Divergences in sex ratio at birth in US Census Regions due to racial factors: chronic stress and female foeticide.

OBJECTIVES: The sex ratio of live births (males/total [M/T]) approximates 0.515. Many factors reduce M/T, and these include stress. Antenatal sexing is used for female foeticide in the setting of male offspring preference. Regional differences and latitude gradients in M/T also occur. This study analysed M/T in the US by Census Regions. STUDY DESIGN: This was an ecological study. METHODS: Live births by sex, Census region, state and mother's race were obtained from CDC Wonder (2007-2020). RESULTS: There were 55,453,437 births (M/T 0.5116, 95% confidence interval: 0.5115-0.5118). M/T was Black/African American < Indian/Alaska Native American < White < Asian (P<<0.0001). M/T was significantly lowest in South and highest in West. The South had the lowest proportion of Asian/Pacific Islander births (3.9%) and the highest proportion of Black/African American (21.9%). West has the highest proportion of Asian/Pacific Islander (11.2%) and the lowest proportion of Black/African American births (5.3%). In Asian/Pacific Islander births, M/T significantly rose to third order and fell to sixth order births, unlike the other races that showed a decline from the first order. CONCLUSIONS: Asian M/T may be elevated because of male offspring preference and selective female foeticide. M/T may be depressed in Black and American Indian/Alaskan births due to chronic stress, as race remains the most important factor associated with wealth inequality in the United States. The lower M/T of these two races when compared with White equates to a constant loss of 4.13 and 2.55/1000 male births. The higher Asian M implies a chronic loss of 3.78 females per 1000 births. Both have public health implications.

The Male-female Birth Ratio in California and the 1992 April Riots in Los Angeles.

OBJECTIVE: Male live births slightly exceed female live births. This is usually expressed as M/F, the ratio of male to total live births. A multitude of external influences have been shown to reduce this ratio, including stress provoked through witnessing violent events; M/F dips occur three to four months later. The April 1992 Los Angeles riots constituted six days of extreme civil unrest in the city of Los Angeles. This study was carried out in order to ascertain whether M/F dipped in California following this event. METHODS: Monthly male and female live births for California were obtained from the Centers for Disease Control and Prevention for the State of California for 1992 and for January 1993. RESULTS: This study analysed 649 073 live births; M/F was lowest in August 1992 (0.5085). This was significantly lower than for the period after (September 1992 to January 1993, p = 0.044). The ratio of male to total live births was higher in January to July 1992 than in August 1992, but this difference was not statistically significant. CONCLUSION: Stress has been shown to reduce M/F through an excess of male fetal loss during gestation and/or from gender-biased conception favouring females. Only the former mechanism is supported by these findings. This is the first time that violent events at state level have been shown to have potentially influenced M/F.

Reduced Male:Female Ratio at Birth in Small Islands.

BACKGROUND: The male:female ratio at birth (M/F: male births divided by total births) is anticipated to approximate 0.515. The M/F in Micronesia in the Pacific Ocean has been noted to be higher than anticipated. This study analysed M/F in island populations available from a World Health Organization dataset. METHODS: The following islands were identified from the dataset as being sufficiently complete for analysis: Bahamas, Barbados, Puerto Rico, Trinidad and Tobago, and Mauritius. RESULTS: There were 540 8629 live births available for analysis over the period 1960-2009 with an overall M/F of 0.5106 (95% CL 0.5101, 0.5110). There were no secular trends in M/F. CONCLUSION: The M/F in these equatorial islands is lower than anticipated, and the reason for this is unknown.

State and Regional Differences in the Male-to-Female Ratio at Birth in the United States of America, 1995-2012.

INTRODUCTION: In humans, live male births slightly exceed females and this ratio is conventionally expressed as male live births divided by total live births (M/F). A wide variety of factors have been shown to influence M/F including latitude, stress, socio-economic status and race. This study was carried out in order to ascertain whether there are differences in M/F in different states and in different geographical regions in the United States of America (USA). METHODS: Annual live births by gender for the period 1995-2012 were obtained from the website of the US Centers for Disease Control and Prevention. These were grouped according to the four regions devised by the United States Census Bureau, Geography Division. RESULTS: This study encompassed 52 601 559 live births for the period 1995-2012 (M/F: 0.5117; 95% CL: 0.5116, 0.5118). Southern states tended to have a lower male-to-female ratio. Hawaii had a high M/F (p < 0.0001). The male-to-female ratio for the South region was significantly less (p = 0.004). This region had the highest proportion of Black mothers. CONCLUSION: The high Hawaiian M/F is in keeping with Micronesian island findings. The M/F latitude gradient accords with that previously noted in the USA. Historically, Blacks have been shown to have a lower M/F than other races. Long-term stress related to maternal socio-economic status has also been shown to influence M/F, and Blacks are known to be disadvantaged to this day. It is possible that the low M/F historically noted in this race may be due to chronically poor socio-economic circumstances.

The influence of migration on secular trends in sex ratios at birth in cuba in the past fifty years.

BACKGROUND: Secular trends have been found in the male-female ratio at birth (M/F: male births divided by total births) in various countries and this ratio is anticipated to approximate 0.515. METHODS: Annual national data for male and female live births in Cuba with contingency tables were obtained from the World Health Organisation and analysed. RESULTS: There were 3 736 718 male and 3 534 270 female births (1960-96). Births declined steadily over the entire period. The male-female ratio at birth remained relatively stable over the period 1960-1985 with significant sharp dips for the years 1966, 1980 and 1985. There was a sharp rise in M/F from 1966 to 1969, another rise after 1985, a steep drop to 1989, and then a sharp rise once more after 1993 (all p < 0.0001). CONCLUSION: The single year dips are associated with the passage of laws in the United States of America (USA) that facilitated Cuban entry to the USA. The increases in M/F tended to be associated with a skew toward an efflux from Cuba that was predominantly male. This paralleled the situation in the Second World War where a surplus of women left behind led to an increase in M/F in belligerent countries. To the author's knowledge, this is the first report of migration influencing M/F.

A population-based paediatric Covid-19 vaccination progress and outcomes: The Malta case.

Background: Covid-19 is still pandemic with population vaccination, including among children, remaining the mainstay for hastening the exit from the pandemic. The article provides an insight in Malta's national paediatric vaccination modus operandi, vaccination uptake, and epidemiological trends while exploring geographical social inequalities among the ≤ 15 years cohort up till end of August 2022. Methods: The Vaccination Coordination Unit in Malta's only regional hospital provided an account of the strategic roll-out along with anonymised cumulative vaccination doses by age band and district. Descriptive and multivariant logistic regression analyses were performed. Results: By mid-August 2022, 44.18% of the under 15's population had received at least 1 vaccine dose. A bi-directional relationship was observed between increased cumulative vaccination and reported Covid-19 cases until early 2022. Central vaccination hubs were set up with invitation letters and SMSs sent to parents. Children residing in the Southern Harbour district (OR: 0.42, P < 0.01) had the highest full vaccination uptake (46.66%) as opposed to the Gozo district (lowest at 27.23%; OR: 0.3, P = 0.01). Conclusion: Successful paediatric vaccination is not only dependent on easily accessible vaccination but also on vaccine effectiveness against variants, as well as population characteristics, with potential geographical social inequalities hindering uptake.

DiGeorge phenotype in the absence of 22q11 deletion - a case report.

DiGeorge syndrome is polytopic developmental field defect which is usually associated with 22q11.2 microdeletion. However, this phenotype may be caused by other conditions. We report such a case and briefly review these alternative causes for this particular phenotype.

The rarest aortic arch anomaly a case report of asymptomatic isolation of the subclavian artery.

We present a rare case of isolated right subclavian artery arising from a right-sided patent arterial duct in a patient with DiGeorge syndrome, diagnosed on cardiac CT, along with potential complications and management approaches.

The first case of the Reveal LINQ™ Insertable Cardiac Monitor implanted in a child in Malta.

BACKGROUND: The Reveal LINQ™Insertable Cardiac Monitor (ICM) or Implantable Loop recorder (ILR), is a miniaturized, subcutaneous, single lead, electrocardiographic monitoring device which has been extensively used in the differential diagnosis of unexplained syncope and palpitations in adults. PATIENT DESCRIPTION: We describe an asymptomatic 20-month-old boy, noted to have incidental bradycardia on routine examination and in whom Holter monitoring revealed complete heart block (CHB). Over 1 year, the longest recorded pause lengthened from 1.8 seconds to 3.6 seconds. RESULTS: The Reveal LINQ™ ICM was inserted for long-term monitoring of the CHB. The device will record the electrocardiogram (ECG) continuously for up to 3 years, freezing in its memory any significant arrhythmic events. This will enable the diagnosis of the longest pauses, confirm whether they are lengthening over time and assist with the decision of pacemaker implantation. CONCLUSION: The Reveal LINQ™ ICM is much smaller than the conventional loop recorder and has been shown to be ideal for close monitoring of asymptomatic yet potentially dangerous arrhythmias in young children.

Seasonal Variation by Race in the Male-to-Female Ratio at Birth in the United States

ABSTRACT Objective: In humans, males' births exceed females' births. This ratio is conventionally referred to as M/F and is used to denote male births divided by total births. This ratio is influenced by a large number of factors and has been shown to exhibit seasonality. This study was carried out in order to ascertain whether seasonal variation in M/F exists in the United States of America and whether such variations are influenced by race. Materials and Methods: Data on births by gender and race from 2003 to 2013 were obtained from Centres for Disease Control and Prevention Wonder section as four races: White, Black/African American, Asian/Pacific Islander and American Indian/Alaska Native. ANOVA and ARIMA tests were carried out. Results: This study analysed 45 103 146 live births (M/F 0.51182) over 2003 to 2013. M/F was highest in Asian/Pacific Islander (p < < 0.0001), followed by White (p = 0.002), American Indian/Alaska Native (p = 0.04) and Black/African American. Significant seasonality was present overall, with a peak in June, for Whites more than Black/African American. Conclusion: Parental stress lowers M/F, and lower M/F found in Black/African and American Indian/Alaskan births may be stress related. The dampened seasonality noted in Black/African American births may also be due to this phenomenon. More males were born in spring, as in other species, with interesting inter-racial differences.

A case of atypical Kawasaki disease with giant coronary artery aneurysm containing thrombus.

INTRODUCTION: Kawasaki disease (KD) is an acute febrile, systemic vasculitic syndrome of unknown etiology, occurring primarily in children younger than 5 years of age. Administration of IVIG within the first 10 days after onset of fever in combination with high dose aspirin reduces the risk of coronary artery damage in KD. Though rare, giant aneurysms of the coronary arteries may develop in untreated cases and prove extremely challenging to manage. CASE PRESENTATION: A 9-month-old Caucasian boy presented to our paediatric emergency department with a 4-week history of intermittent pyrexia and irritability. Typical mucocutaneous signs of Kawasaki Disease were absent upon presentation. A trans-thoracic echocardiogram identified a giant aneurysm of the left anterior descending artery with thrombus formation in-situ and the child was managed with intravenous immunoglobulin, steroids, high dose aspirin therapy and later warfarinisation. DISCUSSION: Cardiovascular sequelae of Kawasaki disease include giant coronary artery aneurysms with thrombosis. Enlargement of a coronary aneurysm after the acute phase of Kawasaki disease is uncommon and the outcome of interventional approaches poorly studied.

Depicting the analyses of the first National Maltese Childhood BMI study.

INTRODUCTION: Obesity is a chronic disease that often commences in childhood. Several publications have shown that a quarter to a third of Maltese children are overweight or obese. Malta will be the first country to measure height and weight (and hence Body Mass Index) for all school children in order to quantify the extent of the problem. METHODS: This study would include 46,000 children in 150 schools. This would be the first time that any country measured its entire childhood cohort, as opposed to sampling. Hence, it was decided to attempt to facilitate data collection and analysis with the use of bespoke spreadsheets. RESULTS: This paper will demonstrate how standard Microsoft Excel was used to accomplish this, greatly speeding up the data analysis process. CONCLUSION: Software should be prepared in advance in anticipation of large amounts of data that need to be analysed and summarised. Particular care must be taken in order to prepare the requisite graphs and tables in advance so as to process the data once and present it in a suitable format for consumption and evaluation.

"Bendy" stents help negotiate hairpin intracardiac curves.

Simple transposition of the great arteries (TGA) occurs in 0.2 per 1000 live births. The condition is surgically repaired in the neonatal period by the arterial switch procedure (ASO) sometimes preceded by an atrial septostomy. The ASO involves transecting the great arteries and relocating them to the appropriate ventriculo-arterial (VA) connection with attachment of the disconnected coronary arteries to the aorta. In the process, the attachment of the pulmonary artery to the right ventricle involves the Le Compte manoeuvre and to achieve this the pulmonary arteries must be fully mobilised and sometimes the main pulmonary artery may require patch augmentation as well. Nevertheless, pulmonary artery stenosis (PAS) is one of the potential problems with the ASO. However, with improved surgical techniques, this has dropped from around 15% in the 1980s to less than 3%. Apart from surgical revision when PAS occurs, there are interventional options which include angioplasty and/or stent insertion. The latter is preferred in small children and works well in around 60% but may require repeat procedures. In older patients or when angioplasty fails, stent insertion can be considered. These procedures may involve negotiating tight bends in order to reach the site of stenosis. The passage of non-premounted stents may be problematic in such situations, especially with longer stents and tighter bends as they tend to slip off balloon. We describe several techniques that may facilitate such interventions, and these were utilised in an adolescent patient who had had ASO for TGA in the neonatal period. These included manually giving the mounted stent a slight bend in order to help the balloon-stent assembly negotiate hairpin bends.

An excess of tetralogy of Fallot in Malta.

STUDY OBJECTIVE: To estimate birth prevalence of tetralogy of Fallot (TF) in Malta. DESIGN: Retrospective data collection and analysis, and comparison with earlier epidemiological studies dealing with congenital heart disease. SETTING: Regional hospital providing exclusive diagnostic and follow up services for the entire country of Malta. PATIENTS: All Maltese live births diagnosed as having TF. MAIN RESULTS: The birth prevalence of TF in Malta for the period 1980-1994 was 0.64/1000 live births (95% confidence intervals 0.48, 0.85/1000 live births). This was significantly higher than previously reported in the medical literature. CONCLUSIONS: The Maltese gene pool seems to have a genetic predisposition towards live births with TF. Population genetic studies with emphasis on the prevalence of 22q11 microdeletion may yield clues regarding the cause of the high rate of this condition.

Secular trends in sex ratios at birth in North America and Europe over the second half of the 20th century.

CONTEXT: A previous study showed that significantly more boys were born in southern latitudes in Europe than in northern latitudes and the converse pattern was observed in North America. OBJECTIVE: This study analyses secular trends in gender ratios for live births over the second half of the 20th century. DESIGN, SETTING, PARTICIPANTS: Analysis was carried out from a World Health Organisation dataset comprising live births over the above period. This included 127034732 North American and 157947117 European live births. MAIN OUTCOME MEASURES: Analysis of trends in gender ratios for countries in both continents. RESULTS: The findings show a highly significant overall decline in male births in both Europe and North America (p<0.0001), particularly in Mexico (p<0.0001). Interestingly, in Europe, male births declined in North European countries (latitude>40 degrees, p<0.0001) while rising in Mediterranean countries (latitude congruent with 35-40 degrees, p<0.0001). These trends produced an overall European male live birth deficit 238693 and a North American deficit of 954714 (total male live birth deficit 1193407). CONCLUSIONS: No reasonable explanation/s for the observed trends have been identified and the causes for these trends may well be multifactorial.

Declining male births with increasing geographical latitude in Europe.

OBJECTIVE: Demographic studies in various industrialised countries have shown a decline in male births in the latter half of the 20th century from the expected ratio of 0.515 (males/total). This study analyses trends in this ratio over the period 1890 to 1995 in Malta, and also analyses this ratio for Western European countries for the period 1990-1995. DESIGN: Births subdivided by sex were obtained from official Maltese publications. European countries were grouped according to geographical latitude by banding countries into three groups: Northern Mediterranean, Central European and Scandinavian. Births by sex for these countries were also analysed for the period 1990-1995. RESULTS: No decline in the ratio of male births to total births was noted in Malta over the period 1916-1995. However, the ratio was higher than expected (n = 151,766, ratio = 0.517 (95% confidence intervals (95% CI): 0.514, 0.519). Moreover, during the period 1890-1899 (n = 66,874), the ratio was 0.523 (95% CI: 0.519, 0.527), even higher than observed during the 20th century (chi 2 = 8.3, p = 0.004). Analysis of European births showed a much higher ratio of male births in the south of Europe than in the north (chi 2 = 87.2, p < 0.0001). CONCLUSIONS: The findings were unable to explain the higher incidence of male births in the south of Europe, but it is speculated that ambient temperatures may not only affect fertility, but also influence sex ratios at birth.

Acute respiratory distress syndrome due to cyanotic spell in an infant with tetralogy of Fallot.

Acute respiratory distress syndrome (ARDS) is characterized by fulminant respiratory failure due to noncardiac pulmonary edema. This can be triggered by a heterogeneous group of diseases. We report an unusual case of an infant who developed severe ARDS in association with a severe cyanotic attack due to tetralogy of Fallot.

Pigeon breeder's lung in childhood: varied clinical picture at presentation.

Extrinsic allergic alveolitis occurs rarely in childhood. We present 5 cases and briefly review the literature regarding this condition in the pediatric population. This report includes all cases (n = 5) of extrinsic allergic alveolitis known to have occurred in childhood on Malta. All cases were males, and were initially misdiagnosed as having other respiratory illnesses or mental disturbances. The diagnosis was based on a history of exposure to birds, clinical findings, positive avian precipitins, a restrictive defect on pulmonary function tests, and a suggestive chest X-ray appearance. All were treated with high-dose oral steroids for 3-4 weeks, with excellent response. Although these patients appear to have suffered no long-term sequelae, delayed diagnosis can lead to irreversible pulmonary fibrosis. The diagnosis of extrinsic allergic alveolitis should be entertained early in the differential diagnosis of children presenting with unusual respiratory symptoms and signs.

Diagnostic and surgical trends, and epidemiology of coarctation of the aorta in a population-based study.

Birth prevalence, and diagnostic and interventional trends for coarctation of the aorta were analysed in an Island population for patients born between 1925 and 1994. This lesion was diagnosed in 64 live births. A declining trend for age at diagnosis and age at surgery was present for the entire period (P<0.0001), predating the introduction of echocardiography, which caused a further decline. Mode of diagnosis changed from clinically, with or without preoperative catheter confirmation, prior to the mid-1980s, to almost exclusively by echocardiogram. Type of intervention was related to era, with patch aortoplasty and end-to-end resection in the mid 1960s to the mid-1970s changing to subclavian flap aortoplasty in the late 1970s and early 1980s followed by a return to end-to-end resection. The perioperative results showed an increase in mortality associated with a change towards earlier age at surgery. Prior to intervention, all Maltese patients are reviewed by a consultant cardiologist from a tertiary referral centre in the United Kingdom, and intervention is undertaken by a consultant paediatric cardiothoracic surgeon in the same setting. For this reason, these trends may be extrapolated to larger European countries. The birth prevalence of coarctation for all patients born between 1980 and 1994 was 0.32/1000 live births (n = 26), well within the range obtained from a review of previous studies. In conclusion, in Malta, coarctation of the aorta has been diagnosed and treated safely, at progressively younger ages, and this has been attributed to improving medical services over the period under study.