Epidemiology of esophageal atresia

Esophageal atresia (EA) is a rare congenital malformation consisting of a lack of continuity between the upper and lower esophageal pouches, frequently associated with tracheoesophageal fistula. The prevalence of such rare abnormalities is established by global birth surveillance programs over the world. EUROCAT is a European program covering 1.7 million births since its creation. The prevalence of EA in Europe seems stable over decades. The National Birth Defects Prevention Network in the USA also shows a stable prevalence with a wide range between states or regions. In France, with the implementation of the national rare diseases plan, a reference center for congenital abnormalities of the esophagus was created in 2006 and a national registry for EA began patient inclusion in 2008. This has resulted in the establishment of the national live birth prevalence for EA, prenatal diagnosis rates, and clinical characteristics of EA patients, early survival, and early morbidity. Prevalence rates seem stable all over the world since many decades. Continuous surveillance of congenital abnormalities and specific registries are useful for epidemiologic data but also for public health authorities for helping families of rare diseases patients.

Esophageal atresia: metaplasia, Barrett

Barrett's esophagus is characterized by the replacement of squamous epithelium by columnar epithelium that is intestinal metaplasia-positive or -negative in the distal esophagus. Gastroesophageal reflux disease, which is frequent and prolonged in esophageal atresia, probably plays a major role in the development of Barrett's esophagus through repeated mucosal damage. Long-term acid exposure contributes to carcinogenesis in Barrett's esophagus of intestinal type, but its effect on gastric metaplasia is less well defined. Recent studies have suggest that metaplasia arises in about 15% of patients with esophageal atresia, with a lag time to developing metaplasia from initial surgical correction of about 10 years. Preliminary data from an ongoing multicenter study including 88 patients with esophageal atresia aged 15-19 years showed gastric metaplasia in 42% of patients (29 fundic and 7 cardial metaplasia), while one patient presented intestinal metaplasia. Esophageal mucosal abnormalities can be observed in esophageal atresia patients at endoscopy despite the absence of symptoms. Whether prolonged, aggressive, acid suppression is beneficial in these situations remains to be determined. Barrett's metaplasia can be removed by endoscopic mucosal resection or destroyed with endoscopic ablative techniques, such as photodynamic therapy, radiofrequency ablation, and cryotherapy. The risk of developing esophageal carcinoma is still a controversial issue as only a few clinical cases have been reported in young adults with esophageal atresia. As late complications of esophageal atresia, particularly esophagitis and Barrett's esophagus, are increasingly being recognized, long-time systematic follow up of the esophageal mucosa including multistage biopsies is therefore required even in asymptomatic patients.

Physical activity attenuates the negative effect of low birth weight on leptin levels in European adolescents; the HELENA study

We examined whether physical activity (PA) influences the association between birth weight and serum leptin in adolescents. The study comprised a total of 538 adolescents (315 girls), aged 12.5-17.49 years, born at term (≥ 37 weeks of gestation). We measured serum leptin levels and time engaged in moderate-vigorous PA (MVPA) by accelerometry. There was an interaction effect between birth weight and meeting the PA recommendations (60 min/day MVPA) on leptin levels in girls (P = 0.023) but not in boys (P = 0.809). Birth weight was negatively associated with leptin levels in girls not meeting the PA recommendations (i.e. more than 60 min/day of MVPA) (β = -0.096, P = 0.009), whereas no significant association was observed in those meeting the PA recommendations (β = -0.061, P = 0.433). In conclusion, meeting the PA recommendations may attenuate the negative effect of low birth weight on serum leptin levels in European female adolescents.

Food consumption and screen-based sedentary behaviors in European adolescents: the HELENA study

OBJECTIVE

To examine the association between time spent on different sedentary behaviors and consumption of certain food and beverage groups in a sample of European adolescents.

DESIGN

Data from the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-sectional Study.

SETTING

Eight survey centers (Athens, Dortmund, Ghent, Lille, Rome, Stockholm, Vienna, and Zaragoza).

PARTICIPANTS

A total of 2202 participants (45.5% boys) aged 12½ to 17½ years.

MAIN OUTCOME MEASURES

Information on sedentary behaviors (weekdays and weekends) collected via a standardized self-reported questionnaire, including watching television, playing computer and video games, using the Internet for studying or recreation, and studying. Food and beverage consumption data of selected groups were obtained using 2 nonconsecutive 24-hour recalls.

RESULTS

Boys reporting more than 4 h/d of watching television, playing computer games, and using the Internet for recreation were more likely to consume sweetened beverages (weekends) (odds ratio [OR], 1.83 [95% CI, 1.21-2.75]; 1.99 [1.31-3.01]; and 1.73 [1.03-2.91], respectively), and less likely to consume fruit (weekdays) (0.39 [0.21-0.72], 0.37 [0.18-0.77], and 0.39 [0.19-0.78], respectively) than those who spent less than 2 h/d. Girls spending more time per day watching television and playing computer or video games (weekdays) and playing computer games or surfing the Internet for recreation (weekends) were more likely to drink sweetened beverages (OR, 1.89 [95% CI, 1.21-2.94]; 1.57 [1.00-2.46]; 2.14 [1.16-3.97]; and 2.30 [1.24-4.28], respectively) and less likely to consume fruit (weekdays) (0.43 [0.23-0.80], 0.40 [0.19-0.83], 0.37 [0.14-0.94], and 0.42 [0.20-0.85], respectively) than those who spent less than 2 h/d.

CONCLUSION

Increased television viewing and computer and Internet use during adolescence is associated with higher odds of consumption of sweetened beverages and lower odds of fruit consumption.

Combined influence of healthy diet and active lifestyle on cardiovascular disease risk factors in adolescents

To investigate the combined influence of diet quality and physical activity on cardiovascular disease (CVD) risk factors in adolescents, adolescents (n = 1513; 12.5-17.5 years) participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence study were studied. Dietary intake was registered using a 24-h recall and a diet quality index was calculated. Physical activity was assessed by accelerometry. Lifestyle groups were computed as: healthy diet and active, unhealthy diet but active, healthy diet but inactive, and unhealthy diet and inactive. CVD risk factor measurements included cardiorespiratory fitness, adiposity indicators, blood lipid profile, blood pressure, and insulin resistance. A CVD risk score was computed. The healthy diet and active group had a healthier cardiorespiratory profile, fat mass index (FMI), triglycerides, and high-density lipoprotein cholesterol (HDL-C) levels and total cholesterol (TC)/HDL-C ratio (all P ≤ 0.05). Overall, active adolescents showed higher cardiorespiratory fitness, lower FMI, TC/HDL-C ratio, and homeostasis model assessment index and healthier blood pressure than their inactive peers with either healthy or unhealthy diet (all P ≤ 0.05). Healthy diet and active group had healthier CVD risk score compared with the inactive groups (all P ≤ 0.02). Thus, a combination of healthy diet and active lifestyle is associated with decreased CVD risk in adolescents. Moreover, an active lifestyle may reduce the adverse consequences of an unhealthy diet.

Gastrointestinal manifestations of cow's milk protein allergy and gastrointestinal motility

Cow's milk protein allergy (CMPA) may cause gastrointestinal motility disorders. Symptoms of both conditions overlap and diagnostic tests do not reliably differentiate between both. A decrease of symptoms with an extensive hydrolysate and relapse during challenge is not a proof of allergy, because hydrolysates enhance gastric emptying, a pathophysiologic mechanism of gastro-oesophageal reflux (GER). Thickened formula reduces regurgitation, and failure to do so suggests CMPA. A thickened extensive hydrolysate may induce more rapid improvement, but does not always differentiate between CMPA and GER. Different hypotheses are discussed: is the overlap between CMPA and functional disorders coincidence, or do both entities present with identical symptoms, or does the fact that symptoms are identical indicates that there is only one entity involved? Studies on the prevention of CMPA focused on 'at-risk families', and resulted in a decrease of CMPA and atopic dermatitis, but did not provide data on the incidence of GER.

CONCLUSION

  As long as there are no objective diagnostic tools to separate GER from CMPA, the physician has two options: first treat the most likely diagnosis, and switch if after 2-4 weeks there is no improvement, or treat both conditions with one intervention, what will not result in a diagnosis.

Long-term outcome of children with oesophageal atresia type III

OBJECTIVE

The aim of this study was to evaluate the outcome of patients with oesophageal atresia type III (EA), focusing on the presence of late sequelae and quality of life.

METHODS

This was a retrospective case ascertainment followed by clinical assessment of patients. The study parameters included the patients' demographic characteristics, associated abnormalities, presence of gastro-oesophageal reflux disease (GERD) and digestive or respiratory symptoms, results of a clinical examination to evaluate nutritional status, spirometry results and quality of life assessed using the PedsQL 4.0 questionnaire.

RESULTS

Of 81 patients with EA type III treated in our institution over a 10-year period, 57 (mean age 13.3 (SE 2.8) years) participated in the study. 39% of the patients underwent fundoplication and 46% presented with anastomotic stenosis requiring dilation. 75% of patients had normal nutritional status (16% were obese, 9% were undernourished). Only 19% of participants had no digestive symptoms; 61% had dysphagia and 35% had symptoms of GERD at the last follow-up. The main respiratory symptoms were chronic cough (19%) and dyspnoea on exertion (37%). Only 37% of patients had no respiratory symptoms. Spirometry showed that 50% of patients had proximal obstruction and/or pulmonary distension, and 11% had restriction syndrome. Their quality of life was good but was lower than in healthy controls (80 vs 84, p<0.05) and lower in patients born prematurely, with symptoms of GERD and with a barky cough.

CONCLUSION

The high frequency of late sequelae in EA type III justifies regular and multidisciplinary follow-up through to adulthood.

Impact of REV-ERB alpha gene polymorphisms on obesity phenotypes in adult and adolescent samples

BACKGROUND

REV-ERBα has been shown to regulate adipogenesis and lipid metabolism as well as to link the circadian timing system to whole body metabolic homeostasis. We thus tested whether polymorphisms in REV-ERBα could be associated with metabolic phenotypes in human population samples.

METHODS

We analyzed the associations between 5 REV-ERBα polymorphisms and anthropometric (body weight, body mass index (BMI), waist and hip circumferences), biochemical (plasma lipid, glucose and insulin levels) and clinical (systolic and diastolic blood pressure) variables in three population-based studies (MONICA Lille n=1155 adults, MONA LISA Lille n=1170 adults and HELENA n=1155 adolescents). We assessed in vitro, the potential influence of one REV-ERBα polymorphism in transient transfection assays using two different cell lines.

RESULTS

We observed significant and consistent associations between the T minor allele of the REV-ERBα rs2071427 polymorphism (located in intron 1) and higher BMI (mean allele effect=+0.33 kg m(-2)) in the MONICA Lille (P=0.02), MONA LISA (P=0.02) and HELENA (P=0.03) studies. The odds ratios for obesity associated with this allele were 1.67 (1.00-2.79) (P=0.05) in MONICA Lille, 1.29 (1.01-1.65) (P=0.04) in MONA LISA Lille and the odds ratio for overweight was 1.48 (1.08-2.03) (P=0.01) in HELENA. In transfection experiments in human hepatocyte-derived cell lines, the REV-ERBα intron 1 directed the transcription of a luciferase reporter gene independently of the rs2071427 polymorphism.

CONCLUSION

Our results suggest that the REV-ERBα rs2071427 polymorphism modulates body fat mass in both adult and young people.

Strong variability of di(2-ethylhexyl)phthalate (DEHP) plasmatic rate in infants and children undergoing 12-hour cyclic parenteral nutrition

BACKGROUND

Medical devices such as perfusion materials in polyvinyl chloride may contain di(2-ethylhexyl)phthalate (DEHP). Several studies have questioned the harmlessness of phthalates, which have been shown to have toxic effects on the reproductive system and general development. This study was designed to assess DEHP exposure in infants and children benefitting from cyclic parenteral nutrition (PN). The results are compared with those obtained from children used as controls and receiving no PN, to estimate the potential risk to this pediatric population, taking into account exposure levels and already published data.

METHODS

Plasmatic concentrations of DEHP were assessed by high-performance liquid chromatography from blood samples taken from 22 children at the start and finish of a 12-hour cyclic PN period and compared with those obtained from 20 control children of comparable age and gender.

RESULTS

After a 12-hour cyclic PN period, DEHP migration varied widely among the patients. The concentrations were not quantifiable in 4 children at the start of PN. In 1 child, they were quantifiable neither at the start nor at the end of PN. However, for 17 children, DEHP concentrations were quantifiable at the start of PN and were very variable from one child to another. At the end, DEHP concentrations had significantly but variably increased in these children. No trace of DEHP was found in the blood samples from 20 healthy controls.

CONCLUSION

Considering published data on phthalate toxicity, it would appear advisable to encourage the use of medical devices that are either phthalate or DEHP free.

Molecular and functional analysis of two new MTTP gene mutations in an atypical case of abetalipoproteinemia

Abetalipoproteinemia (ABL) is an inherited disease characterized by the defective assembly and secretion of apolipoprotein B-containing lipoproteins caused by mutations in the microsomal triglyceride transfer protein large subunit (MTP) gene (MTTP). We report here a female patient with an unusual clinical and biochemical ABL phenotype. She presented with severe liver injury, low levels of LDL-cholesterol, and subnormal levels of vitamin E, but only mild fat malabsorption and no retinitis pigmentosa or acanthocytosis. Our objective was to search for MTTP mutations and to determine the relationship between the genotype and this particular phenotype. The subject exhibited compound heterozygosity for two novel MTTP mutations: one missense mutation (p.Leu435His) and an intronic deletion (c.619-5_619-2del). COS-1 cells expressing the missense mutant protein exhibited negligible levels of MTP activity. In contrast, the minigene splicing reporter assay showed an incomplete splicing defect of the intronic deletion, with 26% of the normal splicing being maintained in the transfected HeLa cells. The small amount of MTP activity resulting from the residual normal splicing in the patient explains the atypical phenotype observed. Our investigation provides an example of a functional analysis of unclassified variations, which is an absolute necessity for the molecular diagnosis of atypical ABL cases.

Muscular and cardiorespiratory fitness are independently associated with metabolic risk in adolescents: the HELENA study

OBJECTIVE

To examine the independent associations of muscular and cardiorespiratory fitness with clustered metabolic risk in adolescents.

METHODS

Participants were 709 adolescents (346 boys) from 10 European centers, aged 12.5-17.5 yr, evaluated as a part of the Healthy Lifestyle in Europe by Nutrition in Adolescents cross-sectional study (HELENA-CSS). A muscular fitness score was computed using handgrip strength and standing long jump. Cardiorespiratory fitness was measured using the 20-m shuttle run test. Age- and gender-specific z-scores of waist circumference, systolic blood pressure, triglycerides, ratio total cholesterol/high-density lipoprotein cholesterol, and insulin resistance (homeostasis model assessment) were summed to create a metabolic risk score.

RESULTS

Muscular fitness was negatively associated with clustered metabolic risk independent of cardiorespiratory fitness (β = -0.249, p < 0.001). Independent of muscular fitness, an inverse association was also found between cardiorespiratory fitness and clustered metabolic risk (β = 0.264, p < 0.001). The odds ratios for having a high clustered risk (above or equal 1 standard deviation) were 5.3 [95% confidence interval (CI) = 2.6-10.6] and 4.3 (95% CI = 2.0-9.3) in the least fit quartile compared with the most fit quartile for muscular and cardiorespiratory fitness, respectively. Significant differences in metabolic risk between muscular fitness levels persisted among non-overweight (p = 0.012) and overweight participants (p = 0.011).

CONCLUSION

Muscular and cardiorespiratory fitness are independently associated with metabolic risk in adolescents. These results support current physical activity recommendations for youth, which include muscle strengthening activities in addition to aerobic exercise.