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Background: People with mental disorders exhibit increased mortality due to colorectal cancer, despite having a similar incidence to the general population. We aimed to evaluate the extent to which people with mental disorders participate in organised colorectal cancer screening. Methods: We conducted a population-based cohort study of all Danish residents aged 50–74 years who were invited to undergo biennial faecal immunochemical testing between March 1, 2014, and Sept 30, 2018. We used national registry data from all first-time invitees. The primary endpoint was participation within 90 days of invitation. We calculated the proportion who participated and assessed their screening results and adherence to and completeness of follow-up colonoscopy according to their history of mental disorders, classified as none, mild or moderate, or severe. We computed crude and adjusted participation differences in percentage points and participation ratios using the pseudo-observations method. Findings: Of 2 036 704 people who were invited, we included 2 036 352 in the final cohort, of whom 1 008 045 (49·5%) were men and 1 028 307 (50·5%) were women, with a mean age of 60·7 years (SD 8·3, range 49–78). Data on ethnicity were not collected. Compared with people with no mental disorders, the adjusted analysis showed lower participation among people with mild or moderate mental disorders (men: participation difference –4·4 percentage points [95% CI –4·7 to –4·1]; women: –3·8 percentage points [–4·1 to –3·6]) and severe mental disorders (men: participation difference –13·8 percentage points [–14·3 to –13·3]; women: –15·4 percentage points [–15·8 to –14·9]). People with mental disorders had a higher proportion of positive faecal immunochemical test results, lower adherence to colonoscopy, and more incomplete colonoscopies than people without mental disorders. Interpretation: People with mental disorders were less likely to participate in colorectal cancer screening than those without these disorders. Patients with mental disorders could benefit from support or encouragement from their general practitioner or mental health-care facility to participate in cancer screening. Potential interventions should consider type of mental disorder, as needs might differ. Funding: Danish Cancer Society, Danish Health Foundation.

Lindsay J Collin,1,2 Anders H Riis,2 Richard F MacLehose,3 Thomas P Ahern,4 Rune Erichsen,2,5 Ole Thorlacius-Ussing,6 Timothy L Lash1 1Department of Epidemiology, Emory University, Atlanta, GA, USA; 2Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; 3Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA; 4Department of Surgery, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, VT, USA; 5Department of Surgery, Randers Regional Hospital, Randers, Denmark; 6Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, DenmarkCorrespondence: Lindsay J CollinDepartment of Epidemiology, Emory University, 1518 Clifton RoadNE, Atlanta, GA 30322, USATel +1 530-386-3341Email lindsay.jane.collin@emory.eduBackground: Among men and women diagnosed with colorectal cancer (CRC), 20– 50% will develop a cancer recurrence. Cancer recurrences are not routinely captured by most population-based registries; however, linkage across Danish registries allows for the development of predictive models to detect recurrence. Successful application of such models in population-based settings requires validation against a gold standard to ensure the accuracy of recurrence identification.Objective: We apply a recently developed validation study design for prospectively collected validation data to validate predicted CRC recurrences against gold standard diagnoses from medical records in an actively followed cohort of CRC patients in Denmark.Methods: We use a Bayesian monitoring framework, traditionally used in clinical trials, to iteratively update classification parameters (positive and negative predictive values, and sensitivity and specificity) in an adaptive validation substudy design. This design allows determination of the sample size necessary to estimate the corresponding parameters and to identify when validation efforts can cease based on predefined criteria for parameter values and levels of precision.Results: Among 355 men and women diagnosed with CRC in Denmark and actively followed semi-annually, there were 63 recurrences diagnosed by active follow-up and 70 recurrences identified by a predictive algorithm. The adaptive validation design met stopping criteria for the classification parameters after 120 patients had their recurrence information validated. This stopping point yielded parameter estimates for the classification parameters similar to those obtained when the entire cohort was validated, with 66% less patients needed for the validation study.Conclusion: In this proof of concept application of the adaptive validation study design for outcome misclassification, we demonstrated the ability of the method to accurately determine when sufficient validation data have been collected. This method serves as a novel validation substudy design for prospectively collected data with simultaneous implementation of a validation study.Keywords: validation study design, colorectal cancer recurrence

Ling-Yue Zhao, Yi-Jun Luo, Jing Zhu Department of Ambulatory Surgery, Shenzhen Nanshan District People’s Hospital, Shenzhen, Guangdong 518052, People’s Republic of ChinaSeveral studies have revealed that the 1-year all-cause mortality rate was about 20% following hip fracture (HF), which highlights the importance of the prognostic impact of other comorbidities on mortality.1Recently, we read with great interest the study by Montomoli et al.2 The authors performed a nationwide cohort study to investigate the prognostic impact of liver disease on 30-day mortality and the 31–365-day mortality among patients with HF. They concluded that relative to patients without liver disease, patients with liver disease, especially those with liver cirrhosis, had higher 30-day mortality and 31–365-day mortality rate following HF. The research appears informative clinically. Thus, there are some issues that that should be addressed regarding this study.View the original paper by Montomoli and colleagues.

Colorectal cancer recurrences are difficult to ascertain accurately and efficiently. We developed and validated an algorithm to identify recurrences that uses Danish medical registries. The algorithm uses metastasis and chemotherapy codes in the Danish National Patient Registry and codes indicating cancer recurrence in the Danish Pathology Registry. We applied the algorithm to a cohort (n=21,246) of colorectal cancer patients diagnosed 2001-2011 and followed through 2012. In a cohort (n=355) of two groups of actively followed patients, we compared the imputed recurrence data with recurrences diagnosed by regular follow-up. We compared cumulative incidence curves of imputed recurrence in local and regional stage patients from the large cohort, and of imputed and diagnosed recurrences in the actively followed cohort. In the 355 members of the actively followed cohort, our algorithm correctly identified 60 of 63 recurrences (sensitivity = 95%; 95% CI 87%, 99%) and misclassified only 10 of 292 without recurrence (specificity = 97%; 95% CI 94%, 98%). Cumulative incidence curves showed that members of the large cohort with regional disease had much higher incidence of imputed recurrence than those with local disease. In the actively followed cohort, the cumulative incidence of recurrence overlapped substantially when recurrence was imputed by our algorithm or using the follow-up data. Despite some limitations regarding ambiguous pathology codes, our algorithm showed excellent performance against actively followed recurrence data, and the expected relation between recurrence risk and cancer stage. It can be used in the Danish registries and adapted to similar registries elsewhere. © 2014 Wiley Periodicals, Inc.

Long-term risk of colorectal cancer in patients with sessile serrated adenomas, traditional serrated adenomas, and hyperplastic polyps

Risk of colorectal cancer in patients with sessile serrated adenomas/polyps is the same magnitude or even higher than in patients with conventinal adenomas

Formålet med denne oppgaven er å se hvordan et undermerke kan bidra til å endre mormerkets posisjon. Oppgaven handler om Nissan Leafs påvirkning på mormerket Nissan, men funnene kan være interessant også for andre merker. Bakgrunnen for at vi valgte Nissan som bedrift var den sterke posisjonen merket har som elbilprodusent i Norge. Vi står ovenfor en stor endring i bilmarkedet, der stadig flere biler blir elektrisk drevet. Vi mente derfor det ville være interessant å se hvordan Nissan kunne utnytte Nissan Leafs posisjon som den ledende elbilen på det norske markedet til å påvirke assosiasjonene til merkevaren Nissan. Oppgaven inneholder teori om merkevarebygging som er relevant i forhold til undersøkelsen. Vi har lagt særlig vekt på trinnene i merkepyramiden, og har brukt denne for å vise hvordan Nissan kan flytte sin merkevare. For å undersøke hvilken effekt Leaf har på Nissan valgte vi en kvantitativ tilnærming. En nettbasert undersøkelse ble sendt ut til studenter ved Markedshøyskolen. Dette var et kvasieksperiement der samme gruppe ble bedt om å svare på i hvilken grad de var enig eller uenig i en rekke påstander. Etter å ha besvart påstandene ble de utsatt for et stimuli i form av en video av Nissan Leaf. Deretter ble respondentene bedt om å besvare påstandene på nytt. Formålet med eksperimentet var dermed å avdekke om det var en endring i respondentenes assosiasjoner, følelser og holdninger til Nissan som følge av at de hadde sett videoen. Resultatene viser at Nissan Leaf hadde en positiv effekt på respondentenes forhold til Nissan. Både holdninger, følelser, inntrykks- og ytelsesassosiasjoner flyttet seg i positiv retning som følge av at respondentene så videoen av Nissan Leaf.

Rune Erichsen1, Timothy L Lash1, Stephen J Hamilton-Dutoit2, Beth Bjerregaard3, Mogens Vyberg2,4, Lars Pedersen11Department of Clinical Epidemiology, 2Institute of Pathology, 4Aalborg Hospital, Aarhus University Hospital, Aarhus, Denmark; 3Department of Pathology and the Pathology Data Bank, Herlev University Hospital, Herlev, DenmarkAbstract: Diagnostic histological and cytological specimens are routinely stored in pathology department archives. These biobanks are a valuable research resource for many diseases, particularly if they can be linked to high quality population-based health registries, allowing large retrospective epidemiological studies to be carried out. Such studies are of significant importance, for example in the search for novel prognostic and predictive biomarkers in the era of personalized medicine. Denmark has a wealth of highly-regarded population-based registries that are ideally suited to conduct this type of epidemiological research. We describe two recent additions to these databases: the Danish National Pathology Registry (DNPR) and its underlying national online registration database, the Danish Pathology Data Bank (DPDB). The DNPR and the DPDB contain detailed nationwide records of all pathology specimens analyzed in Denmark since 1997, and an incomplete but nonetheless valuable record of specimens from some pathology departments dating back to the 1970s. The data are of high quality and completeness and are sufficient to allow precise and efficient localization of the specimens. We describe the relatively uncomplicated procedures required to use these pathology databases in clinical research and to gain access to the archived specimens.Keywords: cohort profile, epidemiology, paraffin blocks, pathology

Background— Inflammatory bowel disease (IBD) is associated with increased cardiovascular risk. We examined the effect of active IBD on major adverse cardiovascular outcomes after myocardial infarction (MI). Methods and Results— In nationwide registries, we identified 86 790 patients with first-time MI from the period 2002 to 2011. A total of 1030 patients had IBD, and we categorized their disease activity stages into either flare (120 days), persistent (>120 days) activity, or remission. Short-term mortality was estimated in a logistic regression-model, whereas risk of recurrent MI, all-cause mortality, and a composite of recurrent MI, cardiovascular death, and stroke were estimated by Cox regression-models. Odds ratio of death during hospitalization or within 30 days of discharge (n=13 339) corresponded to 3.29 (95% confidence interval [CI], 1.98–5.45) for patients in IBD flares, 1.62 (95% CI, 0.95–2.77) for persistent activity, and 0.97 (95% CI, 0.78–1.19) for remission when compared with the non-IBD group. Among 73 451 patients, including 863 with IBD, alive 30 days after discharge, IBD was associated with hazard ratios of 1.21 (95% CI, 0.99–1.49) for recurrent MI, 1.14 (95% CI, 1.01–1.28) for all-cause mortality, and 1.17 (95% CI, 1.03–1.34) for the composite end point. When compared with the non-IBD group, IBD flares, in particular, were associated with increased risks of recurrent MI (hazard ratio, 3.09; 95% CI, 1.79–5.32), all-cause mortality (hazard ratio, 2.25; 95% CI, 1.61–3.15), and the composite end point (hazard ratio, 2.04; 95% CI, 1.35–3.06), whereas no increased risk was identified in remission. Conclusions— Active inflammatory bowel disease worsens prognosis after MI, in particular, in relation with flares.

Background— Inflammatory bowel disease (IBD) has been linked to adverse cardiovascular events, but a relation to heart failure (HF) is uncertain. We investigated the IBD-associated risk of HF in a nationwide setting. Methods and Results— A total of 5 436 647 Danish citizens, with no history of IBD or HF, were included on January 1, 1997, and followed up until first hospitalization for HF, death, or December 31, 2011. Of these subjects, 23 681 developed IBD for which disease activity was determined continuously throughout the study. The risk of hospitalization for HF was estimated with a Poisson regression model adjusting for comorbidity and cardiovascular pharmacotherapy as time-dependent covariates. During a mean follow-up of 11.8 years in the reference population and 6.4 years in the IBD group, hospitalization for HF occurred in 553 subjects with IBD and 171 405 in the reference population. Patients with IBD had a 37% increased risk of hospitalization for HF (incidence rate ratio, 1.37; 95% confidence interval, 1.26–1.49) compared with the reference population. IBD activity-specific analyses showed markedly increased risk of HF hospitalization during flares (incidence rate ratio, 2.54; 95% confidence interval, 2.13–3.04) and persistent activity (incidence rate ratio, 2.73; 95% confidence interval, 2.25–3.33) but not in IBD remission (incidence rate ratio, 1.04; 95% confidence interval, 0.94–1.16). Conclusions— In a nationwide cohort, IBD was associated with an increased risk of hospitalization for HF, and this risk was strongly correlated to periods of active disease. The mechanisms underlying this finding warrant further studies.