Interval Cancer in Population-Based Colorectal Screening Programmes: Incidence and Characteristics of Tumours.

The objective of this study is to evaluate interval cancer (IC) in colorectal cancer (CRC) screening, which is CRC diagnosed in an individual after having received a negative faecal occult blood test and before the next invitation to participate in screening. A follow-up study was conducted on a cohort of participants in the first three screening rounds of four colorectal cancer screening programmes in Spain, n = 664,993. A total of 321 ICs and 2120 screen-detected cancers (SCs) were found. The IC and SC rates were calculated for each guaiac (gFOBT) or immunochemical (FIT) test. A Cox regression model was used to estimate the hazard ratios (HR) of IC risk factors. A nested case-control study was carried out to compare IC and SC tumour characteristics. The IC rate was 1.16‱ with the gFOBT and 0.35‱ with the FIT. Men and people aged 60-69 showed an increased probability of IC (HR = 1.81 and HR = 1.95, respectively). There was a decreased probability of IC in individuals who regularly participated in screening, HR = 0.62 (0.47-0.82). IC risk gradually rose as the amount of Hb detected in the FIT increased. IC tumours were in more advanced stages and of a larger size than SC tumours, and they were mostly located in the cecum. These results may play a key role in future strategies for screening programmes, reducing IC incidence.

One or two faecal immunochemical tests in an organised population-based colorectal cancer screening programme in Murcia (Spain).

OBJECTIVE: Roll-out of population-based colorectal cancer (CRC) screening with faecal immunochemical test (FIT) is limited by availability of further investigations, particularly colonoscopy and examination of excised lesions. Our objective was to assess whether variation in number of faecal samples and threshold adjustment can optimise resource utilisation and CRC detection rate. METHODS: Three different screening strategies were compared for the same FIT threshold using a quantitative FIT system: one FIT, positive when >20 µg Hb/g faeces; two FIT, positive when either was >20 µg Hb/g faeces; and two FIT, positive when the mean was >20 µg Hb/g faeces. We calculated changes in the size of population the provider could invite to screening for an equal number of screening positive results, and CRC and adenoma detected. RESULTS: In our setting, Region of Murcia, south of Spain (not fully rolled out screening programme), changing the usual strategy of two FIT, positive when either to positive when the mean was >20 µg Hb/g faeces, would increase population invited by 37.81% with the same number of positive results (which would generate a CRC detection rate of 19.2%). In a fully rolled out programme, changing the strategy from one to two FIT (positive when the mean is >20 µg Hb/g faeces), would increase CRC detection rate by 4.64% with an increase of only 13.34% in positive FIT. CONCLUSIONS: In a population-based CRC screening programme, smart use of number of FITs and positivity threshold can increase population invited and CRC detection without increasing the number of colonoscopies and pathological examinations needed.

Optimal cut-off value for detecting colorectal cancer with fecal immunochemical tests according to age and sex.

In the fecal immunological test, a suitable cut-off value may be selected to classify results as either positive or negative. Our aim is to estimate the optimal cut-off value for detecting colorectal cancer in different age and sex groups. This is a multicentric retrospective cohort study of participants in CRC screening programs with FIT between 2006 and 2012. A total of 545,505 participations were analyzed. Cancers diagnosed outside of the program were identified after a negative test result (IC_test) up until 2014. The Wilcoxon test was used to compare fecal hemoglobin levels. ROC curves were used to identify the optimal cut-off value for each age and sex group. Screening program results were estimated for different cut-off values. The results show that the Hb concentration was higher in colorectal cancer (average = 179.6µg/g) vs. false positives (average = 55.2µg/g), in IC_test (average = 3.1µg/g) vs. true negatives (average = 0µg/g), and in men (average = 166.2µg/g) vs. women (average = 140.2µg/g) with colorectal cancer. The optimal cut-off values for women were 18.3µg/g (50-59y) and 14.6µg/g (60-69y), and 16.8µg/g (50-59y) and 19.9µg/g (60-69y) for men. Using different cut-off values for each age and sex group lead to a decrease in the IC_test rate compared to the 20µg/g cut-off value (from 0.40‰ to 0.37‰) and an increase in the false positive rate (from 6.45% to 6.99%). Moreover, test sensitivity improved (90.7%), especially in men and women aged 50-59y (89.4%; 90%) and women aged 60-69y (90.2%). In conclusion, the optimal cut-off value varies for different sex and age groups and the use of an optimal cut-off value for each group improves sensitivity and leads to a small decrease in IC_tests, but also to a larger increase in false positives.

[Evaluation of a public health program on early HIV diagnosis with quick test]. / Evaluación de un programa de salud pública sobre diagnostico precoz de VIH con prueba rápida.

OBJECTIVE: The use of HIV planned and structured, community-based rapid tests is one of the main strategies for the early detection of HIV infection. The objective of the study was to assess the HIV early diagnosis programme with rapid test in the Region of Murcia. METHODS: Descriptive analysis of the programme users' epidemiological data during the years 2016 to 2018. Variables related to sociodemographic characteristics, risk exposure, history of HIV test performance and its result were analyzed. All analyzes were performed with statistical software IBM SPSS25 and Microsoft Excel version 2013. Frequencies were calculated in absolute values and the variables of interest were crosshead. RESULTS: There were 1,023 people tested, of which 74% performed risky sexual practices in the last 12 months, both homosexual (50%) and heterosexual (45%), with an age between 18 and 40 years. 18.2% of the users were foreigners and 61.9% had been previously tested. Among the participants in the programme the percentage of reactive tests was 2.1% and the contribution to the diagnosis of new HIV cases in the Region was 4.3%. CONCLUSIONS: The results of the study show that the community-based programme is an effective tool for the diagnosis of HIV infection in vulnerable groups. In addition, several opportunities for improvement were identified in the process assessment, such as accessibility to the program and the collection of information.

OBJETIVO: Entre las principales estrategias para la detección precoz de la infección por VIH se encuentra la utilización planificada y estructurada de pruebas rápidas en entornos comunitarios especialmente vulnerables. El objetivo del presente estudio fue evaluar el programa de diagnóstico precoz de VIH con prueba rápida de la Región de Murcia. METODOS: Se realizó un análisis descriptivo de los datos epidemiológicos de la población participante en el programa durante los años 2016 a 2018. Se analizaron variables relacionadas con características sociodemográficas, exposición de riesgo, antecedentes de realización de la determinación de VIH y resultado de la prueba. Todos los análisis se realizaron con el software estadístico IBM SPSS25 y Microsoft Excel versión 2013. Se calcularon frecuencias en valores absolutos y los porcentajes correspondientes, y se cruzaron las variables de interés. RESULTADOS: Se caracterizaron 1.023 personas participantes, de las que el 74% realizaron prácticas sexuales de riesgo en los últimos 12 meses, tanto de carácter homosexual (50%) como heterosexual (45%), con una edad comprendida entre los 18 y los 40 años. El 18,2% eran extranjeros, y el 61,9% se había realizado la prueba anteriormente. Entre los participantes, el porcentaje de pruebas reactivas fue del 2,1%, y la contribución al diagnóstico de nuevos casos de VIH en la Región fue del 4,3%. CONCLUSIONES: Los resultados del estudio ponen de manifiesto que el programa es una herramienta eficaz para el diagnóstico de la infección por VIH en colectivos vulnerables. Además, en el proceso de evaluación se identifican varias oportunidades de mejora como son la accesibilidad al programa y la recogida de información.

An Update of Twin Research in Spain: The Murcia Twin Registry.

The Murcia Twin Registry (MTR) is the only population-based registry in Spain. Created in 2006, the registry has been growing more than a decade to become one of the references for twin research in the Mediterranean region. The MTR database currently comprises 3545 adult participants born between 1940 and 1977. It also holds a recently launched satellite registry of university students (N = 204). Along five waves of data collection, the registry has gathered questionnaire and anthropometric data, as well as biological samples. The MTR keeps its main research focus on health and health-related behaviors from a public health perspective. This includes lifestyle, health promotion, quality of life or environmental conditions. Future short-term development points to the expansion of the biobank and the continuation of the collection of longitudinal data.

Risk factors for severe complications of colonoscopy in screening programs.

Severe complications (SC) in colonoscopy represent the most important adverse effect of colorectal cancer screening programs (CRCSP). The objective is to evaluate the risk factors for SC in colonoscopy indicated after a positive fecal occult blood test in population-based CRCSP. The SC (n = 161) identified from 48,730 diagnostic colonoscopies performed in a cohort of all the women and men invited from 2000 to 2012 in 6 CRCSP in Spain. A total of 318 controls were selected, matched for age, sex and period when the colonoscopy was performed. Conditional logistic regression models were estimated. The analysis was performed separately in groups: immediate-SC (same day of the colonoscopy); late-SC (between 1 and 30 days after); perforation; and bleeding events. SC occurred in 3.30‰ of colonoscopies. Prior colon disease showed a higher risk of SC (OR = 4.87). Regular antiplatelet treatment conferred a higher risk of overall SC (OR = 2.80) and late-SC (OR = 9.26), as did regular anticoagulant therapy (OR = 3.47, OR = 7.36). A history of pelvic-surgery or abdominal-radiotherapy was a risk factor for overall SC (OR = 5.03), immediate-SC (OR = 8.49), late-SC (OR = 4.65) and perforation (OR = 21.59). A finding of adenoma or cancer also showed a higher risk of overall SC (OR = 8.71), immediate-SC (OR = 12.67), late-SC (OR = 4.08), perforation (OR = 4.69) and bleeding (OR = 17.02). The risk of SC doesn't vary depending on the type of preparation or type of anesthesia. Knowing the clinical history of patients such as regular previous medication and history of surgery or radiotherapy, as well as the severity of the findings during the colonoscopy process could help to focus prevention measures in order to minimize SC in CRCSP.

Evaluación de un programa de salud pública sobre diagnostico precoz de VIH con prueba rápida / Evaluation of a public health program on early HIV diagnosis with quick test

OBJETIVO: Entre las principales estrategias para la detección precoz de la infección por VIH se encuentra la utilización planificada y estructurada de pruebas rápidas en entornos comunitarios especialmente vulnerables. El objetivo del presente estudio fue evaluar el programa de diagnóstico precoz de VIH con prueba rápida de la Región de Murcia. MÉTODOS: Se realizó un análisis descriptivo de los datos epidemiológicos de la población participante en el programa durante los años 2016 a 2018. Se analizaron variables relacionadas con características sociodemográficas, exposición de riesgo, antecedentes de realización de la determinación de VIH y resultado de la prueba. Todos los análisis se realizaron con el software estadístico IBM SPSS25 y Microsoft Excel versión 2013. Se calcularon frecuencias en valores absolutos y los porcentajes correspondientes, y se cruzaron las variables de interés. RESULTADOS: Se caracterizaron 1.023 personas participantes, de las que el 74% realizaron prácticas sexuales de riesgo en los últimos 12 meses, tanto de carácter homosexual (50%) como heterosexual (45%), con una edad comprendida entre los 18 y los 40 años. El 18,2% eran extranjeros, y el 61,9% se había realizado la prueba anteriormente. Entre los participantes, el porcentaje de pruebas reactivas fue del 2,1%, y la contribución al diagnóstico de nuevos casos de VIH en la Región fue del 4,3%. CONCLUSIONES: Los resultados del estudio ponen de manifiesto que el programa es una herramienta eficaz para el diagnóstico de la infección por VIH en colectivos vulnerables. Además, en el proceso de evaluación se identifican varias oportunidades de mejora como son la accesibilidad al programa y la recogida de información

OBJECTIVE: The use of HIV planned and structured, community-based rapid tests is one of the main strategies for the early detection of HIV infection. The objective of the study was to assess the HIV early diagnosis programme with rapid test in the Region of Murcia. METHODS: Descriptive analysis of the programme users' epidemiological data during the years 2016 to 2018. Variables related to sociodemographic characteristics, risk exposure, history of HIV test performance and its result were analyzed. All analyzes were performed with statistical software IBM SPSS25 and Microsoft Excel version 2013. Frequencies were calculated in absolute values and the variables of interest were crosshead. RESULTS: There were 1,023 people tested, of which 74% performed risky sexual practices in the last 12 months, both homosexual (50%) and heterosexual (45%), with an age between 18 and 40 years. 18.2% of the users were foreigners and 61.9% had been previously tested. Among the participants in the programme the percentage of reactive tests was 2.1% and the contribution to the diagnosis of new HIV cases in the Region was 4.3%. CONCLUSIONS: The results of the study show that the community-based programme is an effective tool for the diagnosis of HIV infection in vulnerable groups. In addition, several opportunities for improvement were identified in the process assessment, such as accessibility to the program and the collection of information

El Registro de Gemelos de Murcia. Un recurso para la investigación sobre conductas relacionadas con la salud / The Murcia Twin Registry. A resource for research on health-related behaviour

Los diseños genéticamente informativos, y en particular los estudios de gemelos, constituyen la metodología más utilizada para analizar la contribución relativa de los factores genéticos y ambientales a la variabilidad interindividual. Básicamente, consisten en comparar el grado de similitud, con respecto a una característica o rasgo determinado, entre gemelos monocigóticos y dicigóticos. Además de la clásica estimación de heredabilidad, este tipo de registros permite una amplia variedad de análisis únicos por las características de la muestra. El Registro de Gemelos de Murcia es un registro de base poblacional centrado en el análisis de conductas relacionadas con la salud. Las prevalencias de problemas de salud observadas son comparables a las de otras muestras de referencia de ámbito regional y estatal, lo que avala su representatividad. En conjunto, sus características facilitan el desarrollo de diversas modalidades de investigación, además de diseños genéticamente informativos y la colaboración con distintas iniciativas y consorcios (AU)

Genetically informative designs and, in particular, twin studies, are the most widely used methodology to analyse the relative contribution of genetic and environmental factors to inter-individual variability. These studies basically compare the degree of phenotypical similarity between monozygotic and dizygotic twin pairs. In addition to the traditional estimate of heritability, this kind of registry enables a wide variety of analyses which are unique due to the characteristics of the sample. The Murcia Twin Registry is population-based and focused on the analysis of health-related behaviour. The observed prevalence of health problems is comparable to that of other regional and national reference samples, which guarantees its representativeness. Overall, the characteristics of the Registry facilitate developing various types of research as well as genetically informative designs, and collaboration with different initiatives and consortia (AU)

[The Murcia Twin Registry. A resource for research on health-related behaviour]. / El Registro de Gemelos de Murcia. Un recurso para la investigación sobre conductas relacionadas con la salud.

Genetically informative designs and, in particular, twin studies, are the most widely used methodology to analyse the relative contribution of genetic and environmental factors to inter-individual variability. These studies basically compare the degree of phenotypical similarity between monozygotic and dizygotic twin pairs. In addition to the traditional estimate of heritability, this kind of registry enables a wide variety of analyses which are unique due to the characteristics of the sample. The Murcia Twin Registry is population-based and focused on the analysis of health-related behaviour. The observed prevalence of health problems is comparable to that of other regional and national reference samples, which guarantees its representativeness. Overall, the characteristics of the Registry facilitate developing various types of research as well as genetically informative designs, and collaboration with different initiatives and consortia.

Factors influencing participation in colorectal cancer screening programs in Spain.

To analyze the sociodemographic and organizational factors influencing participation in population-based colorectal cancer screening programs (CRCSP) in Spain, a retrospective study was conducted in a cohort of people invited to participate in the first 3 screening rounds of 6 CRCSP from 2000 to 2012. Mixed logistic regression models were used to analyze the relationship between sociodemographic and organizational factors, such as the type of fecal occult blood test (FOBT) used and the FOBT delivery type. The analysis was performed separately in groups (Initial screening-first invitation, Subsequent invitation for previous never-responders, Subsequent invitation-regular, Subsequent invitation-irregular intervals). The results showed that, in the Initial screening-first invitation group, participation was higher in women than in men in all age groups (OR 1.05 in persons aged 50-59years and OR 1.12 in those aged 60-69years). Participation was also higher when no action was required to receive the FOBT kit, independently of the type of screening (Initial screening-first invitation [OR 2.24], Subsequent invitation for previous never-responders [OR 2.14], Subsequent invitation-regular [OR 2.03], Subsequent invitation-irregular intervals [OR 9.38]) and when quantitative rather than qualitative immunological FOBT (FIT) was offered (Initial screening-first invitation [OR 0.70], Subsequent invitation for previous never-responders [OR 0.12], Subsequent invitation-regular [OR 0.20]) or guaiac testing (Initial screening-first invitation [OR 0.81], Subsequent invitation for previous never-responders [OR 0.88], Subsequent invitation-regular [OR 0.73]). In conclusion, the results of this study show that screening participation could be enhanced by inclusion of the FOBT kit with the screening invitation and the use of the quantitative FIT.

Mapping the association between back pain and type 2 diabetes: A cross-sectional and longitudinal study of adult Spanish twins.

BACKGROUND: Back pain and type 2 diabetes often co-occur, resulting in greater impact on people's health and complexity in their care. Plausible causal mechanisms for this association have been proposed, yet the nature of the link remains unclear. We therefore explored the direction of the association between type 2 diabetes and chronic back pain in twins, controlling for genetics and early environmental confounding. METHODS: 2,096 and 1,098 twins were included in the cross-sectional and longitudinal analyses, respectively. Any or severe (≥ 9) low back pain (LBP), neck pain (NP), and spinal pain (concurrent LBP and NP) and type 2 diabetes were investigated. Sequential analyses were performed using logistic regression. Firstly, twins were analysed unpaired (adjusted age and gender): total sample analyses. Then, to control for genetic and shared environmental factors, a co-twin case-control analysis was performed including monozygotic and dizygotic twin pairs discordant for back pain (cross-sectional only). RESULTS: In the cross-sectional total sample analyses, type 2 diabetes was associated with chronic spinal pain (OR 1.61; 95%CI 1.12 to 2.31), severe chronic spinal pain (OR 3.33; 95%CI 1.47 to 7.53), chronic NP (OR 1.37; 95%CI 1.01 to 1.85), severe chronic NP (OR 2.28; 95%CI 1.24 to 4.21), and severe chronic LBP (OR 1.63; 95%CI 1.00 to 2.64). After further adjustment for genetic and shared environmental factors, none of the associations remained significant. The longitudinal analyses indicated that the presence of type 2 diabetes did not increase the risk of future back pain, or vice-versa, after two to four years. CONCLUSIONS: Chronic back pain (spinal pain, NP, or LBP) was associated with the prevalence of type 2 diabetes. Associations are stronger for severe cases of pain. Future research should investigate the temporal relationships between these conditions with longer follow up in twins.

Are people with chronic low back pain meeting the physical activity guidelines? A co-twin control study.

BACKGROUND: Despite a large amount of research investigating physical activity (PA) levels in people with chronic low back pain (LBP), no study has investigated whether people with chronic LBP are meeting the World Health Organization (WHO) PA guidelines. Furthermore, with genetics and the early shared environment substantially influencing the presence of LBP and PA engagement, these factors could confound the association between LBP and PA and need to be controlled for. PURPOSE: This study aimed to investigate the association between chronic LBP and meeting the PA guidelines, while controlling for the effects of genetics and early shared environment. DESIGN: This is a cross-sectional co-twin control study. PATIENT SAMPLE: A cross-sectional analysis was performed on 1,588 twins from the Murcia Twin Registry in Spain with available data on LBP and PA from the 2013 data collection wave. OUTCOME MEASURES: The exposure and outcome variables in our study were self-reported. Twins reporting a history of chronic LBP were asked follow-up questions to inform on the presence of recent LBP (within the past 4 weeks), previous LBP (no pain within the past 4 weeks), and persistent LBP (no pain-free month in the last 6 months). These were our exposure variables. Our outcome variable was meeting the WHO PA guidelines, which involved at least 75 minutes of vigorous-intensity PA, or at least 150 minutes of moderate-intensity PA per week. METHODS: To investigate the association between chronic LBP and meeting the PA guidelines, we first performed a multivariate logistic regression on the total sample of twins. Co-variables entered the model if the univariate association between the co-variable, and both the exposure and the outcome reached a significance of p<.2. Second, to adjust for the influence of genetics and early shared environment, we performed a conditional multivariate logistic regression on complete twin pairs discordant for LBP. The Murcia Twin Registry is supported by Fundación Séneca, Regional Agency for Science and Technology, Murcia, Spain (08633/PHCS/08 and 15302/PHCS/10) and the Ministry of Science and Innovation, Spain (PSI11560-2009). Funding for this project has also been received from Fundación MAPFRE (2012). The authors declare that there are no conflicts of interest. RESULTS: There was a significant inverse association between recent LBP and meeting the PA guidelines (odds ratio [OR]=0.71, p=.034). When controlling for genetics and early shared environment, this association disappeared. There was no association between previous (OR=0.95, p=.779) or persistent LBP (OR=0.78, p=.192) and meeting the PA guidelines. CONCLUSION: Twins with recent LBP are less likely to meet the PA guidelines than those with no history of chronic LBP, highlighting the importance of incorporating PA promotion in the treatment of these individuals. Genetics and early shared environment appear to be confounding the association between LBP and PA, although this needs to be further tested in larger twin samples.

[Lesions Detected in Six Spanish Colorectal Cancer Screening Population Based Programmes. CRIBEA Project. Spain]. / Lesiones detectadas en seis programas poblacionales de cribado de cáncer colorrectal en España. Proyecto CRIBEA.

OBJECTIVE: In this study, the results of six Colorectal Cancer Screening Population Programmes are shown (Catalonia, Valence, Murcia, Cantabria, the Basque Country and the Canary Islands collected between 2005 and 2012. These programmes use the faeces occult blood test (FOBt) biennial. Objective: To determine and compare the results of lesions detected by the programmes, participation, sex, age and test used. METHODS: Retrospective cohort study based on people invited, aged between 50-74 years, in at least a complete round. Lesions considered: Advanced Adenomas (AA), Colorectal Invasive Cancer (CRC) and both of them, known as Advanced Neoplasia (AN). Logistic Regression and time trends are used. RESULTS: 1,995,719 of invitations registered, with an average participation-rate of 46.7%. 21,228 Advanced Neoplasias (2,813 CRC and 18,415 AA). Differences in detection rates observed between programmes (varying from 15.1‰ to 35.8‰ between participants). Participation rates were related to lesions' detection rates (OR 1.25 in 40-60% of participation). . Inmunochemical qualitative test showed an OR of 4.79 and quantitative test an OR of 7.30 over the guaiac test. Men showed an OR of 2.73 with respect to women. In 2012 the Advanced Neoplasia rate for women and men was 33.1 and 14.2 by 1,000 participants. CONCLUSIONS: The test used was the most important factor for detecting lesions. Time trends showed an increase in detected lesions caused by the change of the type of test in 2010.

OBJETIVO: En este estudio se presentan los resultados de seis programas poblacionales de cribado de cáncer colorrectal desde 2005 a 2012 (Cataluña, Valencia, Murcia, Cantabria, País Vasco y Canarias) que utilizan diferentes tipos de test de cribado de sangre oculta en heces (SOH) bienal. El objetivo fue describir y comparar los resultados en cuanto a lesiones detectadas tanto por programa, participación, sexo, edad, tipo de test y comunidad autónoma. METODOS: Estudio de cohorte retrospectivo de las personas participantes en al menos una ronda completa cuya edad estaba comprendida entre los 50 y los 74 años. Lesiones consideradas: adenomas avanzados (AA), cáncer aolorrectal invasivo (CCR) y la suma de ambos, neoplasia avanzada (NA). Se realizó un nálisis de regresión logística y estudio de tendencias temporales. RESULTADOS: Se obtuvieron 1.995.719 participaciones, lo que supuso el 46,7% de las invitaciones a participar. Se detectaron 21.228 neoplasias avanzadas (2.813 CCR y 18.415 AA). Se observaron diferencias en la detección de neoplasia avanzada (NA) entre los programas variando entre 15,1‰ y 35,8‰ participantes. La participación se relacionó con las tasas de detección (OR: 1,25 en 40-60% de participación). El test inmunoquímico cualitativo obtuvo una OR de 4,79 y el cuantitativo de 7,30 sobre guayaco. Los hombres tuvieron una OR de 2,73 sobre las mujeres, observándose en el 2012 una tasa de detección de neoplasia avanzada en hombres y mujeres de 33,1 y 14,2 x 1.000 respectivamente. CONCLUSIONES: El tipo de test resultó el factor más determinante en la detección de lesiones. Las tendencias temporales mostraron un aumento de la tasa de detección por el cambio de test a partir del 2010.

Does sedentary behavior increase the risk of low back pain? A population-based co-twin study of Spanish twins.

BACKGROUND: The relationship between sedentary lifestyle and low back pain (LBP) remains unclear and previous research has not accounted for genetic and early environmental factors. PURPOSE: Our aim was to investigate if sedentary behavior is associated with the lifetime prevalence of persistent LBP and the risk of developing persistent LBP, care-seeking due to LBP, and activity limiting LBP when genetics and early environmental factors are accounted for. STUDY DESIGN: Both cross-sectional and longitudinal designs with a within-pair twin case-control were implemented. PATIENT SAMPLE: There were 2,148 twins included in the cross-sectional analysis whereas 1,098 twins free of persistent LBP at baseline were included in the longitudinal analysis. OUTCOME MEASURES: Sedentary behavior was the explanatory variable. Lifetime prevalence of LBP was the outcome variable in the cross-sectional analysis. The incidence of persistent LBP, care-seeking due to LBP, and activity limiting LBP were the outcome variables for the longitudinal analysis. METHODS: This observational study was supported by a grant in 2012. No competing interests were declared. RESULTS: In the cross-sectional analysis, sedentary behavior was slightly associated with an increased prevalence of persistent LBP in females but not in males. This association was not apparent when genetics and early environmental factors were accounted for. We acknowledge that the small sample included in the co-twin analyses have yielded wide confidence intervals, and that caution should be exercised when interpreting and an association may not be ruled out. In the longitudinal analysis, sedentary behavior did not significantly increase the risk of persistent LBP, care-seeking due to LBP, or activity limiting LBP. CONCLUSIONS: Sedentary behavior is associated with concurrent LBP. However, this association is weak; it only appears in females and decreases when accounting for genetics. Future studies using a twin design with larger samples should be conducted to further test these findings.

Does educational attainment increase the risk of low back pain when genetics are considered? A population-based study of Spanish twins.

BACKGROUND CONTEXT: There is limited research investigating educational attainment as a risk factor for low back pain (LBP), with the influence of gender commonly being neglected. Furthermore, genetics and early shared environment explain a substantial proportion of LBP cases and need to be controlled for when investigating risk factors for LBP. PURPOSE: To investigate whether educational attainment affects the prevalence and risk of LBP differently in men and women while controlling for the influence of genetics and early shared environment. STUDY DESIGN: This is a cross-sectional and prospective twin case-control study. PATIENT SAMPLE: Adult monozygotic (MZ) and dizygotic (DZ) twins from the Murcia Twin Registry, with available data on educational attainment, formed the base sample for this study. The prevalence analysis considered twins with available data on LBP in 2013 (n=1,580). The longitudinal analysis considered twins free of LBP at baseline (2009-2011), with available data on LBP at follow-up (2013) (n=1,077). OUTCOME MEASURES: Data on the lifetime prevalence of activity limiting LBP (outcome) and educational attainment (risk factor) were self-reported. METHODS: The prevalence analysis investigated the cross-sectional association between educational attainment and LBP, whereas the longitudinal analysis investigated whether educational attainment increased the risk of developing LBP. Both analyses were performed in the following sequence. First, a total sample analysis was performed on all twins (considering them as individuals), adjusting for confounding variables selected by the data. Second, to control for the influence of genetics and early shared environment, a within-pair case-control analysis (stratified by zygosity) was performed on complete twin pairs discordant for LBP (ie, one twin had LBP, whereas the co-twin did not). All analyses were stratified for gender where possible, with an interaction term determining whether gender was a significant moderator of the association between educational attainment and LBP. RESULTS: Women with either general secondary or university education were less likely to experience (prevalence analysis) or to develop LBP (longitudinal analysis). Educational attainment did not affect the risk of LBP in men. When controlling for the effects of genetics and early shared environment, the relationship between educational status and LBP in women was no longer statistically significant. CONCLUSIONS: Educational attainment affects LBP differently in men and women, with higher levels of education only decreasing the risk of developing LBP in women. After adjusting for genetics and early shared environment, the relationship between educational attainment and LBP in women disappears. This suggests that genetics and early shared environment are confounding the relationship between educational attainment and LBP in women.

Implementation of colorectal cancer screening in Spain: main results 2006-2011.

The Spanish Cancer Screening Network involves the participation of all regional programmes and has been working for over 20 years to co-ordinate strategies and implement quality assurance in current and new regional programmes. In colorectal cancer, the target population is the group aged 50-69 years, who are offered biennial testing using the faecal occult blood test in all programmes, with follow-up colonoscopy if the faecal occult blood test is positive. This article presents the main trends, indicators and differences by sex. The main indicators from 2006 to 2011 were analysed: coverage, participation rate, positivity rate, colonoscopy uptake and lesions detected. Annual trends were adjusted by sex and region. In 2011, coverage was 9.74% of the Spanish target population. A total of 1 001 669 first invitations were registered from 2006 to 2011 and 596 649 individuals participated in the programmes (43.83% participation rate). Results were positive in 30 544 individuals (5.47%), with the lowest positivity rate occurring in 2007 (3.06%) and the highest in 2011 (6.30%) (P<0.001). In all, 27 568 colonoscopies were registered, with a high compliance rate (90.00% in 2011 and 95.59% in 2007) (P=0.381). The adenoma and colorectal cancer detection rates increased over the period, reaching 32.25/1000 and 3.42/1000 participants in 2011, respectively (P<0.001 and P=0.001). Comparison of differences by sex showed that detection rates were significantly higher in men than in women (P<0.001). Participation increased over time and has now reached an acceptable rate. Men show low participation but higher detection rates, indicating the need for further intervention. The Spanish Cancer Screening Network provides common evaluation, performance and organizational benchmarking.

Lesiones detectadas en seis programas poblacionales de cribado de cáncer colorrectal en España. Proyecto CRIBEA / CRIBEA Project: Lesions Detected in Six Spanish Colorectal Cancer Screening Population Based Programmes. Spain

Fundamentos: En este estudio se presentan los resultados de seis programas poblacionales de cribado de cáncer colorrectal desde 2005 a 2012 (Cataluña, Valencia, Murcia, Cantabria, País Vasco y Canarias) que utilizan diferentes tipos de test de cribado de sangre oculta en heces (SOH) bienal. El objetivo fue describir y comparar los resultados en cuanto a lesiones detectadas tanto por programa, participación, sexo, edad, tipo de test y comunidad autónoma. Metodos: Estudio de cohorte retrospectivo de las personas participantes en al menos una ronda completa cuya edad estaba comprendida entre los 50 y los 74 años. Lesiones consideradas: adenomas avanzados (AA), cáncer aolorrectal invasivo (CCR) y la suma de ambos, neoplasia avanzada (NA). Se realizó un nálisis de regresión logística y estudio de tendencias temporales. Resultados: Se obtuvieron 1.995.719 participaciones, lo que supuso el 46,7% de las invitaciones a participar. Se detectaron 21.228 neoplasias avanzadas (2.813 CCR y 18.415 AA). Se observaron diferencias en la detección de neoplasia avanzada (NA) entre los programas variando entre 15,1‰ y 35,8‰ participantes. La participación se relacionó con las tasas de detección (OR: 1,25 en 40-60% de participación). El test inmunoquímico cualitativo obtuvo una OR de 4,79 y el cuantitativo de 7,30 sobre guayaco. Los hombres tuvieron una OR de 2,73 sobre las mujeres, observándose en el 2012 una tasa de detección de neoplasia avanzada en hombres y mujeres de 33,1 y 14,2 x 1.000 respectivamente. Conclusiones: El tipo de test resultó el factor más determinante en la detección de lesiones. Las tendencias temporales mostraron un aumento de la tasa de detección por el cambio de test a partir del 2010 (AU)

Background: In this study, the results of six Colorectal Cancer Screening Population Programmes are shown (Catalonia, Valence, Murcia, Cantabria, the Basque Country and the Canary Islands collected between 2005 and 2012. These programmes use the faeces occult blood test (FOBt) biennial. Objective: To determine and compare the results of lesions detected by the programmes, participation, sex, age and test used. Methods: Retrospective cohort study based on people invited, aged between 50-74 years, in at least a complete round. Lesions considered: Advanced Adenomas (AA), Colorectal Invasive Cancer (CRC) and both of them, known as Advanced Neoplasia (AN). Logistic Regression and time trends are used. Results: 1,995,719 of invitations registered, with an average participation- rate of 46.7%. 21,228 Advanced Neoplasias (2,813 CRC and 18,415 AA). Differences in detection rates observed between programmes (varying from 15.1‰ to 35.8‰ between participants). Participation rates were related to lesions’ detection rates (OR 1.25 in 40-60% of participation). Inmunochemical qualitative test showed an OR of 4.79 and quantitative test an OR of 7.30 over the guaiac test. Men showed an OR of 2.73 with respect to women. In 2012 the Advanced Neoplasia rate for women and men was 33.1 and 14.2 by 1,000 participants. Conclusions: The test used was the most important factor for detecting lesions. Time trends showed an increase in detected lesions caused by the change of the type of test in 2010 (AU)

Impact of age- and gender-specific cut-off values for the fecal immunochemical test for hemoglobin in colorectal cancer screening.

BACKGROUND: There is no information on the impact of age and gender on the diagnostic yield of different positivity thresholds for the fecal immunochemical test for hemoglobin (FIT). OBJECTIVES: To evaluate the performance of this test at distinct positivity cut-offs in a population-based colorectal cancer (CRC) screening program. METHODS: CRC detection rate (DR), and analysis of resources were evaluated retrospectively, at different cut-offs of FIT (20, 25, 30, 35 and 40µg Hb/g) respect to a reference value (15µg Hb/g), according to age and gender, in a screening population of 10,611 participants of the ColonPrev study (Quintero. NEJM 2013). RESULTS: At the reference cut-off value, 36 CRC and 252 advanced adenomas (AA) were diagnosed. Increasing the cut-off in women ≤60 years decreases colonoscopies performed by 44.5% without modifying the CRC (DR). Same CRC DR was observed in men ≤60 years and women >60 years increasing cut-off at 25-30µg Hb/g. In men >60 years, all increases in the cut-off affected the CRC DR, especially when the cut-off was increased from 35 to 40µg Hb/g (CRC miss rate 25%). CONCLUSIONS: To improve the performance of FIT in CRC screening programs, FIT cut-offs could be individualized by age and gender.

Intermediate-risk patients with three to four small adenomas should be considered low risk for colorectal cancer screening.

BACKGROUND AND AIM: Intermediate-risk patients following a colorectal cancer screening program may have differential risk of advanced lesions depending on the findings of an index colonoscopy. The aim of the present study was to comparatively assess advanced colorectal neoplasia risk at the first follow-up colonoscopy among the different intermediate-risk subgroups with a focus on patients with three to four adenomas. METHODS: All patients recruited for a baseline screening colonoscopy between 2006 and 2011 were included. Number, size and histopathological characteristics of adenomas were collected. Main outcome was an advanced colorectal neoplasia detection rate (invasive carcinoma or advanced adenoma) at the first follow-up colonoscopy. Low- and high-risk patients were excluded. RESULTS: Five hundred and sixty-one intermediate-risk patients (63.3% men, mean age: 59.01 ± 6.16 years) underwent indexing and follow-up colonoscopy. By multivariate analysis, three to four adenomas (OR: 3.613 [95% CI: 1.661-7.859], P = 0.001) and adenoma size ≥10 <20 mm (OR: 3.374 [95% CI: 1.618-7.034], P = 0.001) were independent factors associated with advanced colorectal neoplasia. Advanced lesions were detected in 7.66% of cases. Of patients with advanced colorectal neoplasia, 51.16% belonged to the three-to-four-adenoma group and ≥1 of ≥10 <20-mm subgroups (n = 132, 23.53%). These patients demonstrated a higher rate of advanced lesions [OR: 3.886 (95% CI: 2.061-7.325), P < 0.001] than patients with three to four small adenomas of <10 mm (16.67% vs 5.07%, P < 0.001). The association between patients with small adenomas (n = 217, 38.68%) and advanced lesions was not significant (OR: 0.521 [95% CI: 0257-1.056], P = 0.066). CONCLUSION: Intermediate-risk patients with three to four small adenomas achieved a very low advanced lesion rate at follow up. Surveillance interval should be lengthened because these patients should be considered low risk.

The Concordance and Heritability of Type 2 Diabetes in 34,166 Twin Pairs From International Twin Registers: The Discordant Twin (DISCOTWIN) Consortium.

Twin pairs discordant for disease may help elucidate the epigenetic mechanisms and causal environmental factors in disease development and progression. To obtain the numbers of pairs, especially monozygotic (MZ) twin pairs, necessary for in-depth studies while also allowing for replication, twin studies worldwide need to pool their resources. The Discordant Twin (DISCOTWIN) consortium was established for this goal. Here, we describe the DISCOTWIN Consortium and present an analysis of type 2 diabetes (T2D) data in nearly 35,000 twin pairs. Seven twin cohorts from Europe (Denmark, Finland, Norway, the Netherlands, Spain, Sweden, and the United Kingdom) and one from Australia investigated the rate of discordance for T2D in same-sex twin pairs aged 45 years and older. Data were available for 34,166 same-sex twin pairs, of which 13,970 were MZ, with T2D diagnosis based on self-reported diagnosis and medication use, fasting glucose and insulin measures, or medical records. The prevalence of T2D ranged from 2.6% to 12.3% across the cohorts depending on age, body mass index (BMI), and national diabetes prevalence. T2D discordance rate was lower for MZ (5.1%, range 2.9-11.2%) than for same-sex dizygotic (DZ) (8.0%, range 4.9-13.5%) pairs. Across DISCOTWIN, 720 discordant MZ pairs were identified. Except for the oldest of the Danish cohorts (mean age 79), heritability estimates based on contingency tables were moderate to high (0.47-0.77). From a meta-analysis of all data, the heritability was estimated at 72% (95% confidence interval 61-78%). This study demonstrated high T2D prevalence and high heritability for T2D liability across twin cohorts. Therefore, the number of discordant MZ pairs for T2D is limited. By combining national resources, the DISCOTWIN Consortium maximizes the number of discordant MZ pairs needed for in-depth genotyping, multi-omics, and phenotyping studies, which may provide unique insights into the pathways linking genes to the development of many diseases.