Risk of diabetes mellitus in HIV-infected patients receiving highly active antiretroviral therapy: A nationwide population-based study.

Previous studies have shown that the incidence of diabetes mellitus (DM) has increased in human immunodeficiency virus (HIV)-infected patients with long-term exposure to highly active antiretroviral therapy (HAART). However, the factors associated with DM among HIV-infected patients in Asia remain unclear in the HAART era.A nationwide cohort studyData from Taiwan's National Health Insurance Research Database (NHIRD) between 2000 and 2010 were used to investigate the incidence of and factors associated with DM among HIV-infected patients. Propensity score matching was conducted to match 4797 patients receiving HAART (HAART cohort) with 4797 patients not receiving HAART (non-HAART cohort). HAART use was treated as a time-dependent variable in a Cox regression model.HAART cohort had a significantly higher 10-year incidence of DM (7.16%; 95% confidence interval [CI], 4.30%-10.03%) than non-HAART cohort (2.24%; 95% CI, 1.28%-3.20%) (P < .001). After adjusting for age, gender, and comorbidities, receiving HAART was associated with an increased incidence of DM, with a subdistribution hazard ratio (sHR) of 2.39 (95% CI, 1.65-3.45). Hypertension (sHR = 5.27; 95% CI, 3.21-8.65), gout (sHR = 2.39; 95% CI, 1.38-4.16), and hepatitis C virus (HCV) infection (sHR = 2.43; 95% CI, 1.28-4.61) were significantly associated with a higher risk of DM. Sensitivity analyses showed exposure to HAART remained significantly associated with an increased risk of DM, particularly in those without pre-existing hypertension, gout, or HCV infection.Exposure to HAART increased the risk of DM in HIV-infected Taiwanese patients, particularly in those without pre-existing hypertension, gout, or HCV infection.

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.

The association between continuous positive airway pressure therapy and liver disease development in obstructive sleep apnea/hypopnea syndrome patients: a nationwide population-based cohort study in Taiwan.

PURPOSE: Studies on the association between continuous positive airway pressure (CPAP) treatment and liver diseases such as non-alcoholic fatty liver disease (NAFLD) and cirrhosis in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are limited. To the best of our knowledge, none exists that makes use of a national database in an Asian population. This study aims to evaluate the effects of CPAP treatment on patients with these two disorders in a retrospective, population-based study in Taiwan. METHODS: Using the Taiwan National Health Insurance claims database, this study collected the data of OSAHS patients diagnosed between 2000 and 2008 and divided them into CPAP treatment and non-CPAP treatment groups. All subjects were followed up until 2010. Liver disease incidence and risk were calculated. RESULTS: The CPAP group had a lower cumulative incidence rate of developing liver disease than the non-CPAP group within the observation periods (p < 0.001). After adjusting for age, gender, urbanization level, and comorbidities, the CPAP treatment group showed a lower risk of developing liver disease compared with the non-CPAP treatment group (sub-aHR of 0.66 (95% CI 0.55-0.80), p < 0.001). CONCLUSIONS: Our observations suggest that CPAP treatment may play an important role to delay the progression of liver disease in OSAHS patients and decreases the incidence of liver disease among OSAHS patients. Thus, CPAP therapy may be a feasible way to decrease the risk of liver disease among patients with OSAHS.

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.

Chinese Herbal Medicine Treatment Improves the Overall Survival Rate of Individuals with Hypertension among Type 2 Diabetes Patients and Modulates In Vitro Smooth Muscle Cell Contractility.

Type 2 diabetes (T2D) is a chronic, multifactorial, and metabolic disorder accounting for 90% diabetes cases worldwide. Among them, almost half of T2D have hypertension, which is responsible for cardiovascular disease, morbidity, and mortality in these patients. The Chinese herbal medicine (CHM) prescription patterns of hypertension individuals among T2D patients have yet to be characterized. This study, therefore, aimed to determine their prescription patterns and evaluate the CHM effect. A cohort of one million randomly sampled cases from the National Health Insurance Research Database (NHIRD) was used to investigate the overall survival rate of CHM users, and prescription patterns. After matching CHM and non-CHM users for age, gender and date of diagnosis of hypertension, 980 subjects for each group were selected. The CHM users were characterized with slightly longer duration time from diabetes to hypertension, and more cases for hyperlipidaemia. The cumulative survival probabilities were higher in CHM users than in non-CHM users. Among these top 12 herbs, Liu-Wei-Di-Huang-Wan, Jia-Wei-Xiao-Yao-San, Dan-Shen, and Ge-Gen were the most common herbs and inhibited in vitro smooth muscle cell contractility. Our study also provides a CHM comprehensive list that may be useful in future investigation of the safety and efficacy for individuals with hypertension among type 2 diabetes patients.

Prompt Oseltamivir Therapy Reduces Medical Care and Mortality for Patients With Influenza Infection: An Asian Population Cohort Study.

There are limited population-based studies on the progress of oseltamivir therapy for influenza infection.Using insurance claims data of 2005, 2009, and 2010, the authors established an "in-time" cohort and a "lag-time" cohort representing influenza patients taking the medicine within and not within 1 week to examine the treatment progress. Incident outpatient visit, emergency care and hospitalization, and fatality were compared between the 2 cohorts in the first week and the second week of follow-up periods, after the oseltamivir therapy.A total of 112,492 subjects diagnosed with influenza on oseltamivir therapy in 2005, 2009, and 2010 were identified. The multivariate logistic regression analysis showed that the in-time treatment was superior to the lag-time treatment with less repeat outpatient visits, hospitalizations, and fatality. The overall corresponding in-time treatment to lag-time treatment odds ratios (OR) were 0.50, 0.54, and 0.71 (all P value < 0.05), respectively. The in-time to lag-time ORs of all events were 0.50 in 2009 and 0.54 in 2010.Our study demonstrates that the in-time oseltamivir therapy leads to significantly better treatment outcomes. Oseltamivir should be administered as early as the onset of influenza symptoms appears.

Obstructive sleep apnea is associated with liver disease: a population-based cohort study.

BACKGROUND: The association between obstructive sleep apnea (OSA) and the risk of liver disease is unclear. Moreover, population-based studies on the risk of liver disease among people with OSA have not yet been conducted. This study aimed to investigate the risk of subsequent development of liver disease among people with OSA. METHODS: Using Taiwan National Health Insurance claims data, this study collected subjects from a cohort of 17,374 people with OSA who were diagnosed between 2000 and 2008. A control group of 69,496 people was selected from the same database and matched by age, gender, urbanization, income, and date of initial admission. All subjects were followed up until 2010. Liver disease incidence and risk were calculated. RESULTS: The overall risk of liver disease among people with OSA was significantly higher than in the control group (aHR = 5.52, p <0.001). Non-alcoholic fatty liver disease, cirrhosis, and hepatitis C had significant aHRs of 5.29, 7.50, and 7.19 (all at p <0.001), respectively. In contrast, hepatitis B had the smallest aHR of 3.71. CONCLUSIONS: The risk of liver disease was more than five times higher among people with OSA compared with the control group; this was particularly for cirrhosis and hepatitis C. Liver disease is thus a very important health issue among people with OSA.

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.

Mortality and complications of hip fracture in young adults: a nationwide population-based cohort study.

BACKGROUND: This study assessed the mortality and complications of hip fractures using in-patients aged 20-40 years from a nationwide population database in Taiwan. METHODS: Subjects were selected from Taiwan's National Health Insurance Research Database for the period 2000-2008, and these subjects were followed up until the end of 2010. A total of 5,079 (3,879 male and 1,200 female) subjects were admitted for the first time with primary diagnosis of hip fracture and treated with operation. We calculated the long-term overall survival rate and complication-free rate. We also assessed the risk factors for mortality and complications. RESULTS: The 1-month, 3-month, 6-month, 1-year, 2-year, 5-year, and 10-year complication-free rates were 98.3%, 96.2%, 94.5%, 86.8%, 80.4%, 75.3%, and 73.5% for the entire cohort, respectively. The 10-year survival rates were 93.3%, 91.8%, and 94.5% for total cases, trochanteric fracture, and cervical fracture, respectively. The 10-year complication-free rates were 73.5%, 80.5%, and 67.3% for total cases, trochanteric fracture, and cervical fracture, respectively. The risk factors for overall death were male, older age, and greater number of Charlson comorbidity index (CCI) comorbidities. The risk factors for complication were cervical fracture, and greater number of CCI comorbidities. Complications resulted in 42.83% of patients receiving internal fixation implants or prothesis removal and 2.01% underwent conversion to revision arthroplasty during follow-up. CONCLUSIONS: The overall 10-year survival rate in hip fracture patients aged 20-40 years in Taiwan was over 90%. The 10-year complication-free rates were around 70%. Preventing the occurrence of severe complications after hip fracture among young adults is an important public health issue that warrants greater attention.

Excess mortality after hip fracture among the elderly in Taiwan: a nationwide population-based cohort study.

Osteoporotic hip fractures cause high mortality in the elderly population. However, few population studies reported the long-term mortality of hip fracture among the elderly in Asian population. This study assessed the incidence, excess mortality, and risk factors after osteoporotic hip fractures through inpatients aged 60 years or older. A total of 143,595 patients with hip fracture were selected from Taiwan National Health Insurance database in the years 1999 to 2009 and followed up until the end of 2010. Annual incidence, mortality and SMR, and mortality and SMR at different periods after fracture were measured. From 1999 to 2005, hip fracture incidence gradually increased and then fluctuated after 2006. From 1999 to 2009, the male-to-female ratio of annual incidence increased from 0.60 to 0.66, annual mortality for hip fracture decreased from 18.10% to 13.98%, male-to-female ratio of annual mortality increased from 1.38 to 1.64, and annual SMR decreased from 13.80 to 2.98. Follow-up SMR at one, two, five, and ten years post-fracture was 9.67, 5.28, 3.31, and 2.89, respectively. Females had higher follow-up SMR in the younger age groups (60-69 yr of age) but lower follow-up SMR in the older age groups (over 80 yr of age) compared with males. Among the studied patients, incidence is gradually decreasing along with annual mortality and SMR. Hip fracture affects short-term but not long-term mortality.

Association between systemic antipsoriatic drugs and cardiovascular risk in patients with psoriasis with or without psoriatic arthritis: a nationwide cohort study.

OBJECTIVE: Psoriasis is associated with ischemic heart disease (IHD). Results of prior studies have suggested that methotrexate (MTX) may improve vascular disease in patients with psoriasis and rheumatoid arthritis. The aim of this study was to assess the risk of new-onset IHDs in psoriasis patients, comparing those taking MTX with those taking other nonbiologic antipsoriatic drugs. METHODS: In this retrospective cohort study, we utilized claims data from the National Health Insurance Research Database of Taiwan to identify 179,200 subjects who had received a diagnosis of psoriasis, with or without psoriatic arthritis, on at least 3 visits. The risk of hospitalization for new-onset IHD was compared between psoriasis patients taking MTX monotherapy (n = 6,578; MTX case cohort) and psoriasis patients taking other nonbiologic antipsoriatic drugs (n = 5,471; reference control cohort) between January 1996 and December 2008. Additional adjustments were made for cardiovascular risk factors, number of hospital visits, Charlson comorbidity score, and use of other antiinflammatory drugs. RESULTS: The incidence rates of IHD were 666 cases per 100,000 person-years in the MTX case cohort and 830 cases per 100,000 person-years in the reference control cohort (unadjusted P = 0.027). Increasing age, male sex, presence of hypertension, presence of diabetes, Charlson comorbidity score, and use of phototherapies were independent risk factors for hospitalization related to a new IHD in the study cohorts. However, the multivariate-adjusted hazard ratio for IHD-related hospitalizations among patients receiving MTX, in comparison with those receiving other nonbiologic antipsoriatic drugs, was 0.97 (95% confidence interval 0.79-1.19), after adjustment for age, sex, comorbidity score, number of hospital visits, and other antiinflammatory treatments for psoriasis. CONCLUSION: In patients with psoriasis with or without coexisting psoriatic arthritis, the adjusted risk of hospitalization for an IHD among individuals receiving MTX was comparable with that among individuals receiving other nonbiologic antipsoriatic drugs.

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.

Long-term peptic ulcer rebleeding risk estimation in patients undergoing haemodialysis: a 10-year nationwide cohort study.

OBJECTIVE: We aimed to study 1-, 5- and 10-year risks of peptic ulcer rebleeding among end-stage renal disease (ESRD) patients with regular haemodialysis, to identify the high-risk subpopulation, and to estimate the number needed to harm (NNH) to increase a peptic ulcer rebleeding in different periods. DESIGN: A nationwide cohort study. SETTING: Data from the Taiwan National Health Insurance Research Database. PATIENTS: Uraemic cohort and matched controls were selected from among hospitalised patients with a primary diagnosis of peptic ulcer bleeding. In total, 6447 uraemic patients and 25,788 age-, gender- and gastroprotective agent use-matched controls were selected. Intervention No. Main outcome measures Cumulative incidences and HRs. RESULTS: The cumulative incidences of ESRD patients were significantly higher than the cumulative incidences of matched controls (1 year: 18.8% vs 14.2%; 5 years: 38.5% vs 31.4%; and 10 years: 46.3% vs 39.4%; all p<0.001). The NNH to increase a peptic ulcer rebleeding by ESRD at 1, 5 and 10 years were 22, 15 and 15, respectively. On multivariate analysis, ESRD (HR=1.38, p<0.0001) was an independent risk factor for rebleeding. Compared with matched controls, ESRD was associated with higher risk of rebleeding especially in patients using ulcerogenic agents (HR=1.33-1.45), indication to prescribe gastroprotective agents (HR=1.44) and with liver cirrhosis (HR=1.45). CONCLUSIONS: ESRD patients had higher long-term risk of peptic ulcer rebleeding, especially in certain populations. The enhanced risk gradually decreased after the first year and stabilised after the fifth year.

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.

Histamine2-receptor antagonists are an alternative to proton pump inhibitor in patients receiving clopidogrel.

BACKGROUND & AIMS: Previous observational studies reported that concomitant use of clopidogrel and proton pump inhibitors (PPIs) in patients with prior acute coronary syndrome (ACS) was associated with adverse cardiovascular outcomes. We investigated whether H(2)-receptor antagonist (H(2)RA) is an alternative to PPI in patients with ACS. METHODS: We conducted a population-based retrospective cohort study of 6552 patients in Taiwan discharged for ACS between 2002 and 2005. Patients were divided into 5 cohorts: clopidogrel plus H(2)RA (n = 252), clopidogrel plus PPI (n = 311), clopidogrel alone (n = 5551), H(2)RA alone (n = 235), and PPI alone (n = 203). The primary outcome was rehospitalization for ACS or all-cause mortality within 3 month of rehospitalization. RESULTS: The 1-year cumulative incidence of the primary outcome was 26.8% (95% CI: 21.5%-33.0%) in the clopidogrel plus H(2)RA cohort and 33.2% (95% CI: 27.8%-39.4%) in the clopidogrel plus PPI cohort, compared with 11.6% (95% CI: 10.8%-12.5%) in the clopidogrel alone cohort (P < .0001). No significant difference was observed between the PPI alone cohort (11.0%; 95% CI: 7.1%-16.8%), the H(2)RA alone cohort (11.8%; 95% CI: 8.2%-16.8%), and the clopidogrel alone cohort in terms of the primary outcome. The number needed to harm was 7 with concomitant H(2)RA and 5 with concomitant PPI. On multivariate analysis, concomitant H(2)RA and PPI were independent risk factors predicting adverse outcomes (adjusted hazard ratios, 2.48 and 3.20, respectively; P < .0001). CONCLUSIONS: Concomitant use of clopidogrel and H(2)RA or PPI after hospital discharge for ACS is associated with increased risk of adverse outcomes.