How large is the lung recruitability in early acute respiratory distress syndrome: a prospective case series of patients monitored by computed tomography

Introduction: The benefits of higher positive end expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS) have been modest, but few studies have fully tested the "open-lung hypothesis". This hypothesis states that most of the collapsed lung tissue observed in ARDS can be reversed at an acceptable clinical cost, potentially resulting in better lung protection, but requiring more intensive maneuvers. The short-/middle-term efficacy of a maximum recruitment strategy (MRS) was recently described in a small physiological study. The present study extends those results, describing a case-series of non-selected patients with early, severe ARDS submitted to MRS and followed until hospital discharge or death. Methods: MRS guided by thoracic computed tomography (CT) included two parts: a recruitment phase to calculate opening pressures (incremental steps under pressure-controlled ventilation up to maximum inspiratory pressures of 60 cmH(2)O, at constant driving-pressures of 15 cmH(2)O); and a PEEP titration phase (decremental PEEP steps from 25 to 10 cmH2O) used to estimate the minimum PEEP to keep lungs open. During all steps, we calculated the size of the non-aerated (-100 to +100 HU) compartment and the recruitability of the lungs (the percent mass of collapsed tissue re-aerated from baseline to maximum PEEP). Results: A total of 51 severe ARDS patients, with a mean age of 50.7 years (84% primary ARDS) was studied. The opening plateau-pressure was 59.6 (+/- 5.9 cmH(2)O), and the mean PEEP titrated after MRS was 24.6 (+/- 2.9 cmH(2)O). Mean PaO2/FiO(2) ratio increased from 125 (+/- 43) to 300 (+/- 103; P < 0.0001) after MRS and was sustained above 300 throughout seven days. Non-aerated parenchyma decreased significantly from 53.6% (interquartile range (IQR): 42.5 to 62.4) to 12.7% (IQR: 4.9 to 24.2) (P < 0.0001) after MRS. The potentially recruitable lung was estimated at 45% (IQR: 25 to 53). We did not observe major barotrauma or significant clinical complications associated with the maneuver. Conclusions: MRS could efficiently reverse hypoxemia and most of the collapsed lung tissue during the course of ARDS, compatible with a high lung recruitability in non-selected patients with early, severe ARDS. This strategy should be tested in a prospective randomized clinical trial

Diversité des agricultures familiales

Dans un contexte d’interrogation sur les modèles agricoles et de profondes transformations des agricultures et des marchés, cet ouvrage s’attache à revisiter la diversité des formes familiales de production et leurs mutations de par le monde. Dès lors, l’analyse intègre les liens aux marchés, aux territoires et à l’Ailleurs — par le fait migratoire — les enjeux d’autonomie et de sécurité alimentaire, les stratégies de survie et d’accumulation ainsi que les formes d’action collective et politique. L’ouvrage est construit autour de dix-huit études de cas, menées dans les cinq continents. Elles ont toutes été conduites avec un cadre méthodologique, identique et original, inspiré du Sustainable Rural Livehoods (cadre d’identification des moyens de subsistance durables en milieu rural). Revisitée pour cet ouvrage, cette méthode d’observations et d’analyses permet aux auteurs de préciser finement « ce qui fait famille », d’analyser les adaptations du travail des actifs familiaux et les mettre en perspective avec le contexte territorial et les politiques publiques de chaque pays. Écrit à plusieurs mains, par un réseau de chercheurs, cet ouvrage contribue autant à l’approfondissement des savoirs scientifiques sur les agricultures familiales dans le monde qu’à la mise à l’épreuve d’un cadre méthodologique d’analyse et d’observations en milieu rural. Il vise un public de chercheurs, d’enseignants et d’étudiants, agronomes, économistes, sociologues et historiens. Les experts du développement agricole et rural y trouveront un grand intérêt. Plus largement, toute personne qui s’intéresse aux agricultures familiales et à leurs évolutions dans divers contextes sociaux trouvera avantage à cette lecture. Les chercheurs qui ont coordonné cet ouvrage sont agronomes, économistes et géographes, au Cirad ou à l’Inra où ils mènent des recherches sur les systèmes agricoles familiaux à des échelles locales, nationales ou internationales. Cet ouvrage est le fruit d’une démarche de recherche collective et partagée permettant à de nombreux scientifiques des pays du Sud d’exprimer la diversité des réalités agraires contemporaines. Certains coordinateurs ou auteurs de cet ouvrage ont également collaboré à Agricultures familiales et mondes à venir, titre paru en 2014 chez Quae. Ce livre est également disponible en anglais sous le titreDiversity of Family Farming Around the Worldauprès des éditions Springer -www.springer.co

Comparative virulence of Caribbean, Brazilian and European isolates of Toxoplasma gondii

Abstract Background Toxoplasma gondii is a zoonotic parasite of global importance. The outcome of infection in humans can depend on a number of factors including the infecting stage of the parasite, inoculating dose and virulence of the infecting strain. Molecular epidemiological studies have demonstrated an abundance of atypical strains of T. gondii in South America, many of which have been associated with more severe sequelae of infection. The aim of this study was to compare the virulence of T. gondii strains isolated in the Caribbean to a virulent Brazilian strain and an avirulent European strain. Methods One hundred and twenty Swiss CD-1 mice were split into 8 groups of 15 mice and each group was inoculated with 200 tachyzoites of one of 8 isolates, comprising ToxoDB genotypes #1, #141, #265, #13, #3 and #6. Five mice per group were euthanized at day 8 post-inoculation (p.i.) and parasite burden was determined in heart, lungs and eyes using quantitative PCR. Lungs and brain were also examined by histopathology and immunohistochemistry. The remaining 10 mice per group were part of a survival experiment to assess virulence. DNA was extracted from tachyzoites of each of the 8 T. gondii isolates and genotyped at four ROP gene loci, including ROP5, ROP16, ROP17 and ROP18 to look for association with markers of virulence. Results Infection with ToxoDB genotype #13 from the Caribbean resulted in 100% of mice being euthanized which was comparative to infection with the virulent Brazilian strain (ToxoDB genotype #6). Significantly higher parasite burdens were recorded in the lungs and eyes of mice infected with ToxoDB genotypes #13 and #6. Genotyping of ROP loci revealed that the virulent Caribbean isolates had a different ROP18/ROP5 allelic profile (3/1) to the virulent Brazilian isolate (1/3); however, the avirulent Caribbean isolate (ToxoDB genotype #1) had the same ROP18/ROP5 profile as the avirulent European isolate (ToxoDB #3) (both 2/2). Caribbean isolates of intermediate virulence (ToxoDB #141 and #265) all had the same ROP18/ROP5 allelic profile (2/2). Conclusions Isolates from the Caribbean with ToxoDB genotype #13 were acutely virulent for mice and comparable to a known virulent Brazilian isolate. The ROP protein allelic profile of the virulent Caribbean and Brazilian isolates differed indicating that perhaps other factors are involved in predicting virulence. Understanding virulence is important for predicting disease outcome in humans and may also aid vaccine design as well as drug discovery

In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case–control study

PurposeStroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment.MethodsObservational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients.ResultsThe in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0–2 at discharge was similar in both groups when adjusting for NIHSS score and age.ConclusionThe same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care

Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil:TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial

OBJECTIVE: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. METHODS: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. CONCLUSION: According to the trial’s best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results. ClinicalTrials.gov registration: NCT0392050

TELE-critical Care verSus usual Care on ICU PErformance (TELESCOPE): Protocol for a cluster-randomised clinical trial on adult general ICUs in Brazil

Introduction Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group. Methods and analysis A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units. Ethics and dissemination The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient's enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit. Trial registration number NCT03920501; Pre-results

TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE): protocol for a cluster-randomised clinical trial on adult general ICUs in Brazil

Introduction Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group.Methods and analysis A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units.Ethics and dissemination The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient’s enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit.Trial registration number NCT03920501; Pre-results