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

Alteração química e mineralógica de argissolo vermelho distrófico submetido ao eflúvio ácido de rejeito de carvão

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Alteração química e mineralógica de argissolo vermelho distrófico submetido ao eflúvio ácido de rejeito de carvão

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Produção de trigo duplo propósito com diferentes doses de adubação nitrogenada em cobertura

Currently, the practice of Crop-Livestock Integration is stimulated as a way of increasing the generation of foreign exchange for Brazil. Integrated systems improve land use efficiency as well as preserve, recover and increment or soil fertility. The aim of this research was to evaluate how different doses of nitrogen fertilization can affect production and quality of dual purpose wheat submitted to grazing. The experimental designed was randomized block with five treatments (0, 75, 150, 225 and 300 Kg N ha-1, like ammonium nitrate) and four repetitions. The forage yield, the percentage crude protein (P=.0001) and acid detergent insoluble protein (P=.0054) had a linear increased because of the nitrogen addition doses. The crude protein percentage changed the estimate of all soluble carbohydrates (P=.0001) and non-fibrous carbohydrates (P=.0186), but did not influence the, nitrogen detergent fiber corrected with ash and proteins percentage contributing for content cell. The crops production (P=.0001) and the number of kernels per ear (P=.0001) showed significantly difference because of the nitrogen additions dose, increasing the number of fertile flowers. The nitrogen topdressing alters forage production, the chemical composition and the production of dual purpose wheat grains subjected to grazing.Atualmente, é estimulada a prática de Integração Lavoura-Pecuária (ILP) como forma de incrementar a geração de divisas para o Brasil. Os sistemas integrados melhoram a eficiência de uso da terra, bem como preservam, recuperam e/ou incrementam a fertilidade do solo. Objetivou-se avaliar a produção e a composição bromatológica de trigo duplo propósito (TDP) manejado sob pastejo com diferentes doses de nitrogênio em cobertura (DAN): 0, 75, 150, 225 e 300 Kg de N ha-1, sob a forma de nitrato de amônia. Utilizou-se delineamento experimental de blocos casualizados com quatro repetições. A produção de forragem e os teores de proteína bruta (P=0,001) e proteína insolúvel em detergente ácido aumentaram (P=0,0054) linearmente, em função das DAN. O teor de proteína bruta (P=0,0001) impactou sobre as estimativas de carboidratos totais e de carboidratos não fibrosos, mas não influenciou (P=0,0186) os teores de fibra em detergente neutro corrigidas para cinzas e proteínas contribuindo para manutenção dos teores de conteúdo celular. A produção de grãos P=(0,0001) e o número de grãos por espigas diferiram (P=0,0001), em função das DAN, aumentando o número de flores férteis. A adubação nitrogenada em cobertura altera a produção de forragem, a composição bromatológica e a produção de grãos de trigo duplo propósito submetido à pastejo

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.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt