Validation of the Maltese version of the Edinburgh Postnatal Depression Scale

This paper reports the validation of the Maltese translated Edinburgh Postnatal Depression Scale against Diagnostic Criteria for Research (DCR-10) diagnosis for severe, moderate and mild depression during pregnancy (antenatally) and at 8 weeks postnatally. A random sample of 239 pregnant women were interviewed at booking and at 8 weeks postnatally using a detailed sociodemographic history, the Revised Version of the Clinical Interview Schedule (CIS-R) and Maltese translation of the Edinburgh Postnatal Depression Scale (EPDS). The Maltese translated EPDS had good face validity and had satisfactory sensitivity and specificity for identifying depression both antenatally and postnatally. Cut-off scores of 13/14 antenatally and 11/12 postnatally are recommended when using the Maltese EPDS. Controversial issues surrounds the use of the EPDS in clinical practice. However, introducing the EPDS in pregnancy will help to identify women who are at high risk of depression so as to treat appropriately and early in the antenatal period.

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.

Syndromes and malformations associated with congenital heart disease in a population-based study

Congenital cardiac malformations are frequently associated with non-cardiac malformations and chromosomal anomalies. Management is therefore influenced by interventional needs for all of the various anomalies. We have studied the association of congenital heart disease with extracardiac anomalies in the relatively closed population of Malta, where echocardiographic screening of all syndromic/multiply malformed infants is routinely carried out. Malformations were classified by using the EUROCAT method, for the first time. During 1990-1994, the birth prevalence of congenital heart disease was 8.8/1000 live births (n = 231). Of these, 21 (9%) had recognised chromosomal anomalies (0.80/1000 live births; 95% CI: 0.51-1.25), four (2%) had recognised non-chromosomal syndromes and 14 (6%) had other, major, non-cardiac malformations (0.69/1000 live births; 95% CI: 0.42-1.11). The commonest non-cardiac anomalies were musculoskeletal anomalies. Down syndrome accounted for 95% of all syndromic congenital heart disease, with a birth prevalence of 0.73/1000 live births (95% CI: 0.45-1.16). Comparison of these results with earlier studies showed wide disparities between studies, and this was attributed to differences in methods. such as differing inclusion criteria for both congenital heart disease and syndromes and malformations. The commonest lesion found in association with Down syndrome was isolated ventricular septal defect, not atrioventricular septal defect, and this was attributed to our screening process which identifies small lesions which would otherwise have been clinically missed and/or closed spontaneously.

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.

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.

Visceral leishmaniasis in Malta--an 18 year paediatric, population based study

BACKGROUND

Visceral leishmaniasis (VL) is a chronic parasitic infection that infects approximately 400,000 individuals annually, with a predilection towards early childhood.

AIMS

To study the epidemiology of VL in childhood.

METHODS

VL is endemic in Malta, a small archipelago of islands in the centre of the Mediterranean with a total population approaching half a million. Notification of human cases of leishmaniasis is compulsory. Case records of all 81 paediatric patients with VL between 1980 and 1998 were analysed.

RESULTS

The annual incidence of VL declined for all cases of VL, and declined significantly for paediatric cases (p = 0.01). For 1994 to 1998, the overall incidence of VL was 0.9 per 100,000 total population and the paediatric incidence was 2.5 per 100,000 population. Median age at presentation was 34 months. Common features at presentation were splenomegaly, hepatomegaly, fever, and pancytopenia with high lymphocyte and monocyte counts. The diagnostic sensitivity of isolated immunofluorescent antibody testing was equivalent to bone marrow aspiration (95%). Blood transfusions for anaemia were required in 93% of patients. Eleven per cent had intercurrent infections. All patients were cured, and were initially treated with intravenous sodium stibogluconate. Defervescence occurred after a median of six days of treatment, and patients continued to be treated on a day case basis. Nine relapsers were retreated with sodium stibogluconate, achieving a cure rate of 94%, but five patients required additional drug therapy. There were no permanent sequelae associated with VL or its treatment.

CONCLUSIONS

The decreased incidence is attributed to the eradication of stray dogs which are the disease reservoir.

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.

Spectrum of congenital heart disease in Malta. An excess of lesions causing right ventricular outflow tract obstruction in a population-base study

AIMS

To quantify birth prevalence and spectrum of congenital heart disease in the Island population of Malta, and compare these rates with previous studies.

METHODS

All patients diagnosed as having congenital heart disease by echocardiography, cardiac catheterization, surgery or post-mortem by 1 year of age between 1990-1994 were included. There were 231 cases of live born congenital heart disease with a birth prevalence of 8.8/1000 live births. The commonest lesions were ventricular septal defect, pulmonary stenosis and tetralogy of Fallot. The rates of individual lesions were compared with two recent epidemiological studies with similar methodologies.

RESULTS

Although the overall birth prevalence of congenital heart disease was similar in three studies, significantly higher rates of pulmonary stenosis, tetralogy of Fallot and double outlet right ventricle were found in Malta, all of which predispose to right ventricular outflow tract obstruction. In contrast, there were lower rates of lesions causing left ventricular outflow tract obstruction. A higher rate of ventricular septal defect was also found. The Maltese gene pool may contain an inherent predisposition towards lesions causing right ventricular outflow tract obstruction.

Fatal, rotavirus-associated myocarditis and pneumonitis in a 2-year-old boy

Rotavirus infection is common in childhood. We report a 2-year-old boy admitted to hospital with gastro-enteritis who suffered cardio-respiratory arrest and died. Autopsy showed evidence of rotavirus-associated myocarditis and pneumonitis. We are not aware of any previous report of death from this type of consequence of rotavirus infection.

The evolution of diagnostic trends in congenital heart disease: A population-based study

OBJECTIVE

To analyse historical trends in diagnosis of congenital heart disease (CHD) in all diagnosed cardiac malformations born between 1945 and 1994 in a population-based study, the first of its type.

METHODOLOGY

Retrospective analysis of age and mode of diagnosis was carried out in 953 patients with CHD, in the setting of a regional hospital providing diagnostic and follow up services for all of Malta. Main outcome measures were age at diagnosis, cumulative percentage diagnosis by age and mode of diagnosis.

RESULTS

A significant negative correlation of age at diagnosis with time was found for both lesions not requiring intervention, and requiring intervention (P < 0.0001). Cumulative percentage diagnosis by age increased progressively with time. Echocardiography increased the birth prevalence of definitively diagnosed defects, particularly of lesions not requiring intervention. The annual number of cardiac catheters for these conditions has decreased with an increased number and proportion of interventional catheters. The current catheterization rate for CHD is 6.1/100 000 population.

CONCLUSION

Echocardiography has led to an increase in the diagnosis in the birth prevalence of CHD, and provided early diagnosis, supplanting cardiac catheterization as a primary diagnostic tool.

Epidemiology and diagnosis of ventricular septal defect in Malta

Malta is a small island with minimal changes in its population, making it an ideal location for epidemiological and historical studies dealing with congenital heart malformations. Ventricular septal defect was studied retrospectively from 1930 to 1994. A sharp and significant decline in age at diagnosis was found, predating echocardiography. All defects are now diagnosed by echocardiography, which has resulted in an increased prevalence of this lesion as seen at birth, particularly of minor defects. The prevalence of ventricular septal defect from 1990 to 1994 was 3.85/1000 live births, with 3.03/1000 not needing surgery and 0.83/1000 requiring operative intervention. Half the defects closed spontaneously. The majority of ventricular septal defects overall, and those spontaneously closing, were muscular defects. The overall prevalence at birth was significantly higher than that reported in recent studies using similar methodologies, implying that the reported rate is more likely to be the true prevalence at birth of clinically detectable defects.

Evolution of surgical trends in congenital heart disease: a population based study

The aim of this study was to establish surgical trends in patients with congenital heart disease operated on between 1947 and 1997 in a population based study. All patients diagnosed as having congenital heart disease, born in Malta up to 1995 inclusive and operated for congenital heart disease up to 1997 inclusive were included. Analysis was carried out for lesions operated, age at surgery, operative centre and mortality rates, in the setting of a regional hospital providing congenital heart disease diagnostic and follow-up services for all Malta. Increasingly more operations for cardiac malformations are being carried out, with a progressively higher proportion of operations performed on complex conditions (P<0.001), at an ever younger age (P<0.001), and with a declining perioperative mortality (P<0.001). For the period 1990-1994, 4.2 operations for congenital heart disease/1000 live births were required. Factors which may increase or decrease this rate in future are discussed, along with costs of surgery. Surgery for congenital heart disease has become progressively more aggressive and safer since this method of treatment for these malformations was initiated, but this has occurred at a significant financial cost.

Declining mortality from congenital heart disease related to innovations in diagnosis and treatment: a population-based study

The majority of live births with severe congenital cardiac malformations that do not undergo intervention of some form die prematurely. The population of Malta provides an ideal closed cohort from which to monitor trends. We have observed a significant declining specific mortality from congenital heart disease, and circumstantial evidence relates this decline to the introduction of new techniques used in the diagnosis and treatment of these malformations.

History, diagnosis, surgery and epidemiology of pulmonary stenosis in Malta

The Maltese population constitutes an ideal location for epidemiological and historical studies dealing with congenital heart malformations. Pulmonary stenosis was studied retrospectively from 1943 to 1994. A sharp, significant decline in age at diagnosis was found, which predates the introduction of echocardiography. All defects are now diagnosed by echocardiography, which has resulted in an increased prevalence at birth of this lesion, particularly of pulmonary stenosis not requiring intervention. The prevalence at birth of pulmonary stenosis from 1990 to 1994 was 1.65/1000 live births (95% CI: 1.21-2.24), with 1.11/1000 mild lesions (95% CI: 0.76-1.62) and 0.54/1000 lesions requiring intervention (95% CI: 0.31-0.92). The prevalence at birth overall was significantly higher than that reported in recent studies with similar methodologies due to the higher pickup of milder variants of pulmonary stenosis by echocardiography. Significantly more pulmonary stenosis was found in females than in males.

Cardiac malformations associated with the congenital nephrotic syndrome

The association of cardiac malformation with the congenital nephrotic syndrome (CNS) has been previously reported in only one family. We report four patients with CNS: three with pulmonary valve stenosis (one requiring valvuloplasty) and one with discrete subaortic stenosis requiring surgical resection. We conclude that the cardiac status of all patients with CNS should be reviewed regularly by a paediatrician, with a low threshold for referral to a cardiologist, as flow murmurs due to chronic anaemia may obscure cardiac pathology. It is important to diagnose any associated cardiac lesions as these may require intervention, and may also predispose to the development of bacterial endocarditis if surgical or dental procedures are undertaken without appropriate antibiotic prophylaxis.

How reliable is axillary temperature measurement?

AIM

To assess whether axillary temperature measurements reliably reflect oral/rectal temperature measurements.

METHODS

This observational study compared paired axillary-rectal and axillary-oral temperatures in a general paediatric ward with the participation of 225 children aged < or = 4 y and 112 children aged between 4 and 14 y.

RESULTS

Changes in oral/rectal and axillary temperatures correlated significantly (p < 0.0001). However, axillary temperature measurements were significantly lower than both oral (mean -0.56 degrees C, SD 0.76 degrees C) and rectal measurements (0.38 degrees C; SD 0.76 degrees C). Ninety-five percent of axillary measurements fell within a 2.5-3 degrees C range around respective paired oral/rectal measurements. The mean difference increased with increasing temperature, and was 0.4 degrees C at low body temperatures, and over 1 degree C with a fever of 39 degrees C. Neither seasonal fluctuations nor the amount of clothing worn influenced this difference.

CONCLUSION

Axillary temperatures in young children do not reliably reflect oral/rectal temperatures and should therefore be interpreted with caution.

Atrial septal defect in Malta

OBJECTIVE

To study diagnostic and surgical trends in atrial septal defect (ASD) in a population-based study, and estimate birth prevalence and spontaneous closure rates.

METHODOLOGY

All patients in Malta diagnosed as having ASD and born between 1990 and 1994 were identified from various sources. This took place in the setting of a regional hospital supplying diagnostic services for the entire population. Echocardiographic follow-up was also undertaken for lesions not requiring intervention.

RESULTS

A total of 190 patients born in this period were diagnosed as having ASD. Age at diagnosis and age at surgery have decreased significantly over the period under study (P < 0.0001). The mode of diagnosis has become entirely noninvasive, and the perioperative mortality decreased dramatically over time. For the period 1990-94, the incidence at birth for defects not requiring intervention was 2.0/1000 live births, defects requiring intervention 0.4/1000 live births. A total of 92% of 50 defects not requiring intervention closed spontaneously, and the remainder had spontaneously decreased in size on follow-up.

CONCLUSIONS

ASD is a relatively benign malformation in which early and noninvasive diagnosis can be achieved, with an extremely low interventional mortality.

Sudden cardiac death in infancy due to histiocytoid cardiomyopathy

Detailed post-mortem is crucial in infants who die suddenly and without a known cause. We report a rare case of histiocytoid cardiomyopathy with endocardial fibroelastosis, the second case in the world literature. The infant presented with sudden death, but the cardiac histological appearance was initially believed to be caused by Pompes disease.

Temporary myoclonus with treatment of congenital transcobalamin 2 deficiency

The treatment of acquired cobalamin deficiency in infants may result in the development of a syndrome defined by temporary involuntary myoclonic movements. A patient with an inborn error of metabolism resulting in transcobalamin 2 deficiency who was treated with cobalamin and then developed this syndrome is presented. Neurologic investigations were normal. The continuance of cobalamin and avoidance of antiepileptic drugs is recommended. To our knowledge this is the first such case.

Seasonality in live births with congenital heart disease in Malta

This study was carried out to analyse seasonal variations in live births with congenital heart disease in the overall population of Malta. Included were all patients diagnosed as having congenital heart disease by echocardiography, cardiac catheterization, surgery or post mortem, by 1 year of age, and who were born between in Malta between 1990 and 1994. Results were analysed by X2 and by Edwards' cyclic method. There were 231 cases of live born congenital heart disease, which were divided into 114 cases not requiring intervention and 117 cases requiring intervention. Although the overall prevalence of congenital heart disease did not demonstrate any seasonal variation, the lesions requiring intervention showed a significant peak in September by Edwards' method (p = 0.03), which was enhanced by seasonal analysis (p = 0.003). These results were confirmed by conventional X2 and X2 for trend. The lesions not requiring intervention, which were comprised almost entirely (96%) of mild pulmonary stenosis and small ventricular septal defects, failed to show any seasonal trend. The literature regarding such seasonal trends in these malformations and statistical analysis of seasonality of congenital heart disease are reviewed. An environmental factor such as a maternal viral infection or treatment of such infections during the first trimester of pregnancy from November to January may precipitate congenital heart disease in predisposed Maltese foetuses.

Diagnostic and interventional trends in tetralogy of fallot and transposition of the great arteries in a population-based study

The goal of this study was to analyze diagnostic and interventional trends in tetralogy of Fallot and transposition of the great arteries in Malta for individuals born during 1920-1994 and calculate birth prevalences. The design was population based, in the setting of a regional hospital providing exclusive diagnostic and follow-up services for the entire population of Malta. Data collection and analysis was retrospective and included comparison with earlier epidemiological studies. Patients included were all Maltese live births diagnosed as having tetralogy of Fallot (TF) and transposition of the great arteries (TGA) born by the end of 1994. There were 109 cases of TF and 30 cases of TGA (n = 30). A significant decline in age at diagnosis and age at surgery was found for both lesions (p < 0.0001), which was associated with a significant decline in perioperative mortality (p = 0.005). Underascertainment was present prior to 1980, however, more cases were diagnosed due to improvement of postmortem services in the early 1980s followed by improvement of clinical services with eventually exclusive premortem diagnosis. The birth prevalence of TGA was 0.31/1000 live births, well within the range described in previous studies, unlike tetralogy of Fallot, which has been found in excess in this population in an earlier study. TF and TGA, the two lesions which comprise the majority of cyanotic congenital heart disease presenting in infancy, have been diagnosed and have undergone intervention at progressively earlier ages over the period under study. This decline was associated with a declining perioperative mortality.