Avanços na abordagem terapêutica da insuficiência cardíaca com fração de ejeção preservada (ICFEP): O uso de inibidores de SGLT-2

A insuficiência cardíaca (IC) com fração de ejeção preservada (ICFEP) é a forma mais prevalente de IC em pacientes com mais de 65 anos e representa mais de 50% dos casos prevalentes de IC na população. As intervenções terapêuticas da ICFEP ainda estão sendo exploradas e pesquisadas, como o uso de inibidores de SGLT-2. O presente estudo de revisão buscou avaliar novos avanços na abordagem terapêutica da insuficiência cardíaca com fração de ejeção preservada (ICFEP) a partir do uso de inibidores de SGLT-2, documentados por meio de estudos clínicos e randomizados. Trata-se de uma pesquisa de revisão integrativa realizada por meio da base de dados PubMed, que levou em consideração os seguintes critérios de inclusão: ensaios clínicos e testes controlados e aleatórios; artigos publicados no último ano; que possuíam texto completo disponível e que abordassem acerca do uso de inibidores de SGLT-2 na ICFEP. Ficou constatado que a dapagliflozina resultou em melhora dos sintomas relacionados à insuficiência cardíaca e limitações físicas nesses pacientes, bem como a canagliflozina, a qual trouxe resultados de melhora rápida e clinicamente significativa dos sintomas de IC. Já a empagliflozina demonstrou uma redução significativa no risco de morte cardiovascular ou hospitalizações por insuficiência cardíaca. Por fim, verificou-se que a ipragliflozina pode contribuir, em determinados subgrupos, reduzindo o índice de massa ventricular esquerda e, ainda, uma redução dos níveis de NT-proBNP, um marcador de disfunção ventricular. Dessa forma, os inibidores de SGLT-2 se fazem importantes medicações para a terapêutica efetiva da ICFEP atualmente

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

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

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Aplicabilidade de medidas antropomÃtricas de distribuiÃÃo de adiposidade no segmento corporal superior (circunferÃncias cervical e escapular) como mÃtodos de avaliaÃÃo de risco cardiometabÃlico

Existem vÃrios mÃtodos clÃnicos de avaliaÃÃo da obesidade, sendo mais utilizados na prÃtica o IMC e a medida da circunferÃncia abdominal (CA), esta Ãltima refletindo obesidade central. Estudos recentes tÃm sugerido que uma distribuiÃÃo de gordura no segmento corporal superior tambÃm pode ter relaÃÃo com aumento do risco cardiovascular (RCV). Este estudo teve por objetivo avaliar as circunferÃncias cervical (CC) e escapular (CE) como marcadores clÃnicos de obesidade superior e relacionÃ-las com outros dados antropomÃtricos e fatores de RCV. Foram avaliados 88 indivÃduos, de outubro de 2008 a janeiro de 2009, no CSAM-SMS/UFC; 24/88 (27,3%) eram do sexo masculino e 64/88 (72,7%) eram do sexo feminino. As principais mÃdias encontradas foram: idade (anos) - 39,1  10,9 (homens - 36,5  10,1 e mulheres - 40,0  11,1; p = 0,2); IMC (kg/mÂ) - 28,9  4,7 (homens - 28,7  4,6 e mulheres - 29,0  4,8); CC (cm) â 35  3,4 (homens â 39  2,6 e mulheres 33,5  2,0); CE (cm) - 94,1  8,4 (homens - 99,8  8,2 e mulheres - 92,0  7,4); CA (cm) - 94,2  11,3 (homens - 98,7  11,0 e mulheres - 92,6  11,0). Neste grupo, 38/88 (43,2%) indivÃduos preenchiam os critÃrios de SM da IDF. Encontrou-se correlaÃÃo (p<0,05) entre a CC e os seguintes parÃmetros: CA, circunferÃncia braquial (CB), CE, IMC, relaÃÃo cintura quadril (RCQ), relaÃÃo cervical coxa, pressÃo arterial sistÃlica (PAS), pressÃo arterial diastÃlica (PAD), Ãcido Ãrico, TGO, TGP, ferritina, HDL - colesterol, triglicÃrides e glicemia jejum; com a CE foram encontradas as seguintes correlaÃÃes: CA, CB, IMC, RCQ, PAS, Ãcido Ãrico, &#61543;GT, TGO, TGP, ferritina, HDL - colesterol, triglicÃrides, glicemia jejum e HOMA-IR. O uso das CC e CE como parÃmetros clÃnicos de obesidade superior neste grupo de indivÃduos mostrou correlaÃÃo com outros parÃmetros antropomÃtricos de obesidade, com componentes da SM e com exames laboratoriais marcadores de patologias associadas à SM, como hiperuricemia e doenÃa gordurosa nÃo-alcoÃlica. Estes dados sugerem que o uso destas circunferÃncias e, particularmente da CC, poderà ter um papel importante na avaliaÃÃo da obesidade e da SM, considerando a sua simplicidade e facilidade de execuÃÃo. Existe a necessidade de mais estudos para a confirmaÃÃo destes dados e para definiÃÃo de possÃveis pontos de corte da CC e CE em ambos os sexos, que possam predizer sobrepeso, obesidade e SM.There are several clinical methods to evaluate obesity, it being used mainly the body mass index (BMI) and the waist circumference (WC), this one reflecting central obesity. Recent studies have suggested that an upper body obesity distribution also have relationship with high cardiovascular risk (CVR). This study aimed to evaluate neck circumference (NC) and scapular circumference (SC) as upper body obesity indexes, and their relationships with others anthropometrics parameters and CVR factors. Eighty-eight adults voluntaries were evaluated, since 2008 October to 2009 January, at the CSAM-SMS/UFC; 24/88 (27,3%) were males and 64/88 (72,7%) were females. The main means were: age - 39,1  10,9 years old (men - 36,5  10,1 and women - 40,0  11,1; p=0,2); BMI (kg/mÂ) - 28,9  4,7 (men - 28,7  4,6 and women - 29,0  4,8); NC (cm)- 35  3,4 (men â 39  2,6 and women - 33,5  2,0); SC (cm)- 94,1  8,4 (men - 99,8  8,2 and women - 92,0  7,4); WC (cm) - 94,2  11,3 (men - 98,7  11,0 and women â 92,6  11,0). In this group, 38/88 (43,2%) voluntaries had metabolic syndrome (MS) (IDF criteria). There was a significant correlation (p<0,05) between NC and: WC, braquial circumference (BC), SC, BMI, waist-to-hip ratio (WHR), SBP, DBP, uric acid, AST, ALP, ferritin, HDL-Chol, triglycerides and fasting glucose; and with SC: WC, BC, BMI, WHR, SBP, uric acid, &#61543;GT, AST, ALP, ferritin, HDL-Chol, triglycerides, fasting glucose and HOMA. NC and SC as upper body obesity indexes in this group showed correlations with other obesity anthropometrics parameters, with MS components and with laboratories parameters of MS associated diseases, hyperuricemia and nonalcoholic steatohepatitis. These data suggest the utility these circumferences and, particularly NC, would be an important tool to evaluated obesity and MS, due your simplicity and easy execution. However, subsequent studies are necessary to confirm these data and to define NC and SC cut points in both sexes to predict overweight, obesity and MS