The changing epidemiology of community-acquired pneumonia: nationwide register-based study in Sweden.

BACKGROUND: There is limited evidence on the impact of pneumococcal conjugate vaccine childhood immunization programmes (PCV-CIP) on community-acquired pneumonia (CAP) in individuals with underlying diseases. METHODS: A nationwide cohort study using Swedish health registers to assess the incidence of hospitalization with all-cause (AC-CAP) and pneumococcal or lobar (PL-CAP) CAP between 2005 and 2015, in relation to PCV-CIP introduction in 2007-09. RESULTS: In total, 303 691 episodes of AC-CAP occurred, of which 14 225 were PL-CAP. Comparing before (2005-06) with after (2014-15) PCV-CIP, relative incidence reductions were 36% (95% Confidence Interval 32-40), 20% (14-25) and 16% (11-22) of AC-CAP for age groups < 2, 2-4 and 5-17 years, respectively, with similar reductions in young children with and without comorbidities. The reductions were more pronounced for PL-CAP. In the age groups 40-64, 65-74, 75-84 and ≥85 years there were relative increases of 11% (8-14), 18% (15-22), 15% (12-17) and 30% (27-34) of AC-CAP, respectively, but these increases were attenuated after adjustment for admittance practices using four control conditions. In adults with comorbidities, there was an increase in incidence of AC-CAP, and PL-CAP, in contrast to adults without reported underlying diseases where the incidence was stable or diminished for some age groups. Over the study period, there was an increased proportion of pneumonia patients with underlying diseases in all ages. CONCLUSION: This emphasizes that direct preventive interventions should be targeted towards individuals with underlying diseases. Future studies should investigate reasons for the observed increased risk in adults with comorbidities, for example due to pneumococcal nonvaccine serotypes, or other pathogens, preferentially affecting subjects with underlying diseases.

Maternal and infant pregnancy outcomes in women with psoriatic arthritis: a Swedish nationwide cohort study.

OBJECTIVE: Studies on pregnancy outcomes in psoriatic arthritis (PsA) are scarce and typically of small size. Available studies have reported conflicting results. The aim of this study was to describe maternal and infant pregnancy outcomes among women with PsA compared with women without PsA. DESIGN: Nationwide cohort study. SETTING: Nationwide Swedish registers. POPULATION: A total of 41 485 singleton pregnancies in 1997-2014, of which 541 pregnancies were identified with PsA exposure and 40 944 pregnancies were unexposed. METHODS: By linkage of national health and population register data, we obtained information on individual pregnancies and compared outcomes among pregnancies with PsA and non-PsA pregnancies. Relative risks were estimated by odds ratios (ORs) with 95% CIs using a generalised linear regression model with generalised estimating equations. Adjustments were made for maternal factors and calendar year of birth. MAIN OUTCOME MEASURES: Maternal and infant pregnancy outcomes. RESULTS: Pregnancies to women with PsA had increased risks of preterm birth (adjusted OR 1.63; 95% CI 1.17-2.28), elective and emergency caesarean deliveries (adjusted OR 1.47; 95% CI 1.10-1.97 and adjusted OR 1.43; 95% CI 1.08-1.88, respectively) compared with non-PsA pregnancies. No increased risks were observed for pre-eclampsia, stillbirth or other infant outcomes apart from preterm birth. CONCLUSION: The majority of women with PsA have uneventful pregnancies with respect to adverse outcomes. In the present study, we found increased risks of preterm birth and caesarean delivery compared with non-PsA pregnancies. TWEETABLE ABSTRACT: Women with psoriatic arthritis have uneventful pregnancies but are at increased risk of preterm birth and caesarean delivery.

Complete mesocolic excision in right-sided colon cancer does not increase severe short-term postoperative adverse events.

AIM: The aim was to assess whether complete mesocolic excision (CME) in patients with right-sided colon cancer is related to short-term mortality or postoperative adverse events requiring reoperation. The complete mobilization of an integral mesocolon and central ligation of blood vessels are essential steps in CME surgery. The resultant specimen, with an intact mesocolic fascia and a high number of harvested lymph nodes, is believed to be oncologically favourable. However, it has been suggested that CME surgery may increase the risk of intra-operative severe adverse events, due to exposure of vital retroperitoneal organs and large blood vessels. METHOD: In a population-based, nested case-control study, all residents in the Stockholm County operated for right-sided colon cancer from 2004 until 2012 were identified from the Swedish Colorectal Cancer Registry. Patients who died within 90 days after surgery or were reoperated within 30 days after surgery, or during the index hospital stay, were defined as cases. Two controls per case were randomly sampled and individually matched for age, sex, TNM stage and emergency vs elective surgery. Exposure status (CME surgery) was assessed from original surgical reports. RESULTS: The estimated proportion of CME surgery was 14.8% (35 of 236) for cases and 19.5% (92 of 473) for controls. The unadjusted OR for short-term mortality or reoperation after CME surgery was 0.72 (95% CI: 0.47-1.10; P = 0.15). The ORs were lower in the late part of the study (0.51; 95% CI: 0.26-1.01) and in high volume hospitals (0.61, 95% CI: 0.35-1.06). CONCLUSIONS: The present study does not indicate that CME surgery is associated with an increased risk of severe adverse events such as 90-day mortality or reoperation.

Editor's Choice - Dual Antiplatelet Therapy Improves Outcome in Diabetic Patients Undergoing Endovascular Femoropopliteal Stenting for Critical Limb Ischaemia.

OBJECTIVE: The purpose of this study was to analyse the effect of dual antiplatelet therapy (DAPT) compared to aspirin on outcome after endovascular interventions in patients with CLI. METHODS: This was a population based retrospective nationwide cohort analysis. Several linked national databases in Sweden: Swedish National Vascular Registry, Prescribed Drug Registry and National Discharge Registry. A total of 1941 patients (median age 79; range 43-103 years; women 58%) were identified with CLI who had undergone primary femoropopliteal endovascular intervention between 2006 and 2012. Of these, 599 (31%) patients were treated after the intervention with DAPT (aspirin and clopidogrel) and 1342 (69%) patients were treated with aspirin only. Percutaneous transluminal angioplasty (PTA) was performed in 1131 patients (58%), stenting in 633 patients (33%), and subintimal angioplasty (SAP) in 177 patients (9%). RESULTS: DAPT was given after PTA, stenting, and SAP to 17% (n = 188), 53% (n = 334), and 44% (n = 77) of the patients, respectively. During the study period, 77 patients (13%) with DAPT and 228 patients (17%) with aspirin underwent a major amputation. Patients receiving DAPT after stenting had a lower rate of amputation (HR 0.56; 95% CI 0.36-0.86) than patients receiving aspirin alone. In the subgroup analysis, the protective effect of DAPT on amputation seemed to be confined to patients with diabetes mellitus receiving a stent (HR 0.26; 95% CI 0.13-0.52; p < .001). DAPT after PTA or SAP did not influence limb salvage, and there was no overall difference in mortality. There was no significant difference in bleeding complications between DAPT and aspirin. CONCLUSION: DAPT with aspirin and clopidogrel compared to aspirin alone was associated with a lower amputation rate but not a higher bleeding rate in patients with diabetes and CLI after endovascular femoropopliteal stenting.

Risk of second primary cancer in patients treated with radiotherapy for rectal cancer.

BACKGROUND: Many patients with rectal cancer receive radiotherapy (RT) to reduce the risk of local recurrence. Radiation may give rise to adverse effects, including second primary cancers. In view of the divergent results of previous studies, the present study evaluated the risk of second primary cancer following RT in all randomized RT rectal cancer trials conducted in Sweden and in the Swedish ColoRectal Cancer Registry (SCRCR). METHODS: Patients included in five randomized trials and the SCRCR were linked to the Swedish Cancer Registry. Cox regression models estimated the hazard ratio (HR) of second primary cancer among patients who received RT compared with those who did not. RESULTS: A total of 13 457 patients were included in this study; 7024 (52·2 per cent) received RT and 6433 (47·8 per cent) had surgery alone. Overall, no increased risk of second primary cancer was observed with RT (HR 1·03; 95 per cent c.i. 0·92 to 1·15), independently of follow-up time and location within or outside of the irradiated volume. In the randomized trials, with longer follow-up (maximum 31 years), a slight increase was observed outside of (HR 1·33, 1·01 to 1·74) but not within (HR 1·11, 0·73 to 1·67) the irradiated volume. Irradiated men had a lower risk of prostate cancer than those treated with surgery alone (HR 0·68, 0·51 to 0·91). CONCLUSION: Overall, there was no increased risk of second primary cancer following RT for rectal cancer within or outside of the irradiated volume up to 20 years of follow-up. Men with rectal cancer who received RT had a reduced risk of prostate cancer.

Narrow-spectrum ß-lactam monotherapy in hospital treatment of community-acquired pneumonia: a register-based cohort study.

OBJECTIVES: To assess the clinical effect of empirical treatment with narrow-spectrum ß-lactam monotherapy (NSBM) versus broad-spectrum ß-lactam monotherapy (BSBM) in non-severe community-acquired pneumonia (CAP). METHODS: Hospitalized patients ≥18 years with CAP who received initial NSBM or BSBM, with a severity score according to CRB-65≤2 (C=confusion, R=respiratory rate >30/min, B=systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg, 65= ≥65 years), in the Swedish Pneumonia Register from 2008 to 2011 were included. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, treatment at intensive care unit (ICU), and length of stay (LOS). Propensity score matching was performed to account for differences in baseline characteristics. RESULTS: There were 5961 patients with CRB-65≤1 and 1344 patients with CRB-65=2. In the propensity score matched cohorts the 30-day mortality was 40/1827 (2.2%) with NSBM and 56/1827 (3.1%) with BSBM in CRB-65≤1, and 57/524 (10.9%) and 51/524 (9.7%), respectively, in CRB-65=2. No significant differences in 30-day mortality were observed between NSBM and BSBM in patients with CRB-65≤1 or CRB-65=2, OR 1.41 (95% CI 0.94-2.14) and 0.88 (95% CI 0.59-1.32), respectively. There was no significant difference in 90-day mortality. Patients who received BSBM were more often treated at ICU and had longer LOS. CONCLUSIONS: Empirical NSBM appears to be effective in the majority of hospitalized immunocompetent adults with non-severe CAP and should be further evaluated in randomized trials.

Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

INTRODUCTION: Outcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer. PATIENTS AND METHODS: Multidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the "Stockholm Colon Cancer Project" all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR). RESULTS: The proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period. DISCUSSION: Surgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the "Stockholm Colon Cancer Project" cannot be established, however it is likely that it contributed to the improved survival.

A coordinated cross-disciplinary research initiative to address an increased incidence of narcolepsy following the 2009-2010 Pandemrix vaccination programme in Sweden.

In response to the 2009-2010 influenza A(H1N1)pdm09 pandemic, a mass vaccination programme with the AS03-adjuvanted influenza A(H1N1) vaccine Pandemrix was initiated in Sweden. Unexpectedly, there were a number of narcolepsy cases amongst vaccinated children and adolescents reported. In this review, we summarize the results of a joint cross-disciplinary national research effort to investigate the adverse reaction signal from the spontaneous reporting system and to better understand possible causative mechanisms. A three- to fourfold increased risk of narcolepsy in vaccinated children and adolescents was verified by epidemiological studies. Of importance, no risk increase was observed for the other neurological and autoimmune diseases studied. Genetic studies confirmed the association with the allele HLA-DQB1*06:02, which is known to be related to sporadic narcolepsy. Furthermore, a number of studies using cellular and molecular experimental models investigated possible links between influenza vaccination and narcolepsy. Serum analysis, using a peptide microarray platform, showed that individuals who received Pandemrix exhibited a different epitope reactivity pattern to neuraminidase and haemagglutinin, as compared to individuals who were infected with H1N1. Patients with narcolepsy were also found to have increased levels of interferon-gamma production in response to streptococcus-associated antigens. The chain of patient-related events and the study results emerging over time were subjected to intense nationwide media attention. The importance of transparent communication and collaboration with patient representatives to maintain public trust in vaccination programmes is also discussed in the review. Organizational challenges due to this unexpected event delayed the initiation of some of the research projects, still the main objectives of this joint, cross-disciplinary research effort were reached, and important insights were acquired for future, similar situations in which a fast and effective task force may be required to evaluate vaccination-related adverse events.

Risks of neurological and immune-related diseases, including narcolepsy, after vaccination with Pandemrix: a population- and registry-based cohort study with over 2 years of follow-up.

OBJECTIVES: To investigate the association between vaccination with Pandemrix and risk of selected neurological and immune-related diseases including narcolepsy. DESIGN: Population-based prospective cohort study using data from regional vaccination registries and national health registries. SETTING: Seven healthcare regions in Sweden comprising 61% of the Swedish population. SUBJECTS: Study population of 3,347,467 vaccinated and 2,497,572 nonvaccinated individuals (vaccination coverage ≈ 60%) followed between 2009 and 2011 for 6.9 million person-years after exposure and 6.0 million person-years without exposure. MAIN OUTCOME MEASURE AND ANALYSIS: First recorded diagnosis of neurological and immune-related diseases. Relative risks [hazard ratios (HRs) with 95% confidence intervals (CIs)] assessed using Cox regression, adjusted for covariates. RESULTS: For all selected neurological and immune-related outcomes under study, other than allergic vaccine reactions (for which we verified an expected increase in risk) and narcolepsy, HRs were close to 1.0 and always below 1.3. We observed a three-fold increased risk of a diagnosis of narcolepsy (HR: 2.92, 95% CI: 1.78-4.79; that is, four additional cases per 100,000 person-years) in individuals ≤ 20 years of age at vaccination and a two-fold increase (HR: 2.18, 95% CI: 1.00-4.75) amongst young adults between 21 and 30 years of age. The excess risk declined successively with increasing age at vaccination; no increase in risk was seen after 40 years of age. CONCLUSIONS: For a large number of selected neurological and immune-related diseases, we could neither confirm any causal association with Pandemrix nor refute entirely a small excess risk. We confirmed an increased risk for a diagnosis of narcolepsy in individuals ≤ 20 years of age and observed a trend towards an increased risk also amongst young adults between 21 and 30 years.

Estimated drinking water fluoride exposure and risk of hip fracture: a cohort study.

The cariostatic benefit from water fluoridation is indisputable, but the knowledge of possible adverse effects on bone and fracture risk due to fluoride exposure is ambiguous. The association between long-term (chronic) drinking water fluoride exposure and hip fracture (ICD-7-9: '820' and ICD-10: 'S72.0-S72.2') was assessed in Sweden using nationwide registers. All individuals born in Sweden between January 1, 1900 and December 31, 1919, alive and living in their municipality of birth at the time of start of follow-up, were eligible for this study. Information on the study population (n = 473,277) was linked among the Swedish National In-Patient Register (IPR), the Swedish Cause of Death Register, and the Register of Population and Population Changes. Estimated individual drinking water fluoride exposure was stratified into 4 categories: very low, < 0.3 mg/L; low, 0.3 to 0.69 mg/L; medium, 0.7 to 1.49 mg/L; and high, ≥ 1.5 mg/L. Overall, we found no association between chronic fluoride exposure and the occurrence of hip fracture. The risk estimates did not change in analyses restricted to only low-trauma osteoporotic hip fractures. Chronic fluoride exposure from drinking water does not seem to have any important effects on the risk of hip fracture, in the investigated exposure range.

Local recurrence after prone vs supine abdominoperineal excision for low rectal cancer.

AIM: Tumour-involved circumferential resection margins (CRMs) and intra-operative perforation (IOP) are well known risk factors for local recurrence after surgery for low rectal cancer. In conventional abdominoperineal excision (APE) the patient remains in the supine position for the perineal part of the procedure. However, turning the patient to the prone position may improve visualization which potentially might reduce the risk of involved CRMs and IOP and thus improve local control. The study was carried out to assess local recurrence rates after APE in relation to the positioning of the patient during the perineal part of the procedure. METHOD: This cohort study includes 466 patients having APE for low rectal cancer between 2001 and December 2010. Data were retrieved from the regional rectal cancer registry in Stockholm and from a retrospective review of patient files. RESULTS: An incomplete resection was reported in 12.4% after APE in the supine position and in 6.8% after APE in the prone position (P = 0.038). Corresponding figures for IOP were 12.4% and 4.0% (P < 0.001). Prone APE was associated with a 39% relative reduction in local recurrence events compared with APE in the supine position, although the difference was not statistically significant (hazard ratio 0.61, 95% CI 0.27-1.37). CONCLUSION: APE in the prone position reduced the incidence of incomplete resection and IOP, but the study did not find a statistically significant difference in local failure rates related to the position of the patient.

Mucosal healing and mortality in coeliac disease.

BACKGROUND: Coeliac disease (CD), characterised by the presence of villous atrophy (VA) in the small intestine, is associated with increased mortality, but it is unknown if mortality is influenced by mucosal recovery. AIMS: To determine whether persistent VA is associated with mortality in CD. METHODS: Through biopsy reports from all pathology departments (n = 28) in Sweden, we identified 7648 individuals with CD (defined as VA) who had undergone a follow-up biopsy within 5 years following diagnosis. We used Cox regression to examine mortality according to follow-up biopsy. RESULTS: The mean age of CD diagnosis was 28.4; 63% were female; and the median follow-up after diagnosis was 11.5 years. The overall mortality rate of patients who underwent follow-up biopsy was lower than that of those who did not undergo follow-up biopsy (Hazard Ratio 0.88, 95% CI: 0.80-0.96). Of the 7648 patients who underwent follow-up biopsy, persistent VA was present in 3317 (43%). There were 606 (8%) deaths. Patients with persistent VA were not at increased risk of death compared with those with mucosal healing (HR: 1.01; 95% CI: 0.86-1.19). Mortality was not increased in children with persistent VA (HR: 1.09 95% CI: 0.37-3.16) or adults (HR 1.00 95% CI: 0.85-1.18), including adults older than age 50 years (HR: 0.96 95% CI: 0.80-1.14). CONCLUSIONS: Persistent villous atrophy is not associated with increased mortality in coeliac disease. While a follow-up biopsy will allow detection of refractory disease in symptomatic patients, in the select population of patients who undergo repeat biopsy, persistent villous atrophy is not useful in predicting future mortality.

Evaluation of prevalent and incident ovarian cancer co-morbidity.

BACKGROUND: The peak in incidence of ovarian cancer occurs around 65 years and concurrent increasing risk by age for a number of diseases strongly influence treatment and prognosis. The aim was to explore prevalence and incidence of co-morbidity in ovarian cancer patients compared with the general population. METHODS: The study population was patients with ovarian cancer in Sweden 1993-2006 (n=11 139) and five controls per case (n=55 687). Co-morbidity from 1987 to 2006 was obtained from the Swedish Patient Register. Prevalent data were analysed with logistic regression and incident data with Cox proportional hazards models. RESULTS: Women developing ovarian cancer did not have higher overall morbidity than other women earlier than 3 months preceding cancer diagnosis. However, at time of diagnosis 11 of 13 prevalent diagnosis groups were more common among ovarian cancer patients compared with controls. The incidence of many common diagnoses was increased several years following the ovarian cancer and the most common diagnoses during the follow-up period were thromboembolism, haematologic and gastrointestinal complications. CONCLUSION: Women developing ovarian cancer do not have higher overall morbidity the years preceding cancer diagnosis. The incidence of many common diagnoses was increased several years following the ovarian cancer. It is crucial to consider time between co-morbidity and cancer diagnosis to understand and interpret associations.

Subacute cutaneous lupus erythematosus and its association with drugs: a population-based matched case-control study of 234 patients in Sweden.

BACKGROUND: Numerous case reports about drug-induced (DI) subacute cutaneous lupus erythematosus (SCLE) have been published. Various drug types with different latencies has been proposed as triggers for this autoimmune skin disease. OBJECTIVES: To evaluate the association between exposure to certain suspected drugs (previously implicated to induce SCLE) and a subsequent diagnosis of SCLE. METHODS: We performed a population-based matched case-control study in which all incident cases of SCLE (n=34) from 2006 to 2009 were derived from the National Patient Register. The control group was selected from the general population, matched (1:10) for gender, age and county of residence. The data were linked to the Prescribed Drug Register. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for the association between exposures to certain suspected drugs and the development of SCLE. RESULTS: During the 6 months preceding SCLE diagnosis, 166 (71%) of the patients with SCLE had at least one filled prescription of the suspected drugs. The most increased ORs were found for terbinafine (OR 52.9, 95% CI 6.6-∞), tumour necrosis factor-α inhibitors (OR 8.0, 95% CI 1.6-37.2), antiepileptics (OR 3.4, 95% CI 1.9-5.8) and proton pump inhibitors (OR 2.9, 95% CI 2.0-4.0). CONCLUSIONS: We found an association between drug exposure and SCLE. More than one third of the SCLE cases could be attributed to drug exposure. No significant OR was found for thiazides, which might be due to longer latency and therefore missed with this study design. DI-SCLE is reversible once the drug is discontinued, indicating the importance of screening patients with SCLE for potentially triggering drugs. A causal relationship cannot be established from this study and the underlying pathogenesis remains unclear.

Increased lymph node harvest in patients operated on for right-sided colon cancer: a population-based study.

AIM: In recent decades, the focus has been on the treatment of rectal cancer with improved surgical techniques. This has resulted in improved results for patients with rectal cancer. Recently, the focus has shifted to colon cancer surgery with the introduction of preoperative staging, new surgical techniques, quality control and enhanced recovery programmes. The change in operative techniques has been most pronounced for patients with tumours on the right side of the colon, with more extensive resections and proximal ligations of the vessels. The aim of this study was to assess the number of analysed lymph nodes and the metastatic index (MI) in patients operated on for right-sided colon cancer in the Stockholm area between 1996 and 2009. METHOD: All patients operated on for cancer of the right colon between January 1996 and December 2009 were divided into three groups based on the year in which they were operated (period 1, 1996-1999; period 2, 2000-2004; and period 3, 2005-2009). The number of lymph nodes and lymph node status were analysed. RESULTS: In total, 3536 patients were operated on for right-sided colon cancer during the study period. There was a significantly lower proportion of emergency operations in the third time period. The mean number of lymph nodes examined increased significantly during the overall study period (seven in period 1, 11 in period 2 and 18 in period 3; P < 0.001). A significant drop in MI was seen during the third time period (0.25, compared with 0.40 in period 1 and 0.40 in period 2; P < 0.001). CONCLUSION: During the study period there was an increase in the number of analysed lymph nodes and a decrease in MI after right-sided hemicolectomies. Further investigations are needed to evaluate the potential impact on short-term and long-term outcome.

Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer.

BACKGROUND: This was a population-based cohort study to determine the incidence, prevalence and risk factors for peritoneal carcinomatosis (PC) from colorectal cancer. METHODS: Prospectively collected data were obtained from the Regional Quality Registry. The Cox proportional hazards regression model was used for multivariable analysis of clinicopathological factors to determine independent predictors of PC. RESULTS: All 11 124 patients with colorectal cancer in Stockholm County during 1995-2007 were included and followed until 2010. In total, 924 patients (8.3 per cent) had synchronous or metachronous PC. PC was the first and only localization of metastases in 535 patients (4.8 per cent). The prevalence of synchronous PC was 4.3 per cent (477 of 11 124). The cumulative incidence of metachronous PC was 4.2 per cent (447 of 10 646). Independent predictors for metachronous PC were colonic cancer (hazard ratio (HR) 1.77, 95 per cent confidence interval 1.31 to 2.39; P = 0.002 for right-sided colonic cancer), advanced tumour (T) status (HR 9.98, 3.10 to 32.11; P < 0.001 for T4), advanced node (N) status (HR 7.41, 4.78 to 11.51; P < 0.001 for N2 with fewer than 12 lymph nodes examined), emergency surgery (HR 2.11, 1.66 to 2.69; P < 0.001) and non-radical resection of the primary tumour (HR 2.75, 2.10 to 3.61; P < 0.001 for R2 resection). Patients aged > 70 years had a decreased risk of metachronous PC (HR 0.69, 0.55 to 0.87; P = 0.003). CONCLUSION: PC is common in patients with colorectal cancer and is associated with identifiable risk factors.

High birth weight and obesity--a vicious circle across generations.

OBJECTIVES: Rates of high birth weight infants, overweight and obese children and adults are increasing. The associations between birth weight and adult weight may have consequences for the obesity epidemic across generations. We examined the association between mothers' birth weight for gestational age and adult body mass index (BMI) and these factors' joint effect on risk of having a large-for-gestational-age (LGA) offspring (>+2 s.d. above the mean). DESIGN: A cohort of 162 676 mothers and their first-born offspring with birth information recorded on mothers and offspring in the nation-wide Swedish Medical Birth Register 1973-2006. RESULTS: Compared with mothers with appropriate birth weight for gestational age (AGA; -1 to +1 s.d.), mothers born LGA had increased risks of overweight (BMI 25.0-29.9; odds ratio (OR), 1.50; 95% CI 1.39-1.61), obesity class I (BMI 30.0-34.9; OR 1.77; 95% CI 1.59-1.98), obesity class II (BMI 35.0-39.9; OR 2.77; 95% CI 2.37-3.24) and obesity class III (BMI ≥40.0; OR 2.04; 95% CI 1.49-2.80). In each stratum of mother's birth weight for gestational age, risk of having an LGA offspring increased with mother's BMI. The risk of an LGA offspring was highest among women with a high (≥30) BMI who also had a high birth weight for gestational age (>+1 s.d.). In these groups, the ORs for LGA offspring ranged from 5 to 14 when compared with mothers born AGA with normal BMI (≤24.9). However, the strongest increase in risk by BMI was seen among mothers born SGA: the OR of having an LGA offspring was 13 times as high among SGA mothers with BMI ≥35.0 compared with the OR among SGA mothers with normal BMI (ORs=4.61 and 0.35, respectively). CONCLUSIONS: Prenatal conditions are important for the obesity epidemic. Prevention of LGA births may contribute to curtail the intergenerational vicious cycle of obesity.

Increased risk of cancer among 3663 patients with cutaneous lupus erythematosus: a Swedish nationwide cohort study.

BACKGROUND: Other autoimmune diseases have been associated with higher risks for cancer, and numerous case reports of cutaneous lupus erythematosus (CLE) and different cancer types are available. OBJECTIVES: To estimate the overall and specific cancer risks in a nationwide cohort study of patients diagnosed with CLE in Sweden and compare that risk with that in a control cohort without CLE. METHODS: A cohort of 3663 individuals with CLE and a matched control cohort from the general population (three controls to each CLE case) without a diagnosis of CLE were derived from the Swedish National Patient Register, 1997-2007, and were electronically linked to the Swedish Cancer Register and the Swedish Cause of Death Register. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to compare the observed vs. the expected numbers of cancers. RESULTS: A total of 183 incident cancers occurred within the observation interval, yielding a HR of 1·8 (95% CI 1·5-2·2) for cancer overall. Median follow-up was 4·1 years. About a fourfold risk increase was seen for buccal cancer, lymphomas, respiratory cancer and nonmelanoma skin cancer. CONCLUSIONS: Patients with CLE appear to have an elevated risk for certain cancer types, an increase that remains when excluding patients also diagnosed with systemic lupus erythematosus. Our findings point to the importance of counselling about not smoking and sun avoidance, and underscore the need for specialized monitoring of this patient group along with bench-to-bedside research efforts to clarify pathogenesis.