Effects of Helicobacter pylori treatment on the incidences of autoimmune diseases and inflammatory bowel disease in patients with diabetes mellitus.

BACKGROUND: Helicobacter pylori infection is known to decrease the incidences of autoimmune diseases and inflammatory bowel disease(IBD). Our aim was investigating the effect of H. pylori treatment in diabetes mellitus(DM) patients.
METHODS: Adults with newly-diagnosed H. pylori infection or peptic ulcer disease(PUD) within the general population and DM population were identified from the National Health Insurance Research Database of Taiwan from 2000-2010. 79,181 patients were assigned to the 3 groups: general population with PUD without H. pylori treatment(PUD-HPRx in general population), DM patients with PUD without H. pylori treatment(PUD-HPRx in DM), and DM patients with PUD who received H. pylori treatment(PUD+HPRx in DM).
RESULTS: Higher incidences of autoimmune diseases and IBD were observed in the PUD+HPRx in DM group than in the PUD-HPRx in general population and PUD-HPRx in DM groups (autoimmune diseases = 5.14% vs 3.47% and 3.65%; IBD = 5.60% vs 3.17% and 3.25%; P<0.0001). A lower all-cause mortality was noted in the PUD+HPRx in DM group (HR: 0.937, P<0.001) than in the PUD-HPRx in DM group. Trends of a higher incidence of IBD and a lower mortality in younger patients in the PUD+HPRx in DM group compared with the PUD-HPRx in DM group were noted.
CONCLUSIONS: The results revealed that H. pylori treatment increased the incidences of autoimmune diseases and IBD and decreased the all-cause mortality in the DM group with PUD. The effect was more significant in younger patients. This finding assists in realizing the influence of H. pylori treatment in the DM population.

Introduction

Helicobacter pylori is known to be one of the most common chronic bacterial infection in humans. Based on regional prevalence estimates, there were around 4.4 billion individuals with H. pylori infection worldwide in 2015, and over half of the world’s population is infected [1]. Evidence suggests that H. pylori plays a protective role against several autoimmune diseases. For example, protective effects of H. pylori against multiple sclerosis [2], asthma [3, 4], and systemic lupus erythematosus [5] have been reported. A recent study even found that an extract of H. pylori effectively inhibited mucus production and various features of inflammation in mice with repeated exposure to house dust mites [6].

An increasing incidence of inflammatory bowel disease (IBD) has been observed in H. pylori endemic regions after widespread eradication of H. pylori [7]. There exists evidence to suggest a negative association between H. pylori infection and inflammatory bowel disease (IBD) [8]. A recent study also indicated that H. pylori infection is associated with less fistulizing or stricturing and less-active colitis in Crohn’s disease (CD) [9].

Hypotheses regarding the mechanism of protection of H. pylori infection have been proposed, including induction of intestinal interleukin (IL)-10 and IL-18-mediated regulatory T cell responses [10] [11]. Several bacterial factors that dampen the immune response of the host were identified, including VacA, CagA, and H. pylori lipopolysaccharide [12-14]. Rad et al. found that those infected with H. pylori expressed higher levels of Foxp3, which is a regular T cell marker [15]. Depletion of regulatory T cells leads to more severe gastric inflammation and decreases bacterial colonization. Another study revealed that peripheral memory T cells decreased in people infected with H. pylori. This reinforced the hypothesis that circulating regulatory T cells in H. pylori-infected hosts may exert a protective effect against autoimmune diseases and IBD [16]. Lin et al. [17] investigated the effects of treatment for H. pylori infection on the incidences of autoimmune diseases and IBD, and concluded that treatment for H. pylori infection is associated with significant increases in the incidences of autoimmune diseases and IBD.

Diabetic mellitus (DM) and H. pylori infection are both common in Taiwan. The aim of this study was to determine the effects of H. pylori treatment on patients with diabetes.

Materials and methods

Data collection

The content and the execution of the current study were approved by the institutional review board of Kaohsiung Medical University Hospital (KMUHIRB-SV(I)-20200018). All methods were carried out in accordance with the guidelines and regulations. Because the analysis was based on de-identified secondary data, individual consent was not required. The consent waiver was approved by the Research Ethics Committee of approved by institutional review board of Kaohsiung Medical University Hospital.

Data from a general population consisting of patients over 18 years of age with newly-diagnosed H. pylori infection or peptic ulcer disease (PUD) from 2000–2010, without a prior diagnosis of autoimmune diseases or IBD, were collected from the National Health Insurance Research Database (NHIRD) in Taiwan. Data of patients with DM were collected from the Longitudinal Cohort of Diabetes Patients, which included patients with a diagnosis code indicating DM or those who were prescribed anti-diabetic agents during admission or at an outpatient department. One-hundred and twenty-thousand patients were randomly sampled from newly-diagnosed DM cases every year, and their medical records obtained from the Longitudinal Cohort of Diabetes Patients.

These patients were assigned to the general population or DM group accordingly. The general population patients did not receive H. pylori treatment therapy. The DM patients were classified into a group with peptic ulcer disease (PUD) that received treatment for H. pylori infection (PUD+HPRx) and a group with PUD without H. pylori treatment (PUD–HPRx) (Fig 1).

Fig 1

Flow chart of the study design.

PUD+HPRx, peptic ulcer disease with Helicobacter pylori treatment; PUD-HPRx, peptic ulcer disease without Helicobacter pylori treatment; DM, diabetes mellitus; AD, autoimmune disease; IBD, inflammatory bowel disease.

Subjects were considered to have received H. pylori treatment if they were given a course of either triple or quadruple therapy for more than 7 days [17]. H. pylori test results for diagnosis or treatment eradication are not available in the NHIRD.

Autoimmune diseases were defined according to International Statistical Classification of Diseases and Related Health Problems 9th Revision (ICD-9) codes as follows: lupus erythematosus (710.0), systemic sclerosis (710.1), rheumatoid arthritis (714.30–714.33), polymyositis (710.4), dermatomyositis (710.3), vasculitis (446.0, 446.2, 446.4, 446.5, 443.1, 446.7, 446.1), pemphigus (694.4), and Sicca syndrome (710.2).

IBD was defined according to ICD-9 codes for Crohn’s disease (555.x) and chronic ulcerative colitis (556.x). We added a primary outcome of IBD treated with asacol or azathioprine in order to provide a more strict definition.

Inclusion criteria

Patients included in this study met the following criteria: newly-diagnosed H. pylori infection or peptic ulcer disease (PUD) between 2000 and 2010; ICD-9 code for H. pylori (041.86) or PUD (531–533) recorded; received treatment for H. pylori infection between 2000 and 2010, with a first treatment date after the study entry date (first date of new diagnosis).

Exclusion criteria

Patients were excluded from our study if they were aged under 18 years on the date of study entry, had missing insurance enrollment data, received H. pylori treatment (in the control group), had a first diagnosis of autoimmune diseases, IBD or a defined event prior to the index date (first date of treatment), or incorrect death information. Index dates were randomly assigned to patients who did not receive H. pylori treatment.

The person-years of follow-up were estimated from the index date plus a two-year washout duration to the date of diagnosis of autoimmune diseases or IBD, or an end date of December 31, 2010. We used the two-year washout duration to eliminate the effect of previous H. pylori treatment in patients with PUD who received treatment for H. pylori infection (PUD+HPRx).

Statistical analysis

Total 713,641 subjects were included and classified to the 3 study cohorts(PUD-HPRx in general population, PUD-HPRx in DM, and PUD+HPRx in DM). PUD-HPRx in general population group and PUD-HPRx in DM group were matched to PUD+HPRx in DM group using propensity score matching by age, sex, income, comorbidities, and Charlson comorbidity index score. Subjects of the 3 groups after matching were PUD-HPRx in general population group (n = 48,542), PUD-HPRx in DM group(n = 48,737), and PUD+HPRx in DM group(n = 48,737) (Table 1).

Table 1

Demographic data of PUD+HPRx and PUD-HPRx in DM and general population post-propensity score-matching.

	PUD-HPRx in GP	PUD+HPRx in DM	PUD-HPRx in DM
N	48,541	48,737	48,737	p-value
Age in years (Mean±SD)*	58.30 (±14.50)	58.11 (±14.12)	58.23 (±14.24)	0.129
Age categories (N, %)
<35	2,462 (5.07%)	2,511 (5.15%)	2,510 (5.15%)	0.0613
35–44	5,682 (11.71%)	5,817 (11.94%)	5,815 (11.93%)
45–54	11,599 (23.90%)	11,800 (24.21%)	11,802 (24.22%)
55–64	11,652 (24.00%)	11,898 (24.41%)	11,898 (24.41%)
65+	17,146 (35.32%)	16,711 (34.29%)	16,712 (34.29%)
Gender (N, %)*
Female	26,509 (54.61%)	26,857 (55.11%)	26,854 (55.10%)	0.2059
Male	22,032 (45.39%)	21,880 (44.89%)	21,883 (44.90%)
Income status (N, %)*
Dependent	12,278 (25.29%)	12,201 (25.03%)	12,199 (25.03%)	0.2106
<20,000	12,799 (26.37%)	12,645 (25.95%)	12,647 (25.95%)
20,000–40,000	16,920 (34.86%)	17,099 (35.08%)	17,100 (35.09%)
≥ 40,000	6,544 (13.48%)	6,792 (13.94%)	6,791 (13.93%)
Comorbidities (N, %)
Hypertension *	21,991 (45.30%)	22,059 (45.26%)	22,053 (45.25%)	0.9838
Hyperlipidemia*	18,981 (39.10%)	19,228 (39.45%)	19,228 (39.45%)	0.4362
Myocardial infraction	926 (1.91%)	815 (1.67%)	815 (1.67%)	0.0054
Congestive heart failure	2,226 (4.59%)	2,282 (4.68%)	2,258 (4.63%)	0.7741
Peripheral vascular disease	867 (1.79%)	782 (1.60%)	778 (1.60%)	0.0326
Cerebral vascular disease	5,692 (11.73%)	4,641 (9.52%)	5,300 (10.87%)	< .0001
Dementia	992 (2.04%)	806 (1.65%)	919 (1.89%)	< .0001
Chronic kideney disease	3,020 (6.22%)	2,548 (5.23%)	2,633 (5.40%)	< .0001
Cancer*	3,228 (6.65%)	3,248 (6.66%)	3,238 (6.64%)	0.9914
Charlson’s Index Score (Mean±SD)	1.99 (±1.75)	1.99 (±1.71)	2.01 (±1.75)	0.4738
Charlson’s Index Categories (N, %)*
0	6,868 (14.15%)	6,854 (14.06%)	6,856 (14.07%)	0.8841
1–2	16,036 (33.04%)	15,973 (32.77%)	15,974 (32.78%)
3	12,116 (24.96%)	12,157 (24.94%)	12,155 (24.94%)
> = 4	13,521 (27.85%)	13,753 (28.22%)	13,752 (28.22%)
Medication (N, %)
Metformin	18,461 (38.03%)	43,147 (88.53%)	41,014 (84.15%)	< .0001
Sulfonylurea	19,101 (39.35%)	43,940 (90.16%)	41,846 (85.86%)	< .0001
DPP4 inhibitor	1,850 (3.81%)	5,704 (11.70%)	4,913 (10.08%)	< .0001
Insulin	9,500 (19.57%)	20,856 (42.79%)	19,617 (40.25%)	< .0001
NSAIDs*	41,493 (85.48%)	41,749 (85.66%)	41,751 (85.67%)	0.642
Antiplatelet agent	6,394 (13.17%)	7,207 (14.79%)	6,277 (12.88%)	< .0001
Warfarin	488 (1.01%)	439 (0.90%)	467 (0.96%)	0.2438
Protom pump inhibitor	22,189 (45.71%)	40,232 (82.55%)	26,823 (55.04%)	< .0001
H2-receptor antagonist	38,746 (79.82%)	46,259 (94.92%)	40,514 (83.13%)	< .0001

Note:

*: variables used in the propensity score matching model.

Values are presented as n (%) or mean ± SD.

GP, general population; NSAID, nonsteroidal anti-inflammatory drug; PUD, peptic ulcer disease; PUD+HPRx, peptic ulcer disease with Helicobacter pylori treatment; PUD-HPRx, peptic ulcer disease without Helicobacter pylori treatment; DPP4 inhibitor, Dipeptidyl peptidase 4 inhibitor; H2-receptor antagonist, Histamine-2-receptor antagonist.

The distributions of risk factors in the 3 study cohorts were analyzed by the variance test, chi-square test, or Fisher’s exact test. Cox proportional hazards regression was used to obtain hazard ratios (HRs) of IBD and mortality among the matched cohorts. Kaplan-Meier curves were used to estimate the probability of autoimmune diseases onset or mortality, and the log-rank test was employed to analyze the differences between groups. All statistical analyses were performed using SAS 9.3 software (SAS Institute, Cary, NC). Statistical significance was set at P < 0.05.

Results

Higher incidence rates of autoimmune diseases and IBD in the PUD+HPRx in DM group as compared with the PUD-HPRx in general population and PUD-HPRx in DM groups

The incidence rates of autoimmune diseases and IBD in the three groups were compared. The baseline characteristics of the three groups (PUD-HPRx in general population, PUD-HPRx in DM, and PUD+HPRx in DM) are shown in Table 1. The average age and percentage of female subjects were 58.3 ± 14.50 years and 54.61% in the PUD-HPRx in general population group, 58.11 ± 14.12 years and 55.11% in the PUD+HPRx in DM group, and 58.23 ± 14.24 years and 55.10% in the PUD-HPRx in DM group.

Following multiple regression to adjust for age, sex, comorbidities, Charlson’s comorbidities index score (CCIS) and medications, the results showed that the new incidence rates of autoimmune diseases and IBD were significantly higher in the PUD+HPRx in DM group than in the PUD-HPRx in general population and PUD-HPRx in DM groups (autoimmune diseases = 5.14% vs 3.47% and 3.65%; IBD = 5.60% vs 3.17% and 3.25%, respectively; P < 0.0001). The incidence rate of IBD with asacol and/or azathioprine therapy was also significantly higher in the PUD+HPRx in DM group than in the PUD-HPRx in general population and PUD-HPRx in DM groups (0.14% vs 0.05% and 0.06%) (Table 2 and Fig 2). The data of IBD was divided into Crohn’s disease and chronic ulcerative colitis. Both the incidence of Crohn’s disease and chronic ulcerative colitis were significantly increased in PUD+HPRx in DM group as that of IBD (Table 2).

Table 2

Autoimmune disease and inflammatory bowel disease outcomes in the matched cohorts.

	General Population	DM Population
	PUD-HPRx	PUD+HPRx	PUD-HPRx	P-value
N	48,541	48,737	48,737
Two-year wash out period
Total follow-up person years (in years)	324,794.24	344,539.06	334,239.47
Health outcomes (N,%)
autoimmune diseases	1,511 (3.11%)	2,253 (4.62%)	1,560 (3.20%)	< .0001
IBD	1,302 (2.68%)	2,349 (4.82%)	1,338 (2.75%)	< .0001
Crohn’s disease	1,094 (2.25%)	2,481 (5.09%)	1,174 (2.41%)	< .0001
Chronic ulcerative colitis	107 (0.22%)	261 (0.54%)	120 (0.25%)	< .0001
Incidence rate ratio (95%CI)
IBD (ref. = PUD-HPRx in GP)	ref.	1.701 (1.589,1.821)***	0.999 (0.925,1.079)
IBD (ref. = PUD-HPRx in DM)	1.001 (0.927,1.082)	1.703 (1.592,1.823)***	ref.
Crohn’s disease (ref. = PUD-HPRx in GP)	ref.	2.138 (2.081,2.195)*	1.043 (1.013,1.073)*
Crohn’s disease (ref. = PUD-HPRx in DM)	0.959 (0.902,1.016)	2.050 (2.020,2.080)*	ref.
Chronic ulcerative colitis(ref. = PUD-HPRx in GP)	ref.	2.299 (2.288,2.311)*	1.090 (1.081,1.099)*
Chronic ulcerative colitis(ref. = PUD-HPRx in DM)	0.918 (0.906,0.929)*	2.110 (2.101,2.119)*	ref.
All-cause mortality
Total follow-up person years	329,944.27	354,406.36	339,675.73
All-cause mortality
No	40,193 (82.80%)	39,000 (80.02%)	38,779 (79.57%)	< .0001
Yes	8,348 (17.20%)	9,737 (19.98%)	9,958 (20.43%)
Mortality rate ratio (95%CI)
Mortality (ref. = PUD-HPRx in GP)	ref.	1.086 (1.054,1.118)***	1.159 (1.125,1.193)***
Mortality (ref. = PUD-HPRx in DM)	0.863 (0.838,0.889)***	0.937 (0.911,0.964)***	ref.

Note:

*: p<0.05

**: p<0.01

*** p<0.001.

Adjusted for age, sex, insurance range, comorbidities, Charlson comorbidity index score, and medications.

GP, general population; IBD, inflammatory bowel disease; CI, confidence interval.

Fig 2

Cumulative incidence of IBD with a two-year washout period.

Higher cumulative incidence of IBD in DM patients with peptic ulcer disease with Helicobacter pylori treatment (PUD+HPRx in DM) as compared with the general population with peptic ulcer disease without Helicobacter pylori treatment (PUD-HPRx in general population) and with DM patients with peptic ulcer disease without Helicobacter pylori treatment (PUD-HPRx in DM).

Lower all-cause mortality rate in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group

Multiple regression was performed to adjust for age, sex, comorbidities, CCIS, and medications in order to analyze the risk of death. The all-cause mortality was 17.20% in the PUD-HPRx in general population group, 19.98% in the PUD+HPRx in DM group, and 20.43% in the PUD-HPRx in DM group. Predictably, the PUD-HPRx in general population group had the lowest all-cause mortality, as compared with the PUD+HPRx in DM group (HR: 1.086; 95% confidence interval (CI), 1.054–1.118, P < 0.001) and the PUD-HPRx in DM group (HR: 1.159; 95%CI, 1.125–1.193, P < 0.001). Furthermore, a lower all-cause mortality was noted in the PUD+HPRx in DM group (HR: 0.937; 95%CI, 0.911–0.964, P < 0.001) as compared with the PUD-HPRx in DM group (Table 2 and Fig 3).

Fig 3

Cumulative survival rate.

Lower cumulative survival rate in DM patients with peptic ulcer disease without Helicobacter pylori treatment (PUD-HPRx in DM) as compared with DM patients with peptic ulcer disease with Helicobacter pylori treatment (PUD+HPRx in DM) and with the general population with peptic ulcer disease without Helicobacter pylori treatment (PUD-HPRx in general population). Kaplan-Meier curves estimated the probability of survival rate.

Higher incidence rate of IBD in younger patients in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group

Cox proportional hazards regression was performed on the outcomes of IBD and mortality among the matched cohorts. A trend of a higher incidence of IBD in the younger patients in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group was observed (< 35 years: HR: 1.805; 35–44 years: HR: 1.726; 45–54 years: HR: 1.603; 55–64 years: HR: 1.606; >65 years: HR: 1.56) (Table 3 and Fig 4).

Table 3

Cox proportional hazards model assessment of outcomes of inflammatory bowel disease and mortality in the matched cohorts.

	IBD incidence with two year washout period	Mortality
Variables	HR (95%CI)	HR (95%CI)
Cohorts (ref. group: PUD-HPRx in DM)
PUD-HPRx in GP	0.999 (0.925,1.078)	0.794 (0.771,0.817)***
PUD+HPRx in DM	1.679 (1.570,1.795)***	0.930 (0.904,0.956)***
Age categories (ref. group: <35)#
35–44	0.850 (0.749,0.965)*	1.489 (1.324,1.676)***
45–54	0.825 (0.733,0.928)**	1.730 (1.549,1.932)***
55–64	0.805 (0.713,0.909)**	2.362 (2.118,2.633)***
65+	0.811 (0.717,0.917)**	6.068 (5.455,6.750)***
Gender (ref. female)
Male	0.827 (0.780,0.878)***	1.623 (1.583,1.663)***
Income status (ref.: dependent)
<20,000	1.039 (0.958,1.126)	1.254 (1.218,1.292)***
20,000–40,000	0.995 (0.924,1.072)	0.825 (0.800,0.851)***
40,000	0.938 (0.849,1.037)	0.372 (0.347,0.399)***
Comorbidities (N, %)
Hypertension (ref.: No)	0.964 (0.905,1.027)	0.966 (0.941,0.991)***
Hyperlipidemia (ref.:No)	0.941 (0.883,1.002)	1.319 (1.286,1.352)***
Myocardial infraction (ref.: No)	0.946 (0.733,1.221)	1.107 (1.041,1.178)**
Congestive heart failure (ref.: No)	1.164 (1.002,1.352)*	1.603 (1.543,1.665)***
Peripheral vascular disease (ref.:No)	1.160 (0.932,1.443)	1.100 (1.023,1.183)*
Cerebral vascular disease (ref.:No)	0.914 (0.816,1.023)	1.302 (1.261,1.344)***
Dementia (ref.:No)	0.909 (0.672,1.229)	1.939 (1.842,2.040)***
Chronic kideney disease (ref.:No)	0.938 (0.809,1.088)	1.487 (1.431,1.546)***
Cancer (ref.:No)	0.973 (0.843,1.123)	1.934 (1.865,2.005)***
Charlson’s Index Categories (ref.: CCI = 0)
1–2	1.015 (0.931,1.106)	1.103 (1.045,1.164)**
3	1.061 (0.967,1.165)	1.324 (1.255,1.398)***
> = 4	1.084 (0.972,1.209)	1.799 (1.702,1.902)***
Medication (N, %)
Metformin (ref.: No)	1.159 (1.099,1.222)***	1.144 (1.116,1.173)***
Sulfonylurea (ref.: No)	1.194 (1.131,1.260)***	1.343 (1.308,1.378)***
Dipeptidyl peptidase 4 inhibitor (ref.: No)	1.081 (0.993,1.176)	0.653 (0.622,0.687)***
Insulin (ref.: No)	1.093 (1.038,1.151)***	3.714 (3.628,3.801)***
NSAIDs (ref.: No)	1.426 (1.298,1.568)***	0.816 (0.790,0.843)***
Antiplatelet agent (ref.: No)	1.141 (1.046,1.245)**	1.014 (0.984,1.044)
Warfarin (ref.: No)	0.917 (0.642,1.309)	1.242 (1.144,1.349)***

Note:

*: p<0.05

**: p<0.01

*** p<0.001.

#Likelihood-ratio test for trend for the age categories were significant for model 1 (LR chisq = 12.73, p = 0.0053), model 2 (LR chisq = 11.42, p = 0.097) and model 3 (LR chisq = 1454.76, p<0.001), indicating a linear trend across age groups for the dependent variables.

Adjusted for age, sex, insurance range, comorbidities, Charlson comorbidity index score, and medications.

HR, hazard ratio; CI, confidence interval; GP, general population; IBD, inflammatory bowel disease; ref.: No, reference: the cohort without the comorbidity or medication.

Fig 4

Forest plots of the PUD+HPRx and PUD-HPRx in DM groups.

A higher hazard ratio of the incidence rate of IBD was noted in the younger patients in the PUD+HPRx in DM group, while a lower hazard ratio of the mortality rate was noted in the younger patients in the PUD+HPRx in DM group.

Younger patients had a lower mortality rate in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group

A trend of a lower mortality rate in the younger patients in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group was observed (<35 years: HR: 0.829; 35–44 years: HR: 0.877; 45–54 years: HR: 0.937; 55–64 years: HR: 0.991; > 65 years: HR: 0.938) (Table 3 and Fig 4).

Discussion

Our results revealed that the incidences of autoimmune diseases and IBD in the PUD+HPRx in DM group were higher than those in the PUD-HPRx in general population and PUD-HPRx in DM groups. This finding suggested that treatment for H. pylori infection can increase the risk of autoimmune diseases and IBD in patients with DM, and not only in the general population.

In a study by Lin et al., the authors demonstrated that treatment for H. pylori infection in the general population is associated with significant increases in the risks of autoimmune diseases and IBD as compared with people who had never received H. pylori therapy. According to the ACG Clinical Guidelines: Treatment of H. pylori Infection (2017) [18], currently, the indications to test for H. pylori infection are to examine patients with PUD or a history of PUD, low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma, or a history of endoscopic resection of early gastric cancer. If the result is positive, then treatment should be performed. However, a recent meta-analysis of 24 studies (mostly in Asia) showed that H. pylori treatment in asymptomatic infected adults had reduced the incidence of gastric cancer. The greatest benefit was found in the area with the highest incidence of gastric cancer [19]. Widely eradication of H. pylori may be a trend in the future.

According to the literature, H. pylori infection may increase several risk factors in diabetic patients. A meta-analysis in 2013 identified relationships between H. pylori infection and increased risks of nephropathy and neuropathy [20]. It has been reported that H. pylori is associated with poor control of blood sugar in type 1 DM patients [21]. In addition, H. pylori infection may increase the risk of cardiovascular disease in patients with coronary heart disease and type 2 DM [22].

Novel information regarding gut microbiota may explain the effects associated with H. pylori infection. We have long been aware that imbalance of intestinal microbiota plays a role in the development of several diseases, including DM and IBD [23, 24]. A recent study revealed that modification of microbiota can repair the structure and function of the intestinal barrier in diabetic mice [25]. Clinical application of microbial therapy is under investigation. On the other hand, H. pylori infection was found to cause peptic ulcers and gastric cancer, but acts against several autoimmune diseases. Therefore, it has been suggested that H. pylori has both protective and pathogenic effects, and thus the interaction between microbiota and host may influence autoimmunity and the inflammatory response [26].

The results of our study also revealed that the earlier an H. pylori infection is treated, the higher the risk of developing IBD (Fig 4); the exact mechanism remains unclear. Study showed that the composition of intestinal microbiota changes with age and disease [27]. Our hypothesis was that the earlier the change in microbiota, the greater the influence on the host response. Nevertheless, a lower all-cause mortality rate was found in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group, and younger patients had a lower mortality in the PUD+HPRx in DM group as compared with the PUD-HPRx in DM group. The exact causes of death in these patients were unclear owing to limitations of the database. However, we speculated that treatment of H. pylori decreases the risks of gastric cancer and cardiovascular disease, which are increased in DM patients.

Congestive heart failure and use of anti-platelet agent are also risk factors for IBD incidence with two-year washout period. We speculate that using anti-platelet agent increase the risk of peptic ulcer, and more patients with peptic ulcer received EGD and H. pylori biopsy. Patients with congestive heart failure frequently use anti-platelet agent may lead to the same result.

On the other hand, Table 3 showed using metformin, sulfonylurea, and insulin increased the incidence of IBD, but DPP4 inhibitor did not. We performed the subgroup analysis to compare the incidence of IBD in patients with and without the specific DM medication in PUD+HPRx in DM and PUD-HPRx in DM group (see S3 Table). The result showed DM medications didn’t increase the incidence of IBD.

There were some limitations in this observational study. First, the report of H. pylori biopsy do not present in the database. In Taiwan, H. pylori biopsy will be performed during EGD. If H. pylori infection is confirmed, H. pyloritherapy will be given. This limitation makes us unable to exclude the rare patients with H. pylori infection but refused or unable to receive H. pylori treatment. But it doesn’t influence our result. Because the patients with H. pylori infected almost always receive treatment in Taiwan, the PUD patients not received H. pylori treatment may represent negative results of H. pylori infection. Secondary, some patients received H. pylori therapy before 2000 might be grouped to PUD-HPRx because our patients were from 2000 to 2010. This doesn’t influence the result because these patients actually with higher risk of IBD were grouped to PUD-HPRx, which has lower risk of IBD. Third, the sample of PUD patients who were treated for H. pylori infection in general population (PUD+HPRx in general population) was too small to match to other three groups. However, our (S1 and S2 Tables) including PUD+HPRx in general population group revealed similar result. Fourth, the result of H. pylori treatment can’t be presented in the database. The success rate of H. pylori treatment in Taiwan was 82–94% under 7 days triple therapy [28], and 84% under third-line therapy [29]. Last, the severity of IBD was defined by the clinical signs such as frequency of diarrhea, abdominal pain, fever, anemia…etc, which were not included in our database.

In conclusion, our results revealed that treatment of H. pylori infection increases the incidence rates of autoimmune diseases and IBD, and decreases the all-cause mortality rate in the DM group with PUD; in addition, the effect was more significant in younger patients. This finding may increase the understanding of clinicians of the possible risks and benefits of H. pylori therapy in patients with DM. Besides, widely treatment of H. pylori may cause unexpected effects such as autoimmune diseases and IBD. Further associated studies should be performed.

Demographic prevalence of PUD+HPRx and PUD-HPRx in a DM population and a general population post-propensity score-matching.

(DOC)

Click here for additional data file.

(DOC)

Click here for additional data file.

Cox proportion model results for outcomes of IBD and mortality among matched cohorts.

(DOC)

Click here for additional data file.

10 Aug 2021

PONE-D-21-21394

Effects of Helicobacter pylori eradication on the incidences of autoimmune diseases and inflammatory bowel disease in patients with diabetes mellitus

PLOS ONE

Dear Dr. Kun-Der Lin,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

This is important study for investigate the relationship between AD and DM etc., and have several new findings. However as reviewers also pointed out, there are several concerns in this study (please especially check the comments by Reviewer 1).  To accept this paper, you should carefully respond each comment by the reviewers. Discussion should have more information about the study.

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2. This is a retrospective study with no control group. As such, we do not feel that any conclusions on the intervention effects can be supported; as such, we ask that you revise the text (especially, but no limited to, the aims and Conclusions) to avoid unsupported statements.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

“This study was funded by a grant from the Ministry of Health and Welfare (MOHW108-TDU-B-212-133006), Kaohsiung Medical University (109CM-KMU- 012), Kaohsiung Medical University Hospital (SA10905), and Kaohsiung Municipal Ta-Tung Hospital (KMTTH-107-014), which had no role in the study design, data analysis, data interpretation, or writing of the manuscript.”

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In this paper, Dr. Sheu et al. performed an observational study using National Health Insurance Research Database in Taiwan. The authors found that H. pylori treatment increased the incidences of autoimmune diseases (AD) and IBDs and decreased the all-cause mortality in the diabetes patients with peptic ulcer disease (PUD). Although the results are interesting, several questions should be addressed to accept the association is a true association.

Major comments

1. Due to the retrospective observation study design, the findings are vulnerable to many biases. Why DM patients were selected as the main study group? Because one of control group was PUD patients not treated for H. pylori in general population (PUD-HpRx in GP), PUD patients who were treated for Hp infection in general population might be better to assess the Hp treatment and AD or IBD association.

2. PUD is a well-known indication for H. pylori treatment since 1990s. Why so many PUD patients in this database had not treated for H. pylori? Especially in DM group, the number who did not receive H. pylori treatment seems more than 10 times in number. This might raise a question about the completeness or correctness of the database.

3. The persons in the control groups who were not treated for H. pylori in general population or in DM patients should be very heterogenous. The persons are one of the cases; 1) H. pylori uninfected persons, 2) H. pylori infected but not treated.

4. The persons in the case group who were treated for H. pylori also seems very heterogenous. Those are one of the cases; 1) H. pylori treatment medication was prescribed but not took at all (poor compliance), 2) H. pylori treatment medication was took, but H. pylori eradication was either successful or failed. Since the eradication success data are not available from the database, the title and description needs be modified to more modest term such as H. pylori treatment not H. pylori eradication. Actually it’s very hard to tell whether exposure to H. pylori treatment as whole, H. pylori eradication itself, or just an exposure of certain antibiotic included in the H. pylori treatment is the main culprit for the authors finding.

5. One of main finding was that H. pylori treatment decreased the all-cause mortality in the DM group with PUD. This finding might also be misleading because there is a chance that the patients having more severe DM were not treated for H. pylori infection. If mild DM patients were more selectively treated for H. pylori, the group should have better survival rates.

6. Please clarify the study entry date and end date. In line 140 on page 6, the persons who had received treatment for H. pylori infection between 1997 and 2013 were enrolled. In line 148 on page 6, the sentence was described as “The person-years of follow-up were estimated from the index date plus a two-year washout duration to the date of diagnosis of AD or IBD, or an end date of December 31, 2010.” The sentence might be interpreted as the end date of follow up of this study was on Dec 31, 2010, which is much earlier than 2013.

7. Discussion seems too short and more plausible link between IBD, AD and mortality needs be provided. Also, the limitations of this study should be described in detail.

Reviewer #2: General:

In this study, the authors investigated effects of H. pylori eradication therapy in patients with diabetes mellitus (DM). Authors showed that higher incidences of autoimmune diseases and inflammatory bowel disease (IBD) were observed in the DM patients with peptic ulcer and received eradication therapy than in the general population with peptic ulcer and received eradication therapy and DM patients with peptic ulcer disease and non-eradication therapy. Authors concluded that H. pylori eradication therapy increased the incidences of autoimmune diseases and IBD and decreased the all-cause mortality in the DM group with peptic ulcer.

This study was well written.

Major comments:

1. Authors selected three groups. However, Authors should add one group: general population with peptic ulcer who received H. pylori treatment.

2. In this study, authors included patients with peptic ulcer. If authors enrolled patients with gastritis, not peptic ulcer, could the results be different?

3. Although authors enrolled many patients, direct association with autoimmune diseases, inflammatory bowel disease and diabetes mellitus is unclear.

4. Why did authors select patients with diabetes mellitus?

5. H. pylori treatment decreased the all-cause mortality in the DM group with peptic ulcer. Why?

6. What is the relationship between the time received H. pylori eradication therapy and the time of autoimmune diseases and IBD onset?

7. Congestive heart failure and use of anti-platelet agent are risk factor for IBD incidence with two-year washout period. Why?

8. Authors should add data of intake, kinds and dose of medication for DM.

9. Please add p values in Table 1.

10. What is a p value in Table 2? PUD+HPRx vs PUD-HPRx?

11. Several H. pylori bacterial virulence factors that dampen the immune response of the host were identified, including VacA, CagA, and H. pylori lipopolysaccharide. However, Western population infected with cagA-negative and vacA s2m2 type H. pylori. Therefore, influence of eradication therapy for IBD may differ between Asian population and Western population.

12. Authors used data received treatment for H. pylori infection between 1997 and 2013. How is the judgment for eradication therapy?

13. How about H. pylori infection rate in a group with peptic ulcer without H. pylori treatment?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

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23 Sep 2021

Editor’s comment:

Comment 1:

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Answer:

We had modified our manuscript to meet the PLOS ONE's style requirements, and renamed our figures according to the cited order in manuscript. Thanks for your kind reminder.

Comment 2:

This is a retrospective study with no control group. As such, we do not feel that any conclusions on the intervention effects can be supported; as such, we ask that you revise the text (especially, but no limited to, the aims and Conclusions) to avoid unsupported statements.

Answer:

Our control groups were PUD-HPRx in DM and PUD-HPRx in GP group. We compared the incidence of IBD and mortality of PUD+HPRx in DM group to other two groups. Besides, we presented the result included PUD+HPRx in GP group in the supporting tables.

Comment 3:

Thank you for stating the following in the Acknowledgments Section of your manuscript:“This study was funded by a grant from the Ministry of Health and Welfare (MOHW108-TDU-B-212-133006), Kaohsiung Medical University (109CM-KMU- 012), Kaohsiung Medical University Hospital (SA10905), and Kaohsiung Municipal Ta-Tung Hospital (KMTTH-107-014), which had no role in the study design, data analysis, data interpretation, or writing of the manuscript.”

We note that you have provided additional information within the Acknowledgements Section that is not currently declared in your Funding Statement. Please note that funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:“The author(s) received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Answer:

Thank you for your suggestion. We would remove the funding-related text from the manuscript. Please change our Funding Statement to

“This study was funded by a grant from the Ministry of Health and Welfare (MOHW108-TDU-B-212-133006), Kaohsiung Medical University (109CM-KMU- 012), Kaohsiung Medical University Hospital (SA10905), and Kaohsiung Municipal Ta-Tung Hospital (KMTTH-107-014), which had no role in the study design, data analysis, data interpretation, or writing of the manuscript. ”

Reviewer 1:

Comment 1:

Due to the retrospective observation study design, the findings are vulnerable to many biases. Why DM patients were selected as the main study group? Because one of control group was PUD patients not treated for H. pylori in general population (PUD-HpRx in GP), PUD patients who were treated for Hp infection in general population might be better to assess the Hp treatment and AD or IBD association.

Answer:

We selected DM patients as the main study group because DM and PUD are common disease in Taiwan. The data of DM patients were more intact in our database. The supporting table include PUD patients who were treated for Hp infection in general population (PUD+HpRx in GP). The result was similar. The sample of PUD+HpRx in GP group was too small to match to other groups.

Comment 2:

PUD is a well-known indication for H. pylori treatment since 1990s. Why so many PUD patients in this database had not treated for H. pylori? Especially in DM group, the number who did not receive H. pylori treatment seems more than 10 times in number. This might raise a question about the completeness or correctness of the database.

Answer:

In Taiwan, H. pylori biopsy will be performed during Esophagogastroduodenoscopy (EGD). If H. pylori infection is confirmed, H. pylori eradication will be given. But the report of H. pylori biopsy do not present in the database. This limitation makes us unable to exclude the rare patients with H. pylori infection but refused or unable to receive H. pylori treatment. But it doesn’t influence our result. Due to the patients with H. pylori infected almost always receive treatment in Taiwan, the PUD patients not received H. pylori treatment may represent negative results of H. pylori infection.

Comment 3:

The persons in the control groups who were not treated for H. pylori in general population or in DM patients should be very heterogenous. The persons are one of the cases; 1) H. pylori uninfected persons, 2) H. pylori infected but not treated.

Answer:

Yes. The condition(H. pylori infected but not treated) is rare in Taiwan. Due to the patients with H. pylori infected almost always receive treatment in Taiwan, the PUD patients not received H. pylori treatment may represent negative results of H. pylori infection.

Comment 4:

The persons in the case group who were treated for H. pylori also seems very heterogenous. Those are one of the cases; 1) H. pylori treatment medication was prescribed but not took at all (poor compliance), 2) H. pylori treatment medication was took, but H. pylori eradication was either successful or failed. Since the eradication success data are not available from the database, the title and description needs be modified to more modest term such as H. pylori treatment not H. pylori eradication. Actually it’s very hard to tell whether exposure to H. pylori treatment as whole, H. pylori eradication itself, or just an exposure of certain antibiotic included in the H. pylori treatment is the main culprit for the authors finding.

Answer:

Yes. The result of H. pylori treatment can’t be presented in the database. It’s one of the limitation in our study. The success rate of H. pylori treatment in Taiwan was 82-94% under 7 days triple therapy, and 84% under third-line therapy. We had modified at Discussion section, paragraph 7, line 12~13. We will modify the term H. pylori eradication to H. pylori treatment. Thanks for your suggestion.

We define the patients with H. pylori treatment by the set of triple or quadruple therapy for more than 7 days as our previous study by Lin et al. (Clin Gastroenterol Hepatol. 2019 Sep;17(10):1991-1999) The therapy include proton pump inhibitor twice daily use, which differ from antibiotic therapy for other infection.

Comment 5:

One of main finding was that H. pylori treatment decreased the all-cause mortality in the DM group with PUD. This finding might also be misleading because there is a chance that the patients having more severe DM were not treated for H. pylori infection. If mild DM patients were more selectively treated for H. pylori, the group should have better survival rates.

Answer:

The condition(H. pylori infected but not treated) is rare in Taiwan. The rare condition may happen in Intensive Care Unit when the patient is critical. However, our database was from Outpatient department where patients were stable. And the result had been adjusted by Charlson Comorbidity Index score.

Comment 6:

Please clarify the study entry date and end date. In line 140 on page 6, the persons who had received treatment for H. pylori infection between 1997 and 2013 were enrolled. In line 148 on page 6, the sentence was described as “The person-years of follow-up were estimated from the index date plus a two-year washout duration to the date of diagnosis of AD or IBD, or an end date of December 31, 2010.” The sentence might be interpreted as the end date of follow up of this study was on Dec 31, 2010, which is much earlier than 2013.

Answer:

The database is 1997-2013. We enrolled patients from 2000-2010 for more intact data. We had modified in line 136~137 on page 6.

Comment 7:

Discussion seems too short and more plausible link between IBD, AD and mortality needs be provided. Also, the limitations of this study should be described in detail.

Answer:

Thanks for your suggestion. We will revise the discussion section and limitations more completely.

Reviewer 2:

Comment 1:

Authors selected three groups. However, Authors should add one group: general population with peptic ulcer who received H. pylori treatment.

Answer:

The supporting table include PUD patients who were treated for Hp infection in general population (PUD+HpRx in GP). The result was similar. The sample of PUD+HpRx in GP group was too small to match to other groups.

Comment 2:

In this study, authors included patients with peptic ulcer. If authors enrolled patients with gastritis, not peptic ulcer, could the results be different?

Answer:

The coding of gastritis is not accurate because many patients with gastritis usually take oral medicine without received Esophagogastroduodenoscopy (EGD). However, patients with peptic ulcer were almost received EGD. So the coding of peptic ulcer is more accurate than gastritis.

Comment 3:

Although authors enrolled many patients, direct association with autoimmune diseases, inflammatory bowel disease and diabetes mellitus is unclear.

Answer:

Our results revealed that treatment of H. pylori infection was associated with the increased incidence rates of ADs and IBD in DM patients with PUD. The incidence rate of IBD in PUD-HPRx in DM group did not increase compared to PUD-HPRx in GP group. However, further studies should be performed.

Comment 4:

Why did authors select patients with diabetes mellitus?

Answer:

We selected DM patients as the main study group because DM and PUD are common disease in Taiwan. And the data of DM patients were more intact in our database. The supporting table include PUD patients who were treated for Hp infection in general population (PUD+HpRx in GP). The result was similar. The sample of PUD+HpRx in GP group was too small to match to other groups.

Comment 5:

H. pylori treatment decreased the all-cause mortality in the DM group with peptic ulcer. Why?

Answer:

H. pylori treatment also decreased the all-cause mortality in the GP group with peptic ulcer (see the supporting table). We speculated that treatment of H. pylori decreases the risks of gastric cancer and cardiovascular disease, which are increased in DM patients.

Comment 6:

What is the relationship between the time received H. pylori eradication therapy and the time of autoimmune diseases and IBD onset?

Answer:

The person-years of follow-up were estimated from the index date plus a two-year washout duration to the date of diagnosis of AD or IBD, or an end date. The H. pylori therapy may change intestinal microbiota, which may induce the incidence of AD or IBD.

Comment 7:

Congestive heart failure and use of anti-platelet agent are risk factor for IBD incidence with two-year washout period. Why?

Answer:

We speculate that using anti-platelet agent increase the risk of peptic ulcer, and more patients with peptic ulcer received EGD and H. pylori biopsy. Patients with congestive heart failure frequently use anti-platelet agent may lead to the same result. We added our speculation at Discussion section, paragraph 6. Thanks for your question.

Comment 8:

Authors should add data of intake, kinds and dose of medication for DM.

Answer:

The data of intake was not included in our database. We added the data of medications for DM in the table 1 and 3. Table 3 showed using metformin, sulfonylurea, and insulin increased the incidence of IBD, but DPP4 inhibitor did not. We performed the subgroup analysis to compare the incidence of IBD in patients with and without the specific DM medication in PUD+HPRx in DM and PUD-HPRx in DM group(see supporting table 2). The result showed DM medications didn’t increase the incidence of IBD. We added this finding at Discussion section, paragraph 7.

Comment 9:

Please add p values in Table 1.

Answer:

We will correct the table in the manuscript. Thanks for your kind reminder.

Comment 10:

What is a p value in Table 2? PUD+HPRx vs PUD-HPRx?

Answer:

We will correct the table in the manuscript. Thanks for your kind reminder.

Comment 11:

Several H. pylori bacterial virulence factors that dampen the immune response of the host were identified, including VacA, CagA, and H. pylori lipopolysaccharide. However, Western population infected with cagA-negative and vacA s2m2 type H. pylori. Therefore, influence of eradication therapy for IBD may differ between Asian population and Western population.

Answer:

Yes, the different types of H. pylori infection between Asian and Western population may influence the result of effect of H. pylori therapy for IBD. The types of H. pylori were not included in our database. It needs more study include Western population for provement.

Comment 12:

Authors used data received treatment for H. pylori infection between 1997 and 2013. How is the judgment for eradication therapy?

Answer:

The database is 1997-2013. We enrolled patients from 2000-2010 for more intact data. We had modified it in line 139~140 on page 6. Patients received H. pylori therapy before 2000 were grouped to PUD-HPRx. This doesn’t influence the result because these patients actually with higher risk of IBD were grouped to PUD-HPRx, which has lower risk of IBD.

Comment 13:

How about H. pylori infection rate in a group with peptic ulcer without H. pylori treatment?

Answer:

The condition (H. pylori infected but not treated) is rare in Taiwan. Due to the patients with H. pylori infection almost always receive treatment in Taiwan, the PUD patients not receive H. pylori treatment may represent negative results of H. pylori infection.

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

14 Dec 2021

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Yoshio Yamaoka

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Authors revised according to reviewer’s suggestion and recommendation.

However, additional revision will be required.

1. Many abbreviations were used. Popular abbreviations will be acceptable, such as DM, IBD and PUD. However, minor abbreviations should be avoided to use, such as AD and GP.

2. IBD included Crohn’s disease and chronic ulcerative colitis. Pathogenesis of Crohn’s disease and chronic ulcerative colitis differ. Please show divide data into Crohn’s disease and chronic ulcerative colitis.

3. How about severity of IBD?

4. Please add data of PPI/H2RA in Table.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

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23 Jan 2022

Dear Professor Yoshio Yamaoka:

I sincerely thank you for your processing our manuscript “PONE-D-21-21394

Effects of Helicobacter pylori eradication on the incidences of autoimmune diseases and inflammatory bowel disease in patients with diabetes mellitus” and for your decision. We also would like to express our cordial appreciation to reviewers for their excellent suggestions. As reviewer’s suggestion, we created supporting tables. Additionally, we have carefully revised our manuscript according to your comments. Our point-by-point responses are listed below.

Reviewer 2:

Comment 1:

Many abbreviations were used. Popular abbreviations will be acceptable, such as DM, IBD and PUD. However, minor abbreviations should be avoided to use, such as AD and GP.

Answer:

We had modified our manuscript to avoid use minor abbreviations such as AD and GP. Thanks for your kind reminder.

Comment 2:

IBD included Crohn’s disease and chronic ulcerative colitis. Pathogenesis of Crohn’s disease and chronic ulcerative colitis differ. Please show divide data into Crohn’s disease and chronic ulcerative colitis.

Answer:

We had divided the data of IBD to Crohn’s disease and chronic ulcerative colitis (see Table 2). Both the incidence of Crohn’s disease and chronic ulcerative colitis were significantly increased in PUD+HPRx in DM group as that of IBD. We had modified at Results section, paragraph 1, line 12~15 on page 8. Cox proportional hazards regression was performed on the outcomes of Crohn’s disease and chronic ulcerative colitis among the matched cohorts (Table S4) and the results were similar. Because the sample of chronic ulcerative colitis was too small that may produce bias in subgroup analysis, we just put the table below the response letter instead of manuscript.

Comment 3:

How about severity of IBD?

Answer:

The severity of IBD was defined by the clinical signs such as frequency of diarrhea, abdominal pain, fever, anemia…etc, which were not included in our database. We had modified at Discussion section, line 273~275 on page 12.

Comment 4:

Please add data of PPI/H2RA in Table.

Answer:

We had added data of PPI/H2RA in Table 1 and S1 table. The use of PPI significantly increased in PUD+HPRx in general population and DM groups due to H. pylori treatment. The use of H2RA significantly increased in PUD+HPRx in general population and DM groups, which may owing to more upper GI symptoms in patients with H. pylori infection.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

1 Mar 2022

Effects of Helicobacter pylori treatment on the incidences of autoimmune diseases and inflammatory bowel disease in patients with diabetes mellitus

PONE-D-21-21394R2

Dear Dr. Kun-Der Lin,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Yoshio Yamaoka

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

This revised version is well-written.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: This version of this study was well revised according to Reviewer’s suggestions and recommendations.

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Reviewer #2: No

12 May 2022

PONE-D-21-21394R2

Effects of Helicobacter pylori treatment on the incidences of autoimmune diseases and inflammatory bowel disease in patients with diabetes mellitus

Dear Dr. Lin:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Yoshio Yamaoka

Academic Editor

PLOS ONE