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

O comércio por vias internas e seu papel sobre crescimento e desigualdade regional no Brasil

Exportado OPUSMade available in DSpace on 2019-08-12T09:20:03Z (GMT). No. of bitstreams: 1 aline_souza_magalh_es_2009.pdf: 694426 bytes, checksum: ee9c94a88e3ad7f2a5ec99fb243d8f21 (MD5) Previous issue date: 17Esta dissertação analisa o comércio por vias internas na Economia Brasileira, estimando o seu papel em termos da eficiência, competitividade internacional, desigualdade regional e bem-estar. Assim, a dissertação busca avaliar a importância dos fluxos de comércio entre os estados brasileiros, e mensurar as interconexões mais relevantes. Para tal, emprega-se como metodologia um modelo de equilíbrio geral computável multi-regional (EGC) para o Brasil IMAGEM-B. O modelo é bottom-up para os 27 estados e 36 setores, e top-down para os 5507 municípios. Aplicando esse modelo, foram explorados os impactos da redução dos custos de transporte entre as Unidades da Federação, identificando os fluxos mais relevantes para diferentes objetivos de política econômica (crescimento nacional, custos de produção, desigualdade regional, bem-estar social e crescimento regional, especificamente para o Nordeste). Os resultados mostram que o comércio entre os estados mais desenvolvidos tem maior impacto sobre o crescimento nacional, bem-estar e competitividade internacional, embora possa aumentar as desigualdades regionais. Além disso, com o intuito de sintetizar e fazer uma análise dos principais resultados para cada Estado, utilizaram-se os conceitos de Acesso a mercados (Market Access) e Acesso a fornecedores (Supplier Access) da Nova Geografia Econômica.This thesis deals with interregional trade in the Brazilian Economy, estimating the role of interregional trade on efficiency, international competitiveness, national welfare and regional inequality. Thus, the dissertation seeks to evaluate the importance of trade flows between the Brazilian states, and measure the most relevant links. Our modeling encompasses much detail. Firstly, we use a large-scale multi-regional computable general equilibrium (CGE) model of Brazil (IMAGEM-B). The model is bottom-up for Brazil's 27 states and disaggregated in 36 sectors. It has the ability to deal with shocks on policies that originate in the regions and the detailed treatment of transport and trading margins, with the possibility of substitution between four modes of transport. Applying the CGE model we explore the impacts of reducing transport costs among Brazilian states, identifying the most relevant links for different economic goals (national growth, production costs, regional inequality, national welfare and regional growth, specifically for the Northeast). We find that the trade among most developed states have impact on national growth, welfare-state and international competitiveness, but can increase regional inequality. Furthermore, in order to summarize and to analyze the main results for the Brazilian states, we use the concepts of Market Access and Supplier Access of the New Economic Geography

Regional economic impacts of greenhouse gas emission mitigation policies in Brazilian agriculture: the role of the degraded paste recovery program

This paper estimates the regional economic impacts of a Brazilian public policy aimed at mitigating greenhouse gases on agriculture. More specifically the Degraded Pasture Recovery Program (RPD) of the ABC Plan during the period from 2015 to 2018 and the projected period (2019 to 2025). A computable general equilibrium (EGC) model is constructed and regionalized especially for this simulation, in order to differentiate geographical spaces according to their geomorphological, climatic and pedological characteristics. Results indicate different impacts between regions and sectors. The greater the representativeness of the ABC plan financing in relation to the value of production in the livestock sectors, the greater the accumulated decrease of the region's GDP. The policy is essential for the economic growth of regions that do not necessarily have large livestock production but have a high ratio between production and value financed by the program. In addition, the impact on production goes beyond the livestock sectors and may interfere with the production of a range of sectors that are important to the economy, both agriculturally and industrially. Keywords: mitigation policy; environmental; degraded pasture; computable general equilibrium mode

Regional economic impacts of greenhouse gas emission mitigation policies in Brazilian agriculture: the role of the degraded paste recovery program

This paper estimates the regional economic impacts of a Brazilian public policy aimed at mitigating greenhouse gases on agriculture. More specifically the Degraded Pasture Recovery Program (RPD) of the ABC Plan during the period from 2015 to 2018 and the projected period (2019 to 2025). A computable general equilibrium (EGC) model is constructed and regionalized especially for this simulation, in order to differentiate geographical spaces according to their geomorphological, climatic and pedological characteristics. Results indicate different impacts between regions and sectors. The greater the representativeness of the ABC plan financing in relation to the value of production in the livestock sectors, the greater the accumulated decrease of the region's GDP. The policy is essential for the economic growth of regions that do not necessarily have large livestock production but have a high ratio between production and value financed by the program. In addition, the impact on production goes beyond the livestock sectors and may interfere with the production of a range of sectors that are important to the economy, both agriculturally and industrially. Keywords: mitigation policy; environmental; degraded pasture; computable general equilibrium mode

Regional Impacts of Future Climate Change on Health and Labor in Brazil

Global climate and environmental change have aggravated in the last decades. In- creased health stress is one of the most alarming consequences of these changes. Although many studies have tried to estimate the direct and indirect consequences of a warmer and dryer environment for the economy, both at a global and local scale, a smaller number of studies have addressed the mid and long term health implications of these changes at a regional level. Building on their previous work, this study takes a multi-stage approach to estimate the climate-related consequences on cardiovascular/respiratory and infectious/vector-borne diseases, morbidity and mortality, and labor supply in Brazil. Combining Spatial Bayes Smoothing, Spatial Econometrics, Global Burden of Disease data, and a Regional Computable General Equilibrium model, this study estimates the future development of climate-sensitive health disorders, their implications for morbidity and mortality, and the consequences for labor sup- ply and productivity for the Brazilian states and regions from 2010 to 2040. Our results suggest that partial effects of climate change on health and labor supply is higher than the total impact (from general equilibrium estimates). Increased morbidity and mortality and labor loss would be higher for vector-borne and infectious than for non-communicable diseases, and mostly concentrated in less developed regions of the country

Regional Impacts of Future Climate Change on Health and Labor in Brazil

Global climate and environmental change have aggravated in the last decades. In- creased health stress is one of the most alarming consequences of these changes. Although many studies have tried to estimate the direct and indirect consequences of a warmer and dryer environment for the economy, both at a global and local scale, a smaller number of studies have addressed the mid and long term health implications of these changes at a regional level. Building on their previous work, this study takes a multi-stage approach to estimate the climate-related consequences on cardiovascular/respiratory and infectious/vector-borne diseases, morbidity and mortality, and labor supply in Brazil. Combining Spatial Bayes Smoothing, Spatial Econometrics, Global Burden of Disease data, and a Regional Computable General Equilibrium model, this study estimates the future development of climate-sensitive health disorders, their implications for morbidity and mortality, and the consequences for labor sup- ply and productivity for the Brazilian states and regions from 2010 to 2040. Our results suggest that partial effects of climate change on health and labor supply is higher than the total impact (from general equilibrium estimates). Increased morbidity and mortality and labor loss would be higher for vector-borne and infectious than for non-communicable diseases, and mostly concentrated in less developed regions of the country

Acute Kidney Failure among Brazilian Agricultural Workers: A Death-Certificate Case-Control Study

Recent evidence suggests that pesticides may play a role in chronic kidney disease. However, little is known about associations with acute kidney failure (AKF). We investigated trends in AKF and pesticide expenditures and associations with agricultural work in two Brazilian regions with intense use of pesticides, in the south and midwest. Using death certificate data, we investigated trends in AKF mortality (1980–2014). We used joinpoint regression to calculate annual percent changes in AKF mortality rates by urban/rural status and, in rural municipalities, by tertiles of per capita pesticide expenditures. We then compared AKF mortality in farmers and population controls from 2006 to 2014 using logistic regression to estimate odds ratios and 95% confidence intervals adjusted by age, sex, region, education, and race. AKF mortality increased in both regions regardless of urban/rural status; trends were steeper from the mid-1990s to 2000s, and in rural municipalities, they were higher by tertiles of pesticide expenditures. Agricultural workers were more likely to die from AKF than from other causes, especially at younger ages, among females, and in the southern municipalities. We observed increasing AKF mortality in rural areas with greater pesticide expenditures and an association of AKF mortality with agricultural work, especially among younger workers

Effectiveness of Educational Technology in Promoting Quality of Life and Treatment Adherence in Hypertensive People

<div><p>The objective of this study was to test the effectiveness of an educational intervention with use of educational technology (flipchart) to promote quality of life (QOL) and treatment adherence in people with hypertension. It was an intervention study of before-and-after type conducted with 116 hypertensive people registered in Primary Health Care Units. The educational interventions were conducted using the flipchart educational technology. Quality of life was assessed through the MINICHAL (lowest score = better QOL) and the QATSH (higher score = better adherence) was used to assess the adherence to hypertension treatment. Both were measured before and after applying the intervention. In the analysis, we used the Student’s t-test for paired data. The average baseline quality of life was 11.66 ± 7.55, and 7.71 ± 5.72 two months after the intervention, showing a statistically significant reduction (p <0.001) and mean of differences of 3.95. The average baseline adherence to treatment was 98.03 ± 7.08 and 100.71 ± 6.88 two months after the intervention, which is statistically significant (p < 0.001), and mean of differences of 2.68. The conclusion was that the educational intervention using the flipchart improved the total score of quality of life in the scores of physical and mental domains, and increased adherence to hypertension treatment in people with the disease.</p></div