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

Immunotherapy of gastric cancer: Present status and future perspectives

In this editorial, we comment on the article entitled "Advances and key focus areas in gastric cancer immunotherapy: A comprehensive scientometric and clinical trial review (1999-2023)," which was published in the recent issue of the World Journal of Gastroenterology. We focused on the results of the authors' bibliometric analysis concerning gastric cancer immunotherapy, which they analyzed in depth by compiling the relevant publications of the last 20 years. Before that, we briefly describe the most recent data concerning the epidemiological parameters of gastric cancer (GC) in different countries, attempting to give an interpretation based on the etiological factors involved in the etiopathogenesis of the neoplasm. We then briefly discuss the conservative treatment (chemotherapy) of the various forms of this malignant neoplasm. We describe the treatment of resectable tumors, locally advanced neoplasms, and unresectable (advanced) cases. Special attention is given to modern therapeutic approaches with emphasis on immunotherapy, which seems to be the future of GC treatment, especially in combination with chemotherapy. There is also a thorough analysis of the results of the study under review in terms of the number of scientific publications, the countries in which the studies were conducted, the authors, and the scientific centers of origin, as well as the clinical studies in progress. Finally, an attempt is made to draw some con-clusions and to point out possible future directions.

Cross-talk between Helicobacter pylori and gastric cancer: a scientometric analysis

Background

Helicobacter pylori (HP) is considered a leading risk factor for gastric cancer (GC). The aim of this article is to conduct bibliometric and visual analysis to assess scientific output, identify highly cited papers, summarize current knowledge, and explore recent hotspots and trends in HP/GC research.

Methods

A bibliographic search was conducted on October 24, 2023, to retrieve relevant studies on HP/GC research between 2003 and 2022. The search terms were attached to HP and GC. The main data were from the Web of Science Core Collection (WoSCC). Data visualization was performed using Biblioshiny, VOSviewer, and Microsoft Excel.

Results

In HP/GC research, 1970 papers were retrieved. The total number of papers (Np) in HP/GC was growing from 2003 to 2022. China and Japan were in the leading position and made the most contributions to HP/GC. Vanderbilt University and the US Department of Veterans Affairs had the highest Np. The most productive authors were Peek Jr Richard M. and Piazuelo M Blanca. Helicobacter received the most Np, while Gastroenterology had the most total citations (TC). High-cited publications and keyword clustering were used to identify the current status and trends in HP/GC research, while historical citation analysis provided insight into the evolution of HP/GC research. The hot topics included the effect of HP on gastric tumorigenesis and progression, the pathogenesis of HP-induced GC (HP factors), and the mechanisms by which HP affects GC (host factors). Research in the coming years could focus on topics such as autophagy, gut microbiota, immunotherapy, exosomes, epithelial-mesenchymal transition (EMT), and gamma-glutamyl transpeptidase (GGT).

Conclusion

This study evaluated the global scientific output in HP/GC research and its quantitative characteristics, identified the essential works, and collected information on the current status, main focuses and emerging trends in HP/GC research to provide academics with guidance for future paths.

Perspectives of the Application of Non-Steroidal Anti-Inflammatory Drugs in Cancer Therapy: Attempts to Overcome Their Unfavorable Side Effects

Non-steroidal anti-inflammatory drugs (NSAIDs) express anti-tumoral activity mainly by blocking cyclooxygenase-2 involved in the synthesis of prostaglandins. Therefore, in the last few decades, many have attempted to explore the possibilities of applying this group of drugs as effective agents for the inhibition of neoplastic processes. This review summarizes the evidence presented in the literature regarding the anti-tumoral actions of NSAIDs used as monotherapies as well as in combination with conventional chemotherapeutics and natural products. In several clinical trials, it was proven that combinations of NSAIDs and chemotherapeutic drugs (CTDs) were able to obtain suitable results. The combination with phospholipids may resolve the adverse effects of NSAIDs and deliver derivatives with increased antitumor activity, whereas hybrids with terpenoids exhibit superior activity against their parent drugs or physical mixtures. Therefore, the application of NSAIDs in cancer therapy seems to be still an open chapter and requires deep and careful evaluation. The literature's data indicate the possibilities of re-purposing anti-inflammatory drugs currently approved for cancer treatments.

A literature review on the potential clinical implications of streptococci in gastric cancer

Streptococcus is widely found in nature and the human body, and most species are not pathogenic. In recent years, studies have found that Streptococcus is associated with gastric cancer. Streptococcus was found to be enriched in the oral cavity, stomach and intestine of gastric cancer patients and found to be increased in gastric cancer tissues, suggesting that Streptococcus may be the pathogenic bacteria underlying gastric cancer. This review discusses the discovery of Streptococcus, the relationship between Streptococcus and gastric cancer, and the possible carcinogenic mechanism of Streptococcus and summarizes the progress of the research on the role of Streptococcus in gastric cancer to provide new ideas for the early detection, diagnosis and treatment of gastric cancer.

Bacteria-Mediated Oncogenesis and the Underlying Molecular Intricacies: What We Know So Far

Cancers are known to have multifactorial etiology. Certain bacteria and viruses are proven carcinogens. Lately, there has been in-depth research investigating carcinogenic capabilities of some bacteria. Reports indicate that chronic inflammation and harmful bacterial metabolites to be strong promoters of neoplasticity. Helicobacter pylori-induced gastric adenocarcinoma is the best illustration of the chronic inflammation paradigm of oncogenesis. Chronic inflammation, which produces excessive reactive oxygen species (ROS) is hypothesized to cause cancerous cell proliferation. Other possible bacteria-dependent mechanisms and virulence factors have also been suspected of playing a vital role in the bacteria-induced-cancer(s). Numerous attempts have been made to explore and establish the possible relationship between the two. With the growing concerns on anti-microbial resistance and over-dependence of mankind on antibiotics to treat bacterial infections, it must be deemed critical to understand and identify carcinogenic bacteria, to establish their role in causing cancer.

Association Between Aspirin Use and Gastric Adenocarcinoma: A Prospective Cohort Study

Prospective data examining the association of aspirin use, according to dose and duration, with long-term risk of gastric adenocarcinoma in non-Asian cohorts are lacking. We evaluated the association between aspirin use and risk of gastric adenocarcinoma in two large prospective U.S. cohort studies, the Nurses' Health Study and the Health Professionals Follow-up Study. Cox proportional hazards regression models were used to calculate multivariable adjusted HRs and 95% confidence intervals (CI). Among the 159,116 participants, we documented 316 gastric adenocarcinoma cases (176 women, 140 men) over 34 years encompassing 4.5 million person-years. Among women, regular aspirin use (at least two times or more per week) was significantly associated with lower risk of gastric adenocarcinoma (multivariable HR, 0.52; 95% CI, 0.37-0.73) compared with nonregular use. However, regular aspirin use was not associated with gastric adenocarcinoma risk among men (multivariable HR, 1.08; 95% CI, 0.77-1.52; Pheterogeneity for sex = 0.003). Among women, the lower risk of gastric adenocarcinoma was more apparent with increasing duration of aspirin use (Ptrend < 0.001) and more than five tablets per week (multivariable HR, 0.51; 95% CI, 0.31-0.84). Regular, long-term aspirin use was associated with lower risk of gastric adenocarcinoma among women, but not men. The benefit appeared after at least 10 years of use and was maximized at higher doses among women. The heterogeneity by sex in the association of aspirin use with risk of gastric adenocarcinoma requires further investigation.

PREVENTION RELEVANCE

Novel prevention is urgently needed to reduce incidence and mortality of gastric cancer. We found that regular aspirin use was associated with lower risk of gastric adenocarcinoma among women, but not men. The benefit appeared after at least 10 years of use and was maximized at higher doses among women. See related Spotlight, p. 213.

Nonsteroidal Anti-Inflammatory Drugs Reduce Second Cancer Risk in Patients With Breast Cancer: A Nationwide Population-Based Propensity Score-Matched Cohort Study in Taiwan

Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce mortality in patients with cancer, especially breast cancer, but their influence on second cancer risk is uncertain. This study aimed to examine whether NSAID use is associated with second cancer risk in patients with breast cancer. This population-based propensity score-matched cohort study using Taiwan’s National Health Insurance Research Database enrolled patients with newly diagnosed breast cancer (n = 7356) with and without (n = 1839) NSAID therapy from 2000 to 2009. They were followed up until the diagnosis of second cancer, death, or end of 2011. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR). The NSAID cohort had a lower incidence rate of second cancer than the non-NSAID cohort (5.57 vs. 9.19 per 1,000 person-years), with an aHR of 0.63 (95% confidence interval (CI) 0.46–0.87). When compared with the non-NSAID cohort, the second cancer incidence was lower in patients taking non-cyclooxygenase 2 inhibitors (aHR 0.67, 95% CI 0.47–0.94) and in those receiving multiple NSAIDs during follow-up (aHR 0.55, 95% CI 0.37–0.84). A dose–response relationship existed in NSAID cumulative days. The findings demonstrate that NSAID use reduces second cancer risk in a dose-dependent manner in patients with primary breast cancer.

Fracture risks in patients with atopic dermatitis: A nationwide matched cohort study

BACKGROUND

The risk of osteoporosis has been explored in atopic dermatitis (AD). The long-term risk of fractures in patients with AD and the effects of various AD treatments on bone health remain to be elucidated.

OBJECTIVE

To evaluate the long-term risk of fractures in patients with AD.

METHODS

This nationwide matched cohort study was conducted using the National Health Insurance Research Database of Taiwan for the period 1997 to 2013. A total of 36,855 patients with AD and 147,420 reference subjects without AD were identified. Demographic characteristics and comorbidities were compared, and cumulative incidence of fractures was evaluated. Adjusted hazard ratios for fracture risks of AD and various AD treatments were calculated using the Cox proportional hazards model.

RESULTS

A total of 1518 patients (4.12%) in the AD cohort and 5579 patients (3.78%) in the reference cohort had fractures (P = .003). The mean ages were 22.6 years in both groups. The 16-year cumulative incidence of fractures in the AD cohort (8.043%) was significantly higher than that in the reference cohort (7.366%) (P = .002). Severe AD (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 1.08-1.59) was independently associated with fractures. Other independent risk factors included exposure to topical (aHR, 1.21; 95% CI, 1.05-1.39) or systemic (≥10 mg/d; aHR, 1.62; 95% CI, 1.38-1.91) corticosteroids. Use of disease-modifying antirheumatic drugs (aHR, 0.71; 95% CI, 0.53-0.90) and phototherapy (aHR, 0.73; 95% CI, 0.56-0.95) was associated with a lower risk of fractures. The results were consistent across sensitivity analyses.

CONCLUSION

Patients with AD have a higher incidence of fractures. Severe AD is independently associated with fractures.

Chemoprevention Against Gastric Cancer

Gastric cancer is the fifth most common cause of cancer and the third leading cause of cancer-related deaths globally. The number of gastric cancer-related deaths is only projected to increase, attributable primarily to the expanding aging population. Prevention is a mainstay of gastric cancer control programs, particularly in the absence of accurate, noninvasive modalities for screening and early detection, and the absence of an infrastructure for this purpose in the majority of countries worldwide. Herein, we discuss the evidence for several chemopreventive agents, along with putative mechanisms. There remains a clear, unmet need for primary chemoprevention trials for gastric cancer.

Nonsteroidal anti-inflammatory drugs prevent gastric cancer associated with the use of proton pump inhibitors after Helicobacter pylori eradication

Background and Aim

Proton pump inhibitors (PPIs) are a potential cause of gastric carcinogenesis after Helicobacter pylori eradication. Thus, appropriate management including chemoprevention is required. The aim of this study was to evaluate the association between nonsteroidal anti‐inflammatory drugs (NSAIDs) and the incidence of post‐eradication gastric cancer in PPI users.

Methods

A multicenter retrospective cohort study was conducted. Patients who used a PPI (≥30 days) after H. pylori eradication between 2014 and 2019 were analyzed in nine hospital databases. Gastric cancer incidence was a primary outcome, and their association with NSAIDs use and clinical factors was evaluated. Hazard ratios were adjusted by age, sex, smoking, and Charlson Comorbidity Index.

Results

During the mean follow‐up period of 2.38 years, 1.13% (31/2431) of all patients developed gastric cancer. The cumulative incidence of gastric cancer in PPI users was 0.25% at 1 year, 0.51% at 3 years, and 1.09% at 5 years in the NSAID users and 0.89% at 1 year, 2.32% at 3 years, and 3.61% at 5 years in nonusers. NSAIDs were associated with a lower gastric cancer risk (adjusted hazard ratio = 0.28, P = 0.005). No gastric cancer was observed in the cyclooxygenase‐2 inhibitor users (n = 256). NSAID use with high dose and long duration was significantly associated with a lower incidence of gastric cancer.

Conclusion

NSAIDs were associated with a 60% decrease in the gastric cancer incidence in H. pylori‐eradicated PPI users, with dose and duration response effects. NSAIDs may be effective for chemoprevention against PPI‐related gastric cancer.

Association of Helicobacter pylori Infection and Host Cytokine Gene Polymorphism with Gastric Cancer

The global cancer burden of new cases of various types rose with millions of death in 2018. Based on the data extracted by GLOBOCAN 2018, gastric cancer (GC) is the third leading cause of mortality related to cancer across the globe. Carcinogenic or oncogenic infections associated with Helicobacter pylori (Hp) are regarded as one of the essential risk factors for GC development. It contributes to the increased production of cytokines that cause inflammation prior to their growth in the host cells. Hp infections and specific types of polymorphisms within the host cells encoding cytokines are significant contributors to the host's increased susceptibility in terms of the development of GC. Against the backdrop of such an observation is that only a small portion of the cells infected can become malignant. The diversities are a consequence of the differences in the pathogenic pathway of the Hp, susceptibility of the host, environmental conditions, and interplay between these factors. It is evident that hosts carrying cytokine genes with high inflammatory levels and polymorphism tend to exhibit an increased risk of development of GC, with special emphasis being placed on the host cytokines gene polymorphisms.

Gastric Adenocarcinoma Presenting as a Rheumatoid Factor and Anti-cyclic Citrullinated Protein Antibody-Positive Polyarthritis: A Case Report and Review of Literature

A 64-year-old male presented with a 6-month history of symmetric polyarthritis involving proximal interphalangeal joints and metacarpophalangeal joints of the hands, wrists, and ankles. Associated symptoms included vomiting, progressive fatigue, and weight loss. Laboratory results showed microcytic anemia, leukocytosis, thrombocytosis, elevated C-reactive protein and erythrocyte sedimentation rate, and rheumatoid factor (RF) and anti-cyclic citrullinated protein (ACPA) antibody positivity. Joints radiographs were normal, without erosions. Upper endoscopy and gastric endoscopic ultrasonography showed a gastric adenocarcinoma with lymphatic involvement. Intraoperatively, peritoneal carcinomatosis was documented, and the patient started palliative chemotherapy. A paraneoplastic seropositive arthritis was assumed, and treatment with low-dose prednisolone and hydroxychloroquine was started. Arthritis remission was achieved and sustained up to 18 months of follow-up, although gastric cancer progression was documented. We describe a unique phenotype of paraneoplastic arthritis (PA) presenting as a seropositive (RF and ACPA positivity) rheumatoid arthritis (RA) with a good response to both low dose corticosteroids and hydroxychloroquine therapy. We also review the literature of PA, mostly the RA-like pattern, and the association between PA and ACPA positivity. This case highlights the importance of considering underlying cancer in elderly male patients, presenting with polyarthritis and systemic symptoms, even in those with ACPA-positive RA-like arthritis.

Use of Antibiotics and Probiotics Reduces the Risk of Metachronous Gastric Cancer after Endoscopic Resection

Metachronous gastric cancer often occurs after endoscopic resection. Appropriate management, including chemoprevention, is required after the procedure. This study was performed to evaluate the association between medication use and the incidence of metachronous gastric cancer after endoscopic resection. This multicenter retrospective cohort study was conducted with data from nine hospital databases on patients who underwent endoscopic resection for gastric cancer between 2014 and 2019. The primary outcome was the incidence of metachronous gastric cancer. We evaluated the associations of metachronous gastric cancer occurrence with medication use and clinical factors. Hazard ratios were adjusted by age and Charlson comorbidity index scores, with and without consideration of sex, smoking status, and receipt of Helicobacter pylori eradication therapy during the study period. During a mean follow-up period of 2.55 years, 10.39% (140/1347) of all patients developed metachronous gastric cancer. The use of antibiotics other than those used for H. pylori eradication was associated with a lower incidence of metachronous gastric cancer than was non-use (adjusted hazard ratio (aHR) 0.56, 95% confidence interval (CI) 0.38-0.85, p = 0.006). Probiotic drug use was also associated with a lower incidence of metachronous gastric cancer compared with non-use (aHR 0.29, 95% CI 0.091-0.91, p = 0.034). In conclusion, the use of antibiotics and probiotic drugs was associated with a decreased risk of metachronous gastric cancer. These findings suggest that the gut microbiome is associated with metachronous gastric cancer development.

Risk of Free Flap Failure in Head and Neck Reconstruction: Analysis of 21,548 Cases From A Nationwide Database

BACKGROUND

Head and neck reconstruction is complicated and is made even more challenging by free flap failure. We identified risk factors associated with free flap failure in records extracted from a nationwide database of a 23 million populations.

METHODS

We used International Classification of Diseases, Ninth Version, codes 140 to 149 and 161 to identify patients in Taiwan's National Health Insurance Research Database with head and neck cancer between 2000 and 2013. Patient's age, sex, neoadjuvant treatment, comorbidities, and anticoagulation use were also retrieved. Free flap reconstruction twice, or free flap and pedicle flap reconstructions during the same hospitalization were recorded as free flap failure. Logistic regression was used to identify factors that increased risk of free flap failure.

RESULTS

A total of 21,548 patients with head and neck cancer were identified; 883 (4.1%) experienced free flap failure. Use of aspirin, clopidogrel, urokinase, prostaglandin (PGE1), low-molecular-weight heparin, and operation time were associated with free flap failure. However, some potential confounders could not be identified from the database.

CONCLUSIONS

Several statistically significant findings were prone to influence by potential confounders. The clinically applicable result was that longer operation time and preoperative chemotherapy could increase the likelihood of free flap failure. On the other hand, several factors were proved to be irrelevant to free flap failure.

Preventing Metachronous Gastric Cancer after the Endoscopic Resection of Gastric Epithelial Neoplasia: Roles of Helicobacter pylori Eradication and Aspirin

Whether Helicobacter pylori eradication actually reduces the risk of metachronous gastric cancer (MGC) development remains a controversial question. In this review, we addressed this topic by reviewing the results of clinical investigations and molecular pathological analyses of the roles of H. pylori eradication and aspirin administration in the prevention of MGC. In regard to the clinical studies, the results of meta-analyses and randomized control trials differ from those of retrospective studies: the former trials show that H. pylori eradication has a preventive effect on MGC, while the latter studies do not. This discrepancy may be at least partly attributable to differences in the follow-up periods: H. pylori eradication is more likely to prevent MGC over a long-term follow-up period (≥5 years) than over a short-term follow-up period. In addition, many studies have shown that aspirin may have an additive effect on MGC-risk reduction after H. pylori eradication has been achieved. Both H. pylori eradication and aspirin use induce molecular alterations in the atrophic gastritis mucosa but not in the intestinal metaplasia. Unfortunately, the molecular pathological analyses of these interventions have been limited by short follow-up periods. Therefore, a long-term prospective cohort is needed to clarify the changes in molecular events caused by these interventions.

Nonaspirin nonsteroidal anti-inflammatory drugs and gastric cancer risk after Helicobacter pylori eradication: A territory-wide study

BACKGROUND

Despite Helicobacter pylori (HP) eradication, individuals can still develop gastric cancer (GC). Prior studies have demonstrated that nonaspirin nonsteroidal anti-inflammatory drugs (NA-NSAIDs) reduce the risk of GC, but this may be caused by immortal time bias and failure to adjust for HP status. The objective of this study was to investigate whether NA-NSAIDs reduced the risk of GC in patients who undergo H. pylori eradication.

METHODS

Adult patients who had received clarithromycin-based triple therapy between 2003 and 2016 were identified from a territory-wide health care database. Exclusion criteria included prior GC or GC diagnosed <6 months after HP eradication, prior gastrectomy, gastric ulcer after HP eradication, and failure of triple therapy. Covariates included age, sex, prior peptic ulcer disease, other comorbidities, and concurrent medications (aspirin, proton pump inhibitors, statins, and metformin). To avoid immortal time bias, NA-NSAID use (≥90 days) was treated as a time-dependent variable in a multivariable Cox model (time-dependent analysis). Time-independent analysis was also performed.

RESULTS

During a median follow-up of 8.9 years (interquartile range, 5.4-12.6 years), 364 of 92,017 patients (0.4%) who underwent HP eradication developed GC. NA-NSAID use was associated with a significant reduction in the risk of GC in time-fixed analysis (adjusted hazard ratio [aHR], 0.65; 95% CI, 0.47-0.90), but not in time-dependent multivariable analysis (aHR, 1.35; 95% CI, 0.97-1.87). Time-dependent subgroup analyses also did not indicate any significant association between NA-NSAID use and either cardia GC (aHR, 0.75; 95% CI, 0.27-2.06) or noncardia GC (aHR, 1.28; 95% CI, 0.83-1.98).

CONCLUSIONS

NA-NSAID use was not associated with a reduced risk of GC among patients who underwent HP eradication. The chemopreventive effect of NA-NSAIDs observed in prior studies may have been confounded by immortal time bias.

Calcium channel blockers are associated with lower gastric cancer risk: A territory-wide study with propensity score analysis

Prior studies showed that calcium channel blockers (CCBs) could modify cancer risk, but data on gastric cancer (GC) are limited. We aimed to investigate whether CCBs could modify GC risk in Helicobacter pylori-eradicated patients. H pylori-infected patients with hypertension who are aged ≥50 and had received clarithromycin-based triple therapy between 2003 and 2016 were identified from a territory-wide healthcare database. Patients with eradication failure, GC diagnosed within 6 months after HP eradication, and gastric ulcer were excluded. Time-fixed Cox model with one-to-one propensity score matching was used to calculate hazard ratio (HR) of GC with CCBs. Sensitivity analysis using time-dependent multivariable Cox model in which CCB use was treated as time-varying covariate was also performed to address immortal time bias. 17 622 (29.6%) H pylori-eradicated patients with hypertension were included. During a median follow-up of 8.6 years, 105 (0.6%) developed GC. After PS matching, CCBs were associated with a lower GC risk (HR: 0.56; 95% CI: 0.32-0.97). Time-dependent analysis showed consistent result (aHR: 0.50; 95% CI: 0.33-0.75). A longer duration of CCB use was associated with even lower GC risk (adjusted HR [aHR]: 0.69; 95% CI: 0.61-0.79 for every 1-year increase in use). Long-acting CCBs (aHR: 0.47; 95% CI: 0.29-0.76) and dihydropyridines (aHR: 0.49; 95% CI: 0.32-0.73) conferred greater benefit than short-acting ones (aHR: 0.60; 95% CI: 0.36-1.03) and nondihydropyridines (aHR: 0.76; 95% CI: 0.24-2.48). The aHR was 0.57 (95% CI: 0.34-0.97) for noncardia and 0.59 (95% CI: 0.27-1.31) for cardia cancer. Use of CCBs was associated with lower risk of GC development in H pylori-eradicated patients, in a duration- and dose-response manner.

A Population-Based Cohort Study Examining the Long-term Risk of Repeated Surgery in Non-Helicobacter pylori-Infected PPU Patients Who Underwent Simple Closure

OBJECTIVES

The management of perforated peptic ulcer (PPU) has shifted from vagotomy/drainage to simple closure, followed by postoperative proton pump inhibitors (PPIs) and Helicobacter pylori (HP) eradication. Few studies have focused on the long-term impacts of this trend shift. We hypothesize that simple closure with PPIs is sufficient and does not carry an elevated rate of repeated surgery in non-HP-infected PPU patients.

METHODS

Hospitalized PPU patients who underwent simple closure or truncal vagotomy/pyloroplasty (TVP) in the National Health Insurance Research Database (NHIRD) from 2000 to 2008 were collected. The index date was defined as the date of ulcer admission. Patients who underwent other ulcer surgeries (e.g., gastrectomy, highly or selective vagotomy), who had a history of HP infection, or who were < 18 or > 100 years old were excluded. Additionally, the distributions of postoperative nonsteroidal anti-inflammatory drug (NSAID) and PPI use were calculated using the Longitudinal Health Insurance Database (LHID).

RESULTS

After exclusion, a total of 66,413 patients were enrolled. There were 7232 (10.9%) patients who underwent TVP and 59,181 (89.1%) patients who underwent simple closure. The incidences of repeated ulcer-associated surgery were 5.10 and 23.05 versus 5.11 and 15.77 per 1000 person-years in the TVP cohort vs. the simple closure cohort before and after propensity score matching, respectively. When adjusted for age, sex, comorbidity, and Charlson comorbidity index score, the TVP cohort had a 68% (HR) and 66% (sHR) decreased risk compared with the simple closure cohort before propensity score matching, with a 67% decreased risk after propensity score matching in Cox proportional subdistribution hazard analysis and a 66% decreased risk in Fine-Gray proportional subdistribution hazard analysis. The LHID analysis showed a lower rate of postoperative NSAID use and a higher rate of postoperative PPI use in simple closure patients.

CONCLUSION

Our findings suggest that in the Asian population, simple closure increases the risk of repeated ulcer-associated surgery in non-HP-infected PPU patients compared with TVP patients. However, further studies are warranted.

Risk of subsequent prostate cancer in peptic ulcer patients who received helicobacter pylori eradication therapy: an Asian population-based cohort study

Background

Studies have shown diverse results regarding the association between H. pylori (HP) infection and the risk of malignancy. There is accumulating evidence relating HP infection to urological diseases. We investigated whether there was an association between HP-infected peptic ulcers and the subsequent risk of prostate cancer.

Methods

We collected HP-infected male patients from 1998 to 2008 from the Longitudinal Health Insurance Database (LHID). HP-infected patients were identified as those who had a diagnosis of peptic ulcers upon admission and received HP eradication therapy within 1 year after diagnosis. The date of HP infection diagnosis upon admission was defined as the index date. Patients aged < 20 years or with a cancer history were excluded. For each HP-infected patient, we selected four males without peptic ulcers or a history of HP eradication in the LHID for the comparison cohort according to propensity score matching by age, index year, and comorbidity. The risk of prostate cancer and associated risk factors was assessed by Cox proportional hazard regression.

Results

A total of 2620 HP infection treatment patients and 10,480 matched comparisons were selected. There were 36 patients in the HP-infected treatment cohort and 117 patients in the comparison cohort with documented prostate cancer development (1.52 and 1.21 per 1000 person-years, respectively). Compared to the comparison cohort, the HP infection cohort had a 1.26-fold increased prostate cancer risk in the Cox models after adjusting for matched-pairs (95% CI = 0.87–1.34). There were no significant differences in subsequent prostate cancer development between HP-infected treatment patients and the comparison cohort.

Conclusion

Our findings showed no significant association between HP-infected peptic ulcers and the subsequent risk of prostate cancer. Further studies are warranted to investigate whether this observation is attributable to an HP eradication policy.

Prognostic value of fibrinogen-to-albumin ratio in patients with gastric cancer receiving first-line chemotherapy

The fibrinogen-to-albumin ratio (FAR), reflecting the systemic coagulation, nutritional and inflammation status of patients, has matured into a prognostic marker for several tumor types. However, only a few studies have assessed the utility of the FAR as a prognostic indicator in patients with advanced gastric cancer (GC) receiving first-line chemotherapy. In the present study, 273 patients with advanced GC who received first-line chemotherapy between January 2014 and January 2019 at the Cancer Hospital of China Medical University (Shenyang, China) were retrospectively analyzed. Using the cut-off values determined by receiver operating characteristic (ROC) analysis, the patients were divided into low-FAR (≤10.03) and high-FAR (>10.03), low-fibrinogen (<3.8 g/l) and high-fibrinogen (≥3.8 g/l), and low-albumin (<40.55 g/l) and high-albumin (≥40.55 g/l) groups. The associations of the pretreatment FAR and clinicopathological characteristics with progression-free survival (PFS) and overall survival (OS) were evaluated. In order to estimate the prognostic value of the FAR for patients with poor prognosis or normal fibrinogen and albumin levels, subgroup analyses were performed. The FAR had a higher area under the ROC curve (0.690; 95% CI: 0.628–0.752; P<0.001) compared with either fibrinogen or albumin alone, which are common indicators of coagulation, nutritional and inflammatory indices. A high FAR was significantly associated with a more advanced stage, peritoneal metastasis, increased CA72-4 levels and anemia (all P<0.05). On survival analysis, a low FAR was associated with a longer PFS and OS compared with a high FAR (202 vs. 130 days and 376 vs. 270 days, respectively; both P<0.001), while the hazard ratio (HR) and P-values of the FAR were lower compared with those of fibrinogen and albumin alone on multivariate analysis (PFS: HR=0.638, 95% CI: 0.436–0.932, P=0.020; OS: HR=0.568, 95% CI: 0.394–0.819, P=0.002). Subgroup analysis indicated that among patients with poor prognosis, including multiple metastases, TNM stage IV and abnormal CA72-4 levels, the FAR may be used as an accurate prognostic marker (all P<0.05), and may also reliably identify patients with poor prognosis among those with normal fibrinogen and albumin levels (all P<0.001). The FAR was indicated to be a valuable marker for predicting PFS and OS in patients with advanced GC receiving first-line chemotherapy and is superior to either fibrinogen or albumin alone.

The special issue on cancer and evolution: Lessons learned

This special issue of evolutionary applications focused on the evolution of cancer has provided a wealth of different viewpoints and results from leaders in the field. Together, these papers emphasize the importance of a broad perspective in order to understand why we and other animals get cancer, how it evolves within an individual, and what we can do about it. We can no longer take reductionist approaches that consider only the cancer cells and their genes. Instead, we need to understand how millions of years of evolution have guided strategies that shape cancer risk, why cancer risk varies across different animals, how cancer risk can vary in a population and be influenced by ecology (and influence this ecology), and of course how cancers evolve within us and the evolutionarily informed strategies to counter their impact. My goal here will be to "bring it all home," providing a refresher of lessons learned with added kibitzing.

Microbiological evidences for gastric cardiac microflora dysbiosis inducing the progression of inflammation

BACKGROUND AND AIM

Nowadays, anti-inflammation treatment is a promising approach for preventing tumorigenesis, and human microflora is closely related to inflammation. This study aimed to investigate the gastric cardiac microbiome and identify inflammation-related microorganisms for gastric cardiac inflammation.

METHODS

We performed 16S rRNA sequencing on a total of 11 healthy individuals and 89 individuals with different degree of gastric cardiac inflammation. Immunohistochemistry was used for verifying candidate bacteria. Phylogenetic reconstruction of unobserved states (picrust) was used for predicting the pathways involved by cardiac microflora.

RESULTS

The resident phyla in normal were Proteobacteria, Firmicutes, Bacteroides, and Actinobacteria, and the dominant genus in normal were Halomonas, shewanella, and Comamonas. In the progression of gastric cardiac inflammation, the diversity of cardiac microflora did not change (P > 0.05). However, the composition structure of cardiac microflora varied between healthy and inflamed tissues (P < 0.05). Meanwhile, there were 64 species parallel increased with inflammation degree, especially Helicobacter pylori, Lactobacillus spp. Additionally, inflammation-related species were detected (P < 0.05), including H. pylori, Acinetobacter ursingii, and Streptococcus agalactiae. Higher H. pylori colonization was positively related to the progression of cardiac inflammation (γ coefficient = 0.678, P < 0.001), and it also influenced the cardiac microbial community structure. Cardiac microflora also participated in DNA repair pathways and is affected by the relative abundance of H. pylori (P < 0.0001).

CONCLUSIONS

Cardiac microflora dysbiosis, especially the increasing of the relevant abundance of H. pylori, promotes the progression of cardiac inflammation.

Intensive care utilization in patients with end-stage liver disease: A population-based comparative study of cohorts with and without comorbid hepatocellular carcinoma in taiwan

BACKGROUND

End-of-life intensive care may be futile and can be a cause of distress to both patients and their families. This study aimed to understand the utilization of intensive care and its associated factors in patients with End-stage liver disease (ESLD) during terminal hospitalization.

METHODS

Population-based retrospective cohort study using the National Health Institute Research Database of Taiwan. All adult patients with ESLD who died during their hospitalization in 2010-2013 were included.

FINDINGS

Of the 14,247 patients with ESLD, the majority (60·8%) was comorbid with hepatocellular carcinoma (HCC). Patients with ESLD only were younger, more deprived, more alcohol-related, and less likely to receive palliative care prior to terminal hospitalization (6·0% vs 29·2% with HCC). Compared to patients with comorbid HCC, relatively more patients without HCC were admitted to ICU (59·6% vs 22·3%), receiving CPR (11·1% vs 4·3%) and mechanical ventilation (36·3% vs 12·5%) during terminal hospitalization. Etiology of alcoholic hepatitis, esophageal varices, septicemia, pneumonia and respiratory failure, and renal failure were associated with a higher probability of ICU admission (adjusted rate ratio (aRR) range: 1·09-2·09). Prior palliative care was associated with lower probability of ICU admission (aRR range: 0·24-0·38).

INTERPRETATION

The intensive care utilization by patients with ESLD in their terminal hospitalization was substantial in Taiwan. Those who are not comorbid with HCC need more attention, especially in terms of their palliative care needs, choices regarding intensive care, and their healthcare utilization.

FUNDING

National Institute of Health Research Health Applied Research Collaboration (ARC) South London.

Statins Were Associated with a Reduced Gastric Cancer Risk in Patients with Eradicated Helicobacter Pylori Infection: A Territory-Wide Propensity Score Matched Study

BACKGROUND

Individuals may still develop gastric cancer even after Helicobacter pylori eradication. We aimed to investigate statin effect on gastric cancer development in H. pylori-eradicated subjects.

METHODS

All adult subjects who were prescribed clarithromycin-based triple therapy between 2003 and 2012 were identified in this retrospective cohort study utilizing a territory-wide electronic healthcare database. Patients were observed from index date of H. pylori therapy, and censored at gastric cancer diagnosis, death, or December 2015 (study end date). Statin use was defined as ≥180-day use after index date. Exclusion criteria included gastric cancer diagnosed within the first year after index date, previous gastric cancer or gastrectomy, and H. pylori treatment failure. Subdistribution hazard ratio (SHR) of gastric cancer with statins was calculated by competing risk regression with propensity score (PS) analysis matching 19 variables (age, sex, comorbidities, and other drug usage, including proton pump inhibitors, nonsteroidal anti-inflammatory drugs, aspirin, cyclooxygenase-2 inhibitors, and metformin).

RESULTS

During a median follow-up of 7.6 years (interquartile range = 5.1-10.3), 169 (0.27%) of 63,605 patients developed gastric cancer at an incidence rate of 3.5 per 10,000 person-years. Among 22,870 PS-matched subjects, statins were associated with a lower gastric cancer risk (SHR = 0.34; 95% confidence interval, 0.19-0.61), in a duration- and dose-response manner (P _trend < 0.05).

CONCLUSIONS

Statins were associated with a lower gastric cancer risk in a duration- and dose-response manner among H. pylori-eradicated patients.

IMPACT

This study provides evidence on the additional benefits of statins as chemopreventive agents against gastric cancer among H. pylori-eradicated patients.

Renal Effects of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Liver Cirrhosis: A Nationwide Cohort Study

Background

The use of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) carries a risk of renal function deterioration in cirrhotic patients with ascites. However, whether the long-term use of ACEis/ARBs is safe in cirrhotic patients without ascites remains unknown.

Methods

In this nationwide cohort study, we identified 311,361 newly diagnosed cirrhotic patients between January 1997 and December 2013. To avoid indication and immortal time biases, patients receiving regular ACEi/ARB therapy, defined as the ACEi/ARB cohort, were matched to patients receiving regular calcium channel blockers (CCBs), defined as the CCB cohort, at a ratio of 1 : 1 by age, sex, and propensity scores for comorbidities and medications (2,188 patients in each cohort). Cumulative incidence rates and multivariate analyses of end-stage renal disease (ESRD) risk were adjusted for competing mortality.

Results

The 10-year cumulative incidence rates of ESRD were 2.32% (95% confidence interval [CI]: 1.45–3.20) in the ACEi/ARB cohort and 1.70% (95% CI: 1.03–2.36) in the CCB cohort (P = 0.610). In multivariate analyses, ACEi/ARB use was not associated with a higher risk of ESRD in cirrhotic patients (hazard ratio [HR] = 1.15; 95% CI: 0.69–1.94, P = 0.591). In the sensitivity test, the 10-year cumulative incidence rates of ESRD in cirrhotic patients with ascites were 6.50% (95% CI: 0.54–12.46) and 1.24% (95% CI: 0.00–2.71) in ACEi/ARB and CCB cohorts, respectively (P = 0.090).

Conclusions

Long-term ACEi/ARB use was not associated with a higher risk of ESRD in cirrhotic patients. However, the risk of ESRD tended to increase in cirrhotic patients with ascites.

Helicobacter pylori infection and the risk of colorectal cancer: a nationwide population-based cohort study

BACKGROUND

The role of Helicobacter pylori (H. pylori) infection in the development of colorectal neoplasia has been a matter of scientific debate with controversial findings.

AIMS

This study examined the association between H. pylori infection and colorectal cancer (CRC) in a nationwide population-based Chinese cohort study.

METHODS

A total of approximately 3936 individuals with newly diagnosed H. pylori infection (the H. pylori-infected cohort) and 15 744 age- and sex-matched patients with diagnoses absence of H. pylori infection (the comparison cohort) from 2000 to 2005 were identified from Taiwan's National Health Insurance Research Database. The Kaplan-Meier method was used for measuring the cumulative incidence of CRC in each cohort. Cox proportional hazards models were used to compute hazard ratios (HRs) and accompanying 95% confidence intervals (CIs) for the estimation of the association between H. pylori infection and CRC.

RESULTS

The cumulative incidence of CRC was higher in H. pylori-infected cohort than that in the comparison cohort (log-rank test, P < 0.001). After adjustment for potential confounders, H. pylori infection was associated with a significantly increased risk of CRC (adjusted HR 1.87; 95% CI 1.37-2.57). In addition, the HR of CRC appeared to increase with increasing frequency of clinical visits for H. pylori infection.

CONCLUSIONS

Our study demonstrated that H. pylori infection was associated with an increased risk of CRC, which warrants confirmation and exploration of the underlying biologic mechanisms by future studies.

British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include Helicobacter pylori infection, family history of gastric cancer-in particular, hereditary diffuse gastric cancer and pernicious anaemia. The stages in the progression to cancer include chronic gastritis, gastric atrophy (GA), gastric intestinal metaplasia (GIM) and dysplasia. The key to early detection of cancer and improved survival is to non-invasively identify those at risk before endoscopy. However, although biomarkers may help in the detection of patients with chronic atrophic gastritis, there is insufficient evidence to support their use for population screening. High-quality endoscopy with full mucosal visualisation is an important part of improving early detection. Image-enhanced endoscopy combined with biopsy sampling for histopathology is the best approach to detect and accurately risk-stratify GA and GIM. Biopsies following the Sydney protocol from the antrum, incisura, lesser and greater curvature allow both diagnostic confirmation and risk stratification for progression to cancer. Ideally biopsies should be directed to areas of GA or GIM visualised by high-quality endoscopy. There is insufficient evidence to support screening in a low-risk population (undergoing routine diagnostic oesophagogastroduodenoscopy) such as the UK, but endoscopic surveillance every 3 years should be offered to patients with extensive GA or GIM. Endoscopic mucosal resection or endoscopic submucosal dissection of visible gastric dysplasia and early cancer has been shown to be efficacious with a high success rate and low rate of recurrence, providing that specific quality criteria are met.

DNA methylation silencing of microRNA gene methylator in the precancerous background mucosa with and without gastric cancer: Analysis of the effects of H. pylori eradication and long-term aspirin use

The risk of gastric cancer (GC) declines after Helicobacter pylori (H. pylori) eradication and long-term aspirin use. We evaluated the effects of H. pylori eradication (Cohort 1) and aspirin use (Cohort 2) on the methylation of microRNAs (miRNAs), such as miR-34c, miR-124a-3, miR-129-2, and miR-137, in the gastric mucosa with and without GC, i.e., in atrophic mucosal glands without intestinal metaplasia (non-IM) and intestinal metaplastic glands (IM). DNA was isolated from non-IM and IM separately using laser caption microdissection. In Cohort 1, H. pylori eradication was associated with a significant reduction of miR-124a-3 methylation only in non-IM, but not in IM. miR-129-2 methylation in non-IM may be a surrogate marker of GC in H. pylori-infected patients. In Cohort 2, aspirin did not reverse miRNA methylation in either non-IM or IM, irrespective of H. pylori infection. miR-129-2 methylation in non-IM was an independent predictive marker of GC in H. pylori-infected but not -eradicated patients. These results indicate that H. pylori eradication and aspirin use were less effective for improving methylation in IM than in non-IM; thus, these interventions are recommended at an early stage prior to the development of IM to prevent GC development. In addition, the effects of the interventions were not uniform for each miRNA gene.

Aspirin and Risk of Gastric Cancer After Helicobacter pylori Eradication: A Territory-Wide Study

Background

Despite successful H. pylori (HP) eradication, some individuals remain at risk of developing gastric cancer (GC). Previous studies showed that aspirin was associated with a reduced GC risk. However, whether aspirin can reduce GC risk in HP-eradicated subjects remains unknown. We aimed to determine the chemopreventive effect of aspirin in HP-eradicated subjects.

Methods

We identified subjects who had received a prescription of clarithromycin-based triple therapy for HP between 2003 and 2012 from a territory-wide health care database. The observation period started from commencement of HP therapy (index date), and the follow-up was censored at the end of the study (December 2015), death, or GC diagnosis. Aspirin use was defined as use once or more often weekly. Subjects who failed HP eradication or were diagnosed with GC within 12 months of HP therapy were excluded. The hazard ratio (HR) of GC with aspirin use was calculated by Cox model with Propensity Score adjustment for age, sex, comorbidities, and concurrent medications. All statistical tests were two-sided.

Results

The median follow-up was 7.6 years (interquartile range [IQR] = 5.1-10.3 years), and 169 (0.27%) out of 63 605 patients developed GC. The incidence rate of GC was 3.5 per 10 000 person-years. Aspirin use was associated with a reduced GC risk (HR = 0.30, 95% confidence interval [CI] = 0.15 to 0.61). The risk of GC decreased with increasing frequency, duration, and dose of aspirin (all Ptrend < .001).

Conclusions

Aspirin use was associated with a frequency-, dose-, and duration-dependent reduction in GC risk after HP eradication. The effect was most prominent in those who used aspirin daily or for five or more years.

Effect of aspirin use on gastric cancer incidence and survival: A systematic review and meta-analysis

Background and Aim

A number of recent studies have been published evaluating the chemopreventive effect of aspirin against gastric cancer, and an updated meta‐analysis is required to evaluate this relationship further. This study presents a meta‐analysis of studies examining the effect of aspirin on gastric cancer incidence and death.

Methods

The PUBMED and Cochrane Central Registration of Controlled Trials databases were searched for eligible studies published up to December 2018. Pooled risk ratios for gastric cancer incidence and death in aspirin users versus nonusers were determined using fixed‐ and random‐effects models. The influence of the frequency of aspirin use, duration of aspirin use, and geographic location on gastric cancer incidence was evaluated.

Results

The meta‐analysis comprised 33 studies with a total of 1 927 971 patients. The pooled risk ratios for gastric cancer incidence in the fixed‐ and random‐effects models were 0.890 (95% confidence interval, 0.871–0.909) and 0.826 (0.740–0.922), respectively. In Asia and North America, the maximum preventive benefit of aspirin use was observed with weekly or daily use. Aspirin use was most effective for noncardiac gastric cancer. The pooled risk ratios for gastric cancer death in the fixed‐ and random‐effects models were 0.798 (0.749–0.850) and 0.894 (0.780–1.024), respectively. Significant heterogeneity was observed among studies of gastric cancer incidence but not gastric cancer death.

Conclusion

Aspirin use may reduce the risk of gastric cancer incidence and death; however, the relationship may be limited to a specific frequency and duration of aspirin use and geographic location.

Application of Big Data analysis in gastrointestinal research

Big Data, which are characterized by certain unique traits like volume, velocity and value, have revolutionized the research of multiple fields including medicine. Big Data in health care are defined as large datasets that are collected routinely or automatically, and stored electronically. With the rapidly expanding volume of health data collection, it is envisioned that the Big Data approach can improve not only individual health, but also the performance of health care systems. The application of Big Data analysis in the field of gastroenterology and hepatology research has also opened new research approaches. While it retains most of the advantages and avoids some of the disadvantages of traditional observational studies (case-control and prospective cohort studies), it allows for phenomapping of disease heterogeneity, enhancement of drug safety, as well as development of precision medicine, prediction models and personalized treatment. Unlike randomized controlled trials, it reflects the real-world situation and studies patients who are often under-represented in randomized controlled trials. However, residual and/or unmeasured confounding remains a major concern, which requires meticulous study design and various statistical adjustment methods. Other potential drawbacks include data validity, missing data, incomplete data capture due to the unavailability of diagnosis codes for certain clinical situations, and individual privacy. With continuous technological advances, some of the current limitations with Big Data may be further minimized. This review will illustrate the use of Big Data research on gastrointestinal and liver diseases using recently published examples.

Trend and risk factors of recurrence and complications after arrhythmias radiofrequency catheter ablation: a nation-wide observational study in Taiwan

OBJECTIVES

This study determined the recurrence and complication rates after radiofrequency catheter ablation (RFCA) for those with paroxysmal supraventricular tachycardia (PSVT), Wolff-Parkinson-White syndrome (WPW), atrial flutter (AFL), atrial fibrillation (AF) and ventricular tachycardia (VT).

STUDY DESIGN AND SETTING

This retrospective study included RFCAs for 2001-2010 in the Taiwan National Health Insurance Research Database. Primary outcomes included perioperative complications (pericardial effusion and new-onset stroke), RFCA recurrence and long-term outcomes (high-grade atrioventricular block (AVB) and pacemaker implantation).

RESULTS

Of 19,475 patients who underwent RFCA, prevalence rates were 56.7% for PSVT, 13.5% for WPW, 9.5% for AFL, 5.1% for AF and 2.7% for VT. Prevalence rates increased in AF, AFL and VT over the study years. During an average follow-up period of 4.3 years (SD: 2.8 years), recurrence rates for PSVT, WPW, VT, AFL and AF were 2.0%, 4.9%, 5.7%, 5.8% and 16.1%, respectively. Compared with the PSVT group, the WPW and AF groups had significantly higher risk of pericardial effusion during admission (adjusted OR (aOR) 2.98, 95% CI (CI) 1.24 to 7.15; aOR 4.09, 95% CI 1.90 to 8.79, respectively); the AFL group had a higher risk of new-onset stroke during admission (aOR 4.07, 95% CI 1.39 to 11.91); the WPW group had a lower risk of high-grade AVB during follow-up (adjusted HR (aHR) 0.37, 95% CI 0.19 to 0.71) while the AFL group had a greater risk (aHR 1.74, 95% CI 1.17 to 2.60); and the AFL group had a higher risk of permanent pacemaker (aHR 2.14, 95% CI 1.27 to 3.62).

CONCLUSIONS

The RFCA rate increased rapidly during 2001-2010 for AF, AFL and VT. Recurrence was associated with congenital heart disease in PSVT and WPW, and with age in AF and AFL. AFL had a higher risk of permanent pacemaker implantation and new stroke. AF had a higher risk of life-threatening pericardial effusion.

Antithrombotic Treatment May Reduce Mortality Among New-Onset Atrial Fibrillation Patients with Gray-Zone Risk of Stroke

In clinical practice, some atrial fibrillation (AF) patients were classified as having low and moderate stroke risk by the CHADS₂ score (≤ 1) in 2001 but in 2012 they were not truly classified as low risk of stroke according to the CHA₂DS₂-VASc score (≥ 2) (defined gray zone). Therefore, a treatment gap exists in gray zone AF patients. This study aimed to evaluate whether gray zone AF patients could benefit from reduced all-cause mortality under antithrombotic treatment. This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance from January 2000 to December 2011. The new-onset AF patients consisted of a gray zone cohort with a total of 1237 patients being enrolled. The primary outcome was all-cause mortality between 2001 and 2011. Patients in the gray zone receiving antithrombotic treatment had a significant reduction in all-cause mortality [hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.16-0.28] compared with the no treatment group [warfarin only: HR, 0.28 (95% CI, 0.15-0.52); warfarin + Aspirin: HR, 0.21 (95% CI, 0.15-0.30); and Aspirin only: HR, 0.22 (95% CI, 0.16-0.29) ]. All-cause mortality was notably increased when any of the following risk factors were present: age 65-74 years, age ≥ 75 years, chronic kidney disease, and vascular disease. We concluded that AF patients in the gray zone must receive either anticoagulant and/or antiplatelet treatment and there is a lower mortality in these groups during long-term follow-up. Further investigation is needed to observe whether the antithrombotic drugs have benefits for patients with AF with a CHA₂DS₂-VASc score < 2.

Risk of cholecystectomy in morbidly obese patients after bariatric surgery in Taiwan

PURPOSE

The anatomic rearrangement of the gastrointestinal tract after bariatric surgery may result in alterations in the bile acid pool and consequently, gallstone disease. We aimed to investigate whether patients undergoing bariatric surgery are at risk of developing gallbladder disease postoperatively.

PATIENTS AND METHODS

We conducted a population-based cohort study by using claims data from the Taiwan National Health Insurance Research Database. The study cohort comprised 4197 patients diagnosed with morbid obesity.

RESULTS

Among the morbidly obese patients, 2698 underwent bariatric surgery. Females and younger subjects were more prevalent in the surgical group than non-surgical group. Bariatric surgery reduced all obesity-related comorbidities. Cox proportional hazards regression was performed, which revealed increased risk of cholecystectomy after bariatric surgery among obese patients (adjusted hazard ratio, 3.43; p=0.0165). After adjusting for sex and age, the incidence of cholecystectomy was increased in the females population (adjusted hazard ratio, 3.74; p<0.05) and in 30-64 years-old-group (adjusted hazard ratio: 3.69, p<0.05). The cumulative incidence rate of cholecystectomy showed an increased tendency in those undergoing bariatric surgery by log-rank test.

CONCLUSION

Based on the Taiwan database population-based cohort study, bariatric surgery increases the risk of cholecystectomy among morbidly obese patients, especially in the female population and patients aged 30-64 years.

Epidemiology of gastric cancer: global trends, risk factors and prevention

Gastric cancer remains one of the most common and deadly cancers worldwide, especially among older males. Based on GLOBOCAN 2018 data, stomach cancer is the 5^th most common neoplasm and the 3^rd most deadly cancer, with an estimated 783,000 deaths in 2018. Gastric cancer incidence and mortality are highly variable by region and highly dependent on diet and Helicobacter pylori infection. While strides in preventing and treating H. pylori infection have decreased the overall incidence of gastric cancer, they have also contributed to an increase in the incidence of cardia gastric cancer, a rare subtype of the neoplasm that has grown 7-fold in the past decades. A better understanding of the etiology and risk factors of the disease can help reach a consensus in approaching H. pylori infection. Dietary modification, smoking cessation, and exercise hold promise in preventing gastric cancer, while genetic testing is enabling earlier diagnosis and thus greater survival.

Cumulative Dose Threshold for the Chemopreventive Effect of Aspirin Against Gastric Cancer

OBJECTIVES

Many studies have found evidence that aspirin has protective effects against certain cancers, but quantitative dose-response data have been available only on a limited basis. This study aimed to confirm the dose-response relationship of aspirin usage and gastric cancer and to estimate the cumulative dose threshold of aspirin to achieve protective effects against gastric cancer in the general population.

METHODS

A total of 461,489 individuals in a population-based longitudinal cohort provided by the National Health Insurance Services (NHIS) in the Republic of Korea were observed from 2007 to 2012 to identify gastric cancer incident cases. The pharmacy claims data of these individuals from 2002 to 2006 were reviewed to assess cumulative medication exposure using the defined daily dose (DDD) system. Hazard ratios (HRs) of aspirin use for gastric cancer were estimated using multivariate Cox Proportional Hazard regression. Sensitivity analyses, including propensity-score matching and a nested case-control design, were performed to evaluate the variability caused by study design.

RESULTS

A total of 5674 incident gastric cancers were identified from 2,965,500 person-years of follow-up observation, giving an overall incidence rate of 191.00 gastric cancers per 100,000 person-years. Compared to non-users, those with aspirin use of ≥3 DDD-years showed a statistically significant protective effect of aspirin use against gastric cancer; the adjusted HR (95% confidence intervals) were 0.79 (0.63-0.98) and 0.63 (0.48-0.83) for those with aspirin use of 3-4 DDD-years and 4-5 DDD-years, respectively (P for trend < 0.001). Sensitivity analyses using propensity-score matching and a nested case-control design consistently showed a chemopreventive effect of aspirin.

CONCLUSION

Long-term aspirin use was associated with reduced gastric cancer incidence in the general population of South Korea when the cumulative dose was >3 DDD-years.

Risk of gastric cancer development after eradication of Helicobacter pylori

Helicobacter pylori (H. pylori) infection is the most important risk factor for gastric cancer (GC) development through the Correa’s gastric carcinogenesis cascade. However, H. pylori eradication alone does not eliminate GC, as pre-neoplastic lesions (atrophic gastritis, intestinal metaplasia and dysplasia) may have already developed in some patients. It is therefore necessary to identify patients at high-risk for gastric cancer after H. pylori eradication to streamline the management plan. If the patients have not undergone endoscopy with histologic assessment, the identification of certain clinical risk factors and non-invasive testing (serum pepsinogen) can predict the risk of atrophic gastritis. For those with suspected atrophic gastritis, further risk stratification by endoscopy with histologic assessment according to validated histologic staging systems would be advisable. Patients with higher stages may require long-term endoscopic surveillance. Apart from secondary prevention to reduce deaths by diagnosing GC at an early stage, identifying medications that could potentially modify the GC risk would be desirable. The potential roles of a number of medications have been suggested by various studies, including proton pump inhibitors (PPIs), aspirin, statins and metformin. However, there are currently no randomized clinical trials to address the impact of these medications on GC risk after H. pylori eradication. In addition, most of these studies failed to adjust for the effect of concurrent medications on GC risk. Recently, large population-based retrospective cohort studies have shown that PPIs were associated with an increased GC risk after H. pylori eradication, while aspirin was associated with a lower risk. The roles of other agents in reducing GC risk after H. pylori eradication remain to be determined.

Aspirin and non-steroidal anti-inflammatory drugs use reduce gastric cancer risk: A dose-response meta-analysis

Background

The association between non-steroidal anti-inflammatory drugs (NSAIDs) and gastric cancer (GC) risk is controversial. The aim of this study is to evaluate the chemopreventive effect of NSAIDs for GC.

Methods

A literature search was performed for relevant studies using the PubMed and Embase database (up to March 2016). Risk ratios (RRs) and 95% confidence intervals (CIs) were used as the effect measures. The dose–response analysis and subgroup analysis were also performed.

Results

Twenty-four studies were included. Our results indicated that NSAIDs could reduce GC risk (any NSAIDs: RR=0.78, 96%CI=0.72-0.85; aspirin: RR=0.70, 95%CI=0.62-0.80; non-aspirin NSAIDs: RR=0.86, 95%CI=0.80-0.94), especially for non-cardia GC risk. Moreover, the dose-response analysis indicated the risk of GC decreased by 11% and 5% for 2 years increment of any NSAIDs and aspirin use, respectively. There were nonlinear relationships between the frequency of any NSAIDs use and aspirin use and GC risk (P for non-linearity<0.01), with a threshold effect of 5 times/week. A monotonically decreasing trend was observed only for the frequency of less than 5 times/week.

Conclusions

Our results indicate that NSAIDs is inversely associated with GC risk, especially for non-cardia GC risk. NSAIDs use may become a feasible approach to prevent GC.

Prior gastroscopy and mortality in patients with gastric cancer: a matched retrospective cohort study

BACKGROUND AND AIMS

The role of prior gastroscopy on the outcome of patients with gastric cancer remains unknown. This study determines the association between intervals of prior gastroscopy and mortality in patients with gastric cancer.

METHODS

We identified 20,066 newly diagnosed patients with gastric cancer in the National Health Insurance Database of Taiwan between 2002 and 2007. After we excluded patients who had gastroscopies performed ≤6 months before the diagnosis of cancer, patients were matched into 3 cohorts according to the intervals of prior gastroscopy: 6 months to 2 years (<2 Y cohort), 2 to 5 years (2-5 Y cohort), and none within the previous 5 years (>5 Y cohort). The 3 cohorts were matched for age, curative treatment for gastric cancer, Helicobacter pylori therapy, and propensity scores comprised of sex, comorbidities, and concomitant medication usage. The primary outcome is the hazard ratio (HR) of all-cause mortality.

RESULTS

After matching, we identified 1286, 1286, and 5144 patients for the <2 Y, 2 to 5 Y, and >5 Y cohorts. Compared with the >5 Y cohort, the HR of all-cause mortality for the <2 Y and 2 to 5 Y cohorts was 0.80 (95% confidence interval [CI], 0.72-0.89; P < .001) and 0.83 (95% CI, 0.76-0.91; P < .001), respectively. The HRs of gastric cancer-specific mortality were significantly lower in the <2 Y (0.80; 95% CI, 0.71-0.91; P < .001) and 2 to 5 Y cohorts (0.83; 95% CI, 0.75-0.93; P < .001).

CONCLUSIONS

Patients with gastric cancer who had a gastroscopy performed within 5 years before the cancer diagnosis had significantly lower mortality. Our results may support the role of repeat endoscopic examination or surveillance endoscopy in selected patients.

Selective serotonin reuptake inhibitors and the risk of hepatocellular carcinoma in hepatitis B virus-infected patients

Background

This study aimed to investigate the association between the use of selective serotonin reuptake inhibitors (SSRIs) and the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B virus (HBV) infection.

Methods

We conducted a population-based cohort study by using claims data from the Taiwan National Health Insurance Research Database (NHIRD). The study cohort comprised 1380 newly diagnosed HBV-infected patients with SSRI use who were frequency matched by age, sex, liver cirrhosis, and index year with HBV-infected patients without SSRI use in the comparison cohort. Each patient case was followed from 2000 to 2012 to identify incident HCC cases. Cox proportional hazards regression was performed to evaluate the association between SSRI use and HCC risk. The further sensitivity analysis used case-control study design. A total of 9070 HCC subjects retrieved from NHIRD, and equal non-HCC subjects were analyzed after matching for age and sex.

Results

We identified 9 and 24 HCC cases in the study and comparison cohorts during the follow-up period of 7056 and 6845 person-years, respectively. The incidence rate of HCC was 1.28 and 3.51 per 1000 person-years for SSRI and non-SSRI users, respectively. After adjusting for potential confounders, the adjusted hazard ratio (HR) for SSRI use was 0.28 (95% confidence interval [CI], 0.12–0.64; p = 0.0027). For SSRI users with a cumulative defined daily dose (cDDD) of 28–89, 90–364, and ≥365, the adjusted HRs were 0.51, 0.22, and 0.12, respectively, (95% CI, 0.21–1.25, 0.05–0.94, and 0.02–0.90, respectively) compared with non-SSRI users (<28 cDDD). The sensitivity analysis showed that the SSRI presented with a dose-response protective effect for HCC in the multivariate analysis.

Conclusion

SSRIs use may possibly reduce the risk of HCC in HBV-infected patients in a dose-responsive manner.

Stroke prediction with CHA2DS2-VASc score in patients with mesenteric ischemia without atrial fibrillation-insights from a nationwide cohort

BACKGROUND

The current study sought to evaluate the accuracy of CHA₂DS₂-VASc score for ischemic stroke prediction in patients with mesenteric ischemia without atrial fibrillation (AF).

METHODS

The study participants included patients aged ≥18years with a new diagnosis of mesenteric ischemia during hospitalization between January 1, 2000 and December 31, 2011. Individuals with atrial fibrillation (AF) or atrial flutter during the study period were excluded. The study participants were followed up until the ischemic stroke appeared or they were censored due to withdrawal from this program, mortality, or the end of the study period, whichever came first. Cox proportional hazards regression models were applied for ischemic stroke risk stratification in the study participants by CHA₂DS₂-VASc score. The c-statistic based on the receiver operating characteristic (ROC) analysis was applied to investigate the accuracy of CHA₂DS₂-VASc score for ischemic stroke risk discrimination.

RESULTS

A total of 24039 study participants were enrolled. Ischemic stroke incidence increased from 1.54% in CHA₂DS₂-VASc score of 0 to 9.23% in CHA₂DS₂-VASc score of 6 or more. Moreover, the Kaplan-Meier curve with a log rank test demonstrated that patients with a higher CHA₂DS₂-VASc score were associated with an increased cumulative incidence rate of ischemic stroke during the follow-up period (p<0.001). The discriminatory performance of the CHA2DS2-VASc score resulted in C-statistics of 0.65(95% CI=0.63-0.66) for predicting ischemic stroke risk among patients with mesenteric ischemia without AF.

CONCLUSIONS

A higher CHA₂DS₂-VASc score is demonstrated to be associated with an increased risk of ischemic stroke among patients with mesenteric ischemia without comorbid AF.

The Human Stomach in Health and Disease: Infection Strategies by Helicobacter pylori

Helicobacter pylori is a bacterial pathogen which commonly colonizes the human gastric mucosa from early childhood and persists throughout life. In the vast majority of cases, the infection is asymptomatic. H. pylori is the leading cause of peptic ulcer disease and gastric cancer, however, and these outcomes occur in 10-15% of those infected. Gastric adenocarcinoma is the third most common cause of cancer-associated death, and peptic ulcer disease is a significant cause of morbidity. Disease risk is related to the interplay of numerous bacterial host and environmental factors, many of which influence chronic inflammation and damage to the gastric mucosa. This chapter summarizes what is known about health and disease in H. pylori infection, and highlights the need for additional research in this area.

Gastric adenocarcinoma

Gastric cancers, with gastric adenocarcinoma (GAC) as the most common histological type, impose a considerable global health burden. Although the screening strategies for early detection have been shown to be successful in Japan and South Korea, they are either not implemented or not feasible in most of the world, leading to late diagnosis in most patients. Helicobacter pylori infection contributes to the development of many endemic GACs, and pre-emptive eradication or early treatment of this bacterial infection might provide effective primary prevention. GACs are phenotypically and genotypically heterogeneous. Localized (clinical stage I) GAC is best treated either endoscopically or with limited surgical resection, but clinical stage II or stage III tumours require multidisciplinary adjunctive approaches in addition to surgery. Although GAC is highly treatable in its early stages, advanced (clinical stage IV) GAC has a median survival of just ∼9-10 months. However, detailed molecular and immune profiling of GAC is yielding promise; early studies with immune checkpoint inhibitors suggest that GAC is amenable to immune modulation. Molecular studies have yielded a vast quantity of new information for potential exploitation. Nevertheless, advances against GACs have lagged compared with other tumours of similar incidence, and more research is necessary to overcome the obstacles to prolong survival.

Consensus on the clinical management, screening-to-treat, and surveillance of Helicobacter pylori infection to improve gastric cancer control on a nationwide scale

BACKGROUND

Previous international consensus statements provided general policies for the management of Helicobacter pylori infection. However, there are geographic differences in the prevalence and antimicrobial resistance of H. pylori, and in the availability of medications and endoscopy. Thus, nationwide or regional consensus statements are needed to improve control of H. pylori infection and gastric cancer.

MATERIALS AND METHODS

This consensus statement for management of H. pylori in Taiwan has three major sections: (1) optimal diagnosis and indications; (2) current treatment strategies; and (3) screening-to-treat and surveillance for control of gastric cancer. The literature review emphasized recent data for development of draft statements and determination of levels of evidence. Twenty-five Taiwan experts conducted a consensus conference, by a modified Delphi process, to modify the draft statements. Consensus, defined as an agreement of least 80% of the experts, and recommendation grade were determined by anonymous voting.

RESULTS

There were 24 consensus statements. Section 1 has seven statements on recommendations for the diagnosis and indications for treatment of H. pylori infection. Section 2 has 10 statements that provide an updated treatment algorithm for first-line, second-line, and third-line regimens. Section 3 has seven statements regarding H. pylori eradication for reducing the risk of gastric cancer, with a cost-benefit analysis. After H. pylori eradication, the consensus highlights the use of endoscopic surveillance and/or chemoprevention to further reduce the burden of gastric cancer.

CONCLUSIONS

This consensus statement has updated recommendations for improving the clinical management of H. pylori infection in areas such as Taiwan, which have high prevalence of H. pylori infection and gastric cancer.

Screening and treating Helicobacter pylori infection for gastric cancer prevention on the population level

Helicobacter pylori infection is the major cause of gastric cancer, and removal of H. pylori infection from a population could theoretically decrease the number of cases by about 89%. However, in real-life settings, few studies have reported the effect of screening and treating this pathogen in population-based programs. This is mainly because of the lack of an adequate infrastructure for delivery of systematic screening services to asymptomatic individuals, the lack of standardization to ensure that each subject receives the correct diagnostic testing and antibiotic treatment, and limited resources. We illustrate our method of implementing two population-based screen-and-treat programs in Taiwan, where the epidemiological characteristics of disease burden have changed from the traditionally Eastern pattern towards that of the Western countries. Our first example is a high-risk population that resides on an offshore island, in which a strategy of mass eradication of H. pylori was applied. The other example is an intermediate-risk population, which is representative of the general average-risk population, in which there is integration of the screen-and-treat method with the established framework of colorectal cancer screening using the fecal-occult blood test. The information provided here may be useful for integration of gastric cancer prevention measures into the healthcare priorities of populations with different gastric cancer risks, such as those with limited resources.

The Effects of Anti-inflammatory Drug Treatment in Gastric Cancer Prevention: an Update of a Meta-analysis

Gastric cancer has high incidence and fatality rates, making chemoprevention agents necessary. There is an ongoing debate about aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) use can significant reduce the risk of GC. We conducted a meta-analysis of existing studies evaluating the association of anti-inflammatory drug and GC. We performed a systematic literature search of PubMed, Web of Science, Embase, OVID, Cochrane Library and Clincialtrials.gov up to August 31, 2015. Either a fixed-effects or a random-effects model using was based on the result of homogeneity analysis. Subgroup, sensitivity, meta-regression, and publication bias analyses were evaluated. Forty-seven studies were finally included in this meta-analysis. The overall GC risk reduction benefit associated with anti-inflammatory drug use represented an RR of 0.78 (95% CI 0.71 to 0.85) and an adjusted RR of 0.74 (95% CI 0.71 to 0.77). Besides, the prevention benefit of aspirin/NSAIDs ingestion appeared to be confined to those patients with regiment of short or middle-term (≤5 years), high-frequency (>30 times per month) and low dose (<200 mg per day). Further, our data also suggest that COX-2 inhibitors use is a more effective approach in GC prevention (RR, 0.45; 95% CI, 0.29-0.70). In this meta-analysis, our finding support short or middle-term (≤5 years), high-frequency (>30 times per month) and low dose (<200 mg per day) aspirin/NSAIDs intake is a well method for GC prevention and also confirm the inverse association between aspirin/NSAIDs use and GC risk. Additionally, selective COX-2 inhibitors use probably a more effective approach to reduce GC risk.

Current Perspectives on Gastric Cancer

Gastric cancer (GC) is third leading cause of cancer-related death. Only 28.3% of new GC cases survive more than 5 years. Although incidence has declined in the United States, an increase is estimated for 2016. Risk factors include sex (risk is higher in men), Helicobacter pylori infection, heredity, and lifestyle. GC is usually diagnosed between the ages of 60-80 years. Prognosis of GC is largely dependent on the tumor stage at diagnosis and classification as intestinal or diffuse type; diffuse-type GC has worse prognosis. Chemoprevention has been shown to decrease risk, but is currently not used clinically.