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Many rectal cancer survivors experience persistent bowel, urinary, and sexual dysfunction. A better understanding of their lived experience can help guide survivorship care.Multi-modal study of patients who underwent rectal cancer surgery from 2015 to 2019 at a single institution. Surveys and qualitative interviews were used to describe patients' postoperative symptom burden and its impact on their quality of life.The total number of survey respondents was 188 (response rate = 63.5%). Among participants, 41.5% reported their bowel habits, bladder habits (7.8%) and sexual function (36.2%) to be a "moderate" or "big problem" in the past four weeks. The lived experiences varied widely even among patients who report similar symptom burden.Rectal cancer survivors commonly face lasting symptoms that negatively impact their quality of life for years after surgery. Additional support extending beyond the perioperative period is needed for patients with persistent dysfunction.

To evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012-2019 in a collaborative quality improvement network.Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall, however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design.We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012-2019. Risk- and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last two years and the first two years of the study period.There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012-2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points).Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.

In this work, we analyse the influence of the topological defects, like a spiral dislocation in two different scenarios, firstly a non-relativistic system using the Schrödinger equation for a charged particle subject to a confining potential. Furthermore, two systems with spiral dislocation in the presence of a nonuniform radial electric field, one of them with a topology-induced cut-off point yields eigenvalues of energy which are infinitely degenerated. Besides, we study Landau levels with and without rotation effects for a point charge. Thus, in this first non-relativistic part we show that there are cases where an analog of the Ahanorov-Bohm effect exists for bound states and quantum revivals. Next, we analyse the interaction of a relativistic electron with a uniform magnetic field in spiral dislocation. As well, the behaviour of the Dirac field subject to a hard-wall potential. We also show that both rotation and the topology of the spacetime impose a restriction on the values of the radial coordinate. As results, we demonstrate through the Foldy-Wouthuysen approximation that the non-relativistic limits of these situations are consistent with the solutions obtained in the first part of the thesis. Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq Neste trabalho, analisamos a influência do defeito topológico de deslocação em espiral em dois diferentes cenários, em primeiro lugar um sistema não-relativístico utilizando as equações de Schrödinger para uma partícula com carga na presença de um potencial do tipo Hard-Wall. Além disso, dois sistemas com deslocação em espiral na presença de um campo elétrico radial não uniforme, sendo um deles com um ponto de corte induzido pela topologia que produz autovalores de energia infinitamente degenerados. Assim como também, estudamos os níveis de Landau com e sem efeitos de rotação para uma carga pontual. Dessa forma, nessa primeira parte não-relativística mostramos que há casos em que existem análogos ao efeito Aharonov-Bohm para estados ligados e quantum revivals. Em seguida, investigamos a interação de um elétron relativístico com um campo magnético uniforme no espaço-tempo de deslocação em espiral. Bem como, o comportamento do campo de Dirac sujeito a um potencial do tipo hard-wall. Mostramos também, que tanto a rotação quanto a topologia do espaço-tempo impõem restrições aos valores da coordenada radial. Como resultados, demonstramos através da aproximação de Foldy-Wouthuysen que o limite não-relativístico dessas situações são consistentes com as soluções obtidas na primeira parte da tese.

Low health literacy is a contributor to healthcare disparities and can be an insurmountable barrier to accessing quality care (1). End stage liver disease is a complex and daunting diagnosis for patients to educate themselves about. In liver transplantation, a lack of easy to understand educational materials and low health literacy have been associated with lower rates of waitlisting (2,3).

OBJECTIVE: To investigate the optimal timing of direct acting antiviral (DAA) administration in patients with hepatitis C-associated hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). SUMMARY OF BACKGROUND DATA: In patients with hepatitis C (HCV) associated HCC undergoing LT, the optimal timing of direct-acting antivirals (DAA) administration to achieve sustained virologic response (SVR) and improved oncologic outcomes remains a topic of much debate. METHODS: The United States HCC LT Consortium (2015–2019) was reviewed for patients with primary HCV-associated HCC who underwent LT and received DAA therapy at 20 institutions. Primary outcomes were SVR and HCC recurrence-free survival (RFS). RESULTS: Of 857 patients, 725 were within Milan criteria. SVR was associated with improved 5-year RFS (92% vs 77%, P < 0.01). Patients who received DAAs pre-LT, 0–3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 92%, and 82%, and 5-year RFS of 93%, 94%, and 87%, respectively. Among 427 HCV treatment-naïve patients (no previous interferon therapy), patients who achieved SVR with DAAs had improved 5-year RFS (93% vs 76%, P < 0.01). Patients who received DAAs pre-LT, 0–3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 93%, and 78% (P < 0.01) and 5-year RFS of 93%, 100%, and 83% (P = 0.01). CONCLUSIONS: The optimal timing of DAA therapy appears to be 0 to 3 months after LT for HCV-associated HCC, given increased rates of SVR and improved RFS. Delayed administration after transplant should be avoided. A prospective randomized controlled trial is warranted to validate these results.

OBJECTIVE Postoperative complications and deaths are unavoidable aspects of a surgical career, but little is known about the impacts of these unwanted outcomes on resident surgeons. The goal of this study was to characterize the impact of complications and deaths on surgery residents in order to facilitate development of improved support systems. DESIGN This qualitative study was designed to explore resident surgeons’ experiences with unwanted outcomes, including postoperative complications and death. Semi-structured interviews explored a range of topics related to personal experiences with unwanted outcomes. Analyses of interview transcripts were performed iteratively and informed by thematic analysis. SETTING An anthropologist at the University of Michigan conducted interviews with general surgery residents from academic, community, and hybrid training programs across the country. PARTICIPANTS Twenty-eight mid-level and senior residents (PGY3 and above) were recruited for participation from 14 different training programs across the United States. RESULTS Resident surgeons described an initial period of emotional response, characterized by feelings of sadness, frustration, or grief. Simultaneously or soon afterward, interviewees described a period of intellectual response aimed at understanding how and why an outcome occurred, with the expressed goal of learning from it. Many residents described impacts to their personal lives. Several factors that influenced the duration and intensity of these responses were identified, including a sense of ownership, which was a powerful driver for improvement. CONCLUSIONS This qualitative study provides a nuanced description of resident surgeons’ responses to unwanted outcomes. While emotional responses were characterized by strong feelings, such as sadness and grief, intellectual responses were focused on learning from the events. These data may help inform the development of structured support systems by residency programs. Structured Abstract Facing post-operative complications and deaths is an unavoidable aspect of surgical training, but the impacts on surgery residents has not been well characterized. Through semi-structured interviews with general surgery residents from programs across the United States, this qualitative study explored the ways that residents respond to unwanted outcomes. Residents described an initial period of emotional response, characterized by strong feelings, often of sadness or grief. There was a subsequent or concomitant period of intellectual response, in which residents examined how and why this outcome occurred, with the goal of learning from it. A feeling of ownership was strengthened by involvement in patient care and length of rotation. In light of this detailed description of resident experiences, residency programs can foster the development of improved support for trainees as they navigate these profoundly impactful events.

Orientador: Marcos Akira D'Ávila Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Engenharia Mecânica Resumo: Compósitos e nanocompósitos poliméricos estabilizados com aditivos Retardantes ao fogo, agentes estabilizadores de radiação UV, antioxidantes e pigmentos de alta solidez e reforços minerais ainda não apresentam consumo representativo e ampla aplicação. Isto devido não somente a dificuldade de balanceamento de formulações, mas muitas vezes por características antagônicas que as misturas físicas de seus componentes podem oferecer. Fatores ainda, tais como, alto valor desses aditivos, perdas durante o processamento, falhas na modelagem do processo caracterizada pelo método de incorporação ou erros de formulações levam muitas vezes a falhas de aplicação e limitação de uso para determinadas áreas da engenharia de produtos que precisam suportar e atender pré-requisitos bastante rigorosos durante o uso. Mercados como de fios e cabos, construção civil, automotivo, embalagens de transporte ou qualquer artefato que precise dentro de sua aplicação atender a condições propicias de estabilidade ao intemperismo, adequado comportamento ao fogo e boas propriedades mecânicas são fortes candidatos serem estudados. No projeto de pesquisa foi avaliado formulações capazes de atender uma serie destas aplicações e esclarecer potenciais mecanismos que podem gerar falhas durante seu uso final. Foi qualificado o estado da arte das melhores matérias primas a serem empregadas bem como o processo mais adequado de incorporação afim de não gerar mecanismos de degradação ou perda durante o uso. Foi planejado também soluções que possam a levar a uma potencial otimização de custos das formulações uma vez que os componentes empregados nas formulações deste tipo podem gerar alto custo de execução atuando de forma a não ter viabilidade de seu uso. Para viabilizar melhor incorporação na fase de preparação dos corpos de prova foi produzido concentrados de aditivos e pigmentos a fim de garantir melhor sua dispersão dentro da matriz de polipropileno e assim os concentrados obtidos foram adicionados na matriz de polipropileno copolímero a fim de gerar modificação da resina e assim garantir melhor desempenho para aplicação final. Foram preparados os corpos de prova. Todos os corpos- de prova foram disponibilizados para análise sob duas condições fundamentais, ou seja, não envelhecido e envelhecido. Foram realizados a caracterização física química e ótica em ambas as condições utilizando técnicas de Espectrometria de plasma induzido, Cromatografia Líquida de Alta eficiência, Termogravimétrica, Análise elementar, Envelhecimento acelerado, Calorimetria Exploratória de Varredura, Resistência ao Impacto, Resistência a tração, variação colorimétrica e Flamabilidade. Através dos resultados obtidos observou-se uma excelente estabilidade do retardante ao fogo, excelente solidez a luz do pigmento aplicado, o aspecto positivo da adição do reforço mineral talco, uma boa efetividade de incorporação das matérias-primas, a não geração de processos degradativos que poderiam consumir os estabilizantes durante o processamento, entretanto alguns aspectos acerca da aplicação da nanoargila observou-se que deve ser consideradas melhorias em sua aplicação Abstract: Polymer composites and nanocomposites stabilized with fire retardant additives, such as: stabilizers of UV radiation, antioxidants and pigments of high strength and mineral reinforcements still do not present representative consumption and wide application. This is due not only to the difficulty of balancing formulations, but often due to the antagonistic characteristics that the physical mixtures of their components can offer. Further factors such as high value of these additives, losses during processing, failures in process modeling characterized by incorporation method or formulation errors often lead to application failures and use limitation for certain areas of product engineering that need Support and meet fairly stringent prerequisites during use. Markets such as wires and cables, civil construction, automotive, transport packaging or any artifact that needs within its application to meet conditions conducive to stability to weathering, appropriate fire behavior and good mechanical properties are strong candidates to be studied. In the research project was evaluated formulations able to attend a series of these applications and to clarify potential mechanisms that can generate failures during their final use. The state of the art was qualified for the best raw materials to be used as well as the most appropriate process of incorporation in order not to generate mechanisms of degradation or loss during use. It was also planned solutions that could lead to a potential cost optimization of the formulations since the components used in the formulations of this type can generate a high cost of execution, acting in a way that does not have feasibility of its use. In order to make possible better incorporation in the preparation phase of the specimens, additives and pigments concentrates were produced in order to better ensure their dispersion within the polypropylene matrix and thus the obtained concentrates were added in the polypropylene copolymer matrix in order to generate the resin modification and thus Performance. The specimens were prepared. All test specimens were available for analysis under two fundamental conditions, that is, not aged and aged. The chemical and optical physical characterization was performed in both conditions using Induced Plasma Spectrometry, High Performance Liquid Chromatography, Thermogravimetry, Elemental Analysis, Accelerated Aging, Scanning Calorimetry, Impact Resistance, Tensile Strength, Variation Colorimetric and Flammability. An excellent fire retardant stability, excellent light fastness of the applied pigment, the positive aspect of the addition of the talc mineral reinforcement, a good incorporation of the raw materials, and the non-generation of degradation processes were observed. Could consume the stabilizers during the processing, however some aspects about the application of nanoclay it was observed that it must be considered improvements in its application Mestrado Materiais e Processos de Fabricação Mestre em Engenharia Mecânica

This study examined US kidney transplant center websites for readability and for inclusion of languages other than English.

This cross-sectional study examines trends in new waiting list registrations and liver transplantation for alcoholic hepatitis before and during the COVID-19 pandemic in the US.

Pediatric brain tumors cause more deaths than any other childhood malignancy, and the identification of potentially actionable genomic alterations in this rare heterogeneous group of tumors may improve treatment and outcome. The genetic landscape of common posterior fossa tumors has been described in the past several years, yet the classification of malignant pediatric supratentorial tumors remains controversial. Next-generation sequencing (NGS) is a promising tool to evaluate multiple genes concurrently. The clinical utility of NGS has not been proven in pediatric brain tumors. We identified patients diagnosed with high-grade supratentorial pediatric brain tumors resected between 2008 and 2012 at our institution. DNA from 12 formalin-fixed paraffin-embedded tumor samples from 9 patients was analyzed, including 3 paired samples from diagnosis and relapse. A panel of 194 cancer-related genes was sequenced using targeted next-generation deep sequencing. Genetic findings were correlated with histology, immunohistochemistry, treatment, and survival. We found one or more pathologic genetic change (mutation, amplification, or deletion) in 8 of 9 (89%) of patients studied. Epidermal Growth Factor Receptor ( EGFR) mutations were found in 3 patients, 2 of which had an exon 20 insertion not previously described in pediatric malignancy. Additional genetic changes were found in EGFR and Platelet-Derived Growth Factor Receptor Alpha ( PDGFRA) at relapse not present in the initial samples. Familial cancer predisposition syndromes were suggested by mutations found in 3 genes in 4 patients, including TP53, MSH2, and CHEK2. Seven of 9 patients in this study died of their disease. In summary, targeted deep sequencing may be used in rare pediatric brain tumors to identify driver mutations for targeted therapy, suggest constitutional and familial testing for cancer predisposition syndromes, and select molecular targets worthy of further study.

Background Being left-handed (LH) is considered a disadvantage in surgical training. We sought to understand the perspectives of LH trainees and surgical educators on the challenges and modifications in training LH surgeons. Methods A survey was distributed to surgeons, surgical residents, and medical students about challenges teaching and learning surgical technique. Results 25 LH surgeons, 65 right-handed (RH) surgeons, and 39 LH trainees completed the survey. Compared to LH surgeons, RH surgeons reported more difficulty (46% vs 16%, p = 0.003) and less comfort teaching LH trainees (28% vs 4%, p = 0.002), and 10 (15%) reported that LH trainees have less technical ability. RH surgeons identified challenges translating technique to LH trainees and physical limitations of an environment optimized for right-handed mechanics. Conclusions The disadvantage LH surgical trainees face is due to barriers in training rather than inherent lesser ability. Nonetheless, minimal modifications are made to overcome these barriers.

The purpose of this work was to investigate the differences and similarities of the Umbanda cults through interviews in four Umbanda temples (located in Belo Horizonte and Contagem) and the identity of each. The analogy with the muiraquitã myth improves the understanding of unity in diversity represented by the different Umbanda temples investigated. Recurring information was sought in the micro / private sphere capable of reflecting Umbanda's practices at the macro / general level, in addition to the importance of mutual respect and the rescue of the collective memory of the different narratives. Through the follow-up of each story it was possible to observe how in the process of syncretism of Umbanda, there were losses, adaptations and gains that generated the specificities of this genuinely Brazilian religion. El objetivo de este artículo fue investigar las diferencias y similitudes de los cultos de umbanda a través de entrevistas en cuatro (4) terreiros (ubicados en Belo Horizonte y Contagem), además de la identidad de cada uno. Asociar Umbanda con el mito de muiraquitã nos permite comprender la unidad en la diversidad. La analogía con el mito representa los diferentes templos de Umbanda estudiados y busca informaciones recurrentes en la esfera micro/privada capaz de reflejar las prácticas umbandistas en la esfera macro/general, además de la importancia de respetar al otro y rescatar la memoria colectiva de diferentes narrativas. En el proceso de sincretismo de Umbanda, considerada una religión genuinamente brasileña, se notó que hubo pérdidas, adaptaciones y ganancias que generaron sus especificidades: la historia única de cada segmento en la formación de la historia de Umbanda. O objetivo deste artigo foi pesquisar as diferenças e as semelhanças dos cultos de umbanda por meio de entrevistas em quatro (4) terreiros (situados em Belo Horizonte e Contagem), além da identidade de cada um deles. Associar a Umbanda ao mito muiraquitã permite entender a unidade na diversidade. A analogia ao mito representa os diferentes templos de umbanda pesquisados e busca informações recorrentes no âmbito micro/particular capazes de refletir práticas umbandistas no âmbito macro/geral, além da importância do respeito ao outro e do resgate da memória coletiva a partir das diferenciadas narrativas. No processo de sincretismo da Umbanda, considerada uma religião genuinamente brasileira, percebeu-se que houve perdas, adaptações e ganhos que geraram suas especificidades: a história singular de cada segmento na formação da história da Umbanda.

Tese (doutorado) - Pontifícia Universidade Católica de Minas Gerais, Programa de Pós-Graduação em Ciências Sociais Bibliografia: f. 272-287 Esta tese se desenvolveu a partir do contexto da religiosidade de duas comunidades quilombolas: o quilombo Carrapatos da Tabatinga (localizado em uma região urbanizada, no município de Bom Despacho/MG, bairro Ana Rosa/Tabatinga) e o quilombo do Mato do Tição ou Matição (situado em uma área rural, no município de Jaboticatubas/MG). Como metodologia utilizei-me da observação direta, do diário de campo e de entrevistas com alguns dos membros das duas famílias pesquisadas. Procurei saber como é a umbanda nestas duas comunidades quilombolas e como ela é vivenciada dentro destes contextos religiosos afrodescendentes. Além da umbanda, pesquisei também a manifestação de outras expressões religiosas, tais como o catolicismo popular negro existente no seio destas comunidades. Nas umbandas das comunidades pesquisadas o sincretismo por justaposição é muito maior e esta justaposição se dá, principalmente, devido à forte presença do catolicismo popular. Ao praticarem seus reinados, folias de reis, candombes, terços, festas de santos católicos e umbanda, os quilombolas utilizam da memória coletiva e reinventam seus cotidianos e suas vivências comunitárias. Em outras palavras, foi necessário analisar nos dois loci pesquisados suas práticas religiosas afrodescendentes vinculadas e contextualizadas tendo em vista a singularidade de uma umbanda quilombola. Assim, as práticas religiosas desses locais seguem uma lógica na qual as manifestações de fé são catalizadoras do fenômeno religioso e servem como reforço de identidade dos seus componentes, bem como instrumentos de transmissão de valores e significados ao promoverem e reelaborarem sentidos de pertencer, de ser e de viver no referido espaço, se orgulhando em dizer que são desta ou daquela comunidade afrodescendente. Palavras-chave: Quilombos. Umbanda. Religiosidade. Afrodescendente. This thesis was developed from the context of the religiosity of two quilombola communities: the Carrapatos da Tabatinga (located in an urbanized region, in the municipality of Bom Despacho / MG, Ana Rosa / Tabatinga neighborhood) and the quilombo of Mato do Tição or Matição (located in a rural area, in the municipality of Jaboticatubas / MG). As a methodology I used direct observation, the field diary and interviews with some of the members of the two families surveyed. I tried to find out how umbanda is in these two quilombola communities and how it is lived within these Afro-descendant religious contexts. Besides umbanda, I also looked for the manifestation of other religious expressions, such as the black popular Catholicism existing within these communities. In the umbandas of the communities surveyed syncretism by juxtaposition is much greater and this juxtaposition is mainly due to the strong presence of popular Catholicism. In practicing their reigns, folias de kings, candombes, thirds, feasts of catholic saints and umbanda, the quilombolas use of the collective memory and reinvent their daily ones and their community experiences. In other words, it was necessary to analyze in the two loci surveyed their Afro descendent religious practices linked and contextualized in view of the singularity of an quilombola umbanda. Thus, the religious practices of these places follow a logic in which the manifestations of faith are catalysts of the religious phenomenon and serve as reinforcement of the identity of its components, as well as instruments of transmission of values and meanings in promoting and reworking the senses of belonging, to be and to live in the said space, being proud to say that they are of this or that afro-descendent community. Keywords: Quilombos. Umbanda. Religiosity. Afro-descendent.

This study compares patient-reported outcomes after surgery between opioid-sparing recovery and standard of care.

With improved survivorship in medulloblastoma, there has been an increasing incidence of late complications. To date, no studies have specifically addressed the risk of radiation-associated diffuse intrinsic pontine glioma (DIPG) in medulloblastoma survivors. Query of the International DIPG Registry identified six cases of DIPG with a history of medulloblastoma treated with radiotherapy. All patients underwent central radiologic review that confirmed a diagnosis of DIPG. Six additional cases were identified in reports from recent cooperative group medulloblastoma trials (total n = 12; ages 7 to 21 years). From these cases, molecular subgrouping of primary medulloblastomas with available tissue (n = 5) revealed only non-WNT, non-SHH subgroups (group 3 or 4). The estimated cumulative incidence of DIPG after post-treatment medulloblastoma ranged from 0.3–3.9%. Posterior fossa radiation exposure (including brainstem) was greater than 53.0 Gy in all cases with available details. Tumor/germline exome sequencing of three radiation-associated DIPGs revealed an H3 wild-type status and mutational signature distinct from primary DIPG with evidence of radiation-induced DNA damage. Mutations identified in the radiation-associated DIPGs had significant molecular overlap with recurrent drivers of adult glioblastoma (e.g. NRAS, EGFR, and PTEN), as opposed to epigenetic dysregulation in H3-driven primary DIPGs. Patients with radiation-associated DIPG had a significantly worse median overall survival (median 8 months; range 4–17 months) compared to patients with primary DIPG. Here, it is demonstrated that DIPG occurs as a not infrequent complication of radiation therapy in survivors of pediatric medulloblastoma and that radiation-associated DIPGs may present as a poorly-prognostic distinct molecular subgroup of H3 wild-type DIPG. Given the abysmal survival of these cases, these findings provide a compelling argument for efforts to reduce exposure of the brainstem in the treatment of medulloblastoma. Additionally, patients with radiation-associated DIPG may benefit from future therapies targeted to the molecular features of adult glioblastoma rather than primary DIPG. Electronic supplementary material The online version of this article (10.1186/s40478-018-0570-9) contains supplementary material, which is available to authorized users.