Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz.&nbsp

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Development rates of Callosobruchus maculatus (Coleoptera: Chrysomelidae) in landrace cowpea varieties occurring in southwestern Amazonia

Cowpea, Vigna unguiculata (L.), constitutes an important source of protein in various parts of the world, and landrace varieties are widespread in the southwestern Amazon. The population growth of insects is related to survival strategies in response to the feeding substrate. Thus, the development of Callosobruchus maculatus (F.) (Coleoptera: Chrysomelidae: Bruchinae) in four landrace varieties of cowpea (VBRL 02, VSNA 02 VRDR 02 and VRBC 02) was determined through daily and accumulated emergence rates. These varieties were selected for this study because they are well distributed throughout the Amazonian communities. Cowpea samples (150 g) of each variety were infested with 50 unsexed adults, and the insects were removed 13 days after beginning the bioassays. To determine the daily emergence rates in the varieties, the adult progeny obtained from the feeding substrate was counted and removed on alternate days after the first emergence, until the end of the emergence period (45 days after the beginning of bioassays). The sum of the daily emergence was accumulated since the initial emergence and resulted in the sum of accumulated emergence (SEa, % day), calculated by SEa = ∑ SEd. We found variations in daily and accumulated emergence rates between the four varieties, and the lowest rates of daily emergence of C. maculatus occurred in the varieties VBRL 02 and VSNA 02. The accumulated emergence was delayed in the variety VBRL 02. These results indicate that landrace varieties of cowpea occurring in the southwestern Amazon are a source of features of resistance to bruchids

Quality of beans stored under hermetic conditions

This study aimed to evaluate the quality of beans (Phaseolus vulgaris L.) stored with different moisture contents under hermetic conditions. Beans with 12.3%, 15.7%, and 17.8% moisture content were used in the experiment. They were packed in bag type silos (3 kg), PET bottles (1.5 L), and glass containers (3 L), covered with organza fabric (control), and stored at 25 ºC and 70±5% relative humidity, for 120 days. The evaluated characteristics included moisture content, apparent density, electrical conductivity, germination percentage, cooking time, and bean classification, every 30 days. Except for the electrical conductivity and cooking time, the other characteristics were kept for 120 days in the stored product with moisture contents of 12.3% and 15.7% in hermetic conditions. Beans with 17.8% of the moisture content, electrical conductivity and cooking time increased, and apparent density and germination were reduced. Beans stored in the control, with any of the moisture contents, showed high quality loss during the long storage. It was concluded that it is possible to storage beans with moisture contents of 12.3% and 15.7%, with quality, for until 120 days, in hermetic conditions

Influência da temperatura da massa de grãos sobre a toxicidade do ozônio a Tribolium castaneum

Considerando que a temperatura da massa de grãos pode influenciar o período de exposição dos fumigantes, desenvolveu-se este trabalho com o propósito de investigar a influência de temperaturas crescentes da massa de grãos (20, 30, 35 e 40 ºC) no período de exposição do ozônio necessário para matar 50 e 95% de insetos adultos de Tribolium castaneum Herbst (Coleoptera: Tenebrionidae). Grãos de milho foram distribuídos em recipientes cilíndricos de PVC com conexões para injeção e exaustão de gás. Os insetos contidos em gaiolas foram colocados na camada mediana da massa de grãos em cada recipiente e estes, por sua vez foram fumigados com ozônio na concentração de 50 ppm. Os tempos letais (TL50 e TL95) para os insetos adultos de T. castaneum foram reduzidos com o aumento da temperatura da massa de grãos, de 20 para 30 ºC, porém a 35 ºC os tempos letais não foram reduzidos em relação às temperaturas menores, mas a 40 ºC os tempos letais foram reduzidos novamente, resultando no menor TL95