Elevated risk of cervical cancer in elderly women with incident ulcerative colitis in South Korea.

The association between ulcerative colitis (UC) and uterine cervical cancer is still unclear. To investigate cervical cancer risk in South Korean women with UC, we analyzed the Korean National Health Insurance claims data. UC was defined using both ICD-10 codes and UC-specific prescriptions. We analyzed incident cases of UC diagnosed between 2006 and 2015. Age-matched women without UC (control group) were randomly selected from the general population (1:3 ratio). Hazard ratios were calculated using multivariate Cox proportional hazard regression, and the event was defined as occurrence of cervical cancer. A total of 12,632 women with UC and 36,797 women without UC were enrolled. The incidence of cervical cancer was 38.8 per 100,000 women per year in UC patients and 25.7 per 100,000 women per year in controls, respectively. The adjusted HR for cervical cancer was 1.56 (95% CI 0.97-2.50) in the UC group with reference to the control group. When stratified by age, the adjusted HR for cervical cancer was 3.65 (95% CI 1.54-8.66) in elderly UC patients (≥ 60 years) compared to elderly control group (≥ 60 years). Within UC patients, increased age (≥ 40 years) and low socioeconomic status were associated with an increased risk of cervical cancer. The incidence of cervical cancer was found to be higher among elderly patients (≥ 60 years) with newly diagnosed UC in South Korea, compared to age-matched controls. Therefore, regular cervical cancer screening is recommended for elderly patients who have recently been diagnosed with UC.

Risk of Gastric Cancer among Patients with Newly Diagnosed Ulcerative Colitis: A Nationwide Population-Based Study.

BACKGROUND: Few studies have investigated the risk of gastric cancer (GC) in ulcerative colitis (UC), and the results have been inconsistent. This study aimed to assess the risk of gastric cancer in newly diagnosed UC patients. METHODS: Based on claims data from Korean National Health Insurance from January 2006 to December 2015, we identified 30,546 patients with UC and randomly selected 88,829 non-UC individuals as controls, who were matched by age and sex. Multivariate Cox proportional hazards regression was used to calculate adjusted hazard ratios (HRs) for gastric cancer events, with covariates taken into account. RESULTS: During the study period, a total of 77 (0.25%) patients with UC and 383 (0.43%) non-UC individuals were diagnosed with GC. After multivariable adjustment, the HR for GC was 0.60 (95% CI: 0.47-0.77) in patients with UC, using non-UC individuals as the reference group. When stratified by age, the adjusted HRs for GC in UC patients were 0.19 (95% CI: 0.04-0.98) for those aged 20-39 years at the time of UC diagnosis, 0.65 (95% CI: 0.45-0.94) for 40-59, and 0.60 (95% CI: 0.49-0.80) for ≥60 as compared to non-UC individuals in the corresponding age groups. When stratified by sex, the adjusted HR for GC was 0.54 (95% CI: 0.41-0.73) in male UC patients of all ages. Within UC patients, a multivariable analysis revealed that the HR for GC was 12.34 (95% CI: 2.23-68.16) for those aged ≥ 60 years at the time of diagnosis of UC. CONCLUSIONS: Patients with UC had a decreased GC risk compared with non-UC individuals in South Korea. Within the UC population, advancing age (≥60 years) was identified as a significant risk factor for GC.

Venous Thromboembolism Risk in Asian Patients with Inflammatory Bowel Disease: A Population-Based Nationwide Inception Cohort Study.

Background/Aims: Inflammatory bowel disease (IBD) is associated with the occurrence of venous thromboembolism (VTE). However, to date, there have been few studies on the risk of VTE in Asian IBD patients. We aimed to estimate the incidence of VTE in Asian IBD patients and to determine if IBD is related to increased VTE risk. Methods: We performed a population-based cohort study between 2004 and 2015 using Korean National Health Insurance data. IBD and VTE were defined by ICD-10 codes. Incidence rates of VTE were calculated among patients with IBD and among age- and sex-matched controls. Hazard ratios were estimated using Cox regression with adjustment for multiple variables. We performed additional analyses stratifying by age, sex, Charlson comorbidity index (CCI) score, and disease type. Results: Among the 45,037 patients with IBD (IBD cohort) and 133,019 matched controls (non-IBD cohort) included in our analysis, 411 IBD patients and 641 controls developed VTE. The IBD cohort had a higher incidence rate ratio and risk of VTE than the non-IBD cohort (incidence rate ratio: 1.92 and hazard ratio: 1.93). Older age, female sex, higher CCI scores, cardiovascular disease, chronic kidney disease, use of steroids, and hospitalization were significant risk factors for VTE in patients with IBD. Conclusions: The IBD patients in this study were approximately two times more likely to develop VTE than the non-IBD individuals. Our findings support the need for thromboprophylaxis in Asian IBD patients with various factors that further increase the risk of VTE.

Incident Crohn's Disease as a Risk Factor for Colorectal Cancer in the First 10 Years after Diagnosis: A Nationwide Population-Based Study.

We investigated the risk of colorectal cancer (CRC) in patients with Crohn's disease (CD) using the claims data of the Korean National Health Insurance during 2006-2015. The data of 13,739 and 40,495 individuals with and without CD, respectively, were analyzed. Hazard ratios (HRs) were calculated using multivariate Cox proportional hazard regression tests. CRC developed in 25 patients (0.18%) and 42 patients (0.1%) of the CD and non-CD groups, respectively. The HR of CRC in the CD group was 2.07 (95% confidence interval (CI), 1.25-3.41). The HRs of CRC among men and women were 2.02 (95% CI 1.06-3.87) and 2.10 (95% CI, 0.96-4.62), respectively. The HRs of CRC in the age groups 0-19, 20-39, 40-59, and ≥60 years were 0.07, 4.86, 2.32, and 0.66, respectively. The HR of patients with late-onset CD (≥40 years) was significantly higher than that of those with early-onset CD (<40 years). CD patients were highly likely to develop CRC. Early-onset CD patients were significantly associated with an increased risk of CRC than matched individuals without CD. However, among CD patients, late-onset CD was significantly associated with an increased risk of CRC.

Medications and the Risk of Colorectal Cancer in Patients with Inflammatory Bowel Diseases: Use of the Landmark Method.

PURPOSE: This study aimed to determine whether the use of drugs in the treatment of inflammatory bowel disease is related to the risk of colorectal cancer using a Cox proportional hazards model with the landmark method to minimize immortal time bias. MATERIALS AND METHODS: This study was conducted as national cohort-based study using data from Korea's Health Insurance Corporation. Newly diagnosed patients with inflammatory bowel disease from 2006 to 2010 were monitored for colorectal cancer until 2015. Hazard ratios and 95% confidence intervals were calculated and compared with the incidence of colorectal cancer with or without medications by applying various landmark points. RESULTS: In patients with Crohn's disease, the prevention of colorectal cancer in the group exposed to immunomodulators was significant in the basic Cox model; however, the effect was not statistically significant in the model using the landmark method. The preventive effect of 5-aminosalicylic acid in patients with ulcerative colitis was significant in the basic and 6-month landmark point application models, but not in the remaining landmark application models. CONCLUSION: In patients with inflammatory bowel disease, the preventive effect of drug exposure on colorectal cancer varies depending on the application of the landmark method. Hence, the possibility of immortal time bias should be considered.

Age- and sex-specific risk of colorectal cancer in incident ulcerative colitis during the first 10 years after diagnosis: a nationwide population-based study.

OBJECTIVE: We assessed the risk of colorectal cancer (CRC) in patients with ulcerative colitis (UC) using the nationwide population-based claims data. MATERIALS AND METHODS: We analyzed the claims data of the Korean National Health Insurance (2006-2015). UC and CRC were defined using ICD-10 codes and UC-specific prescriptions in this study. Age- and sex-matched individuals without UC were randomly selected from the general population. Hazard ratios (HRs), adjusted for different covariates, were calculated using multivariate Cox proportional hazard regression. RESULTS: In total, 30,546 and 88,829 individuals with and without UC, respectively, were enrolled. CRC developed in 85 (0.27%) among UC, and 340 (0.38%) among individuals without UC, respectively. The HR (95% confidence interval [CI]) of CRC in all UC patients was 0.74 (0.58-0.94). Further, UC patients were stratified according to sex (male vs. female: 0.60 [0.44-0.82] vs. 1.10 [0.75-1.61]) and age (HR = 14.37, 2.74, 0.58, and 0.70 for 0-19, 20-39, 40-59, and ≥60 years, respectively). HR was significantly higher for late-onset UC (≥60 years) than for early-onset UC (0-19 years). The long duration of 5-aminosalicylic acid use had a significantly low HR, with reference to the 1st quartile. CONCLUSIONS: The risk of CRC varies with age and sex in Korean patients with UC during the first decade after diagnosis. Early-onset UC (<40 years) increases the CRC risk.

Descriptive Epidemiology and Survival Analysis of Prolactinomas and Cushing's Disease in Korea.

BACKGROUND: Only a few studies have established the epidemiology of prolactinoma and Cushing's disease in Korea. Furthermore, the incidence of these disease are increasing than before associated with the development of technologies. This study was designed to evaluate the epidemiology of prolactinoma and Cushing's disease and their survival analysis according to treatment. METHODS: The nationwide, population-based study evaluated incidence and prevalence of prolactinoma and Cushing's disease using de-identified claims data in The Korean Health Insurance Review and Assessment Service database between 2013 and 2017. The survival analysis investigated regarding treatment over a period of 6 years. A log-rank test and Cox proportional hazard regression analysis were used. RESULTS: The 6,056 patients with newly diagnosed prolactinoma and 584 patients with Cushing's disease were recorded between 2013 and 2017. The annual incidence of prolactinoma was 23.5 cases per million, and its prevalence was 82.5 cases per million, and 2.3 cases per million/year and 9.8 cases per million for Cushing's disease. The survival benefit was insignificant in prolactinoma according to treatment, but treatment of Cushing's disease ameliorated the survival rate significantly. CONCLUSION: Overall, the incidence of prolactinoma and Cushing's disease was similar with those found previously, but the prevalence of two diseases were inconsistent when compared with the early studies. The present study also proposed necessity of treatment in Cushing's disease for improving the survival rate.

Descriptive Epidemiology and Survival Analysis of Acromegaly in Korea.

BACKGROUND: Acromegaly is a rare, slowly progressive disease. Its mechanism is not fully understood, and epidemiological research on Korean patients with acromegaly is scarce. The purpose of this study was to determine the incidence and prevalence of acromegaly and assess the comorbidities and survival benefits based on treatment options. METHODS: This nationwide population-based cohort study was conducted using data of the Korean Health Insurance Review and Assessment claims database to evaluate the incidence of newly diagnosed acromegaly cases during 2013-2017. RESULTS: During the 5-year period, 1,093 patients were newly diagnosed with acromegaly. The average annual incidence was 4.2 cases per million per year, and the prevalence was 32.1 cases per million during this period. The incidence of hypertension was low after medical treatment (hazard ratio, 0.257; 95% confidence interval, 0.082-0.808; P = 0.020), but the incidence of diabetes showed no significant difference across treatment modalities. Over a period of 6 years since diagnosis, we found that patients treated for acromegaly had a significantly higher survival rate than those untreated (P < 0.001). CONCLUSION: The annual incidence rate of Korean patients with acromegaly was similar to that reported in previous studies. Using nationwide population data, our study emphasized the importance of treatment in acromegaly patients.

Colonoscopy Versus Fecal Immunochemical Test for Reducing Colorectal Cancer Risk: A Population-Based Case-Control Study.

INTRODUCTION: Use of colonoscopy or the fecal immunochemical test (FIT) for colorectal cancer (CRC) prevention is supported by previous studies. However, there is little specific evidence regarding comparative effectiveness of colonoscopy or FIT for reducing CRC risk. In this study, we compared the association of CRC risk with colonoscopy and FIT using a nationwide database. METHODS: This population-based case-control study used colonoscopy and FIT claims data from the Korean National Health Insurance System from 2002 to 2013. Data were analyzed from 61,221 patients with newly diagnosed CRC (case group) and 306,099 individuals without CRC (control group). Multivariable logistic regression models were used to evaluate the association between CRC and colonoscopy or FIT. RESULTS: Colonoscopy was associated with a reduced subsequent CRC risk (adjusted odds ratio [OR] 0.29). Stronger associations were found between colonoscopy and distal CRC, compared with proximal CRC (0.24 vs 0.47). In an analysis stratified by sex, the association was weaker in female subjects compared with male subjects (0.33 vs 0.27). Any FIT exposure was associated with CRC risk with an OR of 0.74; this association was stronger for distal cancer. As the frequency of cumulative FIT assessments increased (from 1 to ≥5), the OR of FIT exposure for CRC gradually decreased from 0.81 to 0.45. DISCUSSION: The association of colonoscopy or FIT with reduced CRC risk was stronger for distal CRC than for proximal CRC. FIT showed less CRC risk reduction than colonoscopy. However, as the frequency of cumulative FIT assessments increased, the association with CRC prevention became stronger.

Preliminary Clinical Trial of Balance Compensation System for Improvement of Balance in Patients With Spinocerebellar Ataxia.

OBJECTIVE: To determine the immediate and short-term impact of the application of wearable balance compensation system (BCS) on balance impairment in patients with spinocerebellar ataxia (SCA). METHODS: The study enrolled 6 participants with SCA with varying degrees of balance impairment. After adjustment for individual fitting, wearable BCS with up to 3% body weight was placed in a garment on the trunk. Sway direction and magnitude were measured with sensors placed posteriorly at the lumbosacral junction, immediately before and after, and at day 1, day 2, and day 7 after wearing the BCS. Timed Up & Go test (TUG) and 25-foot timed walk test were performed, and static foot pressure was measured. RESULTS: A significant improvement in static and dynamic balance was found during the 25-foot timed walk and in static foot pressure measurement results after wearing the BCS, when compared with that at baseline (p=0.044 vs. p=0.011). Anterior and posterior sway showed improvements from baseline after wearing the BCS. Improvement in the lateral swaying movement control was also seen. CONCLUSION: Application of the BCS might be beneficial in the improvement ofthe static and dynamic balance in patients with SCA. Further research on long-term effects and with a larger sample size is indicated.

Effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing for patients with pelvic fractures and hemodynamic instability: A propensity score matching analysis.

INTRODUCTION: We evaluated the effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing (PPP) for patients with hemodynamic instability due to severe pelvic fractures. MATERIALS AND METHODS: Between May 2014 and October 2018, 53 of 75 patients who underwent PPP due to hemodynamic instability induced by pelvic fracture were enrolled. Their medical records were prospectively collected and retrospectively analyzed. QuikClot combat gauze (hydrophilic gauze impregnated with kaolin) and general surgical tape were used in 21 patients, while general surgical tape was used in the remaining 32 patients. RESULTS: As there were differences in the characteristics of patients between the hemostatic gauze (HG) group and control group, propensity score matching (PSM) was performed to adjust for age, sex, and lactate levels. After PSM, the clinical characteristics between the two groups became similar. There were no differences in the rates of mortality and hemorrhage-induced mortality between the two groups. However, the packed red blood cell (RBC) requirement for an additional 12 hours in the HG group was significantly lower than that in the control group (4.1 ± 3.5 vs. 7.6 ± 6.1 units, p = 0.035). The lengths of intensive care unit and hospital stays tended to be shorter in the HG group than in the control group (11.6 vs. 18.5 days, p = 0.1582; 30.8 vs. 47.4 days, p = 0.1861, respectively). CONCLUSIONS: The use of HG during PPP did not reduce hemorrhage-induced mortality, but did reduce the need for additional packed RBC transfusions in patients with hemodynamic instability due to severe pelvic fractures.

Correction: Association between the National Cancer Screening Programme (NSCP) for gastric cancer and oesophageal cancer mortality.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Association between the National Cancer Screening Programme (NSCP) for gastric cancer and oesophageal cancer mortality.

BACKGROUND: The aim was to evaluate whether this gastric cancer-screening programme was effective in reducing oesophageal cancer mortality. METHODS: A population-based retrospective cohort study was conducted using the Korean National Cancer Screening Programme (NCSP) database. The study cohort comprised 16,969 oesophageal cancer patients who had been diagnosed in 2007-2014. We analysed the association between the history of NSCP for gastric cancer and oesophageal cancer mortality. RESULTS: Compared with never-screened subjects, ever-screened subjects had an overall HR for oesophageal cancer mortality of 0.647 (95% CI, 0.617-0.679). According to the time interval since screening, the HRs of death were 0.731 (95% CI, 0.667-0.801) for 6-11 months, 0.635 (95% CI, 0.594-0.679) for 12-23 months, 0.564 (95% CI, 0.522-0.610) for 24-35 months and 0.742 (95% CI, 0.679-0.810) for ≥36 months. According to the last screening modality, the HRs of death were 0.497 (95% CI, 0.464-0.531) for upper endoscopy, and 0.792 (95% CI, 0.749-0.838) for UGIS. Upper endoscopy reduced the mortality consistently in all age groups over 50 years, whereas UGIS could not. CONCLUSION: The NCSP for gastric cancer was effective in reducing the mortality of oesophageal cancer, and upper endoscopy was superior to UGIS.

Real-World National Colonoscopy Volume in Korea: A Nationwide Population-Based Study over 12 Years.

Background/Aims: Little is known about the national colonoscopy volume in Asian countries. This study aimed to assess the national colonoscopy volume in Korea over a 12-year period on the basis of a nationwide population-based database. Methods: We conducted a population-based study for colonoscopy claims (14,511,158 colonoscopies performed on 13,219,781 patients) on the basis of the Korean National Health Insurance Service database from 2002 to 2013. The 12-year national colonoscopy burden was analyzed according to patient age, patient sex, and healthcare facility type. Results: The overall volume of colonoscopy increased 8-fold over the 12-year period. The annual colonoscopic polypectomy rate significantly increased in all patient sex and age groups over the 12-years period (all p<0.001). The yearly colonoscopic polypectomy rate for men was significantly increased compared with that for women (2.3% vs 1.7%, p<0.001) and for the screening-age group compared with that for the young-age group (2.0% vs 1.6%, p<0.001). The yearly colonoscopic polypectomy rate relative to the total colonoscopy volume significantly increased in primary, secondary, and tertiary facilities by 2.4%, 1.9%, and 1.4% during the 12-year period (all p<0.001). In addition, the annual colonoscopy volume covered by high-volume facilities significantly increased by 1.8% in primary healthcare facilities over the 12-year period (p<0.001). Conclusions: Healthcare resources should be prioritized to allow adequate colonoscopic capacity, especially for men, individuals in the screening-age group, and at primary healthcare facilities. Cost-effective strategies to improve the quality of colonoscopy may focus on primary healthcare facilities and high-volume facilities in Korea.

Nationwide validation study of diagnostic algorithms for inflammatory bowel disease in Korean National Health Insurance Service database.

BACKGROUND AND AIM: We conducted a nationwide validation study of diagnostic algorithms to identify cases of inflammatory bowel disease (IBD) within the Korea National Health Insurance System (NHIS) database. METHOD: Using the NHIS dataset, we developed 44 algorithms combining the International Classification of Diseases (ICD)-10 codes, codes for Rare and Intractable Diseases (RID) registration and claims data for health care encounters, and pharmaceutical prescriptions for IBD-specific drugs. For each algorithm, we compared the case identification results from electronic medical records data with the gold standard (chart-based diagnosis). A multiple sampling test verified the validation results from the entire study population. RESULTS: A random nationwide sample of 1697 patients (848 potential cases and 849 negative control cases) from 17 hospitals were included for validation. A combination of the ICD-10 code, ≥ 1 claims for health care encounters, and ≥ 1 prescription claims (reference algorithm) achieved excellent performance (sensitivity, 93.1% [95% confidence interval 91-94.7]; specificity, 98.1% [96.9-98.8]; positive predictive value, 97.5% [96.1-98.5]; negative predictive value, 94.5% [92.8-95.8]) with the lowest error rate (4.2% [3.3-5.3]). The multiple sampling test confirmed that the reference algorithm achieves the best performance regarding IBD diagnosis. Algorithms including the RID registration codes exhibited poorer performance compared with that of the reference algorithm, particularly for the diagnosis of patients affiliated with secondary hospitals. The performance of the reference algorithm showed no statistical difference depending on the hospital volume or IBD type, with P-value < 0.05. CONCLUSIONS: We strongly recommend the reference algorithm as a uniform standard operational definition for future studies using the NHIS database.

Complications Following Colonoscopy in a Nationwide Standard Cohort: A Retrospective Case-control Study.

Background/Aims: Despite the many reports of colonoscopy complications worldwide, few studies have been performed at the population level in Korea. In this study, a population-based study was performed to evaluate the incidence of post-colonoscopy perforations compared to a control group. Methods: Between January 2011 and December 2011, data for all cases (age over 45) who underwent a colonoscopy were collected from National Health Insurance Service using a random sampling method. The clinical characteristics and perforation incidence (within 30 days after the colonoscopy) of cases were identified, and cases were then compared with controls who had not undergone a colonoscopy. Results: Among 1,380,000 subjects, 31,177 cases and 62,354 controls were identified. Perforation occurred in 14 patients (0.04%) in the case group and one patient (<0.01%) in the control group (RR, 28.0; 95% CI 3.7-212.9, p<0.001). Subgroup analysis was followed according to the endoscopic procedure, gender and age. In subgroup analysis, colonoscopy-associated perforations occurred more in the therapeutic procedure (RR, 26; 95% CI 1.46-461.46), male (RR, 50; 95% CI 2.96-844.41), and age of 45-60 years (RR, 30; 95% CI 1.71-525.23). Conclusions: A colonoscopy procedure is related to an increased risk of perforation at the population level. In addition, the therapeutic procedure, male, and age of 45-60 years appeared to be associated with an increased risk of perforation.

Long-term evolution of direct healthcare costs for inflammatory bowel diseases: a population-based study (2006-2015).

Introduction: We explored the long-term evolution of direct healthcare costs for inflammatory bowel diseases (IBD) using a population-level database in a country with an escalating burden of IBD. Methods: We searched the database of the Korean National Health Insurance Claims, which covers more than 97% of the South Korean population. An IBD diagnosis was defined as the combination of a billing code for Crohn's disease (CD: K50.xx) or ulcerative colitis (UC: K51.xx) and at least one claim for IBD-specific drugs. Between 2006 and 2015, a total of 59,447 patients (CD: 17,677; UC: 41,770) were included. Results: The total and mean cost per capita increased significantly over time. In the last year of the study (2015), the cost for anti-tumor necrosis factor (TNF) therapy accounted for 68.8% (CD) and 48.8% (UC) of the total cost. Age at diagnosis (<20 years vs. ≥30 years) and anti-TNF use were independent predictors of increased total IBD cost. Anti-TNF therapy was the strongest predictor of high-cost outliers (designated as the top 20 percentile of the total costs) for IBD (OR: 160.4; 95% CI: 89.0-289.2). The mean cost among patients with newly diagnosed CD increased significantly over the 8-year follow-up period (p = .03), while costs associated with UC remained stable. Only medication costs increased significantly during the follow-up period for CD. Conclusions: Over the past 10 years, the increased usage of anti-TNF agents has been the key driver of IBD-related healthcare costs. Long-term cost-cutting strategies for patients with CD are warranted.