Introdução: O impacto da doença renal na saúde é alto para os pacientes e para os serviços de saúde em todo o mundo, e a triagem para doença renal crônica (DRC) tem sido cada vez mais defendida. Estudos de base populacional referentes à prevalência da DRC na comunidade são limitados. Objetivos: Estudamos prospectivamente se a estratificação pelos valores do SCORED registrados poderá ser útil para identificar indivíduos que estão em alto risco de ter doença renal crônica em uma amostra da população geral e comparamos com os métodos de diagnósticos convencionais para DRC. Casuística e métodos: A freqüência de indivíduos com alto risco para a DRC foi determinada utilizando um estudo transversal de 873 indivíduos adultos em Palmas, Tocantins, Brasil. Os indivíduos entrevistados foram selecionados aleatoriamente através de um método estratificado por conglomerados. Idade, sexo e raça foram semelhantes à população urbana de Palmas. DRC foi definida através do ritmo de filtração glomerular estimado (RFGe) <60 ml/min/1.73 m2. Resultados: Um RFGe <60 ml/min/ 1.73 m2 estava presente em 46 (5,3%) dos participantes estudados. O risco de ter doença renal crônica foi maior em mulheres que em homens, e aumentou com a idade de 2...

Lifestyle factors including smoking, obesity, and diabetes can increase colorectal cancer (CRC) risk. Controversy exists regarding screening rates in individuals at increased CRC risk. To examine the effect of risk on CRC screening in primary care, cross-sectional data collected during January 2006–July 2007 from 720 participants in 24 New Jersey primary care practices were analyzed. Participants were stratified by risk: high (personal/family history of CRC, history of polyps, inflammatory bowel disease), increased (obesity, Type II diabetes, current/former smokers), and average. Outcomes were up-to-date with CRC screening, receiving a physician recommendation for screening, and recommendation adherence. Chi-square and generalized linear modeling were used to determine the effect of independent variables on risk group and risk group on outcomes. Thirty-seven percent of participants were high-risk, 46% increased-risk, and 17% average-risk. Age, race, insurance, education, and health status were related to risk. High-risk participants had increased odds of being up-to-date with screening (OR 3.14 95% CI 1.85–5.32) and adhering to physician recommendation (OR 7.18 95% CI 3.58–14.4) compared to average-risk. Increased-risk participants had 32% decreased odds of screening (OR 0.68...

To date, risk profiles based on the known common susceptibility variants have limited value in predicting risk of disease but they could be used for risk stratification in prevention programmes at population level. We illustrate the potential utility of polygenic risk stratification using the case of population-based screening for prostate and breast cancer. We compared the number of individuals eligible for screening and the number of cases potentially detectable by screening in a population undergoing screening based on age alone with a population undergoing stratified screening based on age and polygenic risk profile. Stratified screening strategy based on age and genetic risk would potentially improve the efficiency of screening programmes and reduce their adverse consequences. Organisational, ethical, legal and social issues need to be addressed before stratified screening programmes could be implemented.

Objective To determine the association between concentration of prostate specific antigen (PSA) at age 40-55 and subsequent risk of prostate cancer metastasis and mortality in an unscreened population to evaluate when to start screening for prostate cancer and whether rescreening could be risk stratified.

Individual risk prediction and stratification based on polygenic profiling may be useful in disease prevention. Risk-stratified population screening based on multiple factors including a polygenic risk profile has the potential to be more efficient than age-stratified screening. In this article, we summarize the implications of personalized screening for breast and prostate cancers. We report the opinions of multidisciplinary international experts who have explored the scientific, ethical, and logistical aspects of stratified screening. We have identified (i) the need to recognize the benefits and harms of personalized screening as compared with existing screening methods, (ii) that the use of genetic data highlights complex ethical issues including discrimination against high-risk individuals by insurers and employers and patient autonomy in relation to genetic testing of minors, (iii) the need for transparency and clear communication about risk scores, about harms and benefits, and about reasons for inclusion and exclusion from the risk-based screening process, and (iv) the need to develop new professional competences and to assess cost-effectiveness and acceptability of stratified screening programs before implementation. We conclude that health professionals and stakeholders need to consider the implications of incorporating genetic information in intervention strategies for health-care planning in the future.

Background. Benefits of cardiac screening in kidney transplant candidates (KTC) will be dependent on the availability of effective interventions. We retrospectively evaluated characteristics and outcome of percutaneous coronary interventions (PCI) in KTC selected for revascularization by a cardiac screening approach. Methods. In 267 patients evaluated 2003 to 2006, screening tests performed were reviewed and PCI characteristics correlated with major adverse cardiovascular events (MACE) during a follow-up of 55 months. Results. Stress tests in 154 patients showed ischemia in 28 patients (89% high risk). Of 58 patients with coronary angiography, 38 had significant stenoses and 18 cardiac interventions (6.7% of all). 29 coronary lesions in 17/18 patients were treated by PCI. Angiographic success rate was 93.1%, but procedural success rate was only 86.2%. Long lesions (P = 0.029) and diffuse disease (P = 0.043) were associated with MACE. In high risk patients, cardiac screening did not improve outcome as 21.7% of patients with versus 15.5% of patients without properly performed cardiac screening had MACE (P = 0.319). Conclusion. The moderate procedural success of PCI and poor outcome in long and diffuse coronary lesions underscore the need to define appropriate revascularization strategies in KTC...

Benign breast disease increases the risk of breast cancer. This association has scarcely been evaluated in the context of breast cancer screening programs although it is a prevalent finding in mammography screening. We assessed the association of distinct categories of benign breast disease and subsequent risk of breast cancer, as well as the influence of a family history of breast cancer. A retrospective cohort study was conducted in 545,171 women aged 50–69 years biennially screened for breast cancer in Spain. The median of follow-up was 6.1 years. The age-adjusted rate ratio (RR) of breast cancer for women with benign breast disease, histologically classified into nonproliferative and proliferative disease with and without atypia, compared with women without benign breast disease was estimated by Poisson regression analysis. A stratified analysis by family history of breast cancer was performed in a subsample. All tests were two-sided. The age-adjusted RR of breast cancer after diagnosis of benign breast disease was 2.51 (95 % CI: 2.14–2.93) compared with women without benign breast disease. The risk was higher in women with proliferative disease with atypia (RR = 4.56, 95 % CI: 2.06–10.07) followed by those with proliferative disease without atypia (RR = 3.58; 95 % CI = 2.61–4.91). Women with nonproliferative disease and without a family history of breast cancer remained also at increased risk of cancer (OR = 2.23...

Breast cancer risk is continuing to increase across all societies with rates in countries with traditionally lower risks catching up with the higher rates in the Western world. Although cure rates from breast cancer have continued to improve such that absolute numbers of breast cancer deaths have dropped in many countries despite rising incidence, only some of this can be ascribed to screening with mammography, and debates over the true value of population-based screening continue. As such, enthusiasm for risk-stratified screening is gaining momentum. Guidelines in a number of countries already suggest more frequent screening in certain higher-risk (particularly, familial) groups, but this could be extended to assessing risks across the population. A number of studies have assessed breast cancer risk by using risk algorithms such as the Gail model, Tyrer-Cuzick, and BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm), but the real questions are when and where such an assessment should take place. Emerging evidence from the PROCAS (Predicting Risk Of Cancer At Screening) study is showing not only that it is feasible to undertake risk assessment at the population screening appointment but that this assessment could allow reduction of screening in lower-risk groups in many countries to 3-yearly screening by using mammographic density-adjusted breast cancer risk.

Background: Patterns of methicillin-resistant S. aureus (MRSA) nasal carriage over time and across the continuum of care settings are poorly characterized. Knowledge of prevalence rates and outcomes associated with MRSA nasal carriage patterns could help direct infection prevention strategies. The VA integrated health-care system and active surveillance program provides an opportunity to delineate nasal carriage patterns and associated outcomes of death, infection, and conversion in carriage. Methods/Findings: We conducted a retrospective cohort study including all patients admitted to 5 acute care VA hospitals between 2008–2010 who had nasal MRSA PCR testing within 48 hours of admission and repeat testing within 30 days. The PCR results were used to define a baseline nasal carriage pattern of never, intermittently, or always colonized at 30 days from admission. Follow-up was up to two years and included acute, long-term, and outpatient care visits. Among 18,038 patients, 91.1%, 4.4%, and 4.6% were never, intermittently, or always colonized at the 30-day baseline. Compared to non-colonized patients, those who were persistently colonized had an increased risk of death (HR 2.58; 95% CI 2.18;3.05) and MRSA infection (HR 10.89; 95% CI 8.6;13.7). Being in the non-colonized group at 30 days had a predictive value of 87% for being non-colonized at 1 year. Conversion to MRSA colonized at 6 months occurred in 11.8% of initially non-colonized patients. Age >70 years...

peer-reviewed; Background: Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients’ experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care. Methods: This qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland’s Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer. Results: We identified three overarching themes relevant to the purpose of this paper: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless...

Observational studies have shown an increased lifetime risk of cardiovascular disease (CVD) in women who experienced a hypertensive disorder in pregnancy. This risk is related to the severity of the pregnancy-related hypertensive disease and gestational age at onset. However, it has not been investigated whether these differences in CVD risk factors are already present at postpartum cardiovascular screening. We evaluated postpartum differences in CVD risk factors in 3 subgroups of patients with a history of hypertensive pregnancy. We compared the prevalence of common CVD risk factors postpartum among 448 women with previous early-onset preeclampsia, 76 women with previous late-onset preeclampsia, and 224 women with previous pregnancy-induced hypertension. Women with previous early-onset preeclampsia were compared with women with late-onset preeclampsia and pregnancy-induced hypertension and had significantly higher fasting blood glucose (5.29 versus 4.80 and 4.83 mmol/L), insulin (9.12 versus 6.31 and 6.7 uIU/L), triglycerides (1.32 versus 1.02 and 0.97 mmol/L), and total cholesterol (5.14 versus 4.73 and 4.73 mmol/L). Almost half of the early-onset preeclampsia women had developed hypertension, as opposed to 39% and 25% of women in the pregnancy-induced hypertension and late-onset preeclampsia groups...

OBJECTIVE: To estimate risk of colorectal cancer (CRC) for first-degree relatives of CRC cases based on CRC molecular subtypes and tumour pathology features. DESIGN: We studied a cohort of 33,496 first-degree relatives of 4853 incident invasive CRC cases (probands) who were recruited to the Colon Cancer Family Registry through population cancer registries in the USA, Canada and Australia. We categorised the first-degree relatives into four groups: 28,156 of 4095 mismatch repair (MMR)-proficient probands, 2302 of 301 MMR-deficient non-Lynch syndrome probands, 1799 of 271 suspected Lynch syndrome probands and 1239 of 186 Lynch syndrome probands. We compared CRC risk for first-degree relatives stratified by the absence or presence of specific tumour molecular pathology features in probands across each of these four groups and for all groups combined. RESULTS: Compared with first-degree relatives of MMR-proficient CRC cases, a higher risk of CRC was estimated for first-degree relatives of CRC cases with suspected Lynch syndrome (HR 2.06, 95% CI 1.59 to 2.67) and with Lynch syndrome (HR 5.37, 95% CI 4.16 to 6.94), but not with MMR-deficient non-Lynch syndrome (HR 1.04, 95% CI 0.82 to 1.31). A greater risk of CRC was estimated for first-degree relatives if CRC cases were diagnosed before age 50 years...

A survey was carried out in order to identify elderly patients' perceptions of their health status, their health worries and their opinions regarding health screening before and after the introduction of an annual screening programme. Pre- and post-assessment self report, structured questionnaires and standardized, objectively scored, functional and medical assessments were used. The cohort was an age and sex stratified, 20% sample of those aged 75 years and over (133 patients). Results showed that 96% of patients before the assessment and 98% of patients afterwards, considered the annual assessment useful. The domiciliary visit by the health visitors resulted in one third of those patients who perceived themselves to be in good health and three quarters of those who perceived themselves to be in poor health becoming less worried about their health. Only two patients became more worried. Half of those objectively assessed as being in the medium health risk group and 68% of those in the high health risk group became less worried about their health after screening. Despite the majority of patients having welcomed the assessment their visit resulted in false, and potentially harmful, reassurance for a considerable number of individuals objectively assessed as being at medium and high health risk. An adverse consequence of health screening in elderly people may be inappropriate reassurance for those objectively assessed to be at risk. However...

OBJECTIVE: To determine whether recently trained family physicians were more likely to routinely assess lifestyle health risks during general medical evaluations. To document physicians' perceptions of the difficulties of lifestyle risk assessment, of medical training in that area, and of how often they saw patients with lifestyle health risks. DESIGN: Anonymous mailed survey conducted in 1995. SETTING: Family practices in the province of Quebec. PARTICIPANTS: Stratified random sample of 805 active family physicians of 1111 surveyed; 25 were ineligible or could not be located, and 281 did not respond (74.1% response rate). MAIN OUTCOME MEASURES: Proportion of physicians graduating before and after 1989 who reported routinely (with 90% or more of their patients) assessing their adult and adolescent patients during general medical evaluations for substance use, sexual risk behaviours, and history of family violence and sexual abuse. RESULTS: Except for asking about drug use, recently trained family physicians did not report better assessment of lifestyle health risks during general medical examinations than family physicians who graduated more than 10 years ago did. In both groups, routine assessment averaged 82% for tobacco use, 68% for alcohol consumption...

This is the author accepted manuscript. The final version is available from American association for Cancer Research via http://dx.doi.org/10.1158/1078-0432.CCR-15-1080; PURPOSE: This study aims to quantify the probability of overdiagnosis of prostate cancer by polygenic risk. METHODS: We calculated the polygenic risk score based on 66 known prostate cancer susceptibility variants for 17,012 men aged 50-69 years (9,404 men identified with prostate cancer and 7,608 with no cancer) derived from three UK-based ongoing studies. We derived the probabilities of overdiagnosis by quartiles of polygenic risk considering that the observed prevalence of screen-detected prostate cancer is a combination of underlying incidence, mean sojourn time (MST), test sensitivity, and overdiagnosis. RESULTS: Polygenic risk quartiles one to four had 9%, 18%, 25% and 48% of the cases respectively. For a PSA test sensitivity of 80% and MST of nine years, 43%, 30%, 25% and 19% of the prevalent screen-detected cancers in quartiles one to four, respectively, were likely to be overdiagnosed cancers. Overdiagnosis decreased with increasing polygenic risk, with 56% drop between the lowest and the highest polygenic risk quartiles. CONCLUSION: Targeting screening to men at higher polygenic risk could reduce the problem of overdiagnosis and lead to a better benefit to harm balance in screening for prostate cancer.; NP is Cancer Research UK Clinician Scientist Fellow. The COGS project was funded through a European Commission's Seventh Framework Programme grant (agreement number 223175 - HEALTH-F2-2009-223175)...

This is the author accepted manuscript. The final version is available from American Association for Cancer Research via http://dx.doi.org/10.1158/1940-6207.CAPR-15-0274; Colorectal cancer (CRC) is the second leading cause of cancer-related death in Europe and the United States. Survival is strongly related to stage at diagnosis and population-based screening reduces CRC incidence and mortality. Stratifying the population by risk offers the potential of improving the efficiency of screening. In this systematic review we searched Medline, EMBASE and the Cochrane Library for primary research studies reporting or validating models to predict future risk of primary CRC for asymptomatic individuals. 12,808 papers were identified from the literature search and nine through citation searching. 52 risk models were included. Where reported (n=37), half the models had acceptable-to-good discrimination (c-statistic>0.7) in the derivation sample. Calibration was less commonly assessed (n=21), but overall acceptable. In external validation studies, 10 models showed acceptable discrimination (c-statistic 0.71-0.78). These include two with only three variables (age, gender and BMI; age, gender and family history of CRC). A small number of prediction models developed from case-control studies of genetic biomarkers also show some promise but require further external validation using population-based samples. Further research should focus on the feasibility and impact of incorporating such models into stratified screening programmes.; J Usher-Smith is funded by a National Institute of Health Research (NIHR) Clinical Lectureship and F Walter by an NIHR Clinician Scientist award. J Emery is funded by an Australian National Health and Medical Research Council (NHMRC) Practitioner Fellowship. A Wong has an NHMRC Early Career Fellowship. The views expressed in this publication are those of the authors and not necessarily those of the NHS...

This is the final published version. It first appeared at http://www.nature.com/gim/journal/vaop/ncurrent/full/gim2014192a.html.; Purpose: This study aimed to quantify the probability of overdiagnosis of prostate cancer by polygenic risk. Methods: We calculated the polygenic risk score based on 66 known prostate cancer susceptibility variants for 17,012 men aged 50?69 years (9,404 men identified with prostate cancer and 7,608 with no cancer) derived from three UK-based ongoing studies. We derived the probabilities of overdiagnosis by quartiles of polygenic risk considering that the observed prevalence of screen-detected prostate cancer is a combination of underlying incidence, mean sojourn time (MST), test sensitivity, and overdiagnosis. Results: Polygenic risk quartiles 1 to 4 comprised 9, 18, 25, and 48% of the cases, respectively. For a prostate-specific antigen test sensitivity of 80% and MST of 9 years, 43, 30, 25, and 19% of the prevalent screen-detected cancers in quartiles 1 to 4, respectively, were likely to be overdiagnosed cancers. Overdiagnosis decreased with increasing polygenic risk, with 56% decrease between the lowest and the highest polygenic risk quartiles. Conclusion: Targeting screening to men at higher polygenic risk could reduce the problem of overdiagnosis and lead to a better benefit-to-harm balance in screening for prostate cancer.; N.P. is a Cancer Research UK Clinician Scientist Fellow. The COGS project was funded through a European Commission?s Seventh Framework Programme grant (agreement number: 223175- HEALTH-F2-2009?223175)...

This is the final published version. It first appeared at http://journals.lww.com/spinejournal/Fulltext/2015/03150/Implementing_Stratified_Primary_Care_Management.14.aspx.; STUDY DESIGN: Within-study cost-utility analysis. OBJECTIVE:To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain). SUMMARY OF BACKGROUND DATA: Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up. METHODS: Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence. RESULTS: Stratified care was a dominant treatment strategy compared with usual care for patients at high risk...

This study aims to identify risk factors associated with licit and illicit drugs abuse among adolescent students in various public institutions. Methods: a descriptive study was carried out in Naguanagua, Carabobo, Venezuela and applied the Test Drug Use Screening Inventory questionnaire to an age-stratified sample, involving students between 12 and 17 years old. Results: high-risk areas associated with drugs abuse were family and mental health, while recreation, behavior and school are considered moderate risks. Peers, social abilities and drugs use were identified as low-risk factors. The Total Severity Score is high, which may indicate that Venezuelan adolescents present higher risks for licit and illicit drugs abuse. At the same time, they present lower drugs use rates, that is, the presence of protective factors interact with and modify the risk factors.; Objetivo Identificar factores de riesgo asociados al uso de drogas lícitas e ilícitas en estudiantes adolescentes de ambos sexos cursantes de educación básica y diversificada de instituciones públicas diurnas. Métodos Con base a un estudio descriptiva, de campo y transversal fue realizado estudio en el año 2002 en el Municipio Naguanagua, Estado Carabobo, Venezuela. Se utilizo un cuestionario anónimo auto aplicado denominado Test Drug Use Screening Inventory (DUSI) para adolescentes versión Venezuela...