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Mazzetto R, Sernicola A, Miceli P, Tartaglia J, Ciolfi C, Alaibac M. Anti-tumor immunity and vitiligo: from immune-related adverse reactions to protection from cancer. Immunotherapy 2024; 16:841-843. [PMID: 39058397 DOI: 10.1080/1750743x.2024.2377954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Affiliation(s)
- Roberto Mazzetto
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padova, 35121, Italy
| | - Alvise Sernicola
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padova, 35121, Italy
| | - Paola Miceli
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padova, 35121, Italy
| | - Jacopo Tartaglia
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padova, 35121, Italy
| | - Christian Ciolfi
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padova, 35121, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padova, 35121, Italy
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2
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Siwicki RL, Shore J, Norman RA. Vitiligo and Prostate Cancer Correlation. Cureus 2024; 16:e59349. [PMID: 38817459 PMCID: PMC11137641 DOI: 10.7759/cureus.59349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
A 72-year-old male with a history of systemic hypertension, asthma, chronic obstructive pulmonary disease (COPD), and hyperlipidemia presents with diffuse patches of cutaneous depigmentation. A shave biopsy of different regions of depigmented skin indicated vitiligo. The patient was prescribed Opzelura (ruxolitinib) 1.5% topical cream as well as tacrolimus 0.1% topical ointment for vitiligo. He also had a history of prostate cancer. A prostate biopsy revealed three sites of prostatic adenocarcinoma with a Gleason score of 6 and a Prostate Imaging-Reporting and Data System (PI-RADS) score of 2. The patient remained in active surveillance for prostate cancer without treatment, due to its low severity. A subsequent biopsy five years later revealed a decrease in prostate cancer prevalence, with cancer present in only one core and at a lower severity. The purpose of this case presentation is to discuss possible links between vitiligo and prostate cancer, as well as their shared mechanisms and pathways.
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Affiliation(s)
| | - Jeremy Shore
- Medical School, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Robert A Norman
- Dermatology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
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3
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Rooker A, Ouwerkerk W, Bekkenk MW, Luiten RM, Bakker WJ. The Risk of Keratinocyte Cancer in Vitiligo and the Potential Mechanisms Involved. J Invest Dermatol 2024; 144:234-242. [PMID: 37791932 DOI: 10.1016/j.jid.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 10/05/2023]
Abstract
Although light skin types are associated with increased skin cancer risk, a lower incidence of both melanoma and nonmelanoma skin cancer (NMSC) has been reported in patients with vitiligo. We performed a systematic review and meta-analysis on the NMSC risk in patients with vitiligo, indicating a reduced relative risk ratio of NMSC in vitiligo. Furthermore, we propose a series of hypotheses on the underlying mechanisms, including both immune-mediated and nonimmune-mediated pathways. This study reveals insights into the relationship between vitiligo and keratinocyte cancer and can also be used to better inform patients with vitiligo.
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Affiliation(s)
- Alex Rooker
- Department of Dermatology and Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Wouter Ouwerkerk
- Department of Dermatology and Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Marcel W Bekkenk
- Department of Dermatology and Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands; VU University of Amsterdam, Amsterdam, The Netherlands
| | - Rosalie M Luiten
- Department of Dermatology and Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands.
| | - Walbert J Bakker
- Department of Dermatology and Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
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4
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Sirka CS, Sethy M, Rout AN. Actinic keratoses and squamous cell carcinoma limited to photo-exposed skin in vitiligo vulgaris in pigmented skin type. BMJ Case Rep 2024; 17:e255306. [PMID: 38286583 PMCID: PMC10826530 DOI: 10.1136/bcr-2023-255306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Abstract
Vitiligo skin has a lesser number of photoprotective melanocytes-theoretically, there is a higher risk of development of non-melanoma skin cancers in such patients. But most studies in Caucasian patients have shown decreased incidence of non-melanoma skin cancers in patients with vitiligo. In Indian patients, there is a paucity of literature on such adverse events. We report a case of actinic keratoses, cutaneous horn with dysplasia and squamous cell carcinoma developing exclusively over photo-exposed vitiligo lesions in an Indian woman in her 60s (housewife, Fitzpatrick skin type V and average daily photo-exposure time 2-4 hours) of long-standing vitiligo vulgaris without any history of phototherapy. The photoprotected lesional skin was completely normal with no clinically appreciable enlarged regional lymph nodes. Shave and elliptical excision of the suspicious lesions were done, and histopathology showed various degrees of malignant transformation in various lesions. The patient was started on topical imiquimod for the lesions of actinic keratoses and was referred for staging and wide excision of squamous cell carcinoma lesion. We report this case for its rarity and to emphasise the fact that there is a need for counselling for lifestyle modification in patients with vitiligo as the use of sunscreens is often not practised by Indian patients due to financial constraints and physical measures such as using full sleeves, high-collared dresses and scarves should be encouraged.
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Affiliation(s)
- Chandra Sekhar Sirka
- Dermatology and Venereology, All India Institute of Medical Sciences - Bhubaneswar, Bhubaneswar, Orissa, India
| | - Madhusmita Sethy
- Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Arpita Nibedita Rout
- Dermatology and Venereology, All India Institute of Medical Sciences - Bhubaneswar, Bhubaneswar, Orissa, India
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5
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Mueller E, Shaik Z, Addepalli D, Malik S, Schiefelbein P. Obstructing Stage IV Adenocarcinoma of the Transverse Colon in a Young Patient With Vitiligo. Cureus 2023; 15:e42679. [PMID: 37649943 PMCID: PMC10464542 DOI: 10.7759/cureus.42679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/29/2023] [Indexed: 09/01/2023] Open
Abstract
Advanced colorectal cancer, while uncommon, can occur in a young patient. We present a rare case of advanced transverse colon cancer in a young patient with vague symptoms and unique comorbid conditions, while reviewing the literature on colorectal cancer and its association with autoimmune conditions. With a recent increase in the incidence of colon cancer in young patients, further research is needed as to whether colorectal cancer screening is warranted in younger cohorts outside of current recommendations and guidelines. Investigations are needed into the factors that may explain this and the public health interventions that can be employed to improve colon cancer prevention. The objective of this report is to highlight the importance of recognizing alarming symptoms and raise awareness of the increasing incidence of early-onset colon cancer in young patients.
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Affiliation(s)
- Ellie Mueller
- Medical School, New York Institute of Technology College of Osteopathic Medicine, Jonesboro, USA
| | - Zeba Shaik
- Medical School, New York Institute of Technology College of Osteopathic Medicine, Jonesboro, USA
| | - David Addepalli
- Medical School, New York Institute of Technology College of Osteopathic Medicine, Jonesboro, USA
| | - Sara Malik
- Medical School, New York Institute of Technology College of Osteopathic Medicine, Jonesboro, USA
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6
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Ferolito B, do Valle IF, Gerlovin H, Costa L, Casas JP, Gaziano JM, Gagnon DR, Begoli E, Barabási AL, Cho K. Visualizing novel connections and genetic similarities across diseases using a network-medicine based approach. Sci Rep 2022; 12:14914. [PMID: 36050444 PMCID: PMC9436158 DOI: 10.1038/s41598-022-19244-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/26/2022] [Indexed: 11/08/2022] Open
Abstract
Understanding the genetic relationships between human disorders could lead to better treatment and prevention strategies, especially for individuals with multiple comorbidities. A common resource for studying genetic-disease relationships is the GWAS Catalog, a large and well curated repository of SNP-trait associations from various studies and populations. Some of these populations are contained within mega-biobanks such as the Million Veteran Program (MVP), which has enabled the genetic classification of several diseases in a large well-characterized and heterogeneous population. Here we aim to provide a network of the genetic relationships among diseases and to demonstrate the utility of quantifying the extent to which a given resource such as MVP has contributed to the discovery of such relations. We use a network-based approach to evaluate shared variants among thousands of traits in the GWAS Catalog repository. Our results indicate many more novel disease relationships that did not exist in early studies and demonstrate that the network can reveal clusters of diseases mechanistically related. Finally, we show novel disease connections that emerge when MVP data is included, highlighting methodology that can be used to indicate the contributions of a given biobank.
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Affiliation(s)
- Brian Ferolito
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA.
| | - Italo Faria do Valle
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
- Center for Complex Network Research, Department of Physics, Northeastern University, Boston, 02115, USA
| | - Hanna Gerlovin
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
| | - Lauren Costa
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
| | - Juan P Casas
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
- Brigham and Women's Hospital, Division of Aging, Department of Medicine, Harvard Medical School, Boston, 02115, USA
| | - J Michael Gaziano
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
- Brigham and Women's Hospital, Division of Aging, Department of Medicine, Harvard Medical School, Boston, 02115, USA
| | - David R Gagnon
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
- School of Public Health, Department of Biostatistics, Boston University, Boston, 02215, USA
| | - Edmon Begoli
- Oak Ridge National Laboratory, Oak Ridge, 37830, USA
| | - Albert-László Barabási
- Center for Complex Network Research, Department of Physics, Northeastern University, Boston, 02115, USA
| | - Kelly Cho
- VA Boston Healthcare System, Massachusetts Veterans Epidemiology and Research Information Center, (MAVERIC), 150 S. Huntington Avenue, Boston, 02130, USA
- Brigham and Women's Hospital, Division of Aging, Department of Medicine, Harvard Medical School, Boston, 02115, USA
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7
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Wu YH, Chou CL, Chang HC. Risk of skin cancer after ultraviolet phototherapy in patients with vitiligo: A systematic review and meta-analysis. Clin Exp Dermatol 2021; 47:692-699. [PMID: 34762747 DOI: 10.1111/ced.15010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although ultraviolet (UV) phototherapy is an effective treatment for vitiligo, its effect on skin cancer risk remains controversial. OBJECTIVES This study aimed to investigate the association between UV phototherapy and skin cancer risk in patients with vitiligo. METHODS A systematic review was performed for studies published before May 5, 2021, in the PubMed, Embase, Web of Science, and Cochrane Library databases. The primary outcome was the association of UV phototherapy with the risk of skin cancer in patients with vitiligo. A meta-analysis with a random-effects model was conducted. RESULTS Five retrospective cohort studies with 110,038 patients with vitiligo receiving UV phototherapy and 118,569 patients not receiving phototherapy were included in the meta-analysis. The risk of nonmelanoma skin cancer (Mantel-Haenszel risk ratio [MHRR], 0.950; 95% confidence interval [CI], 0.441-2.046) and melanoma (MHRR, 1.114; 95% CI, 0.325-3.823) did not significantly increase after phototherapy in patients with vitiligo. In the subgroup analysis, we also found no significant association between phototherapy with narrowband UVB and risk of skin cancer in patients with vitiligo. These results of no elevated risk for skin cancer after phototherapy did not change in patients from Europe and Asia. The risk was also not affected by the number of narrowband UVB phototherapy sessions. CONCLUSIONS The findings of this systematic review and meta-analysis suggest that UV phototherapy is safe treatment for vitiligo with no significant risk of skin cancer.
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Affiliation(s)
- Y-H Wu
- Department of Dermatology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - C-L Chou
- Department of Dermatology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan.,Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - H-C Chang
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan.,Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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8
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Weng YC, Ho HJ, Chang YL, Chang YT, Wu CY, Chen YJ. Reduced risk of skin cancer and internal malignancies in vitiligo patients: a retrospective population-based cohort study in Taiwan. Sci Rep 2021; 11:20195. [PMID: 34642421 PMCID: PMC8511292 DOI: 10.1038/s41598-021-99786-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022] Open
Abstract
The relationship between cancer and vitiligo has been explored but with inconsistent results. To examine the long-term cancer risk in vitiligo patients, we conducted a retrospective nationwide cohort study. From the National Health Insurance Research Database of Taiwan, a total of 13,824 vitiligo patients were identified and matched with 55,296 reference subjects without vitiligo by age, gender, and propensity score estimated by major comorbidities from 1997 to 2013. Demographic characteristics and comorbidities were compared between these two groups. Incidence rate ratios and hazard ratios (HRs) were calculated to examine cancer risks. The 16-year incidence rates of overall cancers were 621.06 (566.56–675.55) and 726.99 (697.24–756.74) per 100,000 person-years in the vitiligo and reference groups. Patients with vitiligo showed a significantly decreased risk of overall cancers [adjusted HR, 0.85; 95% confidence interval (CI), 0.77 to 0.93, p < 0.001] compared with reference subjects without vitiligo after adjusting for age, sex, comorbidities, and treatments. The risks of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) were significantly reduced (adjusted HR 0.21, 95% CI 0.11–0.38, p < 0.001), as well as internal malignancies (adjusted HR 0.89, 95% CI 0.81–0.99, p = 0.026). The results were consistent across different subgroups of patients, including male gender, ages more than 40 years, and those receiving long-term systemic disease-modifying antirheumatic drugs and phototherapies. Information related to phenotype, disease duration, vitiligo lesion sites, family history of vitiligo or cancer, occupation, and personal lifestyle was not included in the database. Vitiligo is associated with reduced risks of BCC and SCC, as well as internal malignancies.
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Affiliation(s)
- Yu-Ching Weng
- Department of Dermatology, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Taichung, 407, Taiwan
| | - Hsiu J Ho
- Institute of Biomedical Informatics, Institute of Public Health, National Yang-Ming University, No. 155, Section 2, Linong Street, Taipei, 11221, Taiwan
| | - Yi-Ling Chang
- Department of Dermatology, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Taichung, 407, Taiwan
| | - Yun-Ting Chang
- Faculty of Medicine and Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Ying Wu
- Institute of Biomedical Informatics, Institute of Public Health, National Yang-Ming University, No. 155, Section 2, Linong Street, Taipei, 11221, Taiwan. .,Faculty of Medicine and Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Division of Translational Research and Center of Excellence for Cancer Research, Taipei Veterans General Hospital, Taipei, Taiwan. .,Department of Public Health, China Medical University, Taichung, Taiwan. .,National Institute of Cancer Research, National Health Research Institutes, Miaoli, Taiwan.
| | - Yi-Ju Chen
- Department of Dermatology, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Taichung, 407, Taiwan. .,Faculty of Medicine and Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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9
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Li CY, Dai YX, Chang YT, Bai YM, Tsai SJ, Chen TJ, Chen MH. Proton Pump Inhibitors Are Associated with Increased Risk of Psoriasis: A Nationwide Nested Case-Control Study. Dermatology 2021; 237:884-890. [PMID: 34474411 DOI: 10.1159/000517515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/31/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are among the most widely used drugs. Little is known about the association between PPI use and risk of psoriasis. OBJECTIVE To investigate the association between PPI use and subsequent psoriasis risk. METHODS We included participants from the Taiwan National Health Insurance Research Database. Patients with PPI use and an incidence of psoriasis (n = 5,756) were assigned to the case cohort and 1:1 matched to controls. PPI use was defined as >30 cumulative defined daily doses (cDDDs); PPI nonuse was defined as ≤30 cDDDs. Logistic regression was used for the analyses. RESULTS There was a significant association between PPI use and psoriasis risk. The confounder-adjusted odd ratios (95% confidence interval [CI]) were 1.52 (1.31-1.76) and 1.54 (1.22-1.93) for patients with 120-365 cDDDs and >365 cDDDs, respectively, compared with PPI nonusers. Stratified analyses based on PPI type showed that exposure to lansoprazole (OR, 1.25; 95% CI, 1.11-1.41) was associated with subsequent psoriasis risk. CONCLUSIONS PPI use might be associated with an increased risk of developing psoriasis or as an epiphenomenon. Further prospective studies are needed to elucidate the association and underlying mechanisms.
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Affiliation(s)
- Cheng-Yuan Li
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ying-Xiu Dai
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yun-Ting Chang
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Mei Bai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jen Tsai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mu-Hong Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
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Li CY, Dai YX, Chang YT, Bai YM, Tsai SJ, Chen TJ, Chen MH. Prenatal exposure to acetaminophen increases the risk of atopic dermatitis in children: A nationwide nested case-control study in Taiwan. Pediatr Allergy Immunol 2021; 32:1080-1088. [PMID: 33544946 DOI: 10.1111/pai.13465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/31/2020] [Accepted: 02/02/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acetaminophen (APAP) has been associated with the development of atopic diseases. However, little is known about the relationship between prenatal APAP exposure and atopic dermatitis (AD) in offspring. OBJECTIVE To investigate the association between prenatal APAP exposure and AD risk in offspring. METHODS In this study, 2029 study pairs (AD-affected children and their mothers) and 5,058 control pairs were identified between 1998 and 2008 from the Taiwan Longitudinal Health Insurance Database. Maternal APAP exposure during pregnancy was assessed. RESULTS After adjustment for potential confounders, there was a significant association between risk of offspring AD and exposure to acetaminophen in the first trimester (OR 1.16; 95% CI 1.05-1.28), the second trimester (OR 1.14; 95% CI 1.03-1.27), both first and second trimesters (OR 1.30; 95% CI 1.13-1.51), both first and third trimester (OR 1.20; 95% CI 1.04-1.39), any trimester (OR 1.12; 95% CI 1.00-1.26), and all three trimesters (OR 1.32; 95% CI 1.08-1.62) in a dose-response manner. CONCLUSIONS Prenatal exposure to acetaminophen was associated with an increased incidence of offspring AD.
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Affiliation(s)
- Cheng-Yuan Li
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ying-Xiu Dai
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yun-Ting Chang
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Mei Bai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jen Tsai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mu-Hong Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
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11
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Bulat V, Likic R, Bradic L, Speeckaert R, Azdajic MD. Pembrolizumab-induced vitiligo in a patient with lung adenocarcinoma: A case report. Br J Clin Pharmacol 2020; 87:2614-2618. [PMID: 33217043 DOI: 10.1111/bcp.14663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 12/24/2022] Open
Abstract
Pembrolizumab is an immune checkpoint inhibitor designed to block the interaction between programmed cell death-1 and programmed cell death-ligands 1 and 2. It shows efficacy in the treatment of patients with advanced nonsmall-cell lung cancer, among others. Side effects may involve immune-related adverse events, including vitiligo. We hereby present a 63-year-old Caucasian female with metastatic nonsmall-cell lung cancer. Immunohistochemical analysis showed programmed death-ligand 1 expression on 100% of tumour cells. The patient was eligible for immunotherapy and received pembrolizumab every 3 weeks as the first-line treatment. Three months after initiation of immunotherapy with pembrolizumab, depigmentation appeared on her upper right thoracic area of the skin overlying the affected lung lobe. Immunotherapy was generally well tolerated. Excellent response in our subject with complete remission during 16 months of follow-up potentially indicates that cutaneous immune-related adverse events, such as vitiligo, might be associated with increased efficacy of pembrolizumab in metastatic lung adenocarcinoma.
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Affiliation(s)
- Vedrana Bulat
- Department of Dermatology and Venereology, University Hospital Centre Sestre Milosrdnice, Vinogradska cesta, Zagreb, 29, Croatia
| | - Robert Likic
- University of Zagreb School of Medicine, Zagreb, Croatia.,Associate Professor, Division for Clinical Pharmacology and Therapeutics, Department of Internal Medicine University Hospital Centre Zagreb, Kispaticeva 12, Zagreb, Croatia
| | - Lada Bradic
- Department of Cardiology, University Hospital Centre Zagreb, Kispaticeva 12, Zagreb, Croatia
| | - Reinhart Speeckaert
- Department of Dermatology, Ghent University Hospital; De Pintelaan 185, Ghent, Belgium
| | - Marija Delas Azdajic
- Department of Dermatology and Venereology, University Hospital Centre Sestre Milosrdnice, Vinogradska cesta, Zagreb, 29, Croatia
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12
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Wen Y, Wu X, Peng H, Li C, Jiang Y, Liang H, Zhong R, Liu J, He J, Liang W. Cancer risks in patients with vitiligo: a Mendelian randomization study. J Cancer Res Clin Oncol 2020; 146:1933-1940. [PMID: 32462299 DOI: 10.1007/s00432-020-03245-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Few studies have investigated the relationship between vitiligo and risks of various types of cancers, especially those other than skin cancer. Conventional observational studies are susceptible to potential confounders and inverse causation. With a Mendelian randomization approach, we were able to evaluate the causality between vitiligo and different cancer risks. METHODS 37 vitiligo-related single-nucleotide polymorphisms identified by the published genome-wide association studies were used as instrumental variables in our study. Summary data of individual-level genetic information were obtained from corresponding studies and cancer consortia. A total of 246,706 cases and 1,021,154 controls were included. The inverse variance-weighted method was applied to estimate the causation between vitiligo and different cancers. RESULTS The results revealed that vitiligo patients were at lower risks of lung cancer [odds ratio (OR) 0.9513; 95% confidence interval (CI) 0.9174-0.9864; p = 0.0070], breast cancer (OR 0.9827; 95% CI 0.9659-0.9997; p = 0.0468), ovarian cancer (OR 0.9474; 95% CI 0.9271-0.9682; p < 0.001), melanoma (OR 0.9983; 95% CI 0.9976-0.9990; p < 0.001), non-melanoma skin cancer (OR 0.9997; 95% CI 0.9995-0.9999; p < 0.001), kidney cancer (OR 0.9998; 95% CI 0.9996-1.0000; p = 0.0212), and liver cancer (OR 0.9999; 95% CI 0.9999-1.0000; p = 0.0441), while no correlation was observed for other cancer types. CONCLUSIONS Vitiligo was causally associated with reduced risks of several cancers, suggesting that vitiligo-associated autoimmune process might play a role in the suppression of cancer.
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Affiliation(s)
- Yaokai Wen
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China.,Nanshan School, Guangzhou Medical University, Jingxiu Road, Panyu District, Guangzhou, 511436, China
| | - Xiangrong Wu
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China.,Nanshan School, Guangzhou Medical University, Jingxiu Road, Panyu District, Guangzhou, 511436, China
| | - Haoxin Peng
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China.,Nanshan School, Guangzhou Medical University, Jingxiu Road, Panyu District, Guangzhou, 511436, China
| | - Caichen Li
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China
| | - Yu Jiang
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China.,Nanshan School, Guangzhou Medical University, Jingxiu Road, Panyu District, Guangzhou, 511436, China
| | - Hengrui Liang
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China
| | - Ran Zhong
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China
| | - Jun Liu
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China.,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China
| | - Jianxing He
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China. .,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China. .,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China. .,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China.
| | - Wenhua Liang
- Department of Thoracic Surgery and Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China. .,State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China. .,National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China. .,Guangzhou Institute of Respiratory Health, Guangzhou, 510120, China.
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13
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Abstract
Background Vitiligo is a depigmentation disorder associated with genetic loss of melanocytes and decreased melanin synthesis. The current literature is conflicting in regard to vitiligo patients' risk of cutaneous malignant melanoma and keratinocyte cancer. Objective To investigate the risk of cutaneous malignant melanoma and keratinocyte cancer in vitiligo patients. Methods We conducted a population-based study, including 2,339 subjects with a first-time vitiligo diagnosis between 1994 and 2017 and 23,293 age- and sex-matched (1:10) controls. To address surveillance bias, we included 12,380 subjects with a first-time diagnosis of lichen planus. Results Age was the only significant factor for cutaneous malignant melanoma in comparison of vitiligo with controls and lichen planus (hazard ratio 1.04, 95% confidence interval [CI] 1.03-1.05; and hazard ratio 1.02, 95% CI 1.01-1.04, respectively). Similarly, age was a significant factor for keratinocyte cancer in comparison of vitiligo with controls and lichen planus (hazard ratio 1.07, 95% CI 1.06-1.07; and hazard ratio 1.06, 95% CI 1.05-1.07). Male sex was an additional factor for keratinocyte cancer in comparison of vitiligo with lichen planus (hazard ratio 1.38; 95% CI 1.09-1.75). Phototherapy did not increase the risk of receiving a diagnosis of cutaneous malignant melanoma or keratinocyte cancer in the vitiligo cohort. Conclusion We observed no significant difference in cutaneous malignant melanoma or keratinocyte cancer risk among vitiligo subjects. Phototherapy use was not associated with a higher skin cancer risk in vitiligo compared with other skin diseases.
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14
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Chen CY, Wang WM, Chung CH, Tsao CH, Chien WC, Hung CT. Increased risk of psychiatric disorders in adult patients with vitiligo: A nationwide, population-based cohort study in Taiwan. J Dermatol 2020; 47:470-475. [PMID: 32124495 DOI: 10.1111/1346-8138.15290] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/05/2020] [Indexed: 01/26/2023]
Abstract
Vitiligo is an autoimmune skin disease that has a major impact on the quality of life of patients. However, a nationwide study of the association between vitiligo and the incidence of inclusive psychiatric diseases has not been conducted in the Asian population. Therefore, this study aimed to analyze the association between vitiligo and the risk of psychiatric disorders using a nationwide database in Taiwan. Data were collected from the National Health Insurance Research Database of Taiwan from 2000 to 2013. In total, 1432 subjects with vitiligo and 5728 age-, sex- and index year-matched controls were enrolled in this study. Patients with vitiligo tend to have more coexisting psychiatric disorders than healthy individuals, regardless of their sex, age group and facility level of care. After adjusting for sex, age, comorbidity, urbanization and facility level of care, the adjusted hazard ratio of overall psychiatric disorders for patients with vitiligo was 2.926 (95% confidence interval [CI], 2.646-3.236; P < 0.001). Among them, the highest adjusted hazard ratios were found for obsessive-compulsive disorder, at 10.790 (95% CI, 9.756-11.932; P < 0.001). Vitiligo is associated with an increased risk of various psychiatric disorders. By providing a better understanding of the psychosocial burden associated with vitiligo, these results emphasize the need to evaluate the mental health of patients with vitiligo by treating physicians.
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Affiliation(s)
- Chih-Yu Chen
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ming Wang
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Chang-Huei Tsao
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Department of Microbiology and Immunology, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Tsung Hung
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
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15
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Huraib GB, Al Harthi F, Arfin M, Aljamal A, Alrawi AS, Al-Asmari A. Association of Functional Polymorphism in Protein Tyrosine Phosphatase Nonreceptor 22 (PTPN22) Gene with Vitiligo. Biomark Insights 2020; 15:1177271920903038. [PMID: 32076368 PMCID: PMC7003175 DOI: 10.1177/1177271920903038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/08/2020] [Indexed: 12/27/2022] Open
Abstract
The protein tyrosine phosphatase nonreceptor 22 (PTPN22) is associated with susceptibility to autoimmune diseases. The functional polymorphism in PTPN22 at 1857 is a strong risk factor for vitiligo susceptibility in Europeans; however, controversy exits in other populations. Present study was aimed to determine whether the PTPN22 C1857T polymorphism confers susceptibility to vitiligo in Saudi Arabians. Genomic DNA was extracted and amplified using tetra primer amplification-refractory mutation system polymerase chain reaction (ARMS-PCR) method. The frequencies of allele T and genotype CT of PTPN22 C1858T polymorphism were significantly higher, whereas those of allele C and genotype CC were lower in patients as compared with controls (P < 0.0001). The genotype TT was absent in both the patients and controls. It is concluded that PTPN22 C1858T polymorphism is strongly associated with vitiligo susceptibility. However, additional studies are warranted using large number of samples from different ethnicities and geographical areas.
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Affiliation(s)
| | - Fahad Al Harthi
- Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Misbahul Arfin
- Scientific Research Center, Medical Services Department for Armed Forces, Riyadh, Saudi Arabia
| | - Abdulrahman Aljamal
- Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Abdulrahman Al-Asmari
- Scientific Research Center, Medical Services Department for Armed Forces, Riyadh, Saudi Arabia
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16
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Chen CC, Dai YX, Yeh CP. Efficacy and safety of tofacitinib therapy in Asian patients with severe alopecia areata. DERMATOL SIN 2020. [DOI: 10.4103/ds.ds_26_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Siddiqui MAR, Hussain SZM, Mubarak M. Iris metastasis as the initial presentation of upper gastrointestinal tract carcinoma: a case report. J Med Case Rep 2019; 13:367. [PMID: 31831049 PMCID: PMC6909480 DOI: 10.1186/s13256-019-2303-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/24/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND We report a case of a patient with iris metastasis as the initial manifestation of a systemic cancer: upper gastrointestinal tract carcinoma. CASE PRESENTATION A 24-year-old Asian man presented to our hospital with complaints of red left eye, decreased visual acuity, pain, and photophobia for about 3 weeks with no prior history of cancer or any other medical abnormality. Ocular examination showed a pinkish white lesion on the superonasal part of the iris. The patient's intraocular pressure was progressively increasing despite medications, followed by lymphadenopathy 4 weeks later. Comprehensive examination was performed along with a complete systemic workup, which detected systemic malignancy. Histopathology and immunohistochemistry revealed signet ring cells, which indicated an upper gastrointestinal tract tumor as a primary source of iris metastasis. The systemic condition of the patient deteriorated rapidly thereafter and led to his death in the 12th week of the disease. CONCLUSION A red eye with iris lesions in otherwise healthy individuals should be considered as a possible initial manifestation of underlying systemic malignancy. Prompt referral of such patients to an oncologist is warranted.
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Affiliation(s)
- M A Rehman Siddiqui
- Section of Ophthalmology, Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan. .,Department of Ophthalmology, Shahzad Eye Hospital, Karachi, Pakistan. .,Department of Ophthalmology, South City Hospital, Karachi, Pakistan.
| | - Syed Zohaib Maroof Hussain
- Section of Ophthalmology, Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Muhammed Mubarak
- Javed I. Kazi Department of Histopathology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan
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18
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Affiliation(s)
- S Gran
- University of Nottingham School of Medicine, Centre of Evidence Based Dermatology, King's Meadow Campus, Nottingham, U.K
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19
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Dai YX, Hsu MC, Hu HY, Chang YT, Chen TJ, Li CP, Wu CY. The Risk of Mortality among Psoriatic Patients with Varying Severity: A Nationwide Population-Based Cohort Study in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15122622. [PMID: 30467301 PMCID: PMC6313446 DOI: 10.3390/ijerph15122622] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 11/16/2018] [Accepted: 11/19/2018] [Indexed: 02/08/2023]
Abstract
Background: Previous studies showed conflicting results regarding the mortality risk in psoriasis patients with respect to disease severity and presence of psoriatic arthritis. This study aimed to determine the mortality risk in patients with mild and severe psoriasis and patients with psoriatic arthritis (PsA). Methods: A nationwide population-based cohort study was conducted based on data from the Taiwan National Health Insurance Research Database between 2002 and 2012. Incident psoriasis subjects were classified into two groups: psoriasis without arthritis and psoriasis with arthritis. Patients who had received systemic therapy and/or phototherapy were classified as having severe psoriasis; otherwise, patients were classified as having mild psoriasis. Control subjects without psoriasis were selected to match each psoriasis patient from the database within the same observational period. Cox proportional hazards analysis was used to compare the hazard ratio (HR) of time to death. Results: A total of 106,701 patients with psoriasis were included in this study. After controlling for demographics and comorbidities, psoriasis patients had a higher mortality risk compared with the control group (HR 1.41; 95% confidence interval (CI) 1.36 to 1.46). Compared with psoriasis alone, the mortality risk was not increased for PsA (HR = 1.01; 95% CI 0.93 to 1.10). Besides, severe psoriasis did not increase mortality risk compared with mild psoriasis (HR = 1.0; 95% CI 0.95 to 1.06). Conclusions: Patients with psoriasis had a higher mortality risk compared with control subjects, whereas psoriasis severity and presence of PsA had no impact on mortality risk in psoriasis patients.
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Affiliation(s)
- Ying-Xiu Dai
- Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
| | - Ming-Chun Hsu
- Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
| | - Hsiao-Yun Hu
- Institute of Public Health and Department of Public Health, National Yang-Ming University, Taipei 11217, Taiwan.
- Department of Education and Research, Taipei City Hospital, Taipei 10341, Taiwan.
| | - Yun-Ting Chang
- Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
| | - Tzeng-Ji Chen
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
| | - Chung-Pin Li
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
| | - Chen-Yi Wu
- Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
- Institute of Public Health and Department of Public Health, National Yang-Ming University, Taipei 11217, Taiwan.
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