Comparative study of surgical and oncologic outcomes in oncoplastic versus non-oncoplastic breast conservative surgery for breast cancer treatment

Orientadores: Luiz Carlos Zeferino, Fabrício Palermo BrenelliDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: A cirurgia conservadora associada à radioterapia é o tratamento de escolha para pacientes com câncer de mama em estadios iniciais. A cirurgia oncoplástica é uma importante ferramenta na ampliação da indicação de cirurgia conservadora no tratamento de tumores maiores, com localização desfavorável ou desproporção tumor-mama, possibilitando ressecções com margens mais amplas, melhores resultados estéticos e reduzindo a indicação de mastectomias. O objetivo deste estudo foi comparar as características das pacientes e do tumor e os desfechos cirúrgicos e oncológicos das pacientes submetidas à cirurgia conservadora com e sem oncoplástica para tratamento do câncer de mama. Métodos: foram incluídas 866 pacientes consecutivamente submetidas a cirurgia conservadora de 2011 a 2015 no CAISM (Hospital da Mulher Prof. Dr. José Aristodemo Pinotti - Centro de Atenção Integral à Saúde da Mulher). Foi realizada um estudo de coorte reconstituída baseada em amostra de conveniência. Os dados foram colhidos e gerenciados no REDCap® e exportados para o Excel® para análise estatística. Para comparar os grupos, foram utilizados Teste t de Student ou Mann-Whitney para variáveis contínuas e teste Qui-quadrado ou Exato de Fisher para variáveis categóricas e regressão logística binária para obtenção do Odds ratio (OR) e Intervalo de confiança (IC) de 95% foi considerado significativo. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da instituição. Foram analisados: perfil da população e do tumor, complicações pós-operatórias, status de margem cirúrgica, taxa de ampliação de margem e de conversão em mastectomia, tempo para adjuvância e recidiva local. Resultados: O tempo médio de seguimento foi de 50,4 meses. Em 768 (88,7%) pacientes foi realizada cirurgia conservadora sem oncoplástica e em 98 (11,3%) cirurgia conservadora com oncoplástica. No grupo de cirurgia oncoplástica houve mais pacientes com menos de 50 anos (OR 3,19; IC 2,08-4,90) e foram submetidas com mais frequência à quimioterapia neoadjuvante (OR 2,67; IC 1,26-3,67). Menos pacientes apresentavam diabetes (OR 0,30; IC 0,13-0,70) e hipertensão (OR 0,41; IC 0,26-0,66). No grupo oncoplástica foram mais frequentes os tumores in situ (OR 3,15; IC 1,56-6,35), os invasores maiores do que 2cm (OR 3,40; IC 2,13-5,43) e os tumores multifocais (OR 2,15; IC 1,26-3,67), além de axila clinicamente comprometida (OR 2,03; IC 1,24-3,31) e maior peso de peça cirúrgica excisada (p<0,0001). Indicação de segunda cirurgia para ampliação de margens foi 2,72 vezes maior no grupo sem oncoplástica (OR 2,72; IC 1,07-6,85). Houve mais deiscência de cicatriz no grupo oncoplástica (OR 4,74; IC 2,32-9,65), mas não houve diferença significativa quanto à presença de complicações maiores precoces (OR 0,93; IC 0,45-1,93), conversão em mastectomia (OR 1,48; IC 0,70-3,12), tempo para adjuvância (p=0,32), ou recidiva local (OR 1,50; IC 0,55-4,07). Conclusão: A cirurgia oncoplástica, mesmo sendo utilizada no tratamento de tumores maiores e multifocais, levou a menos cirurgias para ampliação de margem e não levou a aumento de complicações maiores, conversão para mastectomia, atraso no tratamento adjuvante ou recidiva localAbstract: Breast conservative surgery with radiotherapy is the standard treatment for patients with early breast cancer. Oncoplastic surgery plays an important role in extending the indications of breast conservative surgery for larger tumors, unfavorable tumor location or breast-tumor rate, enabling large margin extensions, better cosmetic outcomes and reducing the indications of mastectomy. The aim of this study was to analyze the characteristics and both surgical and oncologic outcomes of patients submitted to oncoplastic and non-oncoplastic conservative surgery. Methods: Data was retrospectively collected from 866 patients consecutively submitted to oncoplastic and non-oncoplastic breast conservative surgery from 2011 to 2015 at CAISM (Women's Hospital Prof. Dr. José Aristodemo Pinotti - Center for Integral Attention to Women's Health). Data management and statistical analysis were done with REDCap® and Excel®. Mann-Whitney or t-Student test were used for comparison of continuous variables and Chi squared or Fisher Exact test for the categorical variables. For multivariate analysis, binary logistic regression was used to obtain the OR, with a 95% Confidence Interval (CI) considered to be statistically significant. The study was approved by the Research Ethics Committee of the institution. The variables analyzed were: population and tumor characteristics, postoperative complications and their risk factors, surgical margin status and factors associated with positive margins, margin extension and mastectomy conversion rates, time for adjuvant therapy and local recurrence. Results: The 866 patients had a median follow up of 50.4 months. Non-oncoplastic conservative surgery was performed in 768 (88.7%) patients and oncoplastic surgery in 98 (11.3%). The oncoplastic group had more young patients (OR 3.19; CI 2.08-4.90), more neoadjuvant chemotherapy (OR 2.67; CI 1.57-4.54) and fewer patients with diabetes (OR 0.30; CI 0.13-0.70) and hypertension (OR0.41; CI 0.26-0.66). The tumors in this group were more frequently in situ (OR 3.15; CI 1.56-6.35), larger invasive tumors (OR 3.40; CI 2.13-5.43) and multifocal (OR 2.15; CI 1.26-3.67), with compromised axilla (OR 2.03; CI 1,24-3.31) and greater weight of surgical specimen (p<0.0001). The indication for a second surgery for margin re-excision was 2.72 times higher in the non-oncoplastic group (OR 2.72; CI 1.07-6.85). There was more scar dehiscence in the oncoplastic group (OR 4.74; CI 2.32-9.65), but there was no significant difference in early major complications (OR 0.93; CI 0.45-1.93), conversion to mastectomy (OR 1.48; CI 0.70-3.12), time to adjuvant therapy (p=0.32) or local recurrence (OR 1.50; CI 0.55-4.07). Conclusion: Oncoplastic surgery, even when used in the treatment of larger and multifocal tumors, resulted in fewer surgeries for margin re-excision and did not increase the rate of early major complications, positive margins, conversion to mastectomy or local recurrenceMestradoOncologia Ginecológica e MamáriaMestra em Ciências da Saúd

Penilaian Kinerja Keuangan Koperasi di Kabupaten Pelalawan

This paper describe development and financial performance of cooperative in District Pelalawan among 2007 - 2008. Studies on primary and secondary cooperative in 12 sub-districts. Method in this stady use performance measuring of productivity, efficiency, growth, liquidity, and solvability of cooperative. Productivity of cooperative in Pelalawan was highly but efficiency still low. Profit and income were highly, even liquidity of cooperative very high, and solvability was good

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI

Differential cross section measurements for the production of a W boson in association with jets in proton–proton collisions at √s = 7 TeV

Measurements are reported of differential cross sections for the production of a W boson, which decays into a muon and a neutrino, in association with jets, as a function of several variables, including the transverse momenta (pT) and pseudorapidities of the four leading jets, the scalar sum of jet transverse momenta (HT), and the difference in azimuthal angle between the directions of each jet and the muon. The data sample of pp collisions at a centre-of-mass energy of 7 TeV was collected with the CMS detector at the LHC and corresponds to an integrated luminosity of 5.0 fb[superscript −1]. The measured cross sections are compared to predictions from Monte Carlo generators, MadGraph + pythia and sherpa, and to next-to-leading-order calculations from BlackHat + sherpa. The differential cross sections are found to be in agreement with the predictions, apart from the pT distributions of the leading jets at high pT values, the distributions of the HT at high-HT and low jet multiplicity, and the distribution of the difference in azimuthal angle between the leading jet and the muon at low values.United States. Dept. of EnergyNational Science Foundation (U.S.)Alfred P. Sloan Foundatio

Severe early onset preeclampsia: short and long term clinical, psychosocial and biochemical aspects

Preeclampsia is a pregnancy specific disorder commonly defined as de novo hypertension and proteinuria after 20 weeks gestational age. It occurs in approximately 3-5% of pregnancies and it is still a major cause of both foetal and maternal morbidity and mortality worldwide1. As extensive research has not yet elucidated the aetiology of preeclampsia, there are no rational preventive or therapeutic interventions available. The only rational treatment is delivery, which benefits the mother but is not in the interest of the foetus, if remote from term. Early onset preeclampsia (<32 weeks’ gestational age) occurs in less than 1% of pregnancies. It is, however often associated with maternal morbidity as the risk of progression to severe maternal disease is inversely related with gestational age at onset2. Resulting prematurity is therefore the main cause of neonatal mortality and morbidity in patients with severe preeclampsia3. Although the discussion is ongoing, perinatal survival is suggested to be increased in patients with preterm preeclampsia by expectant, non-interventional management. This temporising treatment option to lengthen pregnancy includes the use of antihypertensive medication to control hypertension, magnesium sulphate to prevent eclampsia and corticosteroids to enhance foetal lung maturity4. With optimal maternal haemodynamic status and reassuring foetal condition this results on average in an extension of 2 weeks. Prolongation of these pregnancies is a great challenge for clinicians to balance between potential maternal risks on one the eve hand and possible foetal benefits on the other. Clinical controversies regarding prolongation of preterm preeclamptic pregnancies still exist – also taking into account that preeclampsia is the leading cause of maternal mortality in the Netherlands5 - a debate which is even more pronounced in very preterm pregnancies with questionable foetal viability6-9. Do maternal risks of prolongation of these very early pregnancies outweigh the chances of neonatal survival? Counselling of women with very early onset preeclampsia not only comprises of knowledge of the outcome of those particular pregnancies, but also knowledge of outcomes of future pregnancies of these women is of major clinical importance. This thesis opens with a review of the literature on identifiable risk factors of preeclampsia

Search for stop and higgsino production using diphoton Higgs boson decays

Results are presented of a search for a "natural" supersymmetry scenario with gauge mediated symmetry breaking. It is assumed that only the supersymmetric partners of the top-quark (stop) and the Higgs boson (higgsino) are accessible. Events are examined in which there are two photons forming a Higgs boson candidate, and at least two b-quark jets. In 19.7 inverse femtobarns of proton-proton collision data at sqrt(s) = 8 TeV, recorded in the CMS experiment, no evidence of a signal is found and lower limits at the 95% confidence level are set, excluding the stop mass below 360 to 410 GeV, depending on the higgsino mass

Measurement of associated W plus charm production in pp collisions at √s=7 TeV

Peer reviewe

Search for anomalous production of events with three or more leptons in pp collisions at √s = 8TeV

Published by the American Physical Society under the terms of the Creative Commons Attribution 3.0 License. Further distribution of this work must maintain attribution to the author(s) and the published articles title, journal citation, and DOI.A search for physics beyond the standard model in events with at least three leptons is presented. The data sample, corresponding to an integrated luminosity of 19.5fb-1 of proton-proton collisions with center-of-mass energy s=8TeV, was collected by the CMS experiment at the LHC during 2012. The data are divided into exclusive categories based on the number of leptons and their flavor, the presence or absence of an opposite-sign, same-flavor lepton pair (OSSF), the invariant mass of the OSSF pair, the presence or absence of a tagged bottom-quark jet, the number of identified hadronically decaying τ leptons, and the magnitude of the missing transverse energy and of the scalar sum of jet transverse momenta. The numbers of observed events are found to be consistent with the expected numbers from standard model processes, and limits are placed on new-physics scenarios that yield multilepton final states. In particular, scenarios that predict Higgs boson production in the context of supersymmetric decay chains are examined. We also place a 95% confidence level upper limit of 1.3% on the branching fraction for the decay of a top quark to a charm quark and a Higgs boson (t→cH), which translates to a bound on the left- and right-handed top-charm flavor-violating Higgs Yukawa couplings, λtcH and λctH, respectively, of |λtcH|2+|λctH|2<0.21

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030