and HBeAg(-) patients - World Journal of Gastroenterology

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Online Submissions: http://www.wjgnet.com/1007-9327office wjg@wjgnet.com doi:10.3748/wjg.v17.i6.743 BRIEF ARTICLE Perinatal and early life risk factors for inflammatory bowel disease Stephen E Roberts, Clare J Wotton, John G Williams, Myfanwy Griffith, Michael J Goldacre Stephen E Roberts, John G Williams, College of Medicine, Swansea University, Swansea SA2 8PP, United Kingdom Clare J Wotton, Myfanwy Griffith, Michael J Goldacre, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford OX3 7LF, United Kingdom Author contributions: Goldacre MJ and Roberts SE designed the study; Roberts SE and Goldacre MJ reviewed the literature; Wotton CJ and Griffith M undertook the analyses; Roberts SE, Goldacre MJ and Williams JG interpreted the study findings and wrote the manuscript. Supported by (in part) National Institute for Health Research, England, Grant No. NCCRCD ZRC/002/002/026 Correspondence to: Michael J Goldacre, Professor, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road, Oxford OX3 7LF, United Kingdom. michael.goldacre@dphpc.ox.ac.uk Telephone: +44-1865-289377 Fax: +44-1865-289379 Received: July 10, 2010 Revised: August 16, 2010 Accepted: August 23, 2010 Published online: February 14, 2011 Abstract AIM: To investigate associations between perinatal risk factors and subsequent inflammatory bowel disease (IBD) in children and young adults. METHODS: Record linked abstracts of birth registrations, maternity, day case and inpatient admissions in a defined population of southern England. Investigation of 20 perinatal factors relating to the maternity or the birth: maternal age, Crohn’s disease (CD) or ulcerative colitis (UC) in the mother, maternal social class, marital status, smoking in pregnancy, ABO blood group and rhesus status, pre-eclampsia, parity, the infant’s presentation at birth, caesarean delivery, forceps delivery, sex, number of babies delivered, gestational age, birthweight, head circumference, breastfeeding and Apgar scores at one and five minutes. RESULTS: Maternity records were present for 180 children who subsequently developed IBD. Univariate WJG|www.wjgnet.com 743 World J Gastroenterol 2011 February 14; 17(6): 743-749 ISSN 1007-9327 (print) ISSN 2219-2840 (online) © 2011 Baishideng. All rights reserved. analysis showed increased risks of CD among children of mothers with CD (P = 0.011, based on two cases of CD in both mother and child) and children of mothers who smoked during pregnancy. Multivariate analysis confirmed increased risks of CD among children of mothers who smoked (odds ratio = 2.04, 95% CI = 1.06-3.92) and for older mothers aged 35+ years (4.81, 2.32-9.98). Multivariate analysis showed that there were no significant associations between CD and 17 other perinatal risk factors investigated. It also showed that, for UC, there were no significant associations with the perinatal factors studied. CONCLUSION: This study shows an association between CD in mother and child; and elevated risks of CD in children of older mothers and of mothers who smoked. © 2011 Baishideng. All rights reserved. Key words: Crohn’s disease; Ulcerative colitis; Perinatal risk factors; Record linkage Peer reviewer: Wojciech Blonski, MD, PhD, University of Pennsylvania, GI Research-Ground Centrex, 3400 Spruce St, Philadelphia, PA 19104, United States Roberts SE, Wotton CJ, Williams JG, Griffith M, Goldacre MJ. Perinatal and early life risk factors for inflammatory bowel disease. World J Gastroenterol 2011; 17(6): 743-749 Available from: URL: http://www.wjgnet.com/1007-9327/full/v17/i6/ 743.htm DOI: http://dx.doi.org/10.3748/wjg.v17.i6.743 INTRODUCTION Both Crohn’s disease (CD) and ulcerative colitis (UC) are considered to be immune-mediated disorders, although the exact pathogenetic mechanisms are not yet clear. It is thought that a combination of environmental factors in genetically susceptible people lead to disordered im- February 14, 2011|Volume 17|Issue 6|
Roberts SE et al . Perinatal factors and inflammatory bowel disease munity and chronic inflammation. Over the last 50 years, there have been large increases in the incidence of CD and UC in the UK, in other western countries [1-3] , and more recent increases in Asia [4] , which indicate changes over time in the environmental factors that can lead to inflammatory bowel disease (IBD). In recent decades, there have been changes in the management of births, including large increases in caesarean deliveries, advances in neonatal medicine and substantial reductions in neonatal mortality. As perinatal risk factors have been associated with some immune-mediated diseases including asthma [5-7] and type 1 diabetes [8-10] , perinatal risk factors and early life events may be relevant to other immune-mediated diseases, including IBD. One case-control study identified that infectious and non-infectious perinatal health events were linked with 40% of all cases of IBD in the study group [11] . A systematic review and meta analysis of 17 (mainly case-control) studies found a small but significant protective effect of breastfeeding against both CD and UC [12] . However, its authors commented that this finding was far from conclusive, and advocated the need for larger studies. There have been relatively few studies of other perinatal risk factors and IBD. The aim of this study was to investigate associations between 20 perinatal risk factors and the subsequent development of IBD in children and young adults in a large geographically defined population of South East England. These perinatal risk factors include nine maternal characteristics, such as maternal age, parity, smoking during pregnancy, ABO blood group and social class, and 11 neonatal characteristics, including birthweight, gestational age, head circumference, breastfeeding and Apgar scores. MATERIALS AND METHODS Ethical approval for analysis of the record linkage study data was obtained from the Central and South Bristol Multi- Centre Research Ethics Committee (04/Q2006/176). We used the Oxford record linkage study (ORLS). The ORLS comprises abstracts of records of birth registrations, maternities, day cases and inpatient admissions in a defined geographical region of South East England around Oxford. The maternity data covered all National Health Service (NHS) hospitals in two health districts of the ORLS over the 20-year period from 1970 to 1989. The maternity data are linked to data on all inpatient and day case care for all clinical specialties in the ORLS up to 1999, in two health districts of the ORLS from 1970 to 1999 (population 0.9 million) and a further four adjacent districts (total population 1.9 million) from 1975 to 1999. We used the record linked data to identify cases of subsequent IBD in the children covered by the maternity data. We also used the linked data to identify records of IBD in the mothers, before and after childbirth. The original data comprising the ORLS were abstracted from hospital records by staff who were specifically trained for this purpose by senior clinicians. We excluded maternity records in the ORLS for 985 abortions, 1560 stillbirths and 1567 early deaths that oc- WJG|www.wjgnet.com curred within 30 d of birth. We also excluded 289 births in which the birthweight was recorded as < 1000 g, because most of these records had implausibly low values and/or substantial missing data for many of the perinatal risk factors that we were investigating. None of these excluded babies were subsequently identified as having IBD. After applying these exclusion criteria, a total of 248 659 births remained in the study. Cases of CD and UC among offspring and mothers were identified using the following ICD codes on inpatient or day case records: 563.0 and 563.1 for CD and UC, respectively (in the ICD-8th revision), 555 and 556 (ICD-9) and K50 and K51 (ICD-10), when recorded in any diagnostic position on the hospital record. There were 114 and 66 children with both a maternity record and a subsequent admission for CD or UC, respectively. We compared 20 perinatal factors studied in these cases with those in the other 248 479 children without a record of inpatient admission or day case care for CD or UC. Parity was defined as the pregnant woman’s number of previous live and still births, as recorded on the ORLS maternity record. The length of “follow-up” for offspring ranged from 30 years for those born in 1970 to 10 years for those born in 1989, with an average followup of 18 years. Statistical methods used included the chi-square test with Yates’ correction, odds ratios (ORs) and their 95% CI, and multivariate logistic regression. Statistical significance was accepted at the conventional 5% level. When using logistic regression, all perinatal risk factors that were significant (P < 0.05) in the univariate analysis were included in an initial model. Each of the factors that were not significant in the univariate analysis were then re-entered, one at a time, into the regression model. This approach was taken to test whether any perinatal factor that was not significant in the initial univariate analysis, became significant when assessed simultaneously with other significant factors in the multivariate analysis. Cases with missing data for the perinatal risk factors were excluded only for those risk terms that were included in the logistic regression model. Year of birth was routinely included in all of the models, as a potential confounder, because of the different periods of follow-up after different years of birth. RESULTS For the 114 and 66 children identified with CD and UC respectively, the age at first admission (mean ± SD) was 17.5 ± 5.1 years and 17.7 ± 6.0 years. Approximately half of the cases of both CD and UC had a first recorded admission in early adulthood (when aged 18 to 30 years) rather than in childhood (Table 1). A majority of cases were female; 59 (52%) for CD and 37 (56%) for UC. CD Considering risk factors relating to the maternity, in univariate analysis there was a significant association (P = 744 February 14, 2011|Volume 17|Issue 6|
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Robert JL Fraser, Daw Park Jacob Ge
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Italy Donato F Altomare, Bari Piero
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S Contents EDITORIAL REVIEW ORIGINA
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Contents ACKNOWLEDGMENTS APPENDIX A
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Jahn KA et al . Colon cancer and li
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Zhang XQ et al . EEA model of guine
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Zhao R et al . Gene expression anal
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Qiu HB et al . HBV infection and li
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