Are you a medical student feeling lost or maybe thinking of embarking on the journey to become a doctor? Struggling to juggle your studies while living a life outside medicine? Remain calm! THINK Magazine sat down with Dr Sarah Cuschieri to discuss her latest book A Pocket Guide for Medical Students, full of tips and tricks on how to survive and thrive during medical school and beyond.
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We often hear that women are more tolerant to pain than men. Many are also proud of it. However, in the famous game-changing paper titled ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’ the authors Diane E. Hoffman and Anita J. Tarzian found that contrary to popular belief, women report more severe levels of pain, more frequent pain, and pain that lasts longer than men’s. Three Maltese women found out the hard way that confiding in medical practitioners does not always lead to help.
Culture and gender frame our behaviour around pain perception. Boys were, and some still are, told not to express pain by crying or showing emotion. Girls were told to calm down and not make a fuss. Pain meant weakness. Our language lacks the vocabulary to adequately describe pain. In ‘On Being Ill’, Virginia Woolf writes: ‘English which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache… The merest schoolgirl, when she falls in love, has Shakespeare and Keats to speak for her; but let the sufferer try to describe a pain in his head to a doctor and language at once runs dry.’
Gendering pain
By analysing a number of studies, Hoffman and Tarzian found that women are ‘more likely to be treated less aggressively in their initial encounters with the healthcare system until they prove that they are as sick as male patients.’ This is a phenomenon known as the Yentl Syndrome. In other words, doctors may brush female pain off as fabricated or exaggerated. This can impact diagnosis, disease progression, and treatment plans — delaying care and fueling mistrust.
Prescribing uterus removal when a woman was ‘rebellious’ may seem like ancient history, but that bias has not fully retreated. Until the early 1990s, women were mostly excluded from clinical research studies and trials in medicine. What we knew about the body, about disease, and about medicine was based on men. Drugs that didn’t work on men, but might have worked on women, were discarded. With incomplete data, the medical world may have lost opportunities to improve women’s health. Have today’s healthcare professionals been trained to counter this gender bias?
Another doctor later referred Karen for an MRI, and the tumour was detected — a life or death analysis.
Antonia* doubts that. As a teenager she developed digestion problems and nausea every time she ate. When she complained, her family doctor downplayed the problem and suggested that she should just stop eating for a couple weeks. After this shocking response she ignored the issue for a long time, suffering in silence. Another doctor chalked it down to ‘growing pains’ and did not recommend a colonoscopy, even though Antonia asked for it.
Having received no satisfying response from her visits to medical professions, Antonia decided to do her own research, discovering that her symptoms matched the description of a condition called Crohn’s. Because of her constant discomfort and pain Antonia had no choice but to persist until she was granted testing and the correct treatment after years of suffering. This means that two doctors would have left her inflamed digestive system untreated, risking further damage.
‘It is just a phase’
Women are often told that their ailments are due to stress or other emotional factors. A little rest would solve the problem; it is just a ‘phase’. Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests (see e.g. Samulowitz et al. 2018 study and numerous articles in the New York Times, The Atlantic and elsewhere). Thankfully, there are enough doctors who look beyond textbook-like symptoms. They make it a point to listen and investigate as much as necessary. Yet the burden of finding a practitioner ready to listen lies with the patient.
Karen visited her gynaecologist complaining of headaches and substantial weight gain. Test results revealed a high prolactin level, which is normally produced during pregnancy or right after giving birth. Yet when Karen asked to be referred for an MRI to investigate for tumours in the pituitary gland, the doctor refused, telling her that she was ‘making a fuss’. Another doctor later referred Karen for an MRI, and the tumour was detected — a life or death analysis.
Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests.
Gynaecologists feature often when discussing gender bias. Without systematic training to counter biases, women are left to ‘shop around’ for a gynae that doesn’t shame them or belittle their wishes. This is surprising for a profession specialising in women’s health.
Reproductive issues open another can of worms. Some women who decide not to have children are treated as though they don’t know what they’re doing. Their doctors imply that the patient will inevitably change their mind, or try to guilt the patient into considering the feelings of a hypothetical man they might meet.
You would think that commitment to bear biological children would be respected, but women who undergo IVF are often treated with insensitivity too. Sandra* and her husband had a harrowing story to tell me. Sandra’s gynaecologist decided to immediately hurry her to IVF after the first visit about their concerns at not being able to conceive. The gynaecologist was rarely present for her many appointments at hospital, leaving Sandra to be passed from one doctor to another, internally examined by various doctors without explanation or prior request for consent. With the exception of one doctor, none of them introduced themselves. All along she tried to ask questions, but was kept in the dark about the situation, going along with the doctors’ instructions but losing trust. The outcome of the first procedure was unsuccessful, and because of how traumatising all this felt, the couple decided not to try again.
Unlearning the bias
Pain is subjective and difficult to measure. An individual’s tolerance to pain is affected by various factors, and pain perception may change with time and experience. Pain causes distress, which makes it difficult to measure objectively. So how can overworked doctors make the best possible assessment?
In her thesis titled ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals’ (University of Malta, 2008), Maria Campbell studied pain perception in other healthcare professions in Malta back in 2008, finding out that outdated attitudes have not been challenged. She writes, ‘Incomplete knowledge, outdated attitudes, myths, and misconceptions about pain and its management contribute to unsafe, inadequate, and inappropriate pain management.’ Medical practitioners wanted to be more up-to-date: ‘The need for information in the form of leaflets, seminars, and continuing education was echoed in the overall answers (90%) of the close-ended question and in the statements declared by participants.’ But before this training becomes systemic, the radical act of listening to women is a good place to start.
* Name has been changed
Further reading:
Fassler, J. ‘How Doctors Take Women’s Pain Less Seriously’. The Atlantic. October 2015.
Hoffman D.E., Tarzian, A.J. ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’. Journal of Law, Medicine & Ethics, Vol. 29, pp. 13-27, 2001.
Campbell, M. ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals.’ University of Malta. June 2008.
Our bodies produce billions of cells every day. With such industrial production rates, it’s entirely likely that a mistake or two are made along the way. Cancer cells are those mistakes—faulty mutants.
Humans are also equipped with mechanisms that allow them to recognise cancer cells and get rid of them, but there can be trouble when distinguishing ‘bad’ from ‘good’. Part and parcel of cancer is that it compromises the immune system to ‘escape’ our ‘guards’. This precious time during which the body fails to recognise the mutants is the golden opportunity for cancer cells to multiply and thrive. And as the cancer grows, so do the problems that come with it.
Despite the varied types of cancers in existence, treatment usually entails surgery and chemotherapy. But the risks and side-effects that come with them are heart-wrenching.
But what if a vaccine can stop cancer in its tracks? Prof. Pierre Schembri-Wismayer and his team are working on a type of immunotherapy that enables the body to recognise the invading cancer sooner, directing the attack as a result.
Vaccines work by triggering an immune response in the body. These cancer vaccines developed by Schembri-Wismayer work the same way. He collects a piece of the cancerous tumour and denatures (a process not unlike cooking or boiling) it in formalin, which modifies its shape, making it easier for the body to recognise as a foreign body. The body can then remove it.
Our bodies have a naturally low tolerance when it comes to foreign entities, so when a vaccine injects the cooked tumour, the body recognises it and ambushes both the injected and the original cancer present in the patient, ‘engendering a stronger immune response’.
Inspired by a Japanese research paper, yet baffled by its lack of recognition, Schembri Wismayer modified the method outlined there and created his own version of the vaccine to accommodate his first patients: a pair of pet rats.
Schembri-Wismayer had the perfect opportunity to test the potential cancer treatment when a student’s pet rats fell ill. Their owner mistakenly overfed the rats to such an extent that they became obese. ‘The rats became square-shaped,’ Schembri-Wismayer notes. With the increase in body fat, their oestrogen rose too—a female sex hormone that increases the risk of breast cancer. As a result, both rats developed the disease, and even showed metastasis in both underarms, which also happens in humans. Obesity is linked to cancer in many animals.
Within days, Schembri-Wismayer took samples from the rats and produced a tailor-made vaccine for each rat. Two weeks after their treatment, the rats’ owner informed him that they were in a lot of pain. ‘But tumours don’t hurt,’ Schembri-Wismayer explains.
An operation on the rats revealed that the tumours had broken down (were full of dead cells). This confirmed that the rats’ pain was actually stemming from the inflammation caused by the vaccine itself.
Physical anguish aside, this was a good sign, an indication that the body was fighting back. In the end, the tumours burst, necrosed, and died. The rats beat the cancer, and thus a new research project found its beginnings.
Having had such promising results, and with ethical approval from the local Animal Welfare Council as a therapeutic option, Schembri-Wismayer turned his attention to a group of animals which would benefit a lot from such vaccines—people’s pets.
‘In many cases, once a dog or a cat gets cancer, there’s not much you can do if it spreads,’ says Schembri-Wismayer. His vaccines can offer new hope to pet owners when cancer strikes and the only option is to put them down. And so it has.
With consent from owners and vets, Schembri-Wismayer offered the therapy to cats and dogs of different breeds. The types of cancer varied, as were their progressions, and so the results were just as jumbled. The treatment was successful for some, but not all. Considering this treatment is still in its early days, an element of trial-and-error puts some animals at a disadvantage, particularly those who are very ill when the disease is in its last stages. It should also be mentioned that this research project was held back by challenging communication difficulties between everyone involved. ‘Different priorities made the process more difficult than it had to be,’ Schembri-Wismayer notes. The ideal scenario would see him and the veterinarian working hand-in-hand to follow up on the animals and their response to the treatment using blood tests and ultrasound.
That said, the potential of the treatment isn’t limited to individual successes. Each pet-patient contributed to a better understanding of the treatment, especially when owners were immensely helpful and allowed the veterinary surgeon to provide the team with a piece of the tumour after treatment (even if the pet was put down). With that in mind, the prospects of this type of immunotherapy are promising to say the least.
While the vaccine’s promising results might be a step in the right direction, the cure for cancer doesn’t seem to be in the near future. The ongoing animal treatments are providing useful information, but the move to human trials is gruelling. Testing out new therapies comes with storey-high hurdles, including financial ones, that need to be overcome.
The reality is that this kind of therapy would work best as a first response (or after debulking surgery). Because the more widespread the cancer, the bigger the immune response the vaccines create. And ‘if a reaction is strong enough, it might be enough to kill the patient,’ Schembri-Wismayer explains. But medicine works with a set of rules and best practices. Doctors are obliged to try what’s known to work first before moving onto lesser-known experimental drugs. This fact is a challenge. Despite the hurdle, Schembri-Wismayer is certain that people would eventually volunteer to be involved in clinical trials, as happened with HIV/AIDS treatments. ‘Unfortunately in end-stage cancer you have no other options.’
Vaccines for human use need to be produced in Good Medical Practice (GMP) facilities, cites Schembri-Wismayer. However, there are no such facilities locally. After a long search, he has finally found an industry partner that has agreed to create the vaccines in Belgium, against a price, as long as he sets up the clinical trials. This little victory comes with its own set of problems. In this case, the new limiting factor is mainly funding. Clinical trials typically cost millions.
Logistics aside, the hunt for a cure faces problems even more complex than what already seems immensely problematic. Schembri-Wismayer explained that there’s a major systematic flaw.
‘Many cancer researchers are not doctors. Their career depends on peer-reviewed publications and not finding a cure.’ This means that as long as their findings are statistically significant or are ‘good enough’ to be published in a high-end scientific journal, their job is done.
Granted, no research finding can be seen as wasted knowledge. Each can be seen as a small step forward. However, Schembri-Wismayer believes that the millions of funds designated to cancer research should have more rapid deliverables that directly benefit the patients, not just academic careers. Unfortunately, the cancer research community is a circular one, where scientists review other scientists mainly based on publications to get further funding.
‘I am not trying to publish in Nature [the world’s top academic publication], I’m trying to cure cancer’, says Schembri-Wismayer as he confesses that he feels guilty about not letting his students publish papers. But this is a necessary evil in the journey towards therapies. ‘Once a method is published, no company will touch it because it’s in the public domain.’ The method would have no monetary value since anyone could copy it. Needless to say, no pharmaceutical company will industrialise a drug that doesn’t guarantee profit.
Speaking of profit, Schembri Wismayer expressed that the financial aspect of this study is one of his greatest motivations. ‘Most of these drugs cost the Earth’, he said, adding that ‘when each shot costs €30,000 and the success rates are low, very few National Health Care systems are going to provide it.’ Take Yervoy, a drug commonly used to treat melanoma; one dose can cost up to €4,000. Survival rates after treatment are low. And there are no ‘money-back-guarantees’ if the outcome is less than satisfactory. As a result, studies have shown that a quarter of cancer patients in the US choose not to take such prescriptions because of such high prices. Money shouldn’t be the limiting factor in the fight for survival. Schembri-Wismayer believes in cancer treatment that’s affordable for everyone.
Even in the face of all these odds, Schembri-Wismayer persists. A cancer patient isn’t just a number; a cancer patient is also a mother, a brother, or a friend. And knowing this is enough to help him and thousands of other cancer researchers to continue pushing through.
One in two people in the UK will be diagnosed with cancer during their lives. It is a harsh reality, but humankind will eventually find a cure just as it has with other previously deadly diseases such as influenza or measles. This vaccine is in its early stages but with the proper support, it may contribute to an affordable, life-saving cure.
In Malta, diabetes has been a health concern since 1886. In 1981, the World Health Organization performed the first national diabetes study in Malta and reported that the total prevalence of type 2 diabetes mellitus (T2DM) is 7.7% (5.9% previously known diabetics and 1.8% newly diagnosed diabetics).
Since then, we have seen that percentage increase through self-reported questionnaire studies such as 2008’s Maltese European Health Interview Survey, which reported a T2DM prevalence of 8.3% in the population aged between 20 and 79. In 2010, it rose again to 10.1%, according to the Maltese European Health Examination Survey. And while this information is definitely useful, it cannot help researchers and doctors investigate what elements contribute to the diabetes epidemic in Malta.
The economic boom over the last four decades has permanently changed the Maltese Islands. With it came a change in lifestyle habits, like car use and diet, and an influx of different cultural and ethnic populations settling on the islands, which meant that it was time to update our understanding of T2DM in Malta; its prevalence, determinants, and risk factors.
I undertook the project “SAĦĦTEK – The University of Malta Health and Wellbeing study” to find out more about T2DM in Malta. SAĦĦTEK was a cross-sectional study that will effectively act like a snapshot in time.
The study population included a randomised sample of adults that had been living in Malta for at least six months and held a permanent Maltese identification card, irrelevant of their country of origin.
The survey took place between November 2014 and November 2015, and involved 4,000 people (18 to 70 years of age) who were statistically chosen from the national registry. We set up examination hubs in each town where the participants came in to complete socio-demographic questionnaires. While participants were there, we also took several measurements, including blood pressure, weight, height, and waist circumference. Finally, we took blood samples to check for their glucose levels during fasting periods, genetic analysis, and lipid profile (cholesterol and fats in the blood).
In the end, 47.15% of the invited adults actually attended the health survey. From these, we found that the prevalence of type 2 diabetes was 10.39%, with males being more affected than females. From the total T2DM group, 6.31% were known diabetics, while the remaining 4.08% were newly diagnosed with T2DM during the study. The numbers mean that over the past couple of decades there has been a rise in the diabetes rate in adults. Higher levels of T2DM mean that related diseases, such as obesity and heart problems, will also be more common.
In fact, study participants were often overweight (35.66%) or obese (34.11%). The weight increase is very relevant because it puts pressure on the body’s organs, including the pancreas, which has a direct link to T2DM development.
An increase in weight increases waist size, and this too comes with its own set of problems called the metabolic syndrome—increased blood pressure being one of many. A third of survey participants reported a high blood pressure (30.12%), again with a male majority.
Tobacco smoking was also prevalent at 24.3% (male majority). Smoking is linked to T2DM development, increased blood pressure, and stroke.
The survey results are a major public health concern. An unhealthier population means higher demands on Malta’s healthcare services.
In 2016 diabetes cost Malta an estimated €29 million, while obesity cost an estimated €24 million. The increased disease rate identified means that Malta’s bills are set to rise.
Men seem to have a worse health profile than women. Older males with a high body mass index (BMI) were more likely to suffer from high blood pressure. The majority had normal levels of glucose but abnormal lipid profiles, so even though the sugar levels were normal, they were still at risk when it came to acquiring diseases such as heart problems. Those diagnosed with a metabolic syndrome were five-fold more likely to also have T2DM. There is no denying—the gender gap is a concern.
The survey shows that more public health research is in dire demand. Malta’s underlying problem appears to be the increasing overweight-obesity problem. A number of initiatives have already been put in place by the Health Promotion and Disease Prevention Directorate as well as the establishment of “Dar Kenn Għal Saħħtek”, but there is more to be done.
Gender sensitive action is needed. Government, private entities, communities, and NGOs all need to work together to change the harmful lifestyle choices that have become the norm today. Sedentary lifestyles need to change and high intakes of fat, sugar, and salt need to decrease to alleviate Malta’s weight and diabetes problem. A diabetes screening programme also needs to be introduced to help citizens help themselves.
Early diagnosis of this disease will benefit all of Malta’s health and wellbeing and safeguard its health services. What more could we hope for?
Cuschieri, S., Vassallo, J., Calleja, N., Pace, N., & Mamo, J. (2016). Diabetes, pre-diabetes and their risk factors in Malta: A study profile of national cross-sectional prevalence study. Global Health, Epidemiology and Genomics, 1. https://doi.org/10.1017/gheg.2016.18
Cuschieri, S., Vassallo, J., Calleja, N., et al. (2016). The diabesity health economic crisis-the size of the crisis in a European island state following a cross-sectional study. Arch Public Health; 74: 52.
Cuschieri, S., Vassallo, J., Calleja, N., et al. (2016). Prevalence of obesity in Malta. Obes Sci Pract 2016; 2: 466–470.
Author: Clayton Axiak
Picture yourself waking up one morning with a severe, relentless itch that no clinician or diagnostic tool can understand. Your life would be thrown off kilter. Quality of life would suffer financially, psychologically, and socially as you try to look for a glimmer of light at the end of the tunnel. This is what life is like for most people living with a rare disease.
Often barraged with terms like ‘unknown’ or ‘undiagnosed’, matters can get even more challenging when the condition becomes more elusive or develops life-threatening consequences. And all of this is exacerbated by inequities in treatment and high costs of the few existing drugs that are available.
By EU standards, a rare disease is one that affects fewer than one in 2,000 individuals. And these ‘less common’ ailments are difficult to raise monies for to research, leaving large gaps in scientific and medical literature. One such disease is the poorly understood Idiopathic Hypogonadotropic Hypogonadism (IHH).
Characterised by the absence of puberty and infertility, IHH can be compounded by potentially severe characteristics such as congenital heart disease, osteoporosis at a young age, and early onset of Alzheimer’s disease.
Its cause is usually a genetic anomaly, but a single genetic change can affect two people very differently. This gives rise to an unparalleled complexity that makes the cause harder to decipher. Symptoms are not clear-cut and sometimes mask the actual underlying cause, bringing about misdiagnosis and delayed treatment. Timely diagnosis is crucial for successful treatment that enables the patient to achieve puberty and induce fertility. But this is not always possible.
Under the guidance of Dr Rosienne Farrugia, I am currently analysing and expanding upon a preliminary assessment of IHH in Malta using high-throughput sequencing (HTS) technology (conducted by Adrian Pleven). With HTS, we can read a person’s entire DNA sequence and attempt to identify differences in the DNA code which lead to such diseases.
What the team has found is that some genetic variants typical of IHH are more common in the Maltese population when compared to mainland Europe and African populations. This is likely due to the reduced genetic variation of our population, shaped by successive events of population reduction and expansion throughout our history.
By mapping the genetic cause of diseases prevalent on our islands, we can help medical consultants to employ specific screening tests that are tailored for local patients suffering from IHH. Such advancements in genomic technology and personalised medicine can make a huge impact on people’s lives. And not only to those suffering from IHH; researching one disease, however rare it may be, can shed light on mechanisms that prove useful in treating many others, ensuring that when it comes to health, no one is left behind.
This research project is being carried out as part of a Ph.D. program in Applied Biomedical Sciences at the Faculty of Health Sciences.
Modern life is rigidly compartmentalised. Perhaps this is more true of the West than anywhere else, where the materialist, rationalist models that have aided efficiency and technological advancement also require us to absorb vast amounts of knowledge early on, and specialise later.
Many educational systems reflect this tendency and the Maltese model is no exception. From a very young age, exams come in thick and fast, and cramming to pass them replaces a more holistic education.
Dr Joanna Delia is not a fan of the word ‘holistic’—preferring the term ‘polyhedral’ for reasons that will be explained later—and has enjoyed a career trajectory that has flouted excessive specialisation. A doctor turned aesthetic physician with an interest in the world of contemporary art, Delia’s journey is an affront to such restrictive notions.
While she assures me that her own time at the University of Malta (UM) was nothing short of amazing, in recounting the roots of her intellectual curiosity, she is compelled to go even further back.
‘Like every excited little girl, my dreams used to alternate and metamorph somewhere between wanting to be a writer like Emily Brontë or Virginia Woolf and a scientist who would make incredible discoveries and change the world like Marie Curie,’ Delia recalls. ‘I also wanted to be a doctor who would cure people in war-torn countries, yet fantasised about being Alma Mahler or a young Chanel surrounded by philosophers, drenched in fine clothes and surrounded by white rose bouquets…’
Delia recounts this awareness that we’re shaped to view these inclinations as contradictory. But for her, the intuitive desire to learn about and closely observe scientific phenomena matched the heights of aesthetic appreciation.
Vella’s own student enthusiasm did not come as immediately as all that, however. While she is now secure in her three-pronged role as writer, performer, and translator (also acknowledging her former role as a lecturer), forging an early path as a student meant first squinting through the fog.
‘I just loved learning the science subjects… figuring out protein synthesis and DNA replication literally made me feel giddy, light headed, downright euphoric! I was a real geek,’ Delia says with disarming self-deprecation. ‘To me, it was just the same as reading an incredible work of literature or staring at a work of contemporary art alone in one of the silent, perfectly lit halls of a museum.’
Given this internal push-pull across various disciplines, Delia confesses that in terms of pursuing the later strands of her formal education, she ‘floated into medical school’ without feeling the need to strategise things much further. It was only upon graduation that the realities of being slotted into a specialised discipline dawned on her with an ominous pall.
‘The day I graduated I felt a suffocating feeling: the thought that I had somehow sealed my fate,’ Delia says, though the sense of regret which followed did not linger for much longer.
‘Looking at one’s future through a tunnel vision perspective based on the imaginary restrictions of one’s degree is just that a self-imposed illusion,’ Delia observes.
Her University years were active and inspiring, with Delia having happily taken on extra-curricular activities and also quietly rebelled against the notion of boxed-in specialised disciplines.
‘University was amazing! I would repeat those years ten times over,’ Delia unapologetically enthuses. Though she does acknowledge that the Medicine course was challenging to begin with—citing the ‘competition among students’ as an additional factor—she looks back on both her time there, and her association with the UM’s Medical School, with immense pride.
‘My lecturers were charismatic and experts in their field, which of course garners respect and made us feel honoured to be part of that system,’ Delia says, while also recalling her involvement in additional campus activities.
‘I was the chair of the environmental committee at KSU and served two terms as the Officer for the Sub-Committee on Refugees and Peace within MMSA. I loved my time on campus, and encourage all students to participate in campus affairs. We never stopped organising fairs, events, fundraisers, workshops, and outreach programmes with the community…’
Hinting at an essential discomfort with the idea of overbearing specialisation, Delia believes ‘the Maltese education system does not proactively encourage sharing knowledge’, but also notes that she did find hope, solidarity, and inspiration among her peers, from various faculties.’ I socialised with students from the architecture department, and attended their workshop parties. I was invited to history of art lectures and tours. I organised panel discussions to reduce car [use] on campus and lobby for [a] paperless [campus],’ Delia says. All these activities contributed to ‘a feeling of a hopeful future’.
Adjacent to Delia’s academic efforts were her course-related travels abroad, which contributed to expanding her horizons. ‘I did internships in Rio De Janeiro and travelled to India and Nepal through the Malta Medical Students’ Association (MMSA), both of which were incredible experiences.’ During this time, she gained a keener interest in art.
‘My sister was studying history of art and eventually read for a Ph.D. in Museology. I followed her as closely as I could; her subjects fascinated me and a lot of her excitement about art rubbed off on me…’
But first, her early medical career needed seeing to. Delia admits that medical students in Malta are somewhat privileged since they enjoy a relatively smooth changeover from academic to professional life. However, the change happens very rapidly.
‘Young doctors in Malta have the advantage of an almost flawless transition into a job. This also turns out to be the toughest time in your life, but at least there there is a continuity of support at the start of your profession,’ Delia says, citing the diligence and discipline instilled into her and her peers by their University tutors and lecturers. This rigour was crucial to ensure that those early years went on as smoothly as possible.
Pausing to reflect, Delia feels compelled to add that a culture that leaves more breathing room for exploration and enquiry could only be beneficial for the future of Maltese medicine. ‘I wish we had a stronger culture of research and publication in Malta. We need to somehow find time for it as it will not only improve the reputation of the institution but also nurture us as students, alumni, and professionals, and keep us on our toes,’ Delia says, adding that these ideas reflect the same culture of hard work that her course promoted, which rewards diligence and depth. ‘I believe in constantly keeping astride with knowledge by reading publications and actively pursuing ‘continued medical education’. I wish that the institution instilled more of this into its alumni,’ Delia muses.
This approach of constant enquiry arguably gave Delia a fount of knowledge and inspiration to draw from when she found herself at a forking road in her medical career.
”After a few years of working at the general hospital, I was lucky enough to be chosen to pursue some level of surgical training, but by that point I had realised that the life of a surgeon was not for me…’
This was an ‘extremely tough decision’, with regret once again raising its ugly head. ‘However, the 80-hour weeks, and above all the realisation that my professional life would be all about facing and treating ill and dying people, forced me to make a decision to leave the hospital,’ Delia says.
This pushed Delia to explore other careers, and she now juggles her love of both medicine and aesthetics in a sustainable way.
‘After I stopped working as a hospital doctor, there were too many things I was hungry to explore – one of them was medical aesthetics. I started pursuing training in London and Paris, and essentially spent years of salary training with the best doctors I could find.’
After working at a reputable local clinic, Delia finally managed to go at it independently, opening up her own place.
‘It was nothing short of a dream come true. I had to search hard within myself and build up entrepreneurial and management skills. I learnt the hard way sometimes, business-wise, but I was also fortunate to find help from my friends who excel in other fields like marketing, photography and architecture, to help me build my brand and clinic,’ Delia recalls.
In the end, her resistance to rigid specialisation helped her to open a thriving business called Med-Aesthetic Clinic People & Skin. She couples this work to her position as head of the Advisory Board at the newly-opened Valletta Contemporary, a boutique showcase for local and international contemporary art run by artist and architect Norbert Francis Attard.
Which brings her story back to a ‘polyhedral’ conception of the world.
‘I believe everything in life is polyhedral. I prefer polyhedral to ‘holistic’. Every square, or rather, every cube we think we’re trapped in, can be pushed out and reconfigured to welcome other disciplines. I don’t believe any of us purposely split the two fields, but I believe we don’t allocate enough time to explore all the wonders we could discover if we used both their lenses to analyse the world. After all, even Einstein believed that the most important thing in science is creativity…’
Stroke is universally devastating. Often hitting like a bolt from the blue, it is the world’s third leading cause of death. In Malta, over 10% of the deaths recorded in 2011 were due to stroke. But stroke inflicts suffering not only through a loved one’s passing. As the most common cause of severe disability, stroke can instantly rob a person of their independence and dignity—even their very personality. This impact, individually, socially, and globally, makes stroke research a top priority.
Yet while scientists know the risk factors, signs, symptoms, and causes of both main types of stroke—whether ischemic, in which clots stop blood flow to the brain, or haemorrhagic, where blood leaks into the brain tissue from ruptured vessels—they have yet to find a concrete solution.
A dedicated team at the Faculty of Medicine (University of Malta) hopes to change that. Using highly sophisticated technology and advanced microscopic laser imaging techniques, Dr Jasmine Vella and Dr Christian Zammit, led by Prof. Mario Valentino, can follow what happens in a rodent’s brain as a stroke unfolds in real-time.
‘We use powerful lasers and very sensitive detectors coupled with special lenses, which allow us to capture the very fast events that unravel when a blood clot interrupts the blood supply in the brain,’ explains Valentino. ‘We observe what happens to the neighbouring blood vessels, nerve cells, and support cells, and the limb movements of the rodent throughout.’ Their aim is to find out how sensory stimulation might then help protect the brain.
The idea stems from an accidental discovery in 2010 by members of the Frostig Group at the University of Irvine, USA. The scientists found that when the whiskers of a rodent were stimulated within a critical time window following a stroke, its brain protected itself by permanently bypassing the blocked major artery that commonly causes stroke in humans. The brain’s cortical area is capable of extensive blood flow reorganisation when damaged, which can be brought about by sensory stimulation.
The human brain can bypass damage. For example, blind individuals have limited use of their visual cortex, so the auditory and somatosensory cortex expands, giving them heightened sensitivity to hearing and touch. For stroke patients, this means that the brain can compensate for its loss of function by boosting undamaged regions in response to light, touch, or sound stimulation.
‘This accidental discovery could be life-changing for stroke patients. The key is to figure out the mechanism involved in how sensory stimulation affects stroke patients, and then establish the best ways to activate that mechanism. Perhaps touching a stroke victim’s hands and face could have a similar beneficial effect, and this is what this latest research study hopes to define,’ says Valentino.
‘The team is now painstakingly correlating the data obtained during this brain imaging with the rodent’s movement and trajectory,’ he continues. ‘Using a motion-tracking device fitted under a sophisticated microscope, we can record the behaviour of the rodent during high-precision tactile stimulation, such as stroking their whiskers, and detect any gain of [brain] function through behavioural and locomotor readouts whilst ‘looking’ inside the brain in real-time.’
If they can prove that any protection is the direct cause of new blood vessels (or other cells) resulting from the electrical activity inspired by the sensory stimulation, then the next step would be to explore ways of redirecting these blood vessels to the affected brain area.
The team’s track record is encouraging. In collaboration with scientists from the University Peninsula Schools of Medicine and Dentistry, UK, they made another recent breakthrough that was published in Nature Communications, identifying a new drug, QNZ-46, that could protect the rodent brain following a stroke.
‘That project was about neuroprotective agents – to create a drug that will substantially block or reduce the injury, and so benefit a wider selection of patients,’ elaborates Valentino. ‘The study identified the source and activity of the neurotransmitter glutamate, which is the cause of the damage produced in stroke. This led to the discovery that QNZ-46 prevents some damage and protects against the toxic effects of the glutamate. This is potentially the first ever non-toxic drug that could prevent cell death during a stroke, and the results from this research could lead to pharmaceutical trials.’
While ongoing research in these projects has been supported through a €150,000 grant from The Alfred Mizzi Foundation through the RIDT, Valentino points out that globally-significant discoveries such as these are in constant need of support.
‘The funding of such projects is so important. This money is life-changing for people in such a predicament. Health research changes everything—our lifestyle, our quality of life, our longevity. And yet, government funding for research is still lacking. It’s only thanks to private companies and the RIDT, who realise the global potential of our work, that these projects can continue to try to change the lives of people all over the world,’ says Valentino.
And while Malta may be a small country with limited resources, the work conducted within its shores is reaching millions globally, proving that when it comes to knowledge, every contribution counts. We must continue striving for more to leave our best mark on the world.
Help us fund more projects like this, as well as research in all the faculties, by donating to RIDT.
Link: researchtrustmalta.eu/support-research/?#donations
The last decade has seen the number of patent applications worldwide grow exponentially. Today’s innovation- and knowledge-driven economy certainly has a role to play in this.
With over 21,000 European and around 8,000 US patent applications in 2018, the fields of medical technologies and pharmaceuticals—healthcare industries—are leading the pack.
A patent grants its owner the right to exclude others from making, using, selling, and importing an invention for a limited time period of 20 years. What this means is market exclusivity should the invention be commercialised within this period. If the product sells, the owner will benefit financially. The moral of the story? A patent is but one early piece of the puzzle in a much longer, more arduous journey towards success.
Following a patent application, an invention usually needs years of development for it to reach its final product stage. And there are many ‘ifs’ and ‘buts’ along the way to launching a product in a market; only at this point can a patent finally start delivering the financial benefits of exclusivity.
Product development is a race against time. The longer the development phase, the shorter the effective market exclusivity a product will have, leaving less time to make a return on the development and protection costs. If this remaining time is not long enough, and the overall balance stays in the negative, the invention could turn into a financial failure.
Some industries are more challenging than others. The IT sector is infamous for its blink-and-you-miss-it evolution. The average product life cycle on software has been reduced from three–five years to six–12 months. However, more traditional sectors cannot move that quickly.
The health sector is one example. Research, development, and regulatory approval takes much longer, spanning an average of 12–13 years from a drug’s inception to it being released on the market, leaving only seven to eight years for commercial exploitation.
So the real value of a patent is the effective length of market exclusivity, factored in with the size of the market potential. Can exclusivity in the market give a stronger position and increase profits to make a sufficient return on investment? All this makes patenting risky, irrespective of the technological content—it is a business decision first and foremost.
Companies see the opportunity in this investment and are happy to take the associated risks. But why does a university bother with patents at all and what are its aims in this ‘game’?
Universities are hubs of knowledge creation and today’s economy sees the value in that. As a result, research institutions intend to use and commercialise their know-how. And patenting is an essential part of that journey.
The ultimate goal and value of a patent remains the same, however, it serves a different purpose for universities. Patents enable them to legally protect their rights to inventions they helped nurture and claim financial compensation if the invention is lucrative. At the same time, patent protection allows the researchers to freely publish their results without jeopardising the commercial exploitation of the invention. It’s a win-win situation. Researchers can advance their careers, while the university can do its best to exploit the output of their work, bolster its social impact, and eventually reinvest the benefits into its core activity: research.
Patenting may start at a few hundred or thousand euros, but the costs can easily accumulate to tens or even hundreds of thousands over the years. However, this investment carries more risk for universities than for companies.
Risks have two main sources. Firstly, universities’ financial capabilities are usually more limited when compared to those of businesses. Secondly, universities are not the direct sellers of the invention’s eventual final product. For that, they need to find their commercial counterpart, a company that sees the invention’s value and commercial potential.
This partner needs to be someone who is ready to invest in the product’s development. This is the technology transfer process, where the invention leaves the university and enters the industry. This is the greatest challenge for university inventions. Again, here the issue of time raises its head. The process of finding suitable commercial partners further shortens the effective period of market exclusivity.
A unique strategy is clearly needed here. Time and cost are top priorities. All potential inventions deserve a chance, but risks and potential losses need to be minimised. It is the knowledge transfer office’s duty to manage this.
We minimise risks and losses by finding (or trying to find) the sweet spot of time frames with a commercial partner, all while balancing commercial potential and realistic expectations. The answer boils down to: do we have enough time to take this to market and can we justify the cost?
Using cost-optimised patenting strategy, we can postpone the first big jump in the costs to two and a half years. After this point, the costs start increasing significantly. The rule of thumb is that about five years into a patent’s lifetime the likelihood of licensing drops to a minimum. So on a practical level, a university invention needs to be commercialised very quickly.
Maintaining a patent beyond these initial years can become unfeasible, because even the most excellent research doesn’t justify the high patenting costs if the product is not wanted by industry. And the same applies for all inventions. Even in the health sector, despite product development cycles being longer, if a product isn’t picked up patents can be a huge waste of money.
Patenting is a critical tool for research commercialisation. And universities should protect inventions and find the resources to file patent applications. However, the opportunities’ limited lifetime cannot be ignored. A university cannot fall into the trap of turning an interesting opportunity into a black hole of slowly expiring hopes. It must be diligent and level-headed, always keeping an ear on the ground for the golden goose that will make it all worth it.
People are living longer than ever. But a long life has its price. With age come more diseases and health issues, such as hip problems that can limit a person’s mobility.
Hip replacement procedures have become common, although implants have a lifespan too. It might happen that a hip replacement you get at 60 needs to be replaced at 75. This is not the ideal scenario.
To minimise these cases, researchers are testing new materials and designs to prolong prostheses’ lifespans. These potential solutions need to be tested, but each test costs tens of thousands of euro. Enter, the University of Malta’s hip joint simulator.
The hip joint simulator is a machine that replicates the joint movements and loads imposed on the human hip. To do so, the simulator uses three stainless steel frames, each of which can be controlled independently using motors. These motors act as the ‘muscles’ of the hip, programmed to replicate the walking cycle during testing.
When it comes to simulating load and forces, a mechanism can load the implants with weights of up to 300kg in a fraction of a second. This emulates what happens while walking, when the weight of the body rests on one leg due to the body’s shift in the centre of gravity. While running, inertial forces can cause the hip to sometimes take five times a person’s body weight.
Finally, to simulate the environment inside the human body, researchers use a specialised solution that mimics the bodily fluids surrounding the hip joint. They even warm the fluid to imitate body temperature.
The hip joint simulator forms part of the MaltaHip project that intends to radically redesign hip implants to give them the longer lifespan patients want and need. Watch this space for more.
The MALTAHIP project is funded by the Malta Council for Science and Technology through FUSION: The R&I Technology Development Programme 2016 (R&I-2015-023T).
Breast cancer survival rates have been improving steadily in recent years. In Malta, 86.9% of patients currently survive, up 7% over the last decade. Thanks to new targeted therapies, the outlook is increasingly bright. But precision therapies need precision testing.
Breast cancer diagnosis has reached new heights and with current tests using tissue biopsies, pathologists can classify patients for specific treatment. Precision medicine goes a step further. It provides more information, predicting the aggressiveness of the cancer and measuring the number of cells from the tumour that spread into the bloodstream.
This does not mean that all requirements in precision therapy have been met.
At the time of writing, there is no simple method to test patients’ ongoing benefit from treatment or to measure different tumour areas from one sample. For this to be possible, we need super-sensitive tests. This is where Prof. Godfrey Grech and Dr Shawn Baldacchino at the University of Malta come in.
Detecting the undetectable
During his PhD, Baldacchino studied a new class of breast cancer representing most cases of the triple negative type, which affects 12% of breast cancer patients in Malta.
In triple negative breast cancers, tests for estrogen receptors, progesterone receptors, and excess HER2 protein all result in negatives and are associated with aggressive tumours.
To detect this new class of breast cancer, Grech’s team have created a new test that uses molecular substances we naturally produce in our body—biomarkers. By pinpointing the right combination of certain biomarkers, they can test for this new class within the triple negative breast cancer cases.
They initially used the test to look at biopsies from past patients. These exercises showed that they could accurately detect the cases—even in samples that were over a decade old! In fact, the test was so successful that the team is now working with biological testing industry giant Luminex to use it in hospitals worldwide. With a patent filed, research labs will get their hands on it later this year with the hope that by 2021 it will be used to directly help patients in hospitals.
However, there is more work ahead. Encouraged by the results so far, the team wants to take the test and other current biomarker tests a step further. They want to use a simple blood sample which is less invasive, allowing patients to be monitored during therapy.
Pushing boundaries
With the method Grech and his team have optimised, obtaining information on new classes of patients that predict therapy use, detecting different tumour areas in one sample, and the use of blood to monitor the benefits of therapy have become a
Photo by James Moffett
possible reality. With technologies from Luminex and Thermo Fisher, they can now read over 40 biomarkers in one test simultaneously. But with blood they need a new angle. And that is happening through another test using particles that originate from cells called exosomes.
Exosomes are tiny messenger bubbles which cells release into the blood . ‘We believe that when there is a tumour in the patient, there will be a signature in these exosomes circulating in the blood,’ says Baldacchino.
Finding these exosomes could mean detecting cancer at an earlier stage than is currently possible. The team believes they would be able to detect the exosomes that point to cancer long before a tumour shows up in scans and other regular tests—and so, they would be able to nip the cancer in the bud. But to do this, they need to be able to decode the messages the exosomes are carrying.
Positives for patients
It’s not only in the realm of breast cancer diagnosis and classification that the team can help patients—they might also be able to improve treatment. ‘Most targeted therapies currently try to inhibit specific receptors and proteins to stop the uncontrolled growth of cancer cells,’ Grech says. But through their research, the team has found that targeting the low activity of specific complexes of proteins in tumour cells is key. Their research models show that increasing the activity of these protein complexes is possible using specific drugs.
This is true for triple negative breast cancer, where the amount of PP2A protein is extremely low. The PP2A protein enables the body to fight the cancer, so increasing its activity would create a chain reaction in the body which could limit the growth and spread of that category of cancer cells.
This approach to treatment has applications beyond triple negative breast cancer. Grech is hopeful that PP2A production could be amped up for different types of cancer too, and lead to positive results.
Managing the unmanageable
When organising a project like this, it’s expected that things won’t go to plan. One of the biggest challenges for Grech’s team has been establishing collaborations with other groups across the globe. They need these connections to provide the samples required to test their systems. With other groups working on similar projects, time is a limited resource. Thankfully, the team found collaborators in Leeds (UK), and Barcelona (Spain), allowing the group access to the samples they need.
What is certain is that support for this work has come in many shapes and forms. The project received funding both from public donations and the Malta Council for Science and Technology. Baldacchino also found an ally in the charity foundation Alive with the help of the Research Trust of the University of Malta (RIDT). He is the first recipient of funding from them, and their first graduate.
Predicting the future
Thanks to projects like these, cancer research has a bright future in Malta. The team has their product launch to look forward to later this year, which will see a drastic reduction to the time and effort it takes researchers and doctors to determine the type of breast tumour.
But a lot of challenges lie ahead. The biggest challenge will come in the move to early stage cancers. These cancers have low levels of substances to detect, which means that any test they develop will have to be extremely sensitive in order to be effective. Successfully identifying these cancers would signal a massive breakthrough for the global medical community—and, more importantly, for patients. Early detection through basic blood tests would open the door to early stage treatment and a higher rate of survival. Nothing could matter more.
Project ‘Accurate Cancer Screening Tests‘ financed by the Malta Council for Science & Technology through FUSION: The R&I Technology Development Programme 2016.
