Risk of esophagitis among individuals born preterm or small for gestational age

Esophageal Columnar Metaplasia in Childhood: A Population-Based Case Series Analysis

BACKGROUND

Adults with Barrett's esophagus (BE) are often entered into surveillance for esophageal adenocarcinoma (EAC), although cancer risk is relatively low. BE can be detected in children (< 16 years). Little is known about the epidemiology of pediatric BE, and it is unclear what the optimal surveillance regimes are in children.

AIM

To evaluate the demographic and clinical characteristics, and future neoplastic progression risk in all pediatric BE patients diagnosed in Northern Ireland between 1993 and 2010.

METHODS

Data from the population-based Northern Ireland BE register were matched to the Northern Ireland Cancer Registry for EAC outcomes until end 2013. Age-adjusted incidence of pediatric BE was calculated, and characteristics between pediatric and adult BE patients compared using Chi-square tests.

RESULTS

Over 18 years, 42 pediatric BE patients (< 16 years) were identified, equivalent to an age-adjusted incidence of < 2 per 100,000 children. There was a clear age differential, with BE incidence increasing with age within the pediatric population. The majority (85.7%) of patients were male, a significantly higher male/female ratio than adult BE patients (p < 0.001). No pediatric BE patients progressed to high-grade dysplasia (HGD) or EAC, although the eldest patient was aged 34 years by the end of follow-up.

CONCLUSIONS

This is the largest series of pediatric BE ever reported. It demonstrates that pediatric BE is rare. The male preponderance of this condition is more apparent in childhood compared with adult cases. No children developed HGD/EAC during follow-up, suggesting that regular surveillance is not required, at least until adulthood.

Socio-economic status and lifestyle factors are associated with achalasia risk: A population-based case-control study

AIM

To evaluate the association between various lifestyle factors and achalasia risk.

METHODS

A population-based case-control study was conducted in Northern Ireland, including n = 151 achalasia cases and n = 117 age- and sex-matched controls. Lifestyle factors were assessed via a face-to-face structured interview. The association between achalasia and lifestyle factors was assessed by unconditional logistic regression, to produce odds ratios (OR) and 95% confidence interval (CI).

RESULTS

Individuals who had low-class occupations were at the highest risk of achalasia (OR = 1.88, 95%CI: 1.02-3.45), inferring that high-class occupation holders have a reduced risk of achalasia. A history of foreign travel, a lifestyle factor linked to upper socio-economic class, was also associated with a reduced risk of achalasia (OR = 0.59, 95%CI: 0.35-0.99). Smoking and alcohol consumption carried significantly reduced risks of achalasia, even after adjustment for socio-economic status. The presence of pets in the house was associated with a two-fold increased risk of achalasia (OR = 2.00, 95%CI: 1.17-3.42). No childhood household factors were associated with achalasia risk.

CONCLUSION

Achalasia is a disease of inequality, and individuals from low socio-economic backgrounds are at highest risk. This does not appear to be due to corresponding alcohol and smoking behaviours. An observed positive association between pet ownership and achalasia risk suggests an interaction between endotoxin and viral infection exposure in achalasia aetiology.

Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC), a disease with increasing burden in the Western world, especially in white men. Risk factors for BE include obesity, tobacco smoking, and gastroesophageal reflux disease (GERD). EAC is the most common form of esophageal cancer in the United States. Risk factors include GERD, tobacco smoking, and obesity, whereas nonsteroidal antiinflammatory drugs and statins may be protective. Factors predicting progression from nondysplastic BE to EAC include dysplastic changes on esophageal histology and length of the involved BE segment. Biomarkers have shown promise, but none are approved for clinical use.

Does Maternal Country of Birth Matter for Understanding Offspring's Birthweight? A Multilevel Analysis of Individual Heterogeneity in Sweden

Background

Many public health and epidemiological studies have found differences between populations (e.g. maternal countries of birth) in average values of a health indicator (e.g. mean offspring birthweight). However, the approach based solely on population-level averages compromises our understanding of variability in individuals’ health around the averages. If this variability is high, the exclusive study of averages may give misleading information. This idea is relevant when investigating country of birth differences in health.

Methods and Results

To exemplify this concept, we use information from the Swedish Medical Birth Register (2002–2010) and apply multilevel regression analysis of birthweight, with babies (n = 811,329) at the first, mothers (n = 571,876) at the second, and maternal countries of birth (n = 109) at the third level. We disentangle offspring, maternal and maternal country of birth components of the total offspring heterogeneity in birthweight for babies born within the normal timespan (37–42 weeks). We found that of such birthweight variation about 50% was at the baby level, 47% at the maternal level and only 3% at the maternal countries of birth level.

Conclusion

In spite of seemingly large differences in average birthweight among maternal countries of birth (range 3290–3677g), knowledge of the maternal country of birth does not provide accurate information for ascertaining individual offspring birthweight because of the high inter-offspring heterogeneity around country averages. Our study exemplifies the need for a better understanding of individual health diversity for which group averages may provide insufficient and even misleading information. The analytical approach we outline is therefore relevant to investigations of country of birth (and ethnic) differences in health in general.

Life course models for upper aero-digestive tract cancer

Upper aero-digestive tract (UADT) cancers are collectively cancers of various human body sites, such as the oral cavity, pharynx, oesophagus and larynx. Worldwide, they are the fourth most frequent cancer type and the fourth most common cause of mortality from cancer. Many studies have shown that several chronic diseases, such as cancer, which occur more commonly in later adulthood, are influenced by social and psychological circumstances during birth, childhood, adolescence and early adult life. It is suggested that the build up of problematic circumstances throughout life is the cause of disease, rather than circumstances that happen at one point in time. UADT cancer is a chronic disease of complex multifactorial origin and most of the underlying exposures/risks cannot be considered as individual factors or in isolation, as they act at different levels, which differ from time to time. Thus, life-course epidemiology, rather than drawing false dichotomies between different risk factors of the underlying disease, attempts to integrate biological and social risk processes that cause the chronic disease. It studies how socially patterned exposures during all stages of life--childhood, adolescence and early adult--influence disease risk in adulthood and socio-economic position and hence may account for social inequalities in adult health and mortality. Furthermore, varying health effects, according to the timing or duration of exposure to socio-economic circumstances, may indicate important traces to the causes of cancer. In this paper, we have attempted to draw a conceptual framework on the relationships between socio-economic inequalities, oral health risk factors along the life-course of an individual and incidence of UADT cancer.

Familial clustering of Barrett's esophagus and esophageal adenocarcinoma in a European cohort

BACKGROUND & AIMS

Up to 7% of cases of Barrett's esophagus (BE) or esophageal adenocarcinoma (EAC) in the United States occur in family clusters. We identified first-degree and second-degree relatives of patients with BE and EAC to determine the extent of familial clustering in a European cohort and studied differences between familial and nonfamilial cases.

METHODS

A questionnaire was sent to all patients diagnosed with BE or EAC from 2000-2011 at 3 hospitals in the Netherlands (n = 838). Diagnoses of affected relatives were confirmed by using the Dutch Pathology Registry. Familial statuses of BE were defined as definitive (≥1 first-degree or second-degree relative with BE or EAC), possible (≥1 reported relative with BE or esophageal cancer without histologic confirmation), unlikely (no family history), or unknown.

RESULTS

A total of 603 patients with BE or EAC (71%) responded and were included in the analysis. Familial BE was definitive for 7% of cases (n = 39, 10% of first-degree relatives affected), possible for 6% (n = 36), unlikely for 49% (n = 297), and unknown for 38% (n = 231). Definitive cases of familial BE were younger at onset of heartburn and EAC diagnosis; their first-degree relatives more frequently had reflux symptoms and a prior upper endoscopy, compared with unlikely cases of familial BE.

CONCLUSIONS

In a database analysis of patients diagnosed with BE or EAC in the Netherlands, 7% of cases of BE and EAC were familial. These cases have a younger average age of onset of reflux symptoms and diagnosis of EAC than unlikely familial cases. These findings may indicate that genetic factors contribute to BE susceptibility, with a possible central role of gastroesophageal reflux.

Applying measures of discriminatory accuracy to revisit traditional risk factors for being small for gestational age in Sweden: a national cross-sectional study

OBJECTIVES

Small for gestational age (SGA) is considered as an indicator of intrauterine growth restriction, and multiple maternal and newborn characteristics have been identified as risk factors for SGA. This knowledge is mainly based on measures of average association (ie, OR) that quantify differences in average risk between exposed and unexposed groups. Nevertheless, average associations do not assess the discriminatory accuracy of the risk factors (ie, its ability to discriminate the babies who will develop SGA from those that will not). Therefore, applying measures of discriminatory accuracy rather than measures of association only, our study revisits known risk factors of SGA and discusses their role from a public health perspective.

DESIGN

Cross-sectional study. We measured maternal (ie, smoking, hypertension, age, marital status, education) and delivery (ie, sex, gestational age, birth order) characteristics and performed logistic regression models to estimate both ORs and measures of discriminatory accuracy, like the area under the receiver operating characteristic curve (AU-ROC) and the net reclassification improvement.

SETTING

Data were obtained from the Swedish Medical Birth Registry.

PARTICIPANTS

Our sample included 731 989 babies born during 1987-1993.

RESULTS

We replicated the expected associations. For instance, smoking (OR=2.57), having had a previous SGA baby (OR=5.48) and hypertension (OR=4.02) were strongly associated with SGA. However, they show a very small discriminatory accuracy (AU-ROC≈0.5). The discriminatory accuracy increased, but remained unsatisfactorily low (AU-ROC=0.6), when including all variables studied in the same model.

CONCLUSIONS

Traditional risk factors for SGA alone or in combination have a low accuracy for discriminating babies with SGA from those without SGA. A proper understanding of these findings is of fundamental relevance to address future research and to design policymaking recommendations in a more informed way.

Risk of oesophageal adenocarcinoma among individuals born preterm or small for gestational age

BACKGROUND

Gastroesophageal reflux is a main risk factor for oesophageal adenocarcinoma (EAC). Infants born preterm or small for gestational age (SGA) regurgitate more than infants born at term, and some data support the hypothesis of an association with oesophagitis, Barrett's oesophagus and EAC. This study aimed to assess the association between risk of EAC and preterm or SGA birth.

METHODS

In this population-based case-control study, all incident cases of EAC in Sweden between 1st January 1998 and 31st December 2004 with retrievable birth records were eligible as cases. We sampled three matched controls per case from the birth ledger at the same delivery ward as the respective case. Data on gestational age, birth weight and other perinatal exposures were extracted from the original birth records. For comparison, we collected perinatal data for cases of cardia adenocarcinoma and oesophageal squamous cell carcinoma and controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The risk of EAC increased by 13% per week of shorter duration of gestation (OR 1.1, 95%CI 1.0-1.3), while SGA did not influence the risk. No effect of preterm birth or SGA was found on the risk of cardia adenocarcinoma or oesophageal squamous cell carcinoma.

CONCLUSION

Preterm birth, but not SGA, might lead to an increased risk of EAC as an adult.