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

Evaluation of the use of vasopressin in the treatment of hypotension of dogs with sepsis on the microcirculatory sublingual function by orthogonal polarization image

No paciente séptico, utiliza-se como tratamento inicial a reposição volêmica com o objetivo de restabelecer a pressão arterial e consequentemente a perfusão tecidual. Os pacientes não responsivos a expansão volêmica usualmente são tratados com medicações vasoativas. O emprego desses fármacos tais como noradrenalina, nessa situação, torna-se imprescindível, porém a hiporresponsividade do sistema adrenérgico é um obstáculo rotineiro em pacientes sépticos. A vasopressina aparece como uma alternativa, tanto como fármaco de primeira escolha como resgate quando o tratamento com vasoativos adrenérgicos falha. A avaliação da microcirculação é imprescindível visto a sua importância na patogênese da sepse, e no acompanhamento das diferentes terapias. Assim sendo, o presente projeto tem por objetivo avaliar o uso da vasopressina e da noradrenalina no tratamento da hipotensão de cães em sepse decorrente de piometra por meio imagem espectral obtida através da polarização ortogonal (OPS) e sobre variáveis hemodinâmicas, bem como sobre parâmetros de oxigenação e ventilação. Foram utilizados 13 cães em sepse grave apresentando no mínimo duas variáveis da resposta inflamatória sistêmica e no mínimo uma variável de disfunção orgânica na avaliação inicial. Em todos os animais foi realizada ressuscitação volêmica inicial com 15ml/kg em 15 minutos de solução de Ringer com lactato. Caso durante a anestesia a pressão arterial média não assumir valores superiores a 65 mmHg e a pressão venosa central não variasse 2mmHg ou apresentasse valores superiores a 8 mmHg, os animais foram distribuídos em dois grupos. O Grupo VASO recebeu inicialmente 0,0002UI/kg/min de vasopressina e o Grupo NORA 0,05 mcg/kg/min noradrenalina, podendo ter o incremento de 0,0002U/kg/min e 0,02 mcg/kg/min da dose inicial, respectivamente, com o objetivo até se atingir a PAM acima de 65mmHg. Foram confrontados os parâmetros de valores de densidade e fluxo encontrados com o OPS nos dois grupos, bem como dados hemodinâmicos e de ventilação. As imagens coletadas utilizando o OPS foram processadas e analisadas por software especifico. Nao houve diferenca estatistica entre os grupos estudados nos parametros, hemodinamicos, ventilatorios, de oxigenacao e da microcirculacao encontrados com o OPS. A frequência cardíaca foi menor no grupo VASO no momento TG quando comparada ao grupo NORA. Os parametros de densidade e fluxo capilar não diferiram do basal em nenhum dos grupos. Deste modo, conclui-se que tanto a vasopressina quanto a noradrenalina quando empregadas para o tratamento de hipotensao decorrente da sepse grave/choque septico, nao prejudicam a microcirculacaoIn septic patients, volume replacement is used as initial treatment in order to restore blood pressure and consequently the tissue perfusion. Nonresponders patients to the increase in preload are usually treated with vasoactive medications. Those agents such as norepinephrine, in this situation, it is essential, but the hyporesponsiveness of the adrenergic system is a common obstacle in septic patients. Vasopressin is an alternative, both like the drug of choice as rescue when treatment of adrenergic hyporesponsiveness. The evaluation of microcirculation is essential for its importance in the pathogenesis of sepsis, and to guide the different therapies. The aim of this project is to evaluate the use of vasopressin and norepinephrine in the treatment of hypotension in sepsis in dogs due to pyometra through spectral image obtained by orthogonal polarization (OPS) and on hemodynamic variables, as well as oxygenation and ventilation parameters. Thirteen dogs in severe sepsis were used, presenting at least two variables of systemic inflammatory response and at least one organ dysfunction variable at baseline. In all animals was performed initial volume resuscitation with 15ml / kg in 15 minutes of Ringer\'s lactate solution. If during anesthesia mean arterial pressure not assume values greater than 65 mmHg and central venous pressure did not vary 2 mmHg or present values greater than 8 mmHg, the animals were divided into two groups. The Group VASO received 0,0002UI / kg / min of vasopressin and Group NORA 0.1 mcg / kg / min of noradrenaline, may have increment 0,0002U / kg / min and 0. 1mcg / kg / min initial dose, respectively, in order to achieve MAP above of 65 mmHg. The density values of parameters were compared and found flow with OPS in both groups, and hemodynamic data and ventilation. The images collected using OPS were processed and analyzed by specific software. There was no statistical difference between the groups studied in the parameters, hemodynamic, ventilation, oxygenation and microcirculation found with OPS. The heart rate was lower in group VASO in TG moment compared to NORA group. The density and capillary flow parameters from baseline were similar in all groups. Thus, it is concluded that both noradrenaline and vasopressin when used to treat hypertension caused by severe / sepsis, septic shock, do not impair the microcirculatio

AJEUM BÓ: A importância patrimonial cultural das comidas votivas de (para o) Afroturismo como atrativo turístico

The ritualistic food of Candomblé presents Afrotourism with the potential of votive foods from the terreiros, in a decolonial perspective. The central focus of the research is to know the cultural construction of terreiro foods. Presenting the theoretical framework relevant to the Ilês. This is a qualitative research with an exploratory approach, we use the tools of field research and intensive direct observation. The results were obtained from the experience in three terreiros (Ilê) in 2021, Ilê Asé Abarewá, Ilê Axé Obá Oladeji, Ilê Axé Igbá Possum Aziri. Therefore, it was concluded that the connection through the knowledge and practices of the sacred food of the visited Ilês, presents itself as cultural attractions, makes it possible to value the Afro-diasporic culture, considering the act of eating as a decolonial heritage, which comes, making up the crossroads that tourism proposes.A alimentação ritualística e as comidas votivas dos terreiros, sob uma ótica decolonial, são potenciais atrativos para o afroturismo. O objetivo da pesquisa consiste em conhecer as comidas de terreiro, bem como analisar a importância de salvaguarda dos rituais e como pensar o afroturismo. Apresentando referencial teórico pertinente aos Ilês, trata-se de uma pesquisa qualitativa de abordagem exploratória. Utiliza-se as ferramentas de pesquisa de campo e observação direta intensiva. Os resultados foram obtidos a partir da vivência em três terreiros (Ilês) em 2021: Ilê Asé Abarewá (Caucaia), Ilê Ibá Asé KPossu Aziri (Fortaleza) e Ilê Axé Obá Oladeji (Maracanaú). A partir da pesquisa, concluiu-se que a ligação por meio dos saberes e fazeres da alimentação sagrada dos ilês visitados, apresenta-se como um atrativo cultural, onde possibilita valorizar a cultura afrodiaspórica, pensando o ato de comer como patrimônio decolonial e que vem perfazendo as encruzilhadas que o turismo cultural propõe

Lumbosacral epidural magnesium prolongs ketamine analgesia in conscious sheep Sulfato de magnésio prolonga a analgesia epidural lombosacral induzida pela quetamina em carneiros

PURPOSE: To determine the analgesic, motor, sedation and systemic effects of lumbosacral epidural magnesium sulphate added to ketamine in the sheep. METHODS: Six healthy adult male mixed-breed sheep; weighing 43 ± 5 kg and aged 20-36 months. Each sheep underwent three treatments, at least 2 weeks apart, via epidural injection: (1) ketamine (KE; 2.5 mg/kg), (2) magnesium sulphate (MG; 100 mg), and (3) KE + MG (KEMG; 2.5 mg/kg + 100 mg, respectively). Epidural injections were administered through the lumbosacral space. Analgesia, motor block, sedation, cardiovascular effects, respiratory rate, skin temperature, and rectal temperature were evaluated before (baseline) and after drug administration as needed. RESULTS: The duration of analgesia with the lumbosacral epidural KEMG combination was 115 ± 17 min (mean ± SD), that is, more than twice that obtained with KE (41 ± 7 min) or MG (29 ± 5 min) alone. KE and KEMG used in this experiment induced severe ataxia. The heart rate and arterial blood pressures changes were no statistical difference in these clinically health sheep. CONCLUSION: The dose of magnesium sulphate to lumbosacral epidural ketamine in sheep is feasible, and can be used in procedures analgesics in sheep.<br>OBJETIVO: Determinar os efeitos analgésicos, motores, sedativos e sistêmicos da adição de sulfato de magnésio na analgesia epidural com quetamina em carneiros. MÉTODOS: Foram utilizados seis carneiros machos sadios, pesando 43 ± 5 kg, com idade entre 20 a 36 meses. Cada animal recebeu três tratamentos, com duas semanas entre experimentos via administração epidural: (1) quetamina (KE; 2,5 mg/kg), (2) sulfato de magnésio (MG; 100 mg) e (3) KE + MG (KEMG; 2,5 mg/kg + 100 mg, respectivamente). As administrações epidurais foram administradas no espaço lombosacral. Analgesia, bloqueio motor, sedação, efeitos cardiovasculares, freqüência respiratória, temperatura retal e de pele foram avaliados antes (basal) e depois da administração dos fármacos até o fim da analgesia. RESULTADOS: A duração da analgesia com o tratamento KEMG foi 115 ± 17 min (média ± DP), duas vezes superior ao obtido com o tratamento KE (41 ± 7 min) ou tratamento MG (29 ± 5 min) isolados. Os tratamentos KE e KEMG induziram bloqueio motor severo. As pressões arteriais e freqüência cardíaca não foram estatisticamente significantes nestes animais. CONCLUSÃO: A adição de sulfato de magnésio a analgesia epidural com quetamina é viável, e pode ser usado para prolongar os efeitos analgésicos destes bloqueios em carneiros

Núcleos de Ensino da Unesp: artigos 2007

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

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

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Núcleos de Ensino da Unesp: artigos 2008

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq