Short-term and long-term revision rates after lumbar spine discectomy versus laminectomy: a population-based cohort study.

BACKGROUND/OBJECTIVE: Degenerative diseases of the lumbar spine were managed with discectomy or laminectomy. This study aimed to compare these two surgical treatments in the postoperative revision rates. DESIGN: A population-based cohort study from analysis of a healthcare database. SETTING: Data were gathered from the Taiwan National Health Insurance Research Database (NHIRD). PARTICIPANTS: We enrolled 16 048 patients (4450 women and 11 598 men) with a mean age of 40.34 years who underwent lumbar discectomy or laminectomy for the first time between 1 January 1997 and 31 December 2007. All patients were followed up for 5 years or until death. RESULTS: Revision rate within 3 months of the index surgery was significantly higher in patients who underwent discectomy (2.75%) than in those who underwent laminectomy (1.18%; p<0.0001). This difference persisted over the first year following the index surgery (3.38% vs 2.57%). One year afterwards, the revision rates were similar between the discectomy (9.75%) and laminectomy (9.69%) groups. The final spinal fusion surgery rates were also similar between the groups (11.25% vs 12.08%). CONCLUSION: The revision rate after lumbar discectomy was higher than that after laminectomy within 1 year of the index surgery. However, differences were not identified between patient groups for the two procedures with respect to long-term revision rates and the proportion of patients who required final spinal fusion surgery.

One-year mortality and Periprosthetic infection rates after Total knee Arthroplasty in Cancer patients: a population-based cohort study.

BACKGROUND: Knowledge on periprosthetic infection and mortality rate following total knee arthroplasty (TKA) is essential for justifying this treatment in patients with cancer; however, relevant data from population-based studies are lacking. Therefore, we examined 1-year periprosthetic infection, mortality, and 5-year relative survival rates in cancer patients who underwent TKA. METHODS: This is a population-based cohort study based on analysis of the Taiwan National Health Insurance Research Database. We enrolled a total of 2294 cancer patients and 131,849 patients without cancer (control group) who underwent TKA between January 1, 1997, and December 31, 2011. All patients were followed until death, infection, withdrawal from the National Health Insurance, or December 31, 2012. RESULTS: The periprosthetic knee joint infection rate in cancer patients (1.73%) was not significantly higher than that in the control group (1.87%). However, the 1-year mortality rate was significantly higher (p < 0.05) in the cancer group (4.10%) than in the control group (1.66%). The overall 5-year survival rate was 93.10% as compared with those without cancers. CONCLUSION: Low periprosthetic knee joint infection rates and high 5-year relative survival rates indicate the feasibility of TKA in cancer patients. However, the surgeon should take into account a higher mortality rate in the first year following TKA.

Use of corticosteroids is not associated with repeated vertebroplasty or kyphoplasty within one year after the surgery in patient older than 50 years.

OBJECTIVE: The aim of this study was to investigate whether corticosteroid use increases the incidence of repeated PVP or kyphoplasty patients older than 50 years. METHODS: This study enrolled the data of 2,753 eligible patients from the Taiwan National Health Insurance Research Database who were exposed to systemic corticosteroids for at least 3 months during the first year preceding the first PVP or kyphoplasty. These steroid users were matched 1:1 in age, sex, and the index date of surgery with non-user controls during the enrollment period. All patients were followed for 1 year after the first PVP or kyphoplasty. The incidence of repeated PVP or kyphoplasty was compared between the steroid users and controls. A Cox proportional hazards model was developed to account for multiple confounding factors. RESULTS: The number of patients receiving repeated PVP or kyphoplasty was 233 (8.46%) and 205 (7.45%) in the corticosteroid and control groups, respectively. The Cox proportional hazards model revealed no association between corticosteroid use and repeated PVP or kyphoplasty. CONCLUSIONS: Systemic corticosteroid use for longer than 3 months is not associated with repeated PVP or kyphoplasty within one year of surgery in patient older than 50 years old. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Risk of infection following colonoscopy and sigmoidoscopy in symptomatic patients.

Background and study aims Previous studies describing the incidence of infection after colonoscopy and sigmoidoscopy are limited. The aim of this study was to determine the incidence of infection, and to propose a nomogram to predict the probability of infection following colonoscopy and sigmoidoscopy in symptomatic patients. Patients and methods A nationwide retrospective study was conducted by analyzing the National Health Insurance Research Database of Taiwan. The incidence of infection within 30 days after colonoscopy and sigmoidoscopy was assessed and compared with a control group matched at a ratio of 1:1 based on age, sex, and the date of examination. Results In all, 112 543 patients who underwent colonoscopy or sigmoidoscopy and 112 543 matched patients who did not undergo these procedures were included. The overall incidence of infection within 30 days after colonoscopy and sigmoidoscopy was 0.37 %, which was significantly higher than that of the control group (0.04 %; P < 0.001). Diverticulitis, peritonitis, and appendicitis were the most common infections. Patients who underwent colonoscopy or sigmoidoscopy had a 9.38-fold risk of infection (95 % confidence interval, 6.81 - 12.93; P < 0.001) compared with the control group. The predicted infection-free rates of the nomogram were closely aligned with the actual infection-free rates, with a bootstrapping concordance index of 0.763. Conclusions Colonoscopy and sigmoidoscopy are associated with an increased risk of infection, which may occur after these procedures. Our nomogram may provide clinicians with an easy tool to evaluate the risk of infection after colonoscopy and sigmoidoscopy in symptomatic patients.

Gastric microbiota and predicted gene functions are altered after subtotal gastrectomy in patients with gastric cancer.

Subtotal gastrectomy (i.e., partial removal of the stomach), a surgical treatment for early-stage distal gastric cancer, is usually accompanied by highly selective vagotomy and Billroth II reconstruction, leading to dramatic changes in the gastric environment. Based on accumulating evidence of a strong link between human gut microbiota and host health, a 2-year follow-up study was conducted to characterize the effects of subtotal gastrectomy. Gastric microbiota and predicted gene functions inferred from 16S rRNA gene sequencing were analyzed before and after surgery. The results demonstrated that gastric microbiota is significantly more diverse after surgery. Ralstonia and Helicobacter were the top two genera of discriminant abundance in the cancerous stomach before surgery, while Streptococcus and Prevotella were the two most abundant genera after tumor excision. Furthermore, N-nitrosation genes were prevalent before surgery, whereas bile salt hydrolase, NO and N2O reductase were prevalent afterward. To our knowledge, this is the first report to document changes in gastric microbiota before and after surgical treatment of stomach cancer.

Long term antihypertensive drug use and prostate cancer risk: A 9-year population-based cohort analysis.

BACKGROUND: Recent findings from clinical trials have indicated inconsistent associations between angiotensin II receptor blockers and the risk of cancer incidence. Furthermore, the relationship between antihypertensive drugs and prostate cancer in hypertensive patients remains unclear. METHODS: From Taiwan's national health insurance database, we identified 80,299 patients diagnosed with hypertension in 2001 and matched with 321,916 subjects without hypertension by age, income, urbanization level, and index day. A total of 684 hypertensive patients without antihypertensive drug use (drug non-user subcohort) were also matched (1:4) with 2736 patients on antihypertensive medication (drug subcohort) using the same criteria. Each subject in the two study groups was followed up for a maximum of nine years, during which death was considered a competing event when performing the stratified Fine and Gray regression hazards model for the estimation of prostate cancer risk for the cohorts. Uptake of antihypertensive prescription was considered a time-dependent variable. RESULTS: Our findings indicate that patients with hypertension are at significantly increased risk for prostate cancer incidence when compared to their matched non-hypertensive counterparts (sHR=6.80, 95% CI=1.97-23.44, p=0.0024). Among hypertensive patients, those with long term antihypertensive drug use are not at elevated risk of developing prostate cancer relative to non-users of antihypertensive drugs (1-5 year vs. non-user sHR=0.99, 95% CI=0.32-3.05; >5 year vs. non-user sHR=0.88, 95% CI=0.34-2.26). CONCLUSIONS: Hypertension is considered a risk factor for prostate cancer. However, long term uptake of antihypertensive medication in male hypertensive patients should not be a concern for the development of prostate cancer.

A tool to predict risk for gastric cancer in patients with peptic ulcer disease on the basis of a nationwide cohort.

BACKGROUND & AIMS: Patients with gastric ulcers have significantly higher risk of gastric cancer, especially within 2 years after diagnosis. We used data from a national database to develop a personalized risk prediction model for patients with peptic ulcer diseases. METHODS: We collected data from Taiwan's National Health Insurance Research Database on 278,898 patients admitted for the first time with a primary diagnosis of peptic ulcer disease. We used the data to develop a nomogram, which we validated by discrimination and calibration, and in a test cohort. Cumulative incidences of study subjects predicted by the nomogram were examined. RESULTS: In total, 1269 subjects developed gastric cancer. Age, sex, peptic ulcer sites, peptic ulcer complications, Helicobacter pylori eradication, nonsteroidal anti-inflammatory drug use, and surveillance endoscopy were independent factors associated with risk of gastric cancer (all P < .001). The concordance index for the nomogram developed on the basis of these factors was 0.78. Study subjects were divided into quartiles of predicted risk scores; from lowest score quartile to highest, cumulative incidences at 1 year were 7.4/10,000 people, 14.2/10,000 people, 25.5/10,000 people, and 86.6/10,000 people. The cumulative incidences at 2 years were 9.3/10,000 people, 20.9/10,000 people, 38.0/10,000 people, and 135.7/10,000 people for the same quartiles of risk scores. The nomogram was validated in an independent cohort, and similar incidence values were determined. CONCLUSIONS: We developed and validated a nomogram to predict risk for gastric cancer 1 and 2 years after diagnosis of peptic ulcer disease. The nomogram provides a prognostic tool that can be easily used for individuals and can help physicians explain risk levels to patients.

The risk of cancer in patients with psoriasis: a population-based cohort study in Taiwan.

BACKGROUND: An association between psoriasis and malignancy has been explored. However, no studies have been reported regarding cancer risk in Asian psoriasis populations. OBJECTIVES: The aim of this study was to investigate the risk of cancer development in association with psoriasis. The effects of age at diagnosis, treatment modalities, and observation time were also evaluated. METHODS: Data for this retrospective population-based cohort study were obtained from the Taiwan National Health Insurance Research Database (NHIRD). This study included 3,686 patients with first-time diagnosis of psoriasis between 1996 and 2000. Another 200,000 patients without psoriasis served as the comparison group. All enrolled subjects were followed-up until the end of 2007. Cumulative incidences and hazard ratios (HRs) of cancer development were determined. RESULTS: Among the 3,686 psoriasis patients, 116 had incident cancers. The 7-year cumulative incidence of cancer among psoriasis patients was 4.8%. The adjusted HR for developing a cancer in association with psoriasis was 1.66 (95% confidence interval [CI], 1.38-2.00). Cancer risk was higher in male patients than in female patients (adjusted HR 1.86 vs.1.14, respectively). Certain cancers were significantly associated with psoriasis, including those of the urinary bladder and skin, followed by oropharynx/larynx, liver/gallbladder, and colon/rectum. Patients with psoriasis had an increased adjusted HR for cancer that varied by age. Younger patients with psoriasis tended to have the greatest risk of cancer. Finally, systemic phototherapy and oral medication did not significantly increase the risk of cancer. Phototherapy with UVB appeared to reduce the risk of cancer in psoriasis (adjusted HR, 0.52; 95% CI, 0.29-0.95; P = .03). LIMITATIONS: NHIRD did not contain information regarding severity of psoriasis, status of smoking, alcohol use, family history of cancer, or diet. Misclassification of disease cannot be ruled out in a registry-based database. CONCLUSIONS: Psoriasis carries an elevated risk of malignancies, especially in younger and in male patients. This effect is independent of systemic treatment for psoriasis. Finally, phototherapy with UVB did not increase, but rather reduced, the risk of cancer in psoriasis.

The risk of cancer in patients with rheumatoid arthritis: a nationwide cohort study in Taiwan.

OBJECTIVE: The association of rheumatoid arthritis (RA) and malignancy has rarely been explored in Asian populations. The aim of this study was to investigate the relative risk of cancer in Taiwanese patients with RA and to identify groups of patients with a high risk of cancer. METHODS: We conducted a nationwide cohort study of the risk of cancer among 23,644 patients with RA who had no history of malignancies, using the National Health Insurance database of Taiwan from 1996 to 2007. Standardized incidence ratios (SIRs) for various cancers were analyzed. RESULTS: Among the patients with RA, 935 cancers were observed. Patients with RA had an increased risk of cancer (SIR 1.23, 95% confidence interval [95% CI] 1.22-1.23), especially hematologic cancers (SIR 2.74, 95% CI 2.68-2.81). The relative risk of cancer was higher among younger patients. Most cancer cases were detected within the first year following the diagnosis of RA. The relative risk of cancer decreased as the duration of observation increased. Among hematologic cancers, the risk of non-Hodgkin's lymphoma was greatest (SIR 3.54, 95% CI 3.45-3.63). Among solid tumors, the risk of cancers of the kidney and vagina/vulva was highest. A decreased risk of cancers of the cervix and nonmelanoma skin cancer in patients with RA was also observed. CONCLUSION: Patients with RA have an increased risk of cancer, especially hematologic and kidney cancers. The relative risk of cancer in patients with RA decreased with long-term followup. Cancer screening with continued vigilance is recommended for patients with RA.

Malignancy in systemic lupus erythematosus: a nationwide cohort study in Taiwan.

BACKGROUND: an increased risk of malignancy in patients with systemic lupus erythematosus has been reported, but rarely in Asian populations. We aimed to investigate the relative risk of cancer and to identify the high-risk group for cancer in patients with lupus. METHODS: we conducted a retrospective, nationwide cohort study that included 11,763 patients with lupus without a history of malignancies, using the national health insurance database of Taiwan from 1996 to 2007. Standardized incidence ratios (SIRs) of cancers were analyzed. RESULTS: a total of 259 cancers were observed in patients with lupus. An elevated risk of cancer among those with systemic lupus erythematosus was noted (SIR 1.76; 95% confidence interval [CI] 1.74-1.79), especially for hematologic malignancies (SIR 4.96; 95% CI 4.79-5.14). Younger patients had a greater risk ratio of cancer than the general population, and the risk ratio decreased with age. The risk ratio of cancer decreased with time, yet remained elevated compared with that of the general population. The risk of non-Hodgkin lymphoma was greatest (SIR 7.27) among hematologic cancers. Among solid tumors, the risk was greatest for cancers of the vagina/vulva (SIR 4.76), nasopharynx (SIR 4.18), and kidney (SIR 3.99). An elevated risk for less common cancers, including those of the brain, oropharynx, and thyroid glands, was also observed. CONCLUSION: patients with lupus are at increased risk of cancers and should receive age- and gender-appropriate malignancy evaluations, with additional assessment for vulva/vagina, kidney, nasopharynx, and hematologic malignancy. Continued vigilance for development of cancers in follow-up is recommended.

Effective reduction of gastric cancer risk with regular use of nonsteroidal anti-inflammatory drugs in Helicobacter pylori-infected patients.

PURPOSE: Nonsteroidal anti-inflammatory drugs (NSAIDs) play protective roles in gastric carcinogenesis. However, the interaction between NSAIDs and Helicobacter pylori (H pylori) infection and the number needed to treat to prevent gastric cancer remains unclear. PATIENTS AND METHODS: We conducted a nationwide retrospective cohort study based on data from the Taiwan National Health Insurance Database. Hospitalized patients with a primary diagnosis of peptic ulcer disease were selected. Overall, 52,161 patients were divided into non-NSAID user and regular NSAID user cohorts. Standardized incidence ratios (SIRs), cumulative incidences, and hazard ratios (HRs) were calculated. RESULTS: Patients with peptic ulcers who never used NSAIDs had higher risk of gastric cancer compared with the general population (SIR, 2.11; 95% CI, 2.07 to 2.15), but regular NSAID use conferred lower risk (SIR, 0.79; 95% CI, 0.77 to 0.81). The protective role of NSAID use was observed in patients with gastric ulcer, but not in patients with non-H pylori-associated duodenal ulcer. On multivariate analysis, regular NSAID use was an independent protective factor for gastric cancer development (HR, 0.79 for each incremental year; P < .001), especially in H pylori-associated patients (HR, 0.52 for each incremental year; P < .001). Among patients with H pylori-infected gastric ulcers, the NNT to prevent a gastric cancer was 50. CONCLUSION: Regular NSAID use may be a feasible way to prevent gastric cancer, at least in patients with gastric ulcers, and especially in H pylori-infected subjects.

Cancer risks of dermatomyositis and polymyositis: a nationwide cohort study in Taiwan.

INTRODUCTION: The association of idiopathic inflammatory myositis (IIM) and malignancies has been reported, but rarely in Asian countries. Our aim was to investigate the risk of cancer among IIM patients without a prior history of malignancies, in Taiwan. METHODS: We conducted a nationwide cohort study of 1,012 patients with dermatomyositis (DM) and 643 patients with polymyositis (PM), but without prior history of malignancies, utilizing the National Health Insurance Database from 1997 to 2007. Standardized incidence ratios (SIRs) of cancers were analyzed. RESULTS: A total of 95 cancers (9.4%) in DM and 33 cancers (4.4%) in PM were identified. Overall cancer risk was significantly elevated in DM patients (SIR = 5.11, 95% confidence interval [CI] = 5.01 to 5.22) and PM patients (SIR = 2.15, 95% CI = 2.08 to 2.22). Most cancers were detected in the first year of observation. The risk of cancer decreased with observation time, yet remained elevated compared with the general population in both study groups after 5 years of follow-up. DM was associated with sustained elevated risk of cancers in every age group, whereas the risk of cancer in PM was highest in younger patients and decreased with age. DM patients were at the greatest risk of cancers of the nasopharynx, lungs and hematopoietic malignancies. CONCLUSIONS: Patients with IIM are at increased risk for cancer and should receive age-appropriate and gender-appropriate malignancy evaluations, with additional assessment for nasopharyngeal, lung and hematologic malignancy following diagnosis, and with continued vigilance for development of cancers in follow-up.

Early Helicobacter pylori eradication decreases risk of gastric cancer in patients with peptic ulcer disease.

BACKGROUND & AIMS: Helicobacter pylori (H pylori) is a risk factor for gastric cancer. We investigated whether early H pylori eradication is associated with gastric cancer risk in patients with peptic ulcer diseases. METHODS: This nationwide cohort study was based on the Taiwan National Health Insurance Database (NHID), which provided data on 80,255 patients who were hospitalized for the first time between 1997 and 2004 with a primary diagnosis of peptic ulcer diseases and received H pylori eradication therapy. The patient population was divided into early (within 1 year) and late (after 1 year) eradication cohorts; standardized incidence ratios (SIRs) and hazards ratios (HRs) were determined. RESULTS: There was no significant difference in gastric cancer risk between patients who received early H pylori eradication and the general population (SIR, 1.05; 95% confidence interval [CI]: 0.96-1.14), but late eradication was associated with an increased risk (SIR, 1.36; 95% CI: 1.24-1.49). In gastric ulcer patients who received early eradication, SIRs of gastric cancer decreased from 1.60 at 3-4 years to 1.05 at 7-10 years after hospitalization; the SIRs decreased from 0.57 to 0.33 for duodenal ulcer patients over the same period. Among patients who received late eradication, SIRs decreased from 2.14 to 1.32 for those with gastric ulcers and from 0.90 to 0.66 for those with duodenal ulcers. Early H pylori eradication (HR, 0.77) and frequent aspirin or nonsteroidal anti-inflammatory drug use (HR, 0.65) were independent protective factors for gastric cancer. CONCLUSIONS: Early H pylori eradication is associated with decreased risk of gastric cancer in patients with peptic ulcer diseases.