The diabetes epidemic in Malta

A note of appreciation and acknowledgement is forwarded to Professor Julian Mamo, Professor Josanne Vassallo and Professor Neville Calleja for their continuous support and advice during the academic progression.Aim: The small European Mediterranean island state of Malta is a highly prevalent type 2 diabetes (T2DM) country. Over recent decades drastic environmental, cultural and ethnic changes occurred and it was considered timely to undergo a cross-sectional survey to establish up-to-date prevalence of T2DM, its socio-geographical distribution and ultimately estimating the economic burden of T2DM. Methods: A health examination survey was conducted (2014-16) including a representative sample of the adult population stratified by 18-70 years, gender and locality (n=3,947; males n=1,997 male). The survey consisted of a socio-demographic questionnaire, various health examination measurements and blood samples for fasting blood glucose (FBG). Prevalence for T2DM (depending on medical history, medication and FBG >7mmol/L) were calculated for the general population as well as for each of the districts making up the Maltese Islands. The economic burden of T2DM for 2017 and projected burden for 2045 were calculated using secondary sources and by incorporating 2% compound interest per annum respectively. Results: A total response rate of 47.15% was obtained, with a mean age of 48 years for males and 46 years for females. Out of the total adjusted population (n=3,947, male n=1,998), the prevalence of T2DM was of 10.31%, with 6.31% already known to have T2DM while 4% were newly diagnosed. Females were diagnosed with T2DM at an earlier age than the males. No significant geographical T2DM prevalence differences were established. The total annual diabetes health care expenditure was approximately €107,316,517.82 for 2017, while the projected expenditure for 2045 was estimated at €244,136,040. Conclusion: Malta is a country with a high prevalence of diabetes. The females were observed to be at an earlier risk of developing undiagnosed diabetes compared to males. Although geographical location did not appear to have significant effect on T2DM distribution, this disease contributes to a high economic burden. The expected exponential increase in diabetes prevalence is subsequently expected to affect negatively the healthcare expenditure. This puts forward the recommendation for development of early screening programmes as part of preventive action strategies.The author is extremely grateful for the strong support forthcoming from the University of Malta (through the Medical School and Research Innovative Development Trust department) and from the Alfred Mizzi Foundation as major sponsors, as well as that of a host of others, including Atlas Health Insurance (Malta). The in-kind support and encouragement of the Parliamentary Secretariat for Health of the Government of Malta is also gratefully acknowledged.peer-reviewe

Objective Assessment of Surgical Operative Performance by Observational Clinical Human Reliability Analysis (OC-HRA):A Systematic Review

Background: Both morbidity and mortality data (MMD) and learning curves (LCs) do not provide information on the nature of intraoperative errors and their mechanisms when these adversely impact on patient outcome. OCHRA was developed specifically to address the unmet surgical need for an objective assessment technique of the quality of technical execution of operations at individual operator level. The aim of this systematic review was to review of OCHRA as a method of objective assessment of surgical operative performance.Methods: Systematic review based on searching 4 databases for articles published from January 1998 to January 2019. The review complies with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and includes original publications on surgical task performance based on technical errors during operations across several surgical specialties.Results: Only 26 published studies met the search criteria, indicating that the uptake of OCHRA during the study period has been low. In 31% of reported studies, the operations were performed by fully qualified consultant/attending surgeons and by surgical trainees in 69% in approved training programs. OCHRA identified 7869 consequential errors (CE) during the conduct of 719 clinical operations (mean = 11 CEs). It also identified ‘hazard zones’ of operations and proficiency–gain curves (P-GCs) that confirm attainment of persistent competent execution of specific operations by individual trainee surgeons. P-GCs are both surgeon and operation specific.Conclusions: Increased OCHRA use has the potential to improve patient outcome after surgery, but this is a contingent progress towards automatic assessment of unedited videos of operations. The low uptake of OCHRA is attributed to its labor-intensive nature involving human factors (cognitive engineering) expertise. Aside from faster and more objective peer-based assessment, this development should accelerate increased clinical uptake and use of the technique in both routine surgical practice and surgical training.</p

Mobility power flow analysis of coupled plate structure subjected to mechanical and acoustic excitation

The mobility power flow approach that was previously applied in the derivation of expressions for the vibrational power flow between coupled plate substructures forming an L configuration and subjected to mechanical loading is generalized. Using the generalized expressions, both point and distributed mechanical loads on one or both of the plates can be considered. The generalized approach is extended to deal with acoustic excitation of one of the plate substructures. In this case, the forces (acoustic pressures) acting on the structure are dependent on the response of the structure because of the scattered pressure component. The interaction between the plate structure and the acoustic fluid leads to the derivation of a corrected mode shape for the plates' normal surface velocity and also for the structure mobility functions. The determination of the scattered pressure components in the expressions for the power flow represents an additional component in the power flow balance for the source plate and the receiver plate. This component represents the radiated acoustical power from the plate structure. For a number of coupled plate substrates, the acoustic pressure generated by one substructure will interact with the motion of another substructure. That is, in the case of the L-shaped plate, acoustic interaction exists between the two plate substructures due to the generation of the acoustic waves by each of the substructures. An approach to deal with this phenomena is described

Parametric and experimental analysis using a power flow approach

Having defined and developed a structural power flow approach for the analysis of structure-borne transmission of structural vibrations, the technique is used to perform an analysis of the influence of structural parameters on the transmitted energy. As a base for comparison, the parametric analysis is first performed using a Statistical Energy Analysis approach and the results compared with those obtained using the power flow approach. The advantages of using structural power flow are thus demonstrated by comparing the type of results obtained by the two methods. Additionally, to demonstrate the advantages of using the power flow method and to show that the power flow results represent a direct physical parameter that can be measured on a typical structure, an experimental investigation of structural power flow is also presented. Results are presented for an L-shaped beam for which an analytical solution has already been obtained. Furthermore, the various methods available to measure vibrational power flow are compared to investigate the advantages and disadvantages of each method

Extension of vibrational power flow techniques to two-dimensional structures

In the analysis of the vibration response and structure-borne vibration transmission between elements of a complex structure, statistical energy analysis (SEA) or finite element analysis (FEA) are generally used. However, an alternative method is using vibrational power flow techniques which can be especially useful in the mid frequencies between the optimum frequency regimes for SEA and FEA. Power flow analysis has in general been used on 1-D beam-like structures or between structures with point joints. In this paper, the power flow technique is extended to 2-D plate-like structures joined along a common edge without frequency or spatial averaging the results, such that the resonant response of the structure is determined. The power flow results are compared to results obtained using FEA results at low frequencies and SEA at high frequencies. The agreement with FEA results is good but the power flow technique has an improved computational efficiency. Compared to the SEA results the power flow results show a closer representation of the actual response of the structure

Application of the mobility power flow approach to structural response from distributed loading

The problem of the vibration power flow through coupled substructures when one of the substructures is subjected to a distributed load is addressed. In all the work performed thus far, point force excitation was considered. However, in the case of the excitation of an aircraft fuselage, distributed loading on the whole surface of a panel can be as important as the excitation from directly applied forces at defined locations on the structures. Thus using a mobility power flow approach, expressions are developed for the transmission of vibrational power between two coupled plate substructures in an L configuration, with one of the surfaces of one of the plate substructures being subjected to a distributed load. The types of distributed loads that are considered are a force load with an arbitrary function in space and a distributed load similar to that from acoustic excitation

Power flow analysis of two coupled plates with arbitrary characteristics

The limitation of keeping two plates identical is removed and the vibrational power input and output are evaluated for different area ratios, plate thickness ratios, and for different values of the structural damping loss factor for the source plate (plate with excitation) and the receiver plate. In performing this parametric analysis, the source plate characteristics are kept constant. The purpose of this parametric analysis is to be able to determine the most critical parameters that influence the flow of vibrational power from the source plate to the receiver plate. In the case of the structural damping parametric analysis, the influence of changes in the source plate damping is also investigated. As was done previously, results obtained from the mobility power flow approach will be compared to results obtained using a statistical energy analysis (SEA) approach. The significance of the power flow results are discussed together with a discussion and a comparison between SEA results and the mobility power flow results. Furthermore, the benefits that can be derived from using the mobility power flow approach, are also examined

Extension of vibrational power flow techniques to two-dimensional structures

In the analysis of the vibration response and structure-borne vibration transmission between elements of a complex structure, statistical energy analysis (SEA) or Finite Element Analysis (FEA) are generally used. However, an alternative method is using vibrational power flow techniques which can be especially useful in the mid- frequencies between the optimum frequency regimes for FEA and SEA. Power flow analysis has in general been used on one-dimensional beam-like structures or between structures with point joints. In this paper, the power flow technique is extended to two-dimensional plate like structures joined along a common edge without frequency or spatial averaging the results, such that the resonant response of the structure is determined. The power flow results are compared to results obtained using FEA at low frequencies and SEA at high frequencies. The agreement with FEA results is good but the power flow technique has an improved computational efficiency. Compared to the SEA results the power flow results show a closer representation of the actual response of the structure