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Tan NKW, Tang A, MacAlevey NCYL, Tan BKJ, Oon HH. Risk of Suicide and Psychiatric Disorders Among Isotretinoin Users: A Meta-Analysis. JAMA Dermatol 2024; 160:54-62. [PMID: 38019562 PMCID: PMC10687715 DOI: 10.1001/jamadermatol.2023.4579] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/20/2023] [Indexed: 11/30/2023]
Abstract
Importance Isotretinoin is hypothesized to contribute to the development of psychiatric disorders, but the epidemiological association and risk factors associated with psychiatric disorders among isotretinoin users remain unclear. Objective To clarify the absolute and relative risk and risk factors associated with suicide and psychiatric disorders among isotretinoin users. Data Sources PubMed, Embase, Web of Science, and Scopus were searched from inception until January 24, 2023. Study Selection Randomized trials and observational studies were selected if they reported the absolute risk, relative risk, and risk factors for suicide and psychiatric disorders among isotretinoin users. Data Extraction and Synthesis Relevant data were extracted and risk of bias was evaluated at the study level using the Newcastle-Ottawa Scale. Data were pooled using inverse variance-weighted meta-analyses. Heterogeneity was measured using the I2 statistic, and meta-regression analyses were performed. Main Outcomes and Measures Absolute risk (percentage), relative risks (risk ratios [RR]), and risk factors (RR) of suicide and psychiatric disorders among isotretinoin users. Results A total of 25 studies including 1 625 891 participants were included in the review and 24 in the meta-analysis. Among the included studies, participants' average age ranged from 16 to 38 years, and distribution by sex ranged from 0% to 100% male. The 1-year pooled absolute risk from between 2 and 8 studies of completed suicide, suicide attempt, suicide ideation, and self-harm were each less than 0.5%, while that of depression was 3.83% (95% CI, 2.45-5.93; I2 = 77%) in 11 studies. Isotretinoin users were less likely than nonusers to attempt suicide at 2 years (RR, 0.92; 95% CI, 0.84-1.00; I2 = 0%), 3 years (RR, 0.86; 95% CI, 0.77-0.95; I2 = 0%), and 4 years (RR, 0.85; 95% CI, 0.72-1.00; I2 = 23%) following treatment. Isotretinoin was not associated with the risk of all psychiatric disorders (RR, 1.08; 95% CI, 0.99-1.19; I2 = 0%). Study-level meta-regression found that studies with participants of older age reported lower 1-year absolute risk of depression, while those with a higher percentage of male participants reported a higher 1-year absolute risk of completed suicide. Conclusions and Relevance The findings suggest that at a population level, isotretinoin users do not have increased risk of suicide or psychiatric conditions but may instead have a lower risk of suicide attempts at 2 to 4 years following treatment. While these findings are reassuring, clinicians should continue to practice holistic psychodermatologic care and monitor patients for signs of mental distress during isotretinoin treatment.
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Affiliation(s)
- Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Adelina Tang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Hazel H. Oon
- National Skin Centre and Skin Research Institute, Singapore
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Teo YH, Tan BKJ, Tan NKW, Yap DWT, Chai YX, Teo YN, Sia CH, Sundar R, Tan E, See A, Toh ST. Obstructive sleep apnea and the incidence and mortality of gastrointestinal cancers: a systematic review and meta-analysis of 5,120,837 participants. J Gastrointest Oncol 2022; 13:2789-2798. [PMID: 36636076 PMCID: PMC9830329 DOI: 10.21037/jgo-22-153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 08/12/2022] [Indexed: 12/29/2022] Open
Abstract
Background Emerging evidence has shown higher overall cancer incidence in patients with obstructive sleep apnea. Gastrointestinal cancers, including esophageal, stomach, liver, pancreas, and colorectal cancers account for 26% of incident cancers. However, the link between gastrointestinal cancers and obstructive sleep apnea is still unclear. We performed a systematic review and meta-analysis (registered PROSPERO CRD42021220836) to investigate the association between obstructive sleep apnea and incidence of gastrointestinal cancer. Methods We searched four electronic databases (PubMed, Embase, Cochrane Library, Scopus) and included studies published from inception till 15th November 2020 reporting the association of obstructive sleep apnea with gastrointestinal cancer incidence. Extracted data was meta-analyzed in a random-effects model. Results A total of seven studies were included, forming a combined cohort of 5,120,837 patients. Studies which adjusted for demographics and comorbidities were included in meta-analysis. Among four studies with 7-11 years of median follow-up, patients with obstructive sleep apnea experienced increased incidence of colorectal cancer (HR 1.70, 95% CI: 1.48-1.96, I2=22%). Pancreatic cancer incidence was nominally increased in three studies (HR 1.36, 95% CI: 0.88-2.09, I2=96), though this was not statistically significant. There was no association between obstructive sleep apnea and liver cancer incidence among three studies (HR 0.99, 95% CI: 0.81-1.22, I2=84). However, the lack of a statistically significant relationship between obstructive sleep apnea and pancreatic cancer in our meta-analysis does not necessarily imply the true absence of an association. Conclusions An increased risk of colorectal cancer was seen in patients with obstructive sleep apnea among studies with long-term follow-up. Further research is required to explore the utility of incorporating obstructive sleep apnea screening into colorectal cancer screening guidelines to identify high-risk individuals and to confirm a possible association of obstructive sleep apnea with pancreatic cancer. PROSPERO Registration CRD42021220836.
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Affiliation(s)
- Yao Hao Teo
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Benjamin Kye Jyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Dominic Wei Ting Yap
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Yi Xuen Chai
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Yao Neng Teo
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore;,Department of Cardiology, National University Health System, Singapore, Singapore
| | - Raghav Sundar
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Emile Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Anna See
- Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital, Singapore, Singapore;,Surgery Academic Clinical Program, SingHealth, Singapore, Singapore
| | - Song Tar Toh
- Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital, Singapore, Singapore;,Surgery Academic Clinical Program, SingHealth, Singapore, Singapore;,Duke-NUS Sleep Centre, SingHealth, Singapore, Singapore
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Tan BKJ, Han R, Zhao JJ, Tan NKW, Quah ESH, Tan CJW, Chan YH, Teo NWY, Charn TC, See A, Xu S, Chapurin N, Chandra RK, Chowdhury N, Butowt R, von Bartheld CS, Kumar BN, Hopkins C, Toh ST. Prognosis and persistence of smell and taste dysfunction in patients with covid-19: meta-analysis with parametric cure modelling of recovery curves. BMJ 2022; 378:e069503. [PMID: 35896188 PMCID: PMC9326326 DOI: 10.1136/bmj-2021-069503] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To clarify in patients with covid-19 the recovery rate of smell and taste, proportion with persistent dysfunction of smell and taste, and prognostic factors associated with recovery of smell and taste. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, Scopus, Cochrane Library, and medRxiv from inception to 3 October 2021. REVIEW METHODS Two blinded reviewers selected observational studies of adults (≥18 years) with covid-19 related dysfunction of smell or taste. Descriptive prognosis studies with time-to-event curves and prognostic association studies of any prognostic factor were included. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data, evaluated study bias using QUIPS, and appraised evidence quality using GRADE, following PRISMA and MOOSE reporting guidelines. Using iterative numerical algorithms, time-to-event individual patient data (IPD) were reconstructed and pooled to retrieve distribution-free summary survival curves, with recovery rates reported at 30 day intervals for participants who remained alive. To estimate the proportion with persistent smell and taste dysfunction, cure fractions from Weibull non-mixture cure models of plateaued survival curves were logit transformed and pooled in a two stage meta-analysis. Conventional aggregate data meta-analysis was performed to explore unadjusted associations of prognostic factors with recovery. MAIN OUTCOME MEASURES The primary outcomes were the proportions of patients remaining with smell or taste dysfunction. Secondary outcomes were the odds ratios of prognostic variables associated with recovery of smell and taste. RESULTS 18 studies (3699 patients) from 4180 records were included in reconstructed IPD meta-analyses. Risk of bias was low to moderate; conclusions remained unaltered after exclusion of four high risk studies. Evidence quality was moderate to high. Based on parametric cure modelling, persistent self-reported smell and taste dysfunction could develop in an estimated 5.6% (95% confidence interval 2.7% to 11.0%, I2=70%, τ2=0.756, 95% prediction interval 0.7% to 33.5%) and 4.4% (1.2% to 14.6%, I2=67%, τ2=0.684, 95% prediction interval 0.0% to 49.0%) of patients, respectively. Sensitivity analyses suggest these could be underestimates. At 30, 60, 90, and 180 days, respectively, 74.1% (95% confidence interval 64.0% to 81.3%), 85.8% (77.6% to 90.9%), 90.0% (83.3% to 94.0%), and 95.7% (89.5% to 98.3%) of patients recovered their sense of smell (I2=0.0-77.2%, τ2=0.006-0.050) and 78.8% (70.5% to 84.7%), 87.7% (82.0% to 91.6%), 90.3% (83.5% to 94.3%), and 98.0% (92.2% to 95.5%) recovered their sense of taste (range of I2=0.0-72.1%, τ2=0.000-0.015). Women were less likely to recover their sense of smell (odds ratio 0.52, 95% confidence interval 0.37 to 0.72, seven studies, I2=20%, τ2=0.0224) and taste (0.31, 0.13 to 0.72, seven studies, I2=78%, τ2=0.5121) than men, and patients with greater initial severity of dysfunction (0.48, 0.31 to 0.73, five studies, I2=10%, τ2<0.001) or nasal congestion (0.42, 0.18 to 0.97, three studies, I2=0%, τ2<0.001) were less likely to recover their sense of smell. CONCLUSIONS A substantial proportion of patients with covid-19 might develop long lasting change in their sense of smell or taste. This could contribute to the growing burden of long covid. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021283922.
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Affiliation(s)
| | - Ruobing Han
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joseph J Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Emrick Sen Hui Quah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Jing-Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Neville Wei Yang Teo
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Tze Choong Charn
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Sengkang General Hospital, Singapore
| | - Anna See
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Sengkang General Hospital, Singapore
| | - Shuhui Xu
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Nikita Chapurin
- Department of Otorhinolaryngology-Head and Neck Surgery, Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Rakesh K Chandra
- Department of Otorhinolaryngology-Head and Neck Surgery, Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Naweed Chowdhury
- Department of Otorhinolaryngology-Head and Neck Surgery, Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Rafal Butowt
- Department of Molecular Cell Genetics, L Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - B Nirmal Kumar
- Wigan and Leigh Teaching NHS Foundation Trust, Wrightington, UK
- Edge Hill University Medical School, Orsmkirk, UK
| | - Claire Hopkins
- Department of Otorhinolaryngology-Head and Neck Surgery, Guy's and St Thomas' Hospitals, London, UK
- King's College, London, UK
| | - Song Tar Toh
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
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Kye Wen Tan N, Jing-Wen C, Kye Jyn Tan B, Han R, Zhao JJ, Sen Hui Quah E, Kelly C, Wei Yang Teo N, See A, Toh ST, Hopkins C. The burden of prolonged smell and taste loss in covid-19. BMJ 2022; 378:o1895. [PMID: 35896196 DOI: 10.1136/bmj.o1895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | | | - Benjamin Kye Jyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Ruobing Han
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Joseph J Zhao
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Emrick Sen Hui Quah
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | | | - Neville Wei Yang Teo
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital (SGH), Singapore
| | - Anna See
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital (SGH), Singapore
- Department of Otorhinolaryngology-Head & Neck Surgery, Sengkang General Hospital (SKH), Singapore
| | - Song Tar Toh
- Surgery Academic Clinical Program, SingHealth, Singapore
- Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital (SGH), Singapore
| | - Claire Hopkins
- Department of Otorhinolaryngology-Head & Neck Surgery, Guy's and St Thomas' Hospitals, London, United Kingdom
- King's College, London, United Kingdom
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Tan BKJ, Tan NKW, Teo YH, Yap DWT, Raghupathy J, Gao EY, Toh ST, See A. Association of obstructive sleep apnea with thyroid cancer incidence: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2022; 279:5407-5414. [PMID: 35708764 DOI: 10.1007/s00405-022-07457-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is a postulated carcinogen based on epidemiological associations with all-cancer incidence and non-thyroid biological models. However, associations with thyroid carcinoma are unclear. METHODS We included observational/randomized studies of associations of OSA with thyroid carcinoma incidence/mortality in adults, from four databases. Random-effects meta-analyses and the population attributable fraction (PAF; from published global OSA prevalence estimates) were computed. RESULTS We included four observational studies (N = 2,839,325), all with moderate/low risk of bias. OSA diagnosis was associated with twofold incidence of thyroid carcinoma (pooled HR 2.32, 95% CI 1.35-3.98, I2 = 95%), after multi-adjustment for demographics, BMI, smoking, alcohol, and comorbidities. Subgroup analysis of studies with at least 5 years of follow-up showed a stronger association of OSA with thyroid cancer incidence (pooled HR 3.27, 95% CI 2.80-3.82, I2 = 0%). Up to 14.5% (95% CI 4.29-27.6%) of incident thyroid carcinomas globally may be associated with OSA. Thyroid carcinoma mortality data was unavailable. CONCLUSIONS OSA is associated with higher thyroid carcinoma incidence, though this does not prove causation. Biological/clinical studies should investigate OSA severity in relation to thyroid carcinoma progression and mortality, stratified by tumor histology.
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Affiliation(s)
- Benjamin Kye Jyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Dominic Wei Ting Yap
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Jaivikash Raghupathy
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Esther Yanxin Gao
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Song Tar Toh
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital (SGH), Outram Road, Singapore, 169608, Singapore.,Surgery Academic Clinical Program, SingHealth, Singapore, Singapore
| | - Anna See
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital (SGH), Outram Road, Singapore, 169608, Singapore. .,Surgery Academic Clinical Program, SingHealth, Singapore, Singapore.
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Tan BKJ, Teo YH, Tan NKW, Yap DWT, Sundar R, Lee CH, See A, Toh ST. Association of obstructive sleep apnea and nocturnal hypoxemia with all-cancer incidence and mortality: a systematic review and meta-analysis. J Clin Sleep Med 2022; 18:1427-1440. [PMID: 34755597 PMCID: PMC9059590 DOI: 10.5664/jcsm.9772] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVES Biological models suggest that obstructive sleep apnea (OSA) is potentially carcinogenic. We aimed to clarify the inconsistent epidemiological literature by considering various traditional and novel OSA severity indices. METHODS We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for observational or randomized studies of associations of OSA, measured by diagnostic codes or any index, each with all-cancer incidence or mortality in adults, compared with participants with no/mild OSA. Two reviewers independently selected studies, extracted data, and evaluated study bias using the Newcastle-Ottawa scale and quality of evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). We performed inverse variance-weighted, random-effects meta-analyses and sensitivity analyses. RESULTS We included 20 observational studies (5,340,965 participants), all with moderate/low bias, from 1,698 records. Based on T90 (sleep duration with oxygen saturation < 90%), patients with OSA who had moderate (T90 > 1.2%, hazard ratio [HR] = 1.28, 95% confidence interval [CI] = 1.07-1.54) and severe nocturnal hypoxemia (T90 > 12%, HR = 1.43, 95% CI = 1.16-1.76) experienced 30%-40% higher pooled all-cancer risk than normoxemic patients, after multiple adjustment for covariates including obesity. Furthermore, severe nocturnal hypoxemia nearly tripled all-cancer mortality (HR = 2.66, 95% CI = 1.21-5.85). Patients with apnea-hypopnea index-defined severe OSA, but not moderate OSA, had higher all-cancer risk (HR = 1.18, 95% CI = 1.03-1.35) but similar all-cancer mortality as patients without OSA. An OSA diagnosis was not associated with all-cancer risk. Evidence quality ranged from low to moderate. Insufficient evidence was available on the oxygen desaturation index, lowest/median saturation, and arousal index. CONCLUSIONS In patients with OSA, nocturnal hypoxemia is independently associated with all-cancer risk and mortality. Future studies should explore if risk differs by cancer type, and whether cancer screening and OSA treatment are beneficial. SYSTEMATIC REVIEW REGISTRATION Registry: PROSPERO; URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220836; Identifier: CRD42021220836. CITATION Tan BKJ, Teo YH, Tan NKW, et al. Association of obstructive sleep apnea and nocturnal hypoxemia with all-cancer incidence and mortality: a systematic review and meta-analysis. J Clin Sleep Med. 2022;18(5):1427-1440.
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Affiliation(s)
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Raghav Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Hematology-Oncology, National University Cancer Institute, National University Hospital, Singapore,Cancer and Stem Cell Biology Program, Duke-National University of Singapore Medical School, Singapore,The N.1 Institute for Health, National University of Singapore, Singapore,Singapore Gastric Cancer Consortium
| | - Chi Hang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Cardiology, National University Health System, Singapore
| | - Anna See
- Department of Otorhinolaryngology–Head and Neck Surgery, Singapore General Hospital, Singapore,Surgery Academic Clinical Program, SingHealth, Singapore,Address correspondence to: Song Tar Toh, MBBS, MMed (ORL), MMed (Sleep Medicine), FAMS (ORL), Department of Otorhinolaryngology–Head and Neck Surgery, Singapore General Hospital, Outram Road, Singapore 169608; Tel: +65 6222 3322; ; and Anna See, MBBS, MMed (ORL), Department of Otorhinolaryngology–Head and Neck Surgery, Singapore General Hospital, Outram Road, Singapore 169608; Tel: +65 6222 3322;
| | - Song Tar Toh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Otorhinolaryngology–Head and Neck Surgery, Singapore General Hospital, Singapore,Surgery Academic Clinical Program, SingHealth, Singapore,SingHealth Duke-NUS Sleep Centre, SingHealth, Singapore,Address correspondence to: Song Tar Toh, MBBS, MMed (ORL), MMed (Sleep Medicine), FAMS (ORL), Department of Otorhinolaryngology–Head and Neck Surgery, Singapore General Hospital, Outram Road, Singapore 169608; Tel: +65 6222 3322; ; and Anna See, MBBS, MMed (ORL), Department of Otorhinolaryngology–Head and Neck Surgery, Singapore General Hospital, Outram Road, Singapore 169608; Tel: +65 6222 3322;
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Tan BKJ, Ng FYC, Song HJJMD, Tan NKW, Ng LS, Loh WS. Associations of Hearing Loss and Dual Sensory Loss With Mortality: A Systematic Review, Meta-analysis, and Meta-regression of 26 Observational Studies With 1 213 756 Participants. JAMA Otolaryngol Head Neck Surg 2022; 148:220-234. [PMID: 34967895 PMCID: PMC8719275 DOI: 10.1001/jamaoto.2021.3767] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Hearing loss (HL) and dual sensory loss (DSL) are prevalent, disabling, and associated with numerous age-related health conditions, including dementia and frailty. To date, no evidence-based summary of their mortality risk is available. OBJECTIVE To clarify the epidemiological associations between HL/DSL and mortality. DATA SOURCES PubMed, Embase, and Cochrane Library, from inception until June 18, 2021. STUDY SELECTION Two blinded reviewers selected observational or interventional studies, published as full-length English articles in peer-reviewed journals, that reported the presence or severity of HL or DSL (ie, comorbid HL and vision loss), whether objectively measured or self-reported, in association with any mortality estimate, among adults 18 years and older. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data and evaluated study bias using the Newcastle-Ottawa Scale, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)/Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and a PROSPERO-registered protocol. The analysis pooled maximally adjusted estimates using mixed-effects models, measured heterogeneity using I2, investigated sources of heterogeneity using meta-regression and subgroup meta-analyses, examined and adjusted for publication bias, performed influence and cumulative meta-analyses, and assessed evidence quality using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. MAIN OUTCOMES AND MEASURES Hazard ratios (HRs) for all-cause, cardiovascular, or other mortality estimates. RESULTS This review included 14 retrospective and 12 prospective observational studies (1 213 756 participants) from 3220 records. Risk of bias was low to moderate; exclusion of 3 high-risk studies did not alter conclusions. Hearing loss was associated with excess all-cause mortality (HR, 1.13; 95% CI, 1.07-1.19; I2 = 77%; n = 21; 95% prediction interval [PI], 0.93-1.37) and cardiovascular mortality (HR, 1.28; 95% CI, 1.10-1.50; I2 = 60%; n = 6; 95% PI, 0.84-1.96), while DSL was associated with larger excess risks (all-cause: HR, 1.40; 95% CI, 1.30-1.51; I2 = 34%; n = 10; 95% PI, 1.18-1.66; cardiovascular: HR, 1.86; 95% CI, 1.31-2.65; I2 = 0%; n = 2), after adjustment for demographics and comorbidities. Prespecified meta-regression sufficiently explained heterogeneity, with longer follow-up duration weakening the pooled association, leaving low (29%) residual heterogeneity. Meta-regression among audiometric studies showed a dose-response association (doubling of HR per 30-dB increase in HL). Self-reported and audiometric effect sizes were similar, with lower heterogeneity in the latter. Associations were robust to trim-and-fill adjustment for publication bias and single-study influence and cumulative meta-analyses. Associations with accident/injury, cancer, and stroke mortality were inconclusive, with only 1 to 3 studies. Overall evidence quality was moderate. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, HL and DSL were associated with excess all-cause and cardiovascular mortality. Physicians caring for patients with HL should consider its relevance to general health and longevity.
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Affiliation(s)
- Benjamin Kye Jyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Faye Yu Ci Ng
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | | | - Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Li Shia Ng
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore,Department of Otolaryngology–Head & Neck Surgery, National University Health System (NUHS), Singapore
| | - Woei Shyang Loh
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore,Department of Otolaryngology–Head & Neck Surgery, National University Health System (NUHS), Singapore
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Yap DWT, Tan NKW, Tan BKJ, Teo YH, Tan VKM, See A, Toh ST. The Association of Obstructive Sleep Apnea With Breast Cancer Incidence and Mortality: A Systematic Review and Meta-analysis. J Breast Cancer 2022; 25:149-163. [PMID: 35380020 PMCID: PMC9250875 DOI: 10.4048/jbc.2022.25.e11] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/08/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Emerging evidence from animal models suggests that intermittent hypoxia due to obstructive sleep apnea (OSA) is a risk factor for breast cancer. Despite their biological plausibility, human epidemiological studies have reported conflicting results. Therefore, we conducted a meta-analysis to delineate this relationship. Methods We searched the PubMed, Embase, Scopus, and Cochrane Library databases for eligible studies from inception until June 6, 2021. Two reviewers selected randomized trials or observational studies reporting the association between OSA and breast cancer incidence compared with those without OSA. Two reviewers extracted relevant data and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and Newcastle-Ottawa Scale (NOS). We pooled the maximally covariate-adjusted hazard ratios (HRs) using a random-effects inverse variance-weighted meta-analysis and performed pre-specified subgroup analyses. Results We included six studies out of 1,707 records, comprising a combined cohort of 5,165,200 patients. All studies used the International Classification of Diseases codes to classify OSA and breast cancer. OSA patients had a 36% increased breast cancer risk (HR, 1.36; 95% confidence interval [CI], 1.03–1.80; N = 6, I2 = 96%) compared to those without OSA. Most studies adjusted for confounders, such as age, sex, obesity, diabetes mellitus, alcohol use, and hypertension. Subgroup analyses for studies with (1) multivariate adjustment and (2) at least five years of follow-up yielded HRs of 1.35 (95% CI, 0.98–1.87; N = 5, I2 = 96%) and 1.57 (95% CI, 1.14–2.18; N = 4; I2 = 90%), respectively. One Mendelian randomization study suggested a causal relationship, with a two-fold increase in the odds of breast cancer in patients with OSA. Conclusion This meta-analysis suggested that OSA is a risk factor for breast cancer. Future studies should explore the dose-response relationship between OSA and breast cancer, and whether treatment may mitigate breast cancer risk or progression.
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Affiliation(s)
- Dominic Wei Ting Yap
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Benjamin Kye Jyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Veronique Kiak Mien Tan
- Department of Breast Surgery, Singapore General Hospital (SGH), Singapore
- Division of Surgery & Surgical Oncology, National Cancer Centre Singapore
- SingHealth Duke-NUS Breast Centre, SingHealth, Singapore
| | - Anna See
- Department of Otorhinolaryngology–Head & Neck Surgery, Singapore General Hospital (SGH), Singapore
| | - Song Tar Toh
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
- Department of Otorhinolaryngology–Head & Neck Surgery, Singapore General Hospital (SGH), Singapore
- SingHealth Duke-NUS Sleep Centre, SingHealth, Singapore
- Duke-NUS Medical School, Singapore
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Tan NKW, Yap DWT, Tan BKJ, Teo YH, Tan EKH, Chan JY, Lee HY, See A, Toh ST. The association of obstructive sleep apnea with melanoma incidence and mortality: a meta-analysis of 5,276,451 patients. Sleep Med 2021; 88:213-220. [PMID: 34794048 DOI: 10.1016/j.sleep.2021.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/21/2021] [Accepted: 10/23/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Melanoma is the most aggressive and lethal form of skin cancer. While emerging in-vivo evidence suggests that intermittent hypoxia, a hallmark feature of obstructive sleep apnea (OSA), may induce melanoma tumorigenesis, the epidemiological association between OSA and melanoma has been inconsistent. METHODS We performed a literature search of PubMed, Embase, Scopus and Cochrane Library from inception until 6 June 2021. Two reviewers independently selected randomized trials or observational studies that reported the association of OSA with melanoma incidence or mortality in adults, in comparison to participants with no OSA. Two reviewers independently extracted relevant data and assessed the quality of evidence using the GRADE framework and the Newcastle-Ottawa Scale (NOS). We pooled data using an inverse variance-weighted meta-analysis and ran pre-specified subgrourp analyses. RESULTS The meta-analysis included six studies out of 1897 records, comprising a combined cohort of 5,276,451 patients. All studies were adjusted for covariates, with majority of studies adjusting for age (N=5) and sex (N = 4). Compared to those without OSA, patients with OSA had 71% higher pooled hazards of melanoma (HR = 1.71; 95% CI: 1.08-2.69, I2 = 99%). Subgroup analyses for studies with (1) median follow-up duration of at least five years, (2) prospective study design, (3) adjustment for obesity yielded HRs of 1.88 (95%CI:1.32-2.67, N = 5), 1.11 (95%CI:0.77-1.60, N = 2) and 1.52 (95%CI:0.75-3.08, N = 3) respectively. One study investigating the relationship between OSA and melanoma mortality detected no association. There were insufficient studies to assess publication bias. CONCLUSIONS Meta-analysis of mainly retrospective observational studies, with significant heterogeneity, suggests increased melanoma incidence in OSA patients. Future studies should prospectively explore the differential risk of melanoma for varying OSA severity, and whether timely OSA treatment may mitigate this risk.
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Affiliation(s)
- Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Dominic Wei Ting Yap
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Benjamin Kye Jyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | | | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Anna See
- Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital (SGH), Singapore
| | - Song Tar Toh
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore; Department of Otorhinolaryngology-Head & Neck Surgery, Singapore General Hospital (SGH), Singapore; SingHealth Duke-NUS Sleep Centre, SingHealth, Singapore; Duke-NUS Medical School, Singapore.
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