Health Risk Classification Research Articles

Acolhimento com classificação de risco para a Estratégia Saúde da Família: a prática em uma unidade docente-assistencial

O acolhimento é visto, concomitantemente, como tecnologia do encontro, criando redes de conversações para resgatar um enfoque centrado no usuário, e como ação técnico-assistencial para reorganizar os processos de trabalho. Neste artigo, apresenta-se uma reflexão teórica sobre as possibilidades de empregar formas de Acolhimento com Classificação de Risco (ACR) na Estratégia Saúde da Família (ESF), a partir da descrição de sua implantação no processo de trabalho de três equipes da ESF que atuam em uma mesma Unidade de Saúde (US) em Itajaí-SC. A construção coletiva de novos fluxos de atenção e instrumentos auxiliares para a classificação de risco pode ser empregada para qualificar o serviço segundo os princípios da equidade e integralidade. As limitações do processo devem ser identificadas e discutidas como parte de constante reavaliação e reajuste no processo de trabalho. O ACR mostrou-se um desafio e uma possibilidade de avanço no sentido da humanização pela horizontalização das relações e busca de corresponsabilização tanto no interior das ESF como nos contatos destas com os usuários.

Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria

Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.

Clinicopathological Features and Prognostic Factors of Rectal Gastrointestinal Stromal Tumors

AimRectal gastrointestinal stromal tumor (GIST) was a rare disease. This study sought to summarize clinicopathological features and prognostic factors of rectal GISTs. MethodsClinicopathological characteristics and prognostic factors of rectal GISTs were investigated by reviewing patients undergoing curative resection at the Fudan University Shanghai Cancer Center between 1986 and 2010. ResultsTwenty-one patients, 15 male and 6 female, were included. The mean age of onset was 51 years. The most common initial presentation was hematochezia (7 cases). Eleven patients underwent radical resection, and the other 10 received local resection. No lymph node metastases were identified. All cases were positive for CD117. Seventeen patients were classified as high National Institutes of Health (NIH) risk category. The 5-year disease-free survival (DFS) and overall survival were 33 and 46 %, respectively. Fifteen cases had recurrence postoperatively. Both univariate and multivariate analyses demonstrated the NIH risk category (p = 0.028) and hematochezia symptom (p = 0.014) were independent prognostic factors of the DFS of patients. ConclusionsHematochezia was the most common initial symptom. Over 50 % of patients received radical surgery. More than 80 % of patients were at high NIH risk of recurrence. Hematochezia symptom and high NIH risk category indicated poor prognosis of rectal GISTs.

基于干扰的汪清林区森林生态系统健康评价

以汪清林区60个林班为研究对象,提出基于干扰的森林生态系统健康评价模型H=∑B₂W₂-∑B₁W₁,构建了基于干扰理论的汪清林区森林生态系统健康评价体系。其中,有害干扰指标层选取4个指标:森林病害、森林虫害、森林火险以及人为干扰,生态系统内部的增益指标层选取4个指标:树种多样性、群落层次结构、林分更新状况以及近自然度。利用层次分析法和变异系数结合的主客观赋权法计算得到各指标的权重,提出基于干扰的健康评价模型和等级划分标准。最终评价结果显示:汪清林区60个样地中,处于优质状态的样地有6块,占总样地数的10%,健康指数均大于0.2;处于健康状态的林分13块,占总样地数的21.67%,健康指数在0.1-0.2之间;处于亚健康状态的林分23块,占总样地数的38.33%,健康指数在0-0.1之间;处于不健康的林分18块,占总样地数的30%,健康指数小于0。结果表明,在天然林中,无论是针叶纯林还是针阔混交林、阔叶混交林,大多处于亚健康和健康的状况,这与他们近自然度高,物种多样性丰富、具有良好的自我调节能力有关。而在落叶松人工林分中,由于林分物种多样性低,群落结构简单,近自然度最小,林分的增益能力弱,因此不健康的占有绝大多数。该评价结果可为该林场展开相关的健康经营措施提供参考。;Currently, the study of forest ecosystem health, a new and controversial research field within forestry and forest ecology, provides a scientific basis for forest protection. The study of forest ecosystem health also provides a significant practical service by suggesting ways to increase the level of sustainability in forest management although the definition of forest health remains controversial. The concept of health is well understood as applied to humans but the human concept of health may not be appropriate for ecosystems. The difficulties of defining the optimal conditions for ecosystem health have led to a lack of universally accepted indicators used to measure ecosystem health. Several forest ecosystem health assessment systems have already been developed. For example, ecosystem health can be assessed using measures of resilience, vigor and organization and most of today's assessment systems are based on these concepts. In this research, the forest ecosystem health of 60 sample plots in Wangqing Forest was investigated. A new assessment model of forest ecosystem health based on the disturbance, H=∑B₂W₂-∑B₁W₁, is proposed and used in this study, where <em>H</em> represents a measure of ecosystem health and <em>B</em>₁, <em>B</em>₂, <em>W₁</em> and <em>W</em>₂ represent harmful sources of disturbance, forest ecosystem stability, the weights of <em>B</em>₁ and <em>B</em>₂, respectively. Based on qualitative analysis of existing data, eight indices which were divided into two categories were selected as assessment indices of forest ecosystem health in Wangqing Forest. Several harmful sources of disturbance were considered including forest diseases, forest pest species, wildfires and human-caused disturbances. Measurements of forest ecosystem stability include measurements of biological diversity, forest community structure and measurements documenting how closely a forest study plot resembles expected natural forest conditions. These types of data have frequently been used to measure ecosystem complexity and health. Additionally, two types of analysis, the Analytic Hierarchy Process and coefficient of variation analysis, were used in combination with weighted evaluation indictors to objectively evaluate the forest health of the study plots. We propose a new forest ecosystem healthy assessment model and classification system. The 60 sample plots of Wangqing Forest were divided into four health risk categories: very healthy, healthy, fairly healthy and unhealthy. By calculating a composite value for forest health, the status of forest ecosystem health of individual Wangqing Forest plots was determined. As the results showed, 6, 13, 23 and 18 (or 10%, 21.67%, 38.33%, and 30% of all plots) plots were categorized as very healthy, healthy, fairly healthy, and unhealthy, respectively; the health indices for these four groups of plots were measured as 0.5 ≥ 0.2, 0.2 ≥ 0.1, 0 ≥ 0.1,-0.5< 0, respectively. Most of the forest plots with conditions resembling natural forest conditions, high levels of biodiversity and a strong ability to adjust to environmental change, such as pure natural forest, natural mixed needleleaf/broadleaf forest and mixed broadleaf forest, were categorized as healthy or fairly-healthy, while nearly all plantation forests plots which did not have conditions resembling natural forest conditions, but had low levels of biodiversity and a weak ability to adjust to environmental change were classified as unhealthy. This forest health assessment/indicator system establishes a scientific basis for conducting forest health analysis, provides a context for planning ecosystem restoration, and contributes to the understanding of the physical, biological, and human dimensions of these ecosystems. This research may enrich current theories and methods used in assessing the health of ecological systems.

Evaluating Race/Ethnicity in Moderating Baseline Cardiometabolic Risk and Body Composition Changes in North Carolina First-Year College Women

The roles of race/ethnicity and geographical region in the context of first-year college weight gain remain largely under-examined. The present study evaluated whether race/ethnicity: (1) at baseline was associated with greater representation in cardiometabolic health risk categories for body mass index, percent body fat, waist circumference, and waist-to-hip ratio in the full sample of 54 Black/African American and 80 White/European American first-year female undergraduates attending a North Carolina state university; and (2) moderated body composition changes between the beginning of the fall and spring semesters among the 83 participants who completed baseline and follow-up visits (N = 39 Black/African Americans). More Black/African Americans than White/European Americans had percent body fat values ≥32% at baseline; a greater proportion of White/European Americans than Black/African Americans had a waist-to-hip ratio >0.80. Among those who completed baseline and follow-up visits, White/European Americans had higher waist-to-hip ratios (unadjusted: p <0.01, adjusted for family income: p < 0.01) and waist circumferences (adjusted for family income: p < 0.05) at both time points. No strong moderating effects of race/ethnicity were detected. Preliminary results suggested that greater consideration of racial/ethnic indicators and potential regional variation in these biometric attributes among first-year college students is warranted.

Trihalomethanes in Lisbon Indoor Swimming Pools: Occurrence, Determining Factors, and Health Risk Classification

Characterization of water quality from indoor swimming pools, using chorine-based disinfection techniques, was performed during a 6-mo period to study the occurrence, distribution, and concentration factors of trihalomethanes (THM). Several parameters such as levels of water THM, water and air chloroform, water bromodichloromethane (BDCM), water dibromochloromethane (DBCM), water bromoform (BF), free residual chlorine (FrCl), pH, water and air temperature, and permanganate water oxidizability (PWO) were determined in each pool during that period. Chloroform (CFW) was the THM detected at higher concentrations in all pools, followed by BDCM, DBCM, and BF detected at 99, 34, and 6% of the samples, respectively. Water THM concentrations ranged from 10.1 to 155 μg/L, with 6.5% of the samples presenting values above 100 μg/L (parametric value established in Portuguese law DL 306/2007). In this study, air chloroform (CFAir) concentrations ranged from 45 to 373 μg/m3 with 24% of the samples presenting values above 136 μg/m3 (considered high exposure value). Several significant correlations were observed between total THM and other parameters, namely, CFW, CFAir, FrCl, water temperature (TW), and PWO. These correlations indicate that FrCl, TW and PWO are parameters that influence THM formation. The exposure criterion established for water THM enabled the inclusion of 67% of Lisbon pools in the high exposure group, which reinforces the need for an improvement in pool water quality.

Are Young Adults Aware of Their Health Risks? Evaluating the Differences between Perceived vs Measured Body Mass Index, Body Fat Percent, and Health Risk Category of University Students

Are Young Adults Aware of Their Health Risks? Evaluating the Differences between Perceived vs Measured Body Mass Index, Body Fat Percent, and Health Risk Category of University Students

Endoscopic muscularis dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria

Based on our experience with endoscopic submucosal dissection (ESD) and new endoscopic techniques for endoscopic closure of iatrogenic upper gastrointestinal (upper-GI) perforations, we developed methods to remove upper-GI subepithelial tumors (SETs) originating from the muscularis propria by endoscopic muscularis dissection (EMD). The aim of this study is to evaluate the clinical feasibility and safety of EMD. 31 patients with upper-GI SETs originating from the muscularis propria were treated by EMD. The EMD differed from ESD in (1) precutting the overlying mucosa above the lesion by using snare or longitudinal incision instead of circumferential incision, (2) dissecting the complete tumors away from submucosal and muscularis propria tissue by electrical dissection combined with blunt dissection, and (3) closing the wound with clips. Perforations occurring during dissection were closed by endoscopic methods. 30 of 31 tumors were resected completely (96.8 %). One esophageal lesion was resected partially because of severe adhesions with surrounding tissue. Mean resected tumor size was 22.1 mm × 15.5 mm, and mean operation time was 76.8 min (range 15-330 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in 16 lesions [6 esophageal, 3 cardial, 7 gastric; 6 very low risk and 10 low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in 15 lesions (8 esophageal, 4 cardial, 3 gastric). No patient developed delayed hemorrhage. Perforation occurred in four patients (12.9 %), all of which were managed successfully by endoscopic techniques. The mean follow-up time was 17.7 months (range 7-35 months). Follow-up found no tumor recurrence in any patient. In this early experience, EMD appears to be a feasible and minimally invasive treatment for some patients with upper-GI SETs originating from the muscularis propria. Although there is a higher risk of perforation than with ESD, this will improve with extended practice, and perforations have become manageable endoscopically.

Accurate Health Risk Classification for Heart Disease Using Point-of-Care Testing Lipid Quantitation in a Health Screening and Wellness Environment

Point-of-care testing (POCT) has been increasingly used in health screening applications to promote wellness. Point-of-care testing analyses of total cholesterol (TC) and the associated lipid elements, high-density lipoprotein (HDL) and triglycerides (Trig), are an integral part of the assignment of relative risk of heart disease (HD). In a 4-site health screening setting, we evaluated the comparative effectiveness of the CardioChek POCT (lipid panel) and a chemistry reference instrument (Olympus; Quest Labs) in HD risk classification based on TC, HDL, and Trig to assess whether the POCT device was a diagnostic equivalent. A total of 169 comparisons were conducted at geographically diverse centers using professional health screening organizations. As a first measure of comparability of the methods, accuracy of the POCT system was determined based on the overall bias against the reference laboratory showing the equivalence of the 2 systems: TC bias = 1.78%, HDL bias = 4.14%, Trig bias = 10.28%. Correlation (r) values were greater than 0.9 for all analytes at all sites. Cholesterol risk classification and stratification were then assessed for each matched donor based on the use of the POCT or laboratory value. This showed nearly equivalent risk classification of the population across all analytes. To further assess risk categorization, we compiled a 3 × 3 clinical agreement table for each analyte, using these same analyte-specific striation levels and applying strict limits to quantify "agreement." This analysis shows the high degree of agreement of risk classification assignment between the 2 methods even when a small absolute value difference (ie, laboratory TC value of 199; POCT TC value of 205; actual value in site A) is recorded as a "1-category difference," yet the test result is not clinically different. Generally, across the study, complete agreement is 80% or better (TC and HDL) and 90% for Trig. In only 1 instance (site A, TC) is there a "2-category difference." Close analysis of the TC 1-category difference at the clinical limit of 200 mg/dL shows that, in the 19 matched pairs that contributed to this category, the aggregate average difference was a clinically insignificant 16.6 mg/dL, reinforcing the stringent nature of this analysis and comparability of the methods. This multicenter study demonstrates the accuracy of the CardioChek POCT system and establishes the effective utilization of POCT lipid quantitation as an effective health screening tool to identify patients requiring further medical follow-up for prevention of HD.

Longitudinal Outcomes of a Comprehensive, Incentivized Worksite Wellness Program

This study evaluated health benefits of long-term participation in an employer-based wellness program, focusing on selected chronic disease risk factors. A repeated measures longitudinal time-series study was conducted of 8 years of existing prospectively collected annual data, including clinical measures of weight, blood pressure, cholesterol, and body fat percent. Participants were divided into their risk levels at baseline. Outcomes were compared to level of participation, for which annual points earned was a surrogate. Participants had lower increases in body mass index (BMI) than the general population had during the same time period. Greatest improvements in BMI, blood pressure, and cholesterol were seen in those at highest risk levels at baseline and in those whose physical activity increased over time. It was found that long-term participation in this program improved BMI, blood pressure, and cholesterol. Most benefits were found for those in high-risk groups. This program should recruit more employees in high health risk categories and emphasize retention and increased levels of participation.

Does a Physical Education Bout Alter Percent Body Fat and the Adiposity Health Risk Classification When Using Leg-to-leg Bioelectrical Impedance Analysis in Girls?

The purposes of this investigation were to determine: 1) whether a structured in-school physical education exercise bout altered percent body fat (%BF) determined by leg-to-leg bioelectrical impedance analysis (LBIA); and 2) whether the potential exercise-induced %BF magnitude of change altered the health risk classification of the child. Methods: Seventy-six girls (age: 12.2 ± 1.0 yr; height: 153.9 ± 7.5 cm; body mass: 51.9 ± 15.5 kg; BMI: 21.7 ± 5.4 kg/m2) participated in this investigation. LBIA measured %BF values were obtained immediately before and within five minutes after completing a structured, in-school, physical education class. Results: Significant reductions (p &lt; 0.0001) in mean %BF (25.0 ± 10.2 vs. 24.4 ± 10.3 %) were observed for the group following the physical education class. For the majority of the girls (88%), the %BF alteration was less than ± 2.0 %BF. More specifically, the %BF magnitude of change was ± 1.0 %BF in 64.5% of the girls, between 1.1 and 2.0 %BF in 23.7% of the girls, and by more than 2.0 %BF in 11.8% of the girls. Regardless of the %BF magnitude of change, all girls remained in the same adiposity classification category (healthy vs. unhealthy body fat) following exercise. Conclusion: Adhering to the pre-test exercise guideline appears unnecessary when using LBIA to categorize the health risk of an adolescent girl.

Ezrin overexpression in gastrointestinal stromal tumors: an independent adverse prognosticator associated with the non-gastric location

Ezrin, a member of the ezrin–radixin–moesin family, acts as a link between the cell membrane and actin cytoskeleton to integrate cell adhesion-mediated signaling. It implicates tumor progression, metastatic dissemination, and adverse outcomes in several cancer types, including pediatric and adult sarcomas. Although ezrin upregulation was shown by cDNA expression profiling, no study has systematically evaluated the significance of ezrin expression in a large cohort of gastrointestinal stromal tumors (GISTs). Ezrin immunostaining was carried out on tissue microarrays of primary GISTs and assessable in 347 cases, 188 of which were successfully evaluated for mutation variants of KIT and PDGFRA receptor tyrosine kinase (RTK) genes by sequencing with or without screening by denatured high-performance liquid chromatography. These GISTs with known RTK genotypes were dichotomized into two prognostically different groups. The endogenous expression and phosphorylation of ezrin in GIST cell lines were analyzed by western blotting. By immunohistochemistry, ezrin overexpression was present in 66% of GISTs and significantly associated with the non-gastric location (P=0.002) and decreased disease-free survival (P=0.032, univariately). However, it was not related to the National Institute of Health (NIH) risk category, Ki-67 labeling index, RTK genotypes, and other variables. In multivariate analyses, ezrin overexpression remained independently predictive of adverse outcome (P=0.008, risk ratio=2.363), together with Ki-67 labeling index >5% (P<0.001, risk ratio=3.581), high-risk category (P<0.001, risk ratio=2.156), and the non-gastric location (P=0.029, risk ratio=1.899). Despite the variation in the ezrin expression level, phosphorylated ezrin at threonine567 was only detectable in GIST882 and GIST48 cells, but not in colonic smooth muscle cells. In conclusion, ezrin is frequently overexpressed in GISTs, especially those arising from the non-gastric sites. Given that its impact is independent of the NIH risk category, cell proliferation, and tumor location, ezrin immunoreactivity represents a valuable prognostic adjunct of GISTs, suggesting a causative role in conferring an aggressive phenotype.

Prognostic Analysis of Rectal Stromal Tumors by Reference of National Institutes of Health Risk Categories and Immunohistochemical Studies

Prognostic analysis of stromal tumors focusing on the rectal area is rarely performed. This study elucidated prognostic factors by referencing biomarkers of Ki67 and p53. Forty-nine surgically resected rectal stromal tumors were collected from 1986 to 2006. Immunohistochemical studies were performed with antibodies of CD117, CD34, smooth muscle actin, desmin, S100, Ki67, and p53. The immunoreactivities were: CD34, 83.6 percent; smooth muscle actin, 28.5 percent; S100, 4.1 percent; desmin,16.3 percent;, Ki67, 30.6 percent;, and p53 34.7 percent. Both p53+ and Ki67+ tumors were associated with increased tumor mitosis, increased tumor size, nonspindle cell type, and increased cell pleomorphism (P < 0.05). Increased National Institutes of Health risk was associated with old age, nonspindle cell types, and severe nuclear pleomorphism (P < 0.05). Survival analysis demonstrated that older patients (P = 0.0039), large tumor size (P = 0.003), high mitotic count (P < 0.001), increased risk categories (P < 0.001), high cell pleomorphism (P = 0.003), p53+ (P = 0.007), and Ki67 + (P = 0.002) were prognostic factors for poor disease-free survival. An independent prognostic factor was tumor mitotic count. This study demonstrated the prognostic role of Ki67 and p53 in rectal stromal tumors. Notably, tumor mitosis was superior for prognostic prediction compared to National Institutes of Health risk categories.

Asymptomatic CT Scans: A Health Assessment or a Health Risk?

The purpose of this article is to expose the hidden dangers of asymptomatic whole body computerized tomography (CT) scans. Once thought to be a safe and proactive healthcare approach, whole body CT scans for asymptomatic patients are hazardous. The majority of these self referred patients do not fit in any health risk categories, thus unknowingly taking potential detrimental risks to their health. This article reveals overlooked truths regarding the associated health risks, such as a false sense of security, unnecessary radiation exposure, and out of pocket expense. This paper demonstrates the health risks with critical analysis of proven, hardcore evidence. Asymptomatic whole body CT scans should not be used as a screening tool for early detection of possible ailments. Despite the good intentions, more harm is often inflicted with these scans.

Incidence and clinicopathologic features of gastrointestinal stromal tumors. A population-based study

BackgroundAlthough the diagnostic criteria and pathogenesis of gastrointestinal stromal tumors (GIST) have recently been elucidated, knowledge of the epidemiology of this malignancy is still limited. This study examined the incidence of GIST in the province of Modena, including pathologic features and clinical outcome.MethodsGastrointestinal mesenchymal tumors identified by the Modena Cancer Registry between 1991 and 2004 were analyzed with an immunohistochemical panel that included staining for CD-117 and PDGFRα. Size, mitotic rate, and other pathologic parameters were recorded. Each tumor was categorized into National Institutes of Health risk categories (very low, low, intermediate, and high risk).ResultsOne hundred twenty-four cases were classified as GIST. The age-adjusted incidence rate was 6.6 per million. Seventy-five percent of patients were symptomatic; 34% had a previous or concomitant history of cancer. High-risk features were present in 47% of cases. Seventy-eight percent were submitted to radical surgery. After complete resection, the 5-year disease-free survival rates were 94%, 92%, 100%, and 40% for patients at very low, low, intermediate, and high risk, respectively. In multivariate analysis, high risk was the main predictor of recurrence.ConclusionThis population-based study shows that the incidence of GIST in Northern Italy is comparable to that reported in other European countries. Survival was favorable in lower risk categories and in most of the resected cases. In our study, resected patients at very low, low, and intermediate risk had a similar outcome. Our data support the need to consider high-risk patients after complete surgical resection for treatment with the best available approach.

Prognostic significance of p53 gene mutations and protein overexpression in localized gastrointestinal stromal tumours

Mutation of c-kit is a relatively early event in the tumorigenesis of gastrointestinal stromal tumours (GISTs). The aim was to determine the prognostic significance of p53 alterations as an additional genetic change in GISTs. We reviewed 125 patients with localized GISTs subjected to complete resection between 1990 and 2002. Mutational analyses of c-kit exons 9, 11, 13 and 17, p53 exons 4-8 and immunohistochemistry for p53 protein were conducted using paraffin-embedded tissues. Alterations of p53 were observed in 50 patients (40.0%). Based on the National Institutes of Health's risk category, p53 alterations were noted more frequently in the higher risk categories (P = 0.041). With a median follow-up of 56.5 months (range: 2.3-126.8), 5-year relapse-free survival (RFS) rates were 61.7% without p53 alterations, compared with only 40.2% with p53 alterations (P = 0.009). Multivariate analysis indicated that p53 alterations comprised an independent, poor prognostic factor for RFS, in addition to c-kit mutations, large size, a high mitotic count and non-gastric primary sites. Alterations in p53 were more commonly observed in localized GISTs at higher risk of relapse. This suggests that they are significant as an independent, poor prognostic factor.

The expression of p53 and bcl‐2 in gastrointestinal stromal tumours is associated with anatomical site, and p53 expression is associated with grade and clinical outcome

To compare the expression of p53 and bcl-2 in gastrointestinal stromal tumours (GISTs) with anatomical site, National Institutes of Health (NIH) risk category (grade), pathological features, and clinical outcome. The immunohistochemical expression of p53 and bcl-2 in 105 GISTs (71 gastric, 20 small intestinal, four colonic, 10 rectal) was recorded. When all GISTs were assessed, there was p53 positivity in 28% and bcl-2 positivity in 77%. Gastric tumours had a lower prevalence of p53 positivity (20%) than intestinal (40-50%). Rectal GISTs had the lowest prevalence of bcl-2 positivity (20%) and gastric and small intestinal the highest (80% and 90%, respectively). In GISTs from all sites, p53 positivity was associated with size > 50 mm, epithelioid cell shape, nuclear atypia, mucosal invasion, and mitotic count > 5/50 high-power fields. In gastric GISTs the associations were the same, apart from size and mitotic count. In GISTs from all sites and in gastric GISTs, p53 expression correlated with NIH risk category. When GISTs from all sites were subjected to univariate survival analysis, an adverse outcome was associated with p53 positivity, NIH risk category, and several established prognostic factors. When gastric GISTs were assessed, the associations were similar although size was not prognostic. In multivariate survival analysis, p53 expression was independently prognostic for gastric GISTs in some models, while it was never independently prognostic for GISTs from all sites. Whether all GISTs or gastric GISTs were assessed, bcl-2 showed no association with clinical outcome or risk category. Anatomical site influences p53 and bcl-2 expression in GISTs. p53 expression is associated with NIH risk category, various pathological features, and clinical outcome, and may be independently prognostic for gastric GISTs. Bcl-2 expression has no prognostic value.

The impact of the Citibank, NA, health management program on changes in employee health risks over time.

This study estimated the impact of the Citibank Health Management Program on changes in health risks among Citibank employees. McNemar chi-squared tests compared the probability of being at high risk for poor health when the first and last health-risk appraisal surveys were taken. Logistic regression controlled for baseline differences in subsequent analyses when those who participated in more intensive program features were compared with those who participated in less intensive features. Declines in risk were noted for 8 of 10 risk categories. Most changes were small, except those related to exercise habits, seatbelt use, and stress levels. For nine health risk categories, those who participated in more intensive program services were significantly more likely than others to reduce their health risks. Thus, the Citibank Health Management Program was associated with significant reductions in health risk.

Risk profile: multivariate cluster analysis of urban small areas based on socioeconomic indicators - census tracts from the Greater Rio de Janeiro Metropolitan Area

A method based on small area data analysis was developed to build a health risk classification for the Greater Rio de Janeiro Metropolitan Area. The approach uses 1991 census data and studies data pertaining to sanitation, ownership and type of housing, size and occupancy of the household, demography, schooling, and income. Principal component analysis applied over each dimension allowed for the choice of 15 variables, which summarized most of the observed variances. Additional analysis with these variables suggested that just six variables are sufficient for the construction of a classification using k-means method of multivariate cluster analysis. Five classes were obtained: (A) high income; (B) lower income; (C) poor; (D) low schooling and income; (E) low-level access to sanitation. The existing inequality in each of the geopolitical established areas was clearly identified. The proposed method allowed for the construction of compound indices to evaluate quality of life, based on widespread and easily obtained data (the census). Moreover, the method contributed to the detection of socioeconomic inequality, identifying, not only the larger poor regions but also the small excluded areas.

Three-year follow-up of Pawtucket Heart Health's community-based weight loss programs.

The purpose of the study was to evaluate the effectiveness of a community-based weight loss program. A questionnaire was administered by telephone to subjects one to three years following participation in a weight loss program. The study took place in Pawtucket, Rhode Island. The Pawtucket Heart Health Program is part of this setting. A stratified sample of 400 subjects was randomly selected from 2,186 people who participated in weight loss programs between 1985 and 1987. A total of 285 subjects completed the questionnaire; 229 subjects provided sufficient information to be included in the study. The subjects participated in community-based and worksite-based weight loss programs. Self-reported heights and weights before and after intervention and demographic data were collected. Desirable body weight and Garrow's health risk classifications were calculated. Overall, there was a 3.2% reduction in body weight between time of entrance into weight loss programs and time of interview. Eighty percent of the participants lost weight in the program; mean weight loss was 11 pounds. At time of follow-up interview one to three years later, 65% of subjects weighed less than at entrance into the community programs; on average, subjects weighed six pounds less. Sixty-nine percent of the sample was above 20% desirable body weight at entrance and 26% of this group lost enough weight to lower their health risk category. Weight loss in this community-based program compares favorably with those reported by more intense and expensive clinic-bound programs.(ABSTRACT TRUNCATED AT 250 WORDS)