance of Body Positivity and Self-Love

Poor body image and self-worth could give rise to a plethora of problems, including:

• Depression - Women experience depression at much higher rates than men do, and research has shown that body dissatisfaction may play an important role in explaining this gender difference in depression rates. (Ferreiro, Seoane and Senra, 2014)

• Low self-esteem – Research has found that body dissatisfaction is associated with poor self-esteem in adolescents regardless of their gender, age, weight, race, ethnicity, and socioeconomic status. (van den Berg et al., 2010)

• Eating disorders - Research also indicates that body dissatisfaction is linked to disordered eating, particularly among adolescent girlsm (Figueiredo et al., 2018)

Therefore, learning about and practicing body positivity and self-love could prevent the occurrence of problems, as above, as well as improve one’s quality of life significantly.

Body Positivity

As individuals living in the 21st century, we are constantly receiving information from a multitude of sources. Therefore, one can share an opinion on a body type through an endless list of means; from face to face confrontation, to a subtle advertisement. Therefore, one can practice body positivity to combat this by:

• Encouraging individuals with marginalized body types to not only practice self-love but feel worthy of self-love.

• Challenging how society views the body.

• Promoting the acceptance of all bodies.

• Helping build confidence and acceptance of all bodies.

• Addressing unrealistic body standards.

The movement also helps decode how popular media messages contribute to one’s relationship with one’s body, including how s/he feels about food, exercise, clothing, health, identity, and self-care. Understanding the effect of such influences allows for the development of a healthier and more realistic relationship with one’s body.

Self Love

The weight of negative emotions and perspective on one’s self can take a toll on one’s physical, emotional, and mental wellbeing. This can be combatted by practicing self love though:

• Having willingness – Committing to changing one’s ways in relationships, challenging what has not worked so far, and actively committing to understanding one’s self. In addition to building relationships where others can also love you for who you are.

• Self forgiveness– Forgiving one’s self for mistakes and errors in one’s past relationships will help cultivate an open heart that is ready for new experiences.

• Creating a positive mantra – Becoming mindful of one’s inner voice and guiding it to choose loving messages whenever negativity starts to creep in. An example of an empowering mantras is: “I love and accept myself always”.

• Eating well – Being selective about what food one chooses to nourish the body with, is one of the most important forms of self love.

• Surrounding one’s self with beauty – The external environment has a significant influence over one’s internal condition. Fresh flowers, soft music, or an organized home can all be very helpful in creating a high vibe living area.

• Taking one’s self out on a date – Getting dressed up and taking one’s self out on an outing for one, getting to choose the venue and specifics, will act as a reminder as to who is in control of the self and the future, making all of the effort put into body positivity and self love worth it.

On Valentine’s Day, whether you are single, dating, married, separated, or widowed take some time to reflect upon yourself. Are your ideas about your body image and self love what you want them to be, would you be your own Valentine?

Written by: Bernard Von Brockdorff

Interview: Breast Cancer Survivor Experience

Today on the 4th of February MHSA seeks to raise awareness on cancer in recognition of World Cancer Day. As a community of future healthcare professionals MHSA acknowledges the intrapersonal and interpersonal challenges brought about by cancer, hence inspiring this article.

MHSA has been working on finding the voice of breast cancer survivors and give them the opportunity to speak about their experiences. Unfortunately, breast cancer is one of the most common types of cancer in Malta, predominantly found in females. Statistics show that 1 in 8 women in the European Union develop breast cancer. Thankfully, it has one of the most successful prognoses in terms of treatment and survival rate.

Nicholas Aquilina, MHSA’s Social Policy Officer sat down with a cancer survivor and discussed her experience on a personal level as a wife, and mother of two. Her story is just one of many. For the sake of the article, our interviewee who wishes to remain anonymous will be addressed as Emma.

Emma discovered her illness whilst breastfeeding, initially she did not take much notice of the lump in her breast, though she became “Alarmed” on its persistence.

Emma was 33, which is quite young statistically speaking. Doctors were dismissive due to this statistical comparison, but after her breast examination this was no longer the case as they were evidently concerned. When she was informed of the diagnosis, “My first reaction was: Who will love my children?”, was her immediate response and she described the experience as “A rollercoaster of emotions”.

Many individuals find it difficult to come to terms with their diagnosis and many find it even more difficult to tell their family and friends. Emma was very fortunate as her husband was present when she received her diagnosis and got a significant amount of support from him during the difficult time. Her parents played a vital role, especially when she was receiving the aggressive chemotherapy treatment. They supported her by taking care of her two children, making sure that they feel loved and safe while mum was indisposed.

Emma was told she needed surgery, just a week after her diagnosis. Most of her family swiftly supported and aided her through the regression of her physical and emotional state. In fact, Emma described how her best friend made her as comfortable as possible, enjoying “Coffee moments and play dates” as not to disrupt her children’s lives. Unfortunately, other family members and friends were unsure of how to deal with the situation, some would “Start crying and hugging me and I would have to console THEM instead of vice versa”, Emma disclosed.

Emma revealed that her medical treatment was quite comprehensive, involving a mastectomy (a surgical operation to remove part or all of the breast tissue), chemotherapy, radiation therapy and oral medications for over 5 years.

At the time, breast cancer awareness was obviously less advanced than it is nowadays, and she expressed how she felt uninformed. Emma was given options by her surgeon, but it was ultimately her decision to make. She conducted quite a lot of research online, and also found an online support group which helped during such a difficult time. Emma commented that nowadays the healthcare system has improved greatly, particularly with the presence of the breast cancer screening unit, which did not exist 18 years ago.

Emma has certainly gone through an ordeal that she will carry with her for the rest of her life, but expressed that it is important to look at the positive side of things; where she was and still is supported and cared for by her family and friends, through the good and the bad.

Written by: Nicholas Aquilina and Bernard von Brockdorff

Safe Drive, Stay Alive

Christmas, a time often described as the most wonderful of the year, is once again upon us! With tinsel and fairy lights everywhere, being close to friends and family, and often-times given some form of time off from work or school; it is easy to get carried away with festivities. A time of over-indulgence, whether on presents, food, or indeed; alcohol. 

How many times have you heard the old ‘no bro its ok, i’m still good to drive’ after someone’s on their 5th whisky of the evening. Or better yet, the classic ‘you know i drive better when I’m drunk??’ We don’t need to be the ones to tell you, this is definitely wrong and there is no truth behind this. Before we go any further, we’d like you to really think that no distance is beneath what it takes to get into an accident. 

What is drinking and driving?

People differ in what they call it — driving under the influence, driving while intoxicated, booze and cruise,  drunk driving or impaired driving. Call it what you may; it is being in control of a motor vehicle after consuming alcoholic substances.

According to the law in Malta, you can have a maximum of 0.08% Blood Alcohol Content (BAC) in your bloodstream if you are behind the wheel of a car. This equates to a beer, or a small glass of wine, but if you want our advice, if you are driving it is better to steer clear altogether to be on the safe side. 

What does consuming alcohol actually do to your body?

• Reaction Time – Alcohol can slow reflexes, which can decrease the ability to react swiftly to changing situations.

• Vision – Alcohol can slow eye muscle function, alter eye movement, and alter visual perception, possibly resulting in blurred vision. Night vision and colour perception also can be impaired.

• Tracking – Alcohol can decrease the ability to judge the car’s position on the road, or the location of other vehicles, center strip, or road signs.

• Concentration – Alcohol may cause attention to driving to decrease and/or drowsiness to occur.

• Comprehension – Alcohol can hinder the ability to make rational decisions.

• Coordination – Reduced eye/hand/foot coordination can be caused by drinking too much alcohol.

Let’s be real, we don’t want to spoil your fun of smashing down a couple of pints surrounded by loved ones. We do, however, want to ensure your loved ones, yourselves, and anyone else along the way, gets home safely when you do! When planning a night out, knowing that you’re going to have a drink or two, keep the following tips in mind:

Designate a non-drinking driver

If you’re a group of friends/colleagues/coworkers on a night out, it’s simple! Take it in turns and so that the one driving gets to enjoy a pint (or two) the next time you go out.

It’s 100% your choice

Don’t rely on anyone to take your keys from you or make sure you don’t drive. The likelihood is they would have consumed alcohol too. Be responsible, have a plan from the beginning of the evening before judgement begins to become impaired. Resist temptation, and don’t take your car our in the first place if you know you will be drinking.

Know your options

When in doubt, call a taxi, phone up a friend/family member, check nearby hotels. As you budget for your new years eve party ticket, and the dress or tux, also budget for a responsible way to get home that evening.

Know your facts

Know your limits, and know your body. Educate yourself with the limits of how much you can consume, however, if even one glass of wine can affect you, avoid it completely.

Don’t let impaired friends drive

Protect others by taking their keys if they attempt to drive after consuming alcohol. They may be mad at you, but you’re a hero in our eyes!

Don’t fall into peer pressure

Never feel pressured to drink alcohol. If you do plan on drinking, opt for the non-alcoholic beverage instead! On the other hand, if you are the only friend with a car, don’t feel pressured into driving anyone home, no matter how close-by they live.

The morning after

Many people happily hop into their cars the morning after drinking without even realising that they are still over the legal limits. Going to sleep does not get rid of alcohol from your system. In general, alcohol is removed from the blood at the rate of about one unit an hour. But this varies from person to person. It can depend on your size and gender, as men tend to process alcohol quicker than women; how much food you’ve eaten; the state of your liver, and your metabolism (how quickly or slowly your body turns food into energy). The best advice, if you don’t want to put yourself and others in danger, and break the law, is to avoid alcohol altogether the night before you have to drive. 

The local scene

The European Traffic Police Network (TISPOL) has promoted a week-long campaign across Europe, which started on Monday 9th December 2019, to raise awareness of the dangers of drink driving as well as drug driving. Transport Malta has also stated in their latest festive awareness campaign the importance of reinforcing the message that when it comes to drink driving, ‘the best approach is none.’

MHSA has proudly teamed up with eCabs who advocate prominently each year to promote getting each passenger home safely. Stay tuned for an exciting collaboration launched tomorrow and a chance to win a 50euro eCabs voucher to spend this festive season.

Wishing you a fun-filled holiday season and best wishes for the coming new year.

The Diabetic Foot : World Diabetes Day

Diabetes is a chronic disease that causes high blood sugar due to the pancreas not producing enough insulin or when the body cannot effectively use the insulin it produces. The high blood sugar in diabetes may cause damage to various parts of one’s body, such as the nerves, blood vessels and skin. Such complications are often seen at the unbeknownst Diabetic Foot Ward at Mater Dei Hospital with the following conditions:

Peripheral Neuropathy is a condition in which excess blood sugar damages nerves in the foot. This leads to numbness and tingling in the feet, burning, stabbing or shooting pain in the affected areas, loss of balance and coordination as well as muscle weakness. MHSA’s Podiatry students have this complication particularly close to heart as they have volunteered to test the general public’s is peripheral sensation, time and time again.

Peripheral Vascular Disease involves the blockage of blood vessels around the body due to fatty deposits. This blockage results in blood flow, especially to the extremities, to be significantly reduced. This diminished blood flow can cause pain on activity, due to reduced oxygen flow to muscle tissue, thus leaving the individual unable to walk long distances as well as experiencing excruciating pain while lying down in bed, at a more serious stage.

Ulcerations are commonly associated with diabetes, since people suffering with the conditions described above are often predisposed to wounds which fail to heal adequately. Around 15 to 20% of diabetic patients develop a foot ulcer at some point in their life, hence it is important that the patient visits a podiatrist if they notice the development of abnormal changes in their feet.

Practical tips to prevent uncontrolled diabetes and further foot complications include:

●     Regulate Sugar Intake: One could avoid or else control diabetic foot complications by decreasing sugar consumption. This includes both complex sugars such as refined pasta and bread, as well as simple sugars as in chocolates and carbonated drinks.

●     Stay Active: Fortunately or unfortunately, exercise is the solution to everything as exercising regularly will not only decrease blood sugar due to an increased metabolism, but also promotes blood flow to the feet, combating the circulatory complications of diabetes.

●     Wear Appropriate Footwear: Protection of the feet in socks and shoes at all times is recommended by podiatrists, as is the use of the use of cotton socks which do not obstruct circulation. Poor footwear is not excusable in foot deformities as a podiatrist can recommend custom made shoes to help prevent future and accommodate present deformities. For further information please refer to the next point…

●     See your Podiatrist Regularly: Regular examinations by a podiatrist are key to preventing infections, amputations, severe deformities and to maintain overall good foot health. This is offered free of charge to diabetic patients around Malta and Gozo at primary health centres. This examination includes an overall assessment of the feet’s skin and nail quality, circulation, mobility and skin sensation. This will ensure that your feet are in top shape and control the diabetic manifestations.

●     Check Your Feet Daily: A daily self-foot examination can be done by checking the skin of the foot particularly at the sole, toes and in between the toes for visible abnormalities. Not being able the bend down has been made easy in the 1830s with the revolutionary invention of the mirror. 

●     Maintain Good Foot Health: One can start off by carefully trimming the toenails straight across and keeping them just above the free edge to prevent ingrown toenails and infections. Washing and drying the feet well, especially between the toes prevent the possibility of infections. One should also protect the feet from extreme temperatures as exposure to extreme hot and cold can damage the diabetic foot. Therefore, it is not advised that a diabetic patient checks the water temperature in the shower using their feet, as the impaired skin sensation could lead to skin scalding.

According to The International Working Group on the Diabetic Foot, globally, every 20 seconds a leg is amputated due to Diabetes, this means that by the time you have read this article approximately 18 leg amputations have been performed. We hope that we have convinced you to regularly check out your feet and not mouth-watering, crispy (but fluffy) chocolate covered fresh donuts!

Written by: Maria Abela and Federica Bartolo

Activity for Longevity

As Faculty of Health Sciences students, MHSA’s members strive towards health promotion and disease prevention. It was hence vital for us to celebrate the European Week of Sport through an article which explores the health benefits of various sports and forms of exercise for specific demographics; whether these benefits are physical, mental or emotional.

Wii Sport in Sedentary Lifestyles

Millennials and Gen Zs are notoriously known for their screen time, but this might not as bad as you think!

Active gaming such as Wii Sport allows for an active lifestyle by bridging screen time and physical activity. Various Wii utilities promote cardiovascular fitness, muscle strength, and co-ordination.

 The key factor that makes Wii Sport ideal towards combatting a sedentary lifestyle is the audiovisual feedback of the featured games, as they have been shown to increase the individual’s motivation while achieving a cardiovascular response that can reach that of traditional physical activity.

Tai Chi in Elderly Health

Its Tai Chi not chai tea ! This exercise encompasses a self-paced gentle exercise and stretching choreography with positions which flow from one to the other without pause, ensuring that the body is in constant motion, fluidly.

Balance, co-ordination, strength, concentration, and flexibility are enhanced when practicing tai chi. The increase in quality of these factors have shown to benefit the elderly demographic as they decrease the incidence of falls and prevent frailty which accompanies the degenerative changes of ageing.

Cycling in Osteoarthritis

Cycling, whether on a stationary bicycle, or not; has been shown to reap various health benefits, such as; improving muscle strength especially in the legs, as well as improving cardiovascular health.

It is a low impact form of exercise which provides significantly less stress to weight-bearing joints. Examples of such joints are the spine, hips, knees, and ankles.

Osteoarthritis related joint pain and stiffness have been reported to decrease when incorporating cycling into their lifestyle while such a sport has also shown to prevent its incidence in the first place. 

Also a bad cycling joke just for fun: Every time my bike hurts me I punch it right back, it’s  a vicious cycle.

Chess in Mental Health

Chess is a mind sport, (yes, it is an actual sport) played on a square board where opponents compete to strategically checkmate each other. This is achieved by positioning several pieces so as to restrict movement of the opponent’s king in such a way which prevents its further movement.

Chess has been shown to improve the development of the mind especially in children as it improves problem solving skills and abstract decision making, due to its strategic requirement. Additionally an increase in Intelligence Quota (IQ) and allows for logical and efficient thinking when selecting the superior choice out of a multitude.  

Finally, when taking into consideration the physical aspect chess, it allows for the development of fine motor skills though the movement of the pieces along the board.

Group Exercise in Performance Enhancement

We all have that one friend who cannot survive without his or her “Boo Thang”. This might not be too bad of an attribute when working out as a group, as this has been shown to reap superior results due to factors absent in individual workouts.

Group classes offer a social aspect to exercise, whether it be attending with your “Baby Cakes” or forming new friendships, this often motivates individuals to train frequently. Friendly competition also encourages members to train harder so to outperform one another.

This does not only apply to the average Joe, as group exercise has shown to offer a significantly higher improvement in walking ability and balance of stroke rehabilitation patients, in comparison to one-to-one exercise sessions.

The Use of Emergency

There are 2 ways to be admitted to hospital; either by a direct referral to the ward by going to a consultant privately, or through emergency. Entrance to the emergency department is not through main reception, but rather through an adjacent entrance. For most of us, the idea of visiting the accident & emergency department is a daunting prospect. 

The Accident & Emergency Department

A medical emergency is a situation whereby an individual encounters an immediate risk to their life or long-term health. It can be commonly referred to as a life or limb situation This is normally prior to acute injury, disease or illness.

The emergency department at Mater Dei Hospital is made up of different rooms, each designed for a specific purpose for better functionality and service. There is a triage room (where patients are sorted according to the severity of trauma or injury, and need of treatment), a room for paediatric cases, and a day clinic for patients whose condition is not life threatening.

The emergency department is also divided in 2: trauma and non trauma.

Non trauma patients are mainly cardiac, neurological or surgical patients.

Trauma patients are not too common in Malta, however they are on the rise due to a recent increase in motor vehicle accidents and construction site accidents.

Upon arriving at the emergency room, one is greeted at a reception desk and asked for detailed information. This includes but is not limited to name and surname, ID card number and presenting complaint. This is only written as a simple, concise clinical description, meaning that if one is experiencing left hand pain, that is what will be written. However, the receptionists are very experienced and will assess the initial condition and severity. They will then discreetly call the nurses to check up on the patient.  All this is monitored by the nurses in the triage room.

The Professionals

All nurses and doctors working at the emergency department are all highly trained individuals with multiple years of specialisation and previous experience in various wards. This exposes them to different conditions and procedures giving them maturity in their practice. This enables them to carry out certain procedures such as an ESI. This stands for Emergency Severity Index and is used to further aid the triage. This index aids the emergency staff by scoring the patients, and in turn listing priorities. Priority 1 cases are taken straight through for intervention by doctors.

Figure 1 shows how patients are given priority according to certain signs.. This is used in Malta’s Accident & Emergency Department.

Use of the health care professionals

The Health Care Professionals’ (HCP) job is always evolving within hospitals and in the community. In an emergency setting, things are similarly ever-changing. HCPs such as physiotherapists and radiographers are always present and stationed at the emergency department. Physiotherapists are called upon mainly for chest physiotherapy, whilst radiographers carry out medical imaging such as ECGs, ultrasounds and X-rays.

Other health care professionals such as podiatrists and mental health nurses are on call. Unfortunately, they are a limited resource and their time and expertise are usually needed elsewhere.  There are other professionals which are on call such as social workers and psychologists. HCPs such as occupational therapists are then present in the wards for the follow-up care.

Ambulance

In case of an emergency it is important to remember that the right number to call is 112. This will not connect directly to the emergency department but rather to the emergency services department. Upon picking up, the personnel on the line will ask the caller’s location and requirement. This will ensure to the right response team and assistance. In the case of a medical emergency, the caller will be redirected to the ambulance department where they will be asked to describe the situation. In most cases, the professionals on the line will direct the caller with a set of protocols and manoeuvres in case emergency medical intervention such as CPR is needed. 

Malta has a one minute dispatch with a very good recovery time. There are 2 types of responses; green for cases which are not severe, and red/orange for priority 1 and trauma cases.

There is a standard of 1 emergency nurse and 2 paramedics in each ambulance, however this might change according to the situation by sending doctors which are specialised in emergency care.

The Emergency Room in Malta is always a busy place. Many may complain that they spend a long time waiting to be seen. A longer waiting time however, usually signifies a less severe condition. One should remember that health centres are used for many cases where specific emergency services are not required by the patient.

On the scene of an accident, the initial first responder may not be a qualified nurse or doctor. This solidifies the need of first aid as a response at any given situation prior to the arrival of an ambulance is crucial. The use of first aid helps to save lives as one is preventing the worsening of condition and helping to preserve life, until professional help arrives. In Malta, first aiders are protected by the “Good Samaritan Law” stating that they are not legally responsible if the condition of the injured person worsens. One could also make use of the app “112mt” for emergencies. This application uses one’s location from their phone and calls directly.

 We all have our part to play to help save a life.

Chronic Pain and Physiotherapy

We have all experienced the feeling of pain in one form or another, physical, emotional or psychological.

 The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

There are two kinds of pain: acute pain which is short-term pain and chronic pain which is pain felt for over three to six months.

Research has shown that pain is present in one in 10 persons aged 18 to 24, rising to one in four persons aged 45 and over.

One in every five adults in Malta endures chronic pain, a study by the Malta Health Network (MHN) and the No Pain Foundation has found.

A local study carried out in 2018 is the first to give an insight into the number of patients that suffer from chronic pain in which a sample of 1,100 people was used for the research.

The study found that 86% of sufferers are absent from work for at least one week every year as a result of chronic pain.

Individuals with chronic pain report that their conditions are limiting their daily activities by varying degrees from lifting a bag with groceries to going up a flight of stairs. Younger individuals report a higher level of impairment to their social activities due to their physical or emotional state.

‘Musculoskeletal diseases including arthritis, joint pain and fibromyalgia make up 75% of the causes of chronic pain while 20% results from chronic headaches and migraines.’ Other sources of pain include cancer, vascular disease, poor circulation or various injuries.

‘The pain can limit persons in basic activities such as washing and bathing, walking short distances, catching a bus or driving. This impacts the quality of life of people, causing emotional distress and a sense of failure.’

Some people live with chronic pain as a result of trauma e.g. after a road traffic accident, where technically they are medically fit, but they end up with chronic pain or they survive cancer but have to live with chronic pain due to the treatment they experienced. Nowadays patients and professionals are demanding that Pain is recognised as a disease in its own right.

Pain is also related to obesity so one needs to look at healthy living including weight management and physical activity. Occupational hazards also need to be addressed; for example positioning one's computer at the right height and angle.

Emotional and mental issues also affect chronic pain patients’ families immensely, such as missing work and family events because of pain all contribute to stress.

(Retrieved from: Duenas et al, 2016)

A holistic policy must be considered which provides chronic pain prevention where possible. Quite a large proportion of chronic pain, especially that related to back pain can be prevented with adequate education.

The Chronic Pain Management Service, popularly known as the ‘Pain Clinic’ is a specialized clinic at Mater Dei Hospital, run by Trained Pain Specialist Consultants with the co-operation of a multidisciplinary team.

The team consists of three Consultant Anaesthetists specialising in pain management and one visiting Consultant, a Practice Nurse Pain, Deputy Charge Nurse, Staff Nurse, Clerk, Nurse Aide, Two Physiotherapists, Psychotherapy Nurse, and with the cooperation of Radiographers, Theatre Anaesthetic Nurses and Day-care nurses for procedures.

A ticket of referral needs to be completed by the patient’s Family doctor, Primary Health doctor or another Consultant for an appointment to be made at the Pain Clinic.

People may experience pain on a daily basis, and it is essential to distinguish pain as a symptom and chronic pain.

Improving the definition of pain, in order to conclude a pain diagnosis and adequate classification of its clinical forms is the way forward in modern health care.

Don't be afraid to consult with a health care professional or a doctor of your choosing to tackle pain firsthand!

References:

Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251–258. doi:10.1001/archinternmed.2008.543

Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J Pain Res. 2016;9:457–467. Published 2016 Jun 28. doi:10.2147/JPR.S105892

Why Health Care Needs Trees

In light of the recent controversy of the removing of trees from Attard, MHSA has decided to give a factual review of just a couple of benefits of trees [and nature in general] in the world of science, medicine, and health care.

Asthma:

Is a chronic respiratory, obstructive, disease of the lungs. Symptoms include shortness of breath, chest tightness, coughing, and wheezing. By inhaling direct pollutants from the atmosphere, with CO2 levels in Malta constantly on the rise, this is a direct trigger which can bring on an asthma attack. Respiratory diseases are one of the leading causes of morbidity worldwide secondary to CVD. In Malta, it is as follows:

Taken from the Malta Annual Mortality Report (2015) [[neoplasms including lungs or bronchi]].

Trees play an essential role in purifying the air in the environment by reducing the level of some pollutants and particulate matter. It is for this reason, that more should be planted in order to release more oxygen and absorb more CO2. By removing and uprooting trees, more adverse effects will be seen on the general respiratory health of the country.

Green exercise:

This is physical activity in the presence of nature. Studies show, when cross compared to indoor activity of the same duration and intensity, green exercise boosts both self-esteem and mood in both men and women. In multiple studies, changes are even noted after 5 minutes of exercise. Intensity and duration were also able to be increased in a green setting. Although not the scope of most studies, it was an interesting find nonetheless

It is therefore apparent that trees and nature in general are fundamental in exercise psychology. Given the obesity rate, it is extremely important the Maltese population gets active and begins to make lifestyle changes. Green exercise is definitely a way forward and worth investing in.

Taken from WHO in Malta’s NCD country profile, 2018

Temperature:

Admittance to hospital due to heat stroke, severe sunburn, dehydration, and general over-heating is abundant in the summer months. In a study conducted in Japan, a total of 127 patients who suffered heat illness were analyzed. Of these, 49 (37%) were admitted, with 59% discharged on the day following admission. This shows that out of the study, 74.93 patients occupied a hospital bed, human resources, and medication, for a day and a night. With trees around, if standing under it, people can cool down by being shielded from the sun by their shade. By sequestering CO2, they also affect global temperature. There are not many areas in Malta where one can do this. Particularly with the very young, elderly, or active, there are not many places to seek shelter from the burning sun in peak hours unless indoors. Of course, sun protection (SPF), appropriate hydration, protective clothing, etc. are also fundamental in the protection of the individual.

Based on the US population.

Drugs:

Much of the medication used for antibiotics, NSAIDs, opiates, and more, feature basic ingredients from trees. An estimated 50,000 plant species are used medicinally. The medicine can be extracted from roots, bark, leaves, flowers, fruits, and seeds. An example of this is witch hazel. This is a topical agent known as an astringent which tends to ‘constrict’. It is useful in closing pores and in oily skin. Another example is the ‘yew’ species, which produce ‘Taxol’. This is used in chemotherapy drugs. Although some of these species are not indigenous to Malta, it is still fundamental to sculpt a conservational mentality and understand the importance of the nature around us. It is also worth noting that such things may be grown in biotechnical centres and labs. However, this is not available in every economy and country.

Communication Impairments as Portrayed in the Media.

We’re used to tuning into Netflix or heading to the cinema, and our screens being occupied by stunning celebrities. We skim through our Instagram feed and it’s infiltrated with all sorts of influencers with millions of followers who ‘keep it real’ by talking about something like a break out in their skin.

In our Kardashian-esque era, there is a noticeable lack of diversity present in the media. Impairments and health issues are prominent in real life and therefore excluding them is not a true depiction and portrayal of our society.

The hereafter mentioned are just a few instances where this much welcomed diversity portrayal is apparent!

Stuttering:

Fluency, is the aspect of speech production that refers to how continuous, smooth, and effortless the speech itself is. It is not to say that at any time that someone is dysfluent, it is an impairment. Quite the contrary, as we all may tend to make use of additions to our speech such as ‘um’ or word repetitions. The use of additions/repetitions once in a while is something rather common, however if it happens frequently, it may be a speech impairment known as stuttering.

Over the years, several movies have involved characters who stutter, such as, the famous Porky Pig from Looney Tunes and Piglet in Winnie the Pooh.

Other famous movies which show such a speech impediment include;

·      Charlotte’s Web (1972) [where Agnes Moorehead performed the voice of a stuttering goose]

·      Harry Potter and the Sorcerer’s Stone , acted out by the character Professor Quirrell

·       The King’s Speech which is a movie about King George VI with a special focus on difficulties faced due to his stuttering.

 Hearing Impairments:

This is an impairment affecting the way the individual hears and may occur in one or both ears. It is better described as a partial or total loss of hearing. Such an impairment has been featured in the series Switched at birth which has several deaf characters, including the main character Daphne Vasquez, with one episode being performed entirely in sign language.

The newly released Toy Story 4 features a boy wearing a cochlear implant. This is seen to be as rather ground-breaking for the media and gained a lot of intrigue, appreciation, and respect from the viewers. It is a passageway that can help young individuals whom may feel threatened or brought down by their impairment, suddenly normalise it.

 Autism:

Autism or autism spectrum disorder (ASD) is an umbrella term for a range of conditions, primarily characterised by difficulty with social skills, speech, and nonverbal communication, with other challenges such as repetitive behaviours.

In the media, autism is often portrayed in a negative light and often as a disorder which is extremely difficult to deal with.

Breaking this norm, a renowned series called ‘The Good Doctor’ highlights ASD through its main character, Shaun Murphy. He plays a young surgeon with autism and Savant syndrome who is recruited in a reputable hospital. The show follows Shaun and his challenges that are due to the disorder but also shines an admirable light on his perseverance and not allowing his disorder to take control of his life.