Microenvironment-induced restoration of cohesive growth associated with focal activation of P-cadherin expression in lobular breast carcinoma metastatic to the colon.

Invasive lobular carcinoma (ILC) is a special breast cancer type characterized by noncohesive growth and E-cadherin loss. Focal activation of P-cadherin expression in tumor cells that are deficient for E-cadherin occurs in a subset of ILCs. Switching from an E-cadherin deficient to P-cadherin proficient status (EPS) partially restores cell-cell adhesion leading to the formation of cohesive tubular elements. It is unknown what conditions control EPS. Here, we report on EPS in ILC metastases in the large bowel. We reviewed endoscopic colon biopsies and colectomy specimens from a 52-year-old female (index patient) and of 18 additional patients (reference series) diagnosed with metastatic ILC in the colon. EPS was assessed by immunohistochemistry for E-cadherin and P-cadherin. CDH1/E-cadherin mutations were determined by next-generation sequencing. The index patient's colectomy showed transmural metastatic ILC harboring a CDH1/E-cadherin p.Q610* mutation. ILC cells displayed different growth patterns in different anatomic layers of the colon wall. In the tunica muscularis propria and the tela submucosa, ILC cells featured noncohesive growth and were E-cadherin-negative and P-cadherin-negative. However, ILC cells invading the mucosa formed cohesive tubular elements in the intercryptal stroma of the lamina propria mucosae. Inter-cryptal ILC cells switched to a P-cadherin-positive phenotype in this microenvironmental niche. In the reference series, colon mucosa infiltration was evident in 13 of 18 patients, one of which showed intercryptal EPS and conversion to cohesive growth as described in the index patient. The large bowel is a common metastatic site in ILC. In endoscopic colon biopsies, the typical noncohesive growth of ILC may be concealed by microenvironment-induced EPS and conversion to cohesive growth.

Programmed death-ligand 1 (PD-L1) expression in cervical intraepithelial neoplasia and cervical squamous cell carcinoma of HIV-infected and non-infected patients.

Programmed death-ligand 1 (PD-L1) is overexpressed in cervical carcinoma, hindering tumor destruction. The aim of this study was to assess PD-L1 expression by immunohistochemistry in cervical squamous cell carcinoma (SCC) and squamous intraepithelial lesions (SILs) from human immunodeficiency virus-positive (HIV+) and human immunodeficiency virus-negative (HIV-) patients. A total of 166 SCC and SIL samples of HIV+ and HIV- patients were included and analyzed for PD-L1 expression through tumor proportion score (TPS), and results were stratified in five TPS groups using SP263 antibody and, combined positive score (CPS) using 22C3 antibody. In cohort 1 (SP263 clone), all HIV+ patients were negative for intraepithelial lesion or malignancy (NILM), and low-grade squamous intraepithelial lesions (LSILs) scored < 1; and 87.5% of high-grade squamous intraepithelial lesions (HSILs) adjacent to SCC, 19% of HSILs non-adjacent to SCC, and 69% of SCCs scored ≥ 1 (15.4% scored 5). In HIV- patients, all NILM, LSILs, HSILs adjacent to SCC, and two HSILs non-adjacent to SCC scored < 1. SCC: 88.2% scored ≥ 1 and 5.9% scored 5. In cohort 2 (SP263 and 22C3 clones), 16.7% of HIV+ patients with SCC were positive with both clones, CPS ≥ 1 (22C3) or score 5 (≥ 50%) (SP263), showing no significant differences in positivity between both clones. These results indicate that a relatively low percentage of SCCs (16.7%; both in HIV+ and in HIV- patients) express PD-L1 (TPS ≥ 50% and CPS > 1), which may be due to some samples being archival material, sample characteristics, or use of different methodologies, highlighting the need for standardization of PD-L1 assessment in SCC of the cervix. The fact that PD-L1 is overexpressed in SILs of HIV+ patients suggests potential additional applications for immunotherapy in this disease.

Evaluation of PIK3CA mutations in advanced ER+/HER2-breast cancer in Portugal - U-PIK Project.

Background: Around 40% of ER+/HER2-breast carcinomas (BC) present mutations in the PIK3CA gene. Assessment of PIK3CA mutational status is required to identify patients eligible for treatment with PI3Kα inhibitors, with alpelisib currently the only approved tyrosine kinase inhibitor in this setting. U-PIK project aimed to conduct a ring trial to validate and implement the PIK3CA mutation testing in several Portuguese centers, decentralizing it and optimizing its quality at national level. Methods: Eight Tester centers selected two samples of patients with advanced ER+/HER2- BC and generated eight replicates of each (n = 16). PIK3CA mutational status was assessed in two rounds. Six centers used the cobas® PIK3CA mutation test, and two used PCR and Sanger sequencing. In parallel, two reference centers (IPATIMUP and the Portuguese Institute of Oncology [IPO]-Porto) performed PIK3CA mutation testing by NGS in the two rounds. The quality of molecular reports describing the results was also assessed. Testing results and molecular reports were received and analyzed by U-PIK coordinators: IPATIMUP, IPO-Porto, and IPO-Lisboa. Results: Overall, five centers achieved a concordance rate with NGS results (allele frequency [AF] ≥5%) of 100%, one of 94%, one of 93%, and one of 87.5%, considering the overall performance in the two testing rounds. NGS reassessment of discrepancies in the results of the methods used by the Tester centers and the reference centers identified one probable false positive and two mutations with low AF (1-3%, at the analytical sensitivity threshold), interpreted as subclonal variants with heterogeneous representation in the tissue sections processed by the respective centers. The analysis of molecular reports revealed the need to implement the use of appropriate sequence variant nomenclature with the identification of reference sequences (HGVS-nomenclature) and to state the tumor cell content in each sample. Conclusion: The concordance rates between the method used by each tester center and NGS validate the use of the PIK3CA mutational status test performed at these centers in clinical practice in patients with advanced ER+/HER2- BC.

Lymphocyte Subsets in Cervicovaginal Lavage Specimens of HIV-Infected Women: A Surrogate Risk Marker of HPV-Associated Cervical Lesions.

INTRODUCTION: To better understand the role of mucosa immunity in the development of cervical carcinoma in HIV infection, cervical lymphocyte subsets were characterized in HIV+ and HIV- women, as well as their relation to HPV-associated cervical lesions. METHODS: Eighty-three (52 HIV+, 31 HIV-) cell suspensions of cervicovaginal lavage (CVL) and 52 HIV+ peripheral blood (PB) samples were assessed by flow cytometry to evaluate lymphoid populations. High-risk (HR) HPV was assessed in liquid-based cytology and HIV mRNA in PB in the same patients. RESULTS: Cervical CD4+ T cells and CD4+/CD8+ ratio were decreased (p < 0.0001) and cervical CD8+ T cells were increased (p = 0.0080) in HIV+ women. These patients had lower CD4+ T-cell percentages in CVL compared to PB (p = 0.0257), and the opposite was true for CD8+ T cells (p = 0.0104). They also had a higher prevalence of high-grade squamous intraepithelial lesions (SILs) with an increased prevalence of HR HPV. Cervical CD8+ T cells were increased in HR HPV+ patients (p = 0.0300) and related to higher prevalence of SILs (p = 0.0001). DISCUSSION/CONCLUSION: Cervical lymphoid populations can be characterized by flow cytometry, showing a distinct cervical T-cell compartment in HIV+ women. This may represent a surrogate risk marker of HPV-associated cervical lesions in this population and prompt further research on this subject, contributing to improving patients' management.

Problemas éticos vivenciados por enfermeiros gestores na pandemia da COVID-19 em um hospital universitário / Ethical problems experienced by nurse managers in the pandemic of COVID-19 in a university hospital

RESUMO Objetivo compreender os problemas éticos vivenciados por enfermeiros gestores no contexto da pandemia da COVID-19. Métodos estudo qualitativo, realizado com 19 enfermeiros gestores. Os critérios de inclusão foram enfermeiros que exerciam a função de gestão há, pelo menos, seis meses, e os de exclusão, os que ocupavam cargo assistencial. Coleta de dados realizada por meio de entrevistas individuais com roteiro semiestruturado e análise documental, e analisados por meio da Análise de Conteúdo. Resultados os problemas éticos estão relacionados a: duplicidade e falta de informação sobre as normas e rotinas; ausência de fluxo dos pacientes; mudanças de rotina sem comunicação com os enfermeiros coordenadores; absenteísmo e presenteísmo da equipe de enfermagem; recusa de remanejamento por parte dos técnicos; profissionais da enfermagem que optaram por atuar no setor da COVID-19 e ganhar adicional de insalubridade e os que não optaram devido ao medo da doença; e conflitos provenientes do paciente. Conclusão a análise revelou situações marcadas por problemas éticos que comprometem a dinâmica de trabalho e a qualidade do atendimento. Contribuições para a prática a compreensão dos problemas éticos contribui para a promoção de melhorias no planejamento, intervenção e preparo dos profissionais para lidar com questões conflitantes vivenciadas na gestão hospitalar.

ABSTRACT Objective to understand the ethical problems experienced by nurse managers in the context of the COVID-19 pandemic. Methods qualitative study, conducted with 19 nurse managers. The inclusion criteria were nurses who had held a management position for at least six months, and the exclusion criteria were those who held an assistance position. Data were collected through individual interviews with a semi-structured script and document analysis and analyzed using Content Analysis. Results the ethical problems were related to duplicity and lack of information about norms and routines; lack of patient flow; routine changes without communication with the nurse coordinators; absenteeism and presenteeism of the nursing team; refusal of reassignment by technicians; nursing professionals who chose to work in the COVID-19 sector and earn additional unhealthy salary and those who did not choose due to fear of disease; and conflicts arising from the patient. Conclusion the analysis revealed situations marked by ethical problems that compromise the dynamics of work and the quality of care. Contributions to practice understanding ethical problems contributes to the promotion of improvements in planning, intervention, and preparation of professionals to deal with conflicting issues experienced in hospital management.

No caminho da Estratégia da Saúde da Família: itinerário terapêutico das trabalhadoras rurais durante a pandemia de covid-19 / On the way to the Family Health Strategic: therapeutic program for rural workers during the COVID-19 pandemic

Resumo Este artigo teve como objetivo descrever o itinerário terapêutico das trabalhadoras rurais durante a pandemia de covid-19. Realizou-se um estudo qualitativo por meio da metodologia da história oral temática. Foram realizadas 15 entrevistas com trabalhadoras rurais pertencentes ao território da Estratégia da Saúde da Família (ESF) de um distrito municipal do interior de Minas Gerais. As narrativas foram submetidas à análise de conteúdo proposta por Bardin. Os resultados apontaram duas categorias: "Um caminho a percorrer: desvelando o contexto e a organização da ESF no território"; e "Entre medo e (des)atenção à saúde: visibilidade para as trajetórias das trabalhadoras rurais durante a pandemia de covid-19". Na primeira categoria, revelou-se o itinerário terapêutico das trabalhadoras rurais para a busca de cuidados na ESF do território, bem como a organização do serviço de saúde local. A segunda retratou a intensificação da desatenção à saúde para com as trabalhadoras rurais. Conclui-se que, no itinerário terapêutico das trabalhadoras rurais, a utilização da ESF do território se apresentou como rede preferencial, evidenciando a premência de fortalecimento da APS rural. A pandemia de covid-19 acentuou os dilemas para a busca de cuidados de saúde, revelando a urgência de ações de saúde para esse território.

Abstract This study aimed to describe the therapeutic itinerary of rural female workers during the COVID-19 pandemic. It is a qualitative study using oral history methodology. A total of 15 interviews were carried out with rural female workers belonging to the field of the Family Health Strategy (ESF in Portuguese) of a municipal district in the state of Minas Gerais. The narratives were subjected to content analysis following Bardin. The results pointed to two categories: "A way to go: revealing the context and the organization of ESF in the area;" and "Between fear and (lack of) health assistance: visibility for the trajectories of rural female workers during the COVID-19 pandemic." The first category demonstrated the therapeutic itinerary of rural female workers aiming to access health care in the ESF of their area besides the organization of local health service. The second category illustrated the intensified lack of assistance experienced by rural workers. In conclusion, the use of ESF represented the preferred network in the therapeutic itinerary of rural workers demonstrating the urgent action to strengthen Primary Health Care in rural areas. The COVID-19 pandemic stressed the challenges concerning the search of health assistance showing the urgency of health actions for this territory.

Results of a worldwide survey on the currently used histopathological diagnostic criteria for invasive lobular breast cancer.

Invasive lobular carcinoma (ILC) represents the second most common subtype of breast cancer (BC), accounting for up to 15% of all invasive BC. Loss of cell adhesion due to functional inactivation of E-cadherin is the hallmark of ILC. Although the current world health organization (WHO) classification for diagnosing ILC requires the recognition of the dispersed or linear non-cohesive growth pattern, it is not mandatory to demonstrate E-cadherin loss by immunohistochemistry (IHC). Recent results of central pathology review of two large randomized clinical trials have demonstrated relative overdiagnosis of ILC, as only ~60% of the locally diagnosed ILCs were confirmed by central pathology. To understand the possible underlying reasons of this discrepancy, we undertook a worldwide survey on the current practice of diagnosing BC as ILC. A survey was drafted by a panel of pathologists and researchers from the European lobular breast cancer consortium (ELBCC) using the online tool SurveyMonkey®. Various parameters such as indications for IHC staining, IHC clones, and IHC staining procedures were questioned. Finally, systematic reporting of non-classical ILC variants were also interrogated. This survey was sent out to pathologists worldwide and circulated from December 14, 2020 until July, 1 2021. The results demonstrate that approximately half of the institutions use E-cadherin expression loss by IHC as an ancillary test to diagnose ILC and that there is a great variability in immunostaining protocols. This might cause different staining results and discordant interpretations. As ILC-specific therapeutic and diagnostic avenues are currently explored in the context of clinical trials, it is of importance to improve standardization of histopathologic diagnosis of ILC diagnosis.

Targeted Axillary Dissection after Chemotherapy: Feasibility Study with Clip and Carbon Dye Tattoo - Neotarget Trial.

Background: Axillary staging in patients with complete response after neoadjuvant chemotherapy (NAC) is still controversial. Our objective was to test tattoo alone and subsequentially tattoo plus clip as markers in the targeted axillary dissection of ycN0 patients. Methods: Prospective cohort of cT1-T3, cN1 (proven histologically), M0 patients scheduled to receive NAC. Exclusion criteria were lobular histology, prior axillary surgery, and clinical N2/3. In cohort 1 this positive node (Neotarget node) was tattooed at diagnosis. If ycN0, a targeted axillary dissection was performed. After an interim analysis with negative results we changed the protocol in order to do a double marking procedure (Cohort 2): the positive node was clipped at diagnosis and after NAC a tattoo was done before surgery. Results: Thirteen patients in Cohort 1 and 18 patients in Cohort 2. Failure to identify the Neotarget node with multiple nodes retrieved in 9/13 (69%) of Cohort 1 patients. Also in 5/13 (38%) of Cohort 1 patients and 3/18 (17%) of Cohort 2 there was a failure to clearly identify tattooed nodes. In Cohort 2, clip identification by surgical specimen radiography allowed the identification of the tagged node in 17/18 (94,4%) of cases. The concordance between the clipped node and sentinel nodes was 16/18 (89%). Conclusions: The introduction of double marking by clipping the metastatic node and verifying their removal by surgical specimen radiography, using carbon ink as a tracer, allowed the identification of the metastatic node in 94% of cases, with a simple, reproducible, and easy-to-implement targeted axillary dissection procedure.

Prontuário eletrônico na gestão do cuidado em equipes de saúde da família / Electronic medical charts for care management in family health teams / Historia clínica electrónica para la gestión de la atención en equipos de salud de la familia

RESUMO Objetivo: compreender a utilização do Prontuário Eletrônico do Cidadão na Gestão do Cuidado em equipes de Saúde da Família. Método: estudo de caso com abordagem qualitativa, utilizando como referencial teórico as dimensões da Gestão do Cuidado. Realizado em dois municípios de Minas Gerais, Brasil, com 37 profissionais da Estratégia Saúde da Família, por meio de entrevistas e observação direta, de março a junho de 2019. A análise dos dados foi feita por meio da Análise de Conteúdo, modalidade Temático-Categorial e sistematizada por meio do programa MaxQDA. Resultado: os resultados apontaram que a utilização do Prontuário Eletrônico do Cidadão ocorre em três dimensões da Gestão do Cuidado: profissional, organizacional e sistêmica. Conclusão: o estudo contribui para a reflexão sobre a importância de um olhar que permeie as várias dimensões da Gestão do Cuidado no cotidiano das equipes de Estratégia Saúde da Família, frente à introdução do Prontuário Eletrônico do Cidadão.

ABSTRACT Objective: to understand the use of the Citizen's Electronic Medical Chart for Care Management in Family Health teams. Method: a case study with a qualitative approach, using the Care Management dimensions as its theoretical framework. It was conducted from March to June 2019 in two municipalities from Minas Gerais, Brazil, with 37 professionals working in the Family Health Strategy, by means of interviews and direct observation. Data analysis was performed through Content Analysis, Thematic-Categorical modality, and systematized in the MaxQDA program. Result: the results indicated that use of the Citizen's Electronic Medical Chart takes place in three Care Management dimensions, namely: professional, organizational, and systemic. Conclusion: the study contributes to the reflection on the importance of a perspective that permeates the several Care Management dimensions in the Family Health Strategy teams' routine, given the introduction of the Citizen's Electronic Medical Chart.

RESUMEN Objetivo: comprender cómo se utiliza la Historia Clínica Electrónica del Ciudadano para la Gestión de la Atención en equipos de Salud de la Familia. Método: estudio de caso de enfoque cualitativo, en el cual se utilizaron las dimensiones de la Gestión de la Atención como marco de referencia teórico. El estudio se realizó entre marzo y junio de 2019 con 37 profesionales de la Estrategia Salud de la Familia por medio de entrevistas y observación directa en dos municipios de Minas Gerais, Brasil. El análisis de los datos se realizó a través de la modalidad Temático-Categórica del Análisis de contenido, y se sistematizó por medio del programa MaxQDA. Resultado: los resultados indicaron que la Historia Clínica Electrónica del Ciudadano se utiliza en tres dimensiones de la Gestión de la Atención, a saber: profesional, organizacional y sistémica. Conclusión: el estudio contribuyó a la reflexión sobre la importancia de una perspectiva que abarque a las variadas dimensiones de la Gestión de la Atención en la rutina de los equipos de la Estrategia Salud de la Familia, frente a la incorporación de la Historia Clínica Electrónica del Ciudadano.

Clinical correlation of lymphovascular invasion and Silva pattern of invasion in early-stage endocervical adenocarcinoma: proposed binary Silva classification system.

Silva invasion pattern can help predict lymph node metastasis risk in endocervical adenocarcinoma. We analysed Silva pattern of invasion and lymphovascular invasion to determine associations with clinical outcomes in stage IA and IB1 endocervical adenocarcinomas. International Federation of Gynecology and Obstetrics (FIGO; 2019 classification) stage IA-IB1 endocervical adenocarcinomas from 15 international institutions were examined for Silva pattern, presence of lymphovascular invasion, and other prognostic parameters. Lymph node metastasis status, local/distant recurrences, and survival data were compared using appropriate statistical tests. Of 399 tumours, 152 (38.1%) were stage IA [IA1, 77 (19.3%); IA2, 75 (18.8%)] and 247 (61.9%) were stage IB1. On multivariate analysis, lymphovascular invasion (p=0.008) and Silva pattern (p<0.001) were significant factors when comparing stage IA versus IB1 endocervical adenocarcinomas. Overall survival was significantly associated with lymph node metastasis (p=0.028); recurrence-free survival was significantly associated with lymphovascular invasion (p=0.002) and stage (1B1 versus 1A) (p=0.002). Five and 10 year overall survival and recurrence-free survival rates were similar among Silva pattern A cases and Silva pattern B cases without lymphovascular invasion (p=0.165 and p=0.171, respectively). Silva pattern and lymphovascular invasion are important prognostic factors in stage IA1-IB1 endocervical adenocarcinomas and can supplement 2019 International Federation of Gynecology and Obstetrics staging. Our binary Silva classification system groups patients into low risk (patterns A and B without lymphovascular invasion) and high risk (pattern B with lymphovascular invasion and pattern C) categories.

Prática colaborativa na estratégia saúde da família: expressões, possibilidades e desafios para produção do cuidado / La práctica colaborativa en la estrategia de salud familiar: expresiones, posibilidades y desafíos para la producción de cuidados / Collaborative practice in the family health strategy: expressions, possibilities and challenges for the production of care

RESUMO Objetivo: compreender a configuração da prática colaborativa no contexto da Estratégia Saúde da Família (ESF). Método: trata-se de um estudo de caso único, de natureza qualitativa, realizado com 35 profissionais das equipes de saúde da família. A coleta de dados ocorreu por meio de entrevistas guiadas por roteiro semiestruturado e observação não participante. Os dados foram analisados por meio de Análise de Conteúdo Temática. Resultados: os resultados evidenciaram potencialidades da prática colaborativa para a qualificação das práticas profissionais e dos resultados de saúde no contexto da ESF. Entretanto observou-se insuficiência de dispositivos organizacionais para apoiar o trabalho compartilhado na ESF, inclusive no que tange às políticas públicas, revelando o chamamento para a educação interprofissional no contexto dos serviços de saúde para estimular a colaboração. Conclusão: a configuração da prática colaborativa interprofissional no contexto da Estratégica Saúde da Família é desafiadora e requer processos interacionais e de organização do trabalho.

RESUMEN Objetivo: comprender la configuración de la Práctica Colaborativa en el contexto de la Estrategia de Salud Familiar. Método: se trata de un estudio de caso único, de carácter cualitativo, realizado con treinta y cinco profesionales de equipos de salud familiar. La recogida de datos se realizó mediante entrevistas guiadas por un guión semiestructurado y la observación no participante. Los datos se analizaron mediante un Análisis de Contenido Temático. Resultados: los resultados mostraron el potencial de la práctica colaborativa para la cualificación de las prácticas profesionales y los resultados de salud en el contexto del ESF. Sin embargo, se observaron insuficientes dispositivos organizativos para apoyar el trabajo compartido en los ESF, un reto a superar, incluso en lo que respecta a las políticas públicas, lo que revela la necesidad de una educación interprofesional en el contexto de los servicios de salud para estimular la colaboración. Conclusión: la configuración de la Práctica Colaborativa interprofesional en el contexto de la Estrategia de Salud Familiar es un reto y requiere procesos de interacción y organización del trabajo.

ABSTRACT Objective: to understand the configuration of collaborative practice in the context of the Family Health Strateg y (FHS). Method: this is a single case study, of a qualitat ive nature, carried out with 35 professionals from the family health teams. Data collection took place through interviews guided by a semi-structured script and non-participant observation. Data were analyzed using Thematic Content Analysis. Results: the results showed the potential of collaborative practice for the qualification of professional practices and health outcomes in the conte xt of the FHS. However, there was a deficiency of organizational devices to support shared work in the FHS, including with regard to public policies, revealing the call for interprofessional education in the context of health services to encourage collaboration. Conclusion: the configuration of interprofessional collaborative practice in the context of the Family Health Strategy is challenging and requires interactional processes and work organization.

Gestão e ambientes de trabalho na atenção primária à saúde: revisão de escopo / Gestión y entornos de trabajo en la atención primaria de salud: revisión del alcance / Management and work environments in primary health care: scope review

RESUMO Objetivo: identificar subsídios teóricos e empíricos sobre ambientes de trabalho na atenção primária à saúde (APS) em sua relação à saúde do trabalhador (questão preliminar) que indiquem elementos relativos à gestão (questão específica). Métodos: Scoping Review de seis etapas com consulta aos sujeitos, busca na literatura do período de 2010 a 2019 em seis bases de dados e bibliotecas virtuais com seleção de 21 artigos. A etapa complementar, de consulta, operacionalizou grupo focal com 14 trabalhadores da APS em um município do Sul do Brasil. Resultados: foram organizados em três categorias temáticas: i) Aspectos administrativos no ambiente de trabalho: dificuldades relacionadas à gestão; ii) Percepções sobre as relações de trabalho: barreiras entre equipe e gestão; e iii) Conflitos no ambiente de trabalho: estratégias de enfrentamento. Considerações finais: questões de ordem burocrática e de rotina da APS influenciam as relações interpessoais e os resultados alcançados, sendo fundamentais para o alcance de ambientes saudáveis de trabalho dos atores em cena. O suporte institucional, o diálogo e a possibilidade de exercer um trabalho pleno de sentido e valor é direito do trabalhador, reafirmando a promoção de ambientes de trabalho saudáveis na APS como prioridade ético-política.

RESUMEN Objetivo: identificar subsidios teóricos y empíricos sobre ambientes de trabajo en APS en su relación con la salud de los trabajadores (cuestión preliminar) que indiquen elementos relacionados con la gestión (cuestión específica). Métodos: Scoping Review de seis etapas con consulta a los sujetos, búsqueda bibliográfica en el período de 2010 a 2019 en seis bases de datos y bibliotecas virtuales con selección de 21 artículos. La fase complementaria, de consulta, consistió en un grupo de reflexión con 14 trabajadores de Atención Primaria de Salud en un municipio del Sur de Brasil. Resultados: organizados en tres categorías temáticas: Aspectos administrativos en el entorno laboral: dificultades relacionadas con la gestión; Percepciones sobre las relaciones laborales: barreras entre el equipo y la dirección; Conflictos en el entorno laboral: estrategias de afrontamiento. Consideraciones finales: las cuestiones burocráticas y rutinarias de la APS influyen en las relaciones interpersonales y en los resultados alcanzados, siendo fundamentales para el logro de ambientes de trabajo saludables de los actores en escena. El apoyo institucional, el diálogo y la posibilidad de ejercer un trabajo lleno de sentido y valor es un derecho del trabajador, reafirmando la promoción de ambientes de trabajo saludables en la APS como una prioridad ético-política.

ABSTRACT Objective: to identify theoretical and empirical subsidies on work environments in primary health care (PHC) in relation to workers' health (preliminary question) that indicate elements related to management (specific question). Methods: six-step Scoping Review with consultation with the subjects, literature search from 2010 to 2019 in six databases and virtual libraries with selection of 21 articles. The complementary stage, consultation, operated a focus group with 14 PHC workers in a municipality in southern Brazil. Results: they were organized into three thematic categories: i) Administrative aspects in the work environment: difficulties related to management; ii) Perceptions about labor relations: barriers between staff and management; and iii) Conflicts in the workplace: coping strategies. Final considerations: bureaucratic and routine PHC issues influence interpersonal relationships and the results achieved, being fundamental for achieving healthy work environments for the actors on the scene. Institutional support, dialogue and the possibility of carrying out work full of meaning and value are workers' rights, reaffirming the promotion of healthy work environments in PHC as an ethical-political priority.

Horizontal tumor extent (HZTE) has limited prognostic significance in 2018 FIGO stage I endocervical adenocarcinoma (ECA): a retrospective study of 416 cases.

PURPOSE: The 2018 International Federation of Gynecology and Obstetrics (FIGO) update on cervical cancer staging eliminated horizontal tumor extent (HZTE) as a staging parameter in stage IA (microscopic) disease. We aimed to determine whether HZTE correlates with outcomes in early stage ECAs and FIGO should reinstate HZTE as a staging parameter in futures updates. METHODS: We retrospectively analyzed 416 FIGO 2009 stage I ECAs from 17 institutions and re-assigned stage using FIGO 2018. Correlation between HZTE, overall (OS) and recurrence free survival (RFS) was performed using univariable and multivariable analyses. RESULTS: Re-staging 416 cases resulted in 126 (30.3%) IA and 290 (69.7%) IB cases; 85 (67.5%) IA tumors had HZTE ≤ 7 mm, while 41 (32.5%) were > 7 mm; 32 (11%) IB tumors had HZTE ≤ 7 mm, while 258 (89%) were > 7 mm (p = 0.0001). Four (3.2%) IA (1 IA1, 3 IA2) patients developed recurrence (3 ≤ 7 mm, 1 > 7 mm) compared to 41 (14.1%) IB patients (p = 0.002). Fourteen IB and no IA patients died of disease (8 IB1, 1 ≤ 7 mm). Cox univariate analysis demonstrated that only RFS is significantly influenced by HZTE (p = 0.01), while OS and RFS were not influenced by HZTE on multivariate analysis. CONCLUSION: HZTE has limited prognostic value in early stage ECAs and is only associated with RFS on univariate but not multivariate analysis. HZTE does not improve prognostication of patients with stage I ECAs as per 2018 FIGO staging. Consequently, the rationale to remove this variable from FIGO staging is justified for ECAs.

Building Culturally Competent Compassion in Nurses Caring for Vulnerable Populations.

Objective: To understand the process of building culturally competent compassion in nurses who care for vulnerable populations. Method: This is a qualitative study of a "single case study" type, developed with 18 nurses who worked in an emergency care unit in the city of Belo Horizonte, Brazil, between October 2020 and January 2021. Data collection was performed through individual online or one-to-one interviews, following a semi-structured script. Data were treated following thematic content analysis, proposed by Bardin. All ethical precepts were taken into account. Results: After data analysis, the following categories were created: a) Looking within: the recognition of cultural identity; b) Paths to be taken: from the gap to cultural knowledge; c) Attentive listening as essential nursing care; d) Culturally competent compassion as an infinite opportunity for growth. Final considerations: Culturally competent compassion is a subjective, complex, and essential construct in holistic nursing care. When implemented successfully, we gain a significant improvement in the quality of healthcare provided to patients and their families as well as a decrease in social inequality, and the protection of human rights.

Inter-observer agreement for the histological diagnosis of invasive lobular breast carcinoma.

Invasive lobular breast carcinoma (ILC) is the second most common breast carcinoma (BC) subtype and is mainly driven by loss of E-cadherin expression. Correct classification of BC as ILC is important for patient treatment. This study assessed the degree of agreement among pathologists for the diagnosis of ILC. Two sets of hormone receptor (HR)-positive/HER2-negative BCs were independently reviewed by participating pathologists. In set A (61 cases), participants were provided with hematoxylin/eosin (HE)-stained sections. In set B (62 cases), participants were provided with HE-stained sections and E-cadherin immunohistochemistry (IHC). Tumor characteristics were balanced. Participants classified specimens as non-lobular BC versus mixed BC versus ILC. Pairwise inter-observer agreement and agreement with a pre-defined reference diagnosis were determined with Cohen's kappa statistics. Subtype calls were correlated with molecular features, including CDH1/E-cadherin mutation status. Thirty-five pathologists completed both sets, providing 4,305 subtype calls. Pairwise inter-observer agreement was moderate in set A (median κ = 0.58, interquartile range [IQR]: 0.48-0.66) and substantial in set B (median κ = 0.75, IQR: 0.56-0.86, p < 0.001). Agreement with the reference diagnosis was substantial in set A (median κ = 0.67, IQR: 0.57-0.75) and almost perfect in set B (median κ = 0.86, IQR: 0.73-0.93, p < 0.001). The median frequency of CDH1/E-cadherin mutations in specimens classified as ILC was 65% in set A (IQR: 56-72%) and 73% in set B (IQR: 65-75%, p < 0.001). Cases with variable subtype calls included E-cadherin-positive ILCs harboring CDH1 missense mutations, and E-cadherin-negative ILCs with tubular elements and focal P-cadherin expression. ILCs with trabecular growth pattern were often misclassified as non-lobular BC in set A but not in set B. In conclusion, subtyping of BC as ILC achieves almost perfect agreement with a pre-defined reference standard, if assessment is supported by E-cadherin IHC. CDH1 missense mutations associated with preserved E-cadherin protein expression, E- to P-cadherin switching in ILC with tubular elements, and trabecular ILC were identified as potential sources of discordant classification.

A ética da virtude na prática da equipe de saúde da família / La ética de las virtudes en la práctica del equipo de salud de la familia / Virtue ethics in family health team's practice

Resumo Objetivo Compreender a prática da equipe de saúde da família sob o prisma da ética da virtude. Métodos Estudo de caso único de abordagem qualitativa, realizado entre janeiro e julho de 2019, em Estratégias de Saúde da Família, de um município do interior de Minas Gerais. Os participantes foram médicos, enfermeiros, técnicos de enfermagem e agentes comunitários de saúde, totalizando 35 profissionais das equipes da Estratégia Saúde da Família. Os dados foram coletados por meio de entrevistas e observação e, analisados por meio da análise de conteúdo, com auxílio do software Atlas.ti. Resultados A prática da equipe de saúde da família se desenvolve pelo cuidado centrado nos usuários, na busca de atender suas necessidades objetivas e subjetivas. Contudo, existem obstáculos que transitam na interface entre a legalidade/burocracia (ethos burocrático) referente ao atendimento de normas preconizadas para organização e funcionamento do serviço e o ethos profissional relacionado ao compromisso dos profissionais com as pessoas. Conclusão A prática da equipe de saúde da família na ótica da ética da virtude permite reconhecer que profissional e paciente são agentes morais que se orientam por valores e virtudes na busca pelo bem interno de suas vidas e prática.

Resumen Objetivo Comprender la práctica del equipo de salud de la familia bajo la perspectiva de la ética de las virtudes. Métodos Estudio de caso único de enfoque cualitativo, realizado entre enero y julio de 2019, en Estrategia Salud de la Familia de un municipio del interior de Minas Gerais. Los participantes fueron médicos, enfermeros, técnicos de enfermería y agentes comunitarios de salud, que sumaron un total de 35 profesionales de los equipos de Estrategia Salud de la Familia. Los datos fueron recopilados mediante entrevistas y observación y analizados mediante el análisis de contenido, con ayuda del software Atlas.ti. Resultados La práctica del equipo de salud de la familia se desarrolla mediante el cuidado centrado en los usuarios, buscando satisfacer sus necesidades objetivas y subjetivas. Sin embargo, existen obstáculos que transitan la interfaz entre la legalidad/burocracia (ethos burocrático), relacionado con el cumplimiento de normas recomendadas para la organización y el funcionamiento del servicio, y el ethos profesional, relacionado con el compromiso de los profesionales con las personas. Conclusión La práctica del equipo de salud de la familia bajo la perspectiva de la ética de las virtudes permite reconocer que profesional y paciente son agentes morales que se guían por valores y virtudes en la búsqueda del bien interno de su vida y práctica.

Abstract Objective To understand Family Health team's practice from the perspective of virtue ethics. Methods A single case study of a qualitative approach, conducted between January and July 2019 in Family Health Strategies in a municipality in the countryside of Minas Gerais. Participants were physicians, nurses, nursing technicians and community health workers, totaling 35 professionals from Family Health Strategy teams. Data were collected through interviews and observation and analyzed through content analysis, with the help of atlas.ti software. Results Family Health team's practice is developed by care centered on users, in the search to meet their objective and subjective needs. However, there are obstacles that pass through the interface between legality/bureaucracy (bureaucratic ethos) regarding compliance with standards recommended for service organization and operation and professional ethos related to professionals' commitment to people. Conclusion Family Health team's practice from the perspective of virtue ethics allows us to recognize that professional and patient are moral agents who are guided by values and virtues in the search for the internal good of their lives and practice.

Elementos associados à deliberação moral na equipe de saúde da família: em busca da excelência da prática profissional / Elements associated with moral deliberation in family health teams: in search of excellence in professional practice

Resumo Este artigo objetiva identificar os elementos associados à deliberação moral na Estratégia Saúde da Família (ESF); utilizando um estudo de caso único de abordagem qualitativa, realizado com trinta e cinco profissionais das equipes de saúde da família. A coleta de dados ocorreu por meio de entrevistas, guiadas por roteiro semiestruturado e observação. Os dados foram analisados por meio de análise de conteúdo temática. Os resultados evidenciaram que a deliberação moral no contexto concreto da prática dos profissionais da Estratégia Saúde da Família mostrou ser uma construção subjetiva e incipiente, influenciada por fatores internos e externos aos indivíduos. Chegou-se à conclusão de que identificar os elementos influenciadores da deliberação moral no contexto da ESF pode favorecer o aprimoramento ético das práticas em saúde.

Abstract This single-case qualitative study aims to identify the elements associated with moral deliberation in the Family Health Strategy (ESF) by interviewing thirty-five professionals from family health teams. Data were collected via interviews guided by a semi- structured script and observation and analyzed using thematic content analysis. The results showed that moral deliberation in the concrete context of the practice of ESF professionals proved to be a subjective and incipient construction, influenced by factors internal and external to individuals. We concluded that identifying the elements that influence moral deliberation in the context of the ESF can favor the ethical improvement of health practices.

Prontuário eletrônico na gestão do cuidado em equipes de saúde da família / Electronic medical charts for care management in family health teams / Historia clínica electrónica para la gestión de la atención en equipos de salud de la familia

RESUMO Objetivo: compreender a utilização do Prontuário Eletrônico do Cidadão na Gestão do Cuidado em equipes de Saúde da Família. Método: estudo de caso com abordagem qualitativa, utilizando como referencial teórico as dimensões da Gestão do Cuidado. Realizado em dois municípios de Minas Gerais, Brasil, com 37 profissionais da Estratégia Saúde da Família, por meio de entrevistas e observação direta, de março a junho de 2019. A análise dos dados foi feita por meio da Análise de Conteúdo, modalidade Temático-Categorial e sistematizada por meio do programa MaxQDA. Resultado: os resultados apontaram que a utilização do Prontuário Eletrônico do Cidadão ocorre em três dimensões da Gestão do Cuidado: profissional, organizacional e sistêmica. Conclusão: o estudo contribui para a reflexão sobre a importância de um olhar que permeie as várias dimensões da Gestão do Cuidado no cotidiano das equipes de Estratégia Saúde da Família, frente à introdução do Prontuário Eletrônico do Cidadão.

ABSTRACT Objective: to understand the use of the Citizen's Electronic Medical Chart for Care Management in Family Health teams. Method: a case study with a qualitative approach, using the Care Management dimensions as its theoretical framework. It was conducted from March to June 2019 in two municipalities from Minas Gerais, Brazil, with 37 professionals working in the Family Health Strategy, by means of interviews and direct observation. Data analysis was performed through Content Analysis, Thematic-Categorical modality, and systematized in the MaxQDA program. Result: the results indicated that use of the Citizen's Electronic Medical Chart takes place in three Care Management dimensions, namely: professional, organizational, and systemic. Conclusion: the study contributes to the reflection on the importance of a perspective that permeates the several Care Management dimensions in the Family Health Strategy teams' routine, given the introduction of the Citizen's Electronic Medical Chart.

RESUMEN Objetivo: comprender cómo se utiliza la Historia Clínica Electrónica del Ciudadano para la Gestión de la Atención en equipos de Salud de la Familia. Método: estudio de caso de enfoque cualitativo, en el cual se utilizaron las dimensiones de la Gestión de la Atención como marco de referencia teórico. El estudio se realizó entre marzo y junio de 2019 con 37 profesionales de la Estrategia Salud de la Familia por medio de entrevistas y observación directa en dos municipios de Minas Gerais, Brasil. El análisis de los datos se realizó a través de la modalidad Temático-Categórica del Análisis de contenido, y se sistematizó por medio del programa MaxQDA. Resultado: los resultados indicaron que la Historia Clínica Electrónica del Ciudadano se utiliza en tres dimensiones de la Gestión de la Atención, a saber: profesional, organizacional y sistémica. Conclusión: el estudio contribuyó a la reflexión sobre la importancia de una perspectiva que abarque a las variadas dimensiones de la Gestión de la Atención en la rutina de los equipos de la Estrategia Salud de la Familia, frente a la incorporación de la Historia Clínica Electrónica del Ciudadano.

Treatment optimization of locally advanced and metastatic pancreatic cancer (Review).

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant tumor types, being the sixth leading cause of mortality worldwide and the fourth in Europe. Globally, it has a mortality/incidence ratio of 98%, and the 5­year survival rate in Europe is only 3%. Although risk factors, such as obesity, diabetes mellitus, smoking, alcohol consumption and genetic factors, have been identified, the causes of PDAC remain elusive. Additionally, the only curative treatment for PDAC is surgery with negative margins. However, upon diagnosis, ~30% of the patients already present with locally advanced disease. In these cases, a multidisciplinary approach is required to improve disease­related symptoms and prolong patient survival. In the present article, a comprehensive review of PDAC epidemiology, physiology and treatment is provided. Moreover, guidelines on patient treatment are suggested. Among the different available therapeutic options for the treatment of advanced PDAC, results are modest, most likely due to the complexity of the disease, and so the prognostic remains poor. Molecular approaches based on multi­omics research are promising and will contribute to groundbreaking personalized medicine. Thus, economic investment that promotes research of pancreatic cancer will be critical to the development of more efficient diagnostic and treatment strategies.

Bedside nurses' care model: challenges and perspectives for an innovative practice.

OBJECTIVE: To understand the practice of nurses in the context of the care model at the bedside of the patient in an Intensive Care Unit, in the light of the ethics of virtue. METHOD: Qualitative research, carried out in an Intensive Care Unit of a University Hospital MG/Brazil. Data were collected in February 2016 through a semi-structured interview applied to the 12 nurses who worked at the unit. The data were submitted to Thematic Content Analysis. RESULTS: The "bedside" care model encourages innovative practice, (re)directing nurses in the search for their telos, patient care, overcoming the fragmentation of nursing care and reconfiguring professional identity. However, the organization of the model in the scenario raised challenges related to the recognition of nurses by the multi-professional team, generating identity ruptures. CONCLUSION: The adopted bedside model interferes in the nurses' relationship with care, bringing together professional and patient, enhancing innovative and excellent practice.