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

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

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- Divulgação dos SUMÁRIOS das obras recentemente incorporadas ao acervo da Biblioteca Ministro Oscar Saraiva do STJ. Em respeito à lei de Direitos Autorais, não disponibilizamos a obra na íntegra.- Localização na estante: 336.2:34 B395t

The oxygen binding properties of hemocyanin from the mollusk Concholepas concholepas

Hemocyanins have highly conserved copper-containing active sites that bind oxygen. However, structural differences among the hemocyanins of various mollusks may affect their physicochemical properties. Here, we studied the oxygen-binding cooperativity and affinity of Concholepas concholepas hemocyanin (CCH) and its two isolated subunits over a wide range of temperatures and pH values. Considering the differences in the quaternary structures of CCH and keyhole limpet hemocyanin (KLH), we hypothesized that the heterodidecameric CCH has different oxygen-binding parameters than the homodidecameric KLH. A novel modification of the polarographic method was applied in which rat liver submitochondrial particles containing cytochrome c oxidase were introduced to totally deplete oxygen of the test solution using ascorbate as the electron donor. This method was both sensitive and reproducible. The results showed that CCH, like other hemocyanins, exhibits cooperativity, showing an inverse relationship between the oxygen-binding parameters and temperature. According to their Hill coefficients, KLH has greater cooperativity than CCH at physiological pH; however, CCH is less sensitive to pH changes than KLH. Appreciable differences in binding behavior were found between the CCH subunits: the cooperativity of CCH-A was not only almost double that of CCH-B, but it was also slightly superior to that of CCH, thus suggesting that the oxygen-binding domains of the CCH subunits are different in their primary structure. Collectively, these data suggest that CCH-A is the main oxygen-binding domain in CCH; CCH-B may play a more structural role, perhaps utilizing its surprising predisposition to form tubular polymers, unlike CCHA, as demonstrated here using electron microscopy.FONDECYT Grants 1050150, 1110651 and 1151337 Grant No. 1061086 from FONDECYT and ACT 29 Anillo Bicentenario awarde

A Novel Immunomodulatory Hemocyanin from the Limpet Fissurella latimarginata Promotes Potent Anti- Tumor Activity in Melanoma

Artículo de publicación ISIHemocyanins, the huge oxygen-transporting glycoproteins of some mollusks, are used as immunomodulatory proteins with proven anti-cancer properties. The biodiversity of hemocyanins has promoted interest in identifying new anti-cancer candidates with improved immunological properties. Hemocyanins promote Th1 responses without known side effects, which make them ideal for long-term sustained treatment of cancer. In this study, we evaluated a novel hemocyanin from the limpet/gastropod Fissurella latimarginata (FLH). This protein has the typical hollow, cylindrical structure of other known hemocyanins, such as the keyhole limpet hemocyanin (KLH) and the Concholepas hemocyanin (CCH). FLH, like the KLH isoforms, is composed of a single type of polypeptide with exposed N- and O-linked oligosaccharides. However, its immunogenicity was significantly greater than that of KLH and CCH, as FLH induced a stronger humoral immune response and had more potent anti-tumor activity, delaying tumor growth and increasing the survival of mice challenged with B16F10 melanoma cells, in prophylactic and therapeutic settings. Additionally, FLH-treated mice demonstrated increased IFN-c production and higher numbers of tumor-infiltrating CD4+ lymphocytes. Furthermore, in vitro assays demonstrated that FLH, but not CCH or KLH, stimulated the rapid production of pro-inflammatory cytokines (IL-6, IL-12, IL-23 and TNF-a) by dendritic cells, triggering a pro-inflammatory milieu that may explain its enhanced immunological activity. Moreover, this effect was abolished when deglycosylated FLH was used, suggesting that carbohydrates play a crucial role in the innate immune recognition of this protein. Altogether, our data demonstrate that FLH possesses increased anti-tumor activity in part because it activates a more potent innate immune response in comparison to other known hemocyanins. In conclusion, FLH is a potential new marine adjuvant for immunization and possible cancer immunotherapy

Ambientalismo e concepções de RESEX, extrativismo e conhecimento no ICMBIO na Amazônia Legal Environmentalism and conceptions of RESEX, extractivism and knowledge in the ICMBIO in the Brazilian Amazon

O trabalho discute o posicionamento de técnicos de nível superior do Instituto Chico Mendes de Conservação da Biodiversidade ICMBIO , em exercício na Amazônia Brasileira, em relação ao ambientalismo e identifica possíveis relações entre os posicionamentos e visões do conhecimento, concepção de Reserva Extrativista RESEX e de extrativismo. Consoante a base teórica discutida, foram adotadas as seguintes tipologias para as categorias estudadas: correntes ou vertentes ambientalistas: preservacionista, Sustentabilista e Socioambientalista; visões do conhecimento: anarquista, dialógica ou saber ambiental ; interdisciplinar; e, científica pura; visões de RESEX: RESEX como Unidade de Conservação UC de uso sustentável, RESEX servindo à reforma agrária e RESEX oportunista; visões sobre extrativismo: extrativismo legítimo, extrativismo falido e extrativismo oportunista. O método utilizado foi o comparativo com partições cruzadas, verificando similaridades e dissimilaridades de grupos de respondentes. Para levantamento dos posicionamentos dos respondentes foi disponibilizado a todos os técnicos um questionário com afirmações representativas das diferentes visões, utilizando escala do tipo Likert. Foi realizada a classificação dos técnicos em categorias, utilizando análise de agrupamento pelo método hierárquico aglomerativo, tendo como parâmetro a proximidade de posicionamento. Constatou-se que não há visão única a respeito do ambientalismo no Instituto Chico Mendes na Amazônia Legal e não existem linhas ambientalistas puras, mas compostas por concepções de várias vertentes. As visões sobre RESEXs e extrativismo estão relacionadas com concepções sociaombientalistas, reforçando a defesa de que este tipo de Unidade de Conservação faz parte dessa linha de pensamento.<br>The paper discusses the positioning of high level technicians the "Instituto Chico Mendes de Conservação da Biodiversidade (ICMBIO)", acting in the Brazilian Amazon, in relation to environmentalism and identifies possible relationships between the positioning and views on knowledge, conception of Extractive Reserve (RESEX) and extractivism. According to the theoretical discussion, we make the following types for the studied categories: environmentalist slope: preservationist, sustainabilist and socio-environmentalist; views of knowledge: anarchist, dialogic (or environmental knowledge), interdisciplinary and pure science; views of RESEX: RESEX as Conservation Unit (UC) for sustainable use, RESEX serving the agrarian reform and opportunist RESEX; views on extractivism: legitimate extractivism, legitimate extractivism and opportunistic extractivism. The method used was a comparative cross-partition, checking similarities and dissimilarities of respondents groups. To survey the positions of the respondents was made a questionnaire available to all staff with statements representing different views, using Likert scale. It was done a classification into categories of technicians, using cluster analysis by the agglomerative hierarchical method, having as parameter the proximity of placement. It was found that no single view about environmentalism in the Chico Mendes in the Legal Amazon and there are not pure environmentalist lines, but composed of several strands of ideas. The views on RESEXs and extractivism are related concepts socio- environmentalism, reinforcing the argument that this type of conservation is a part this line of thought

FLH is more immunogenic than CCH and KLH.

<p>(<b>A</b>). Humoral immune response against hemocyanins. Groups of 3 mice were immunized ip with 200 µg of FLH or CCH and KLH in PBS, and the immunization was repeated 15 days later. Ten days later, specific antibody titers were determined by ELISA from serially diluted sera. The mouse IgG antibodies were revealed using goat anti-mouse IgG ALP-conjugated serum; subsequently, pNPP was added. The reaction was read at 405 nm. Data are shown as mean + SEM of <i>n</i> = 3 mice per group and are representative of two independent experiments, *p<0.05 between FLH <i>versus</i> KLH and CCH. (<b>B</b>). Determination of the carrier property of FLH. The hemocyanins were coupled to DNFB; subsequently, groups of 3 C57BL/6 or BALB/c mice were immunized ip with 300 µg of each conjugate with Freund's adjuvants as a repository. Ten days after, the titers against DNFB were determined by ELISA. FLH <i>versus</i> CCH and KLH p not significant.</p

N- and O-linked oligosaccharide profile of FLH and CCH.

<p>The structure assignment was based on general knowledge of possible glycosylation in mollusk. The most likely structure was drawn on the spectra; however, additional monosaccharide matches were found for some masses.</p

Immunotherapeutic effect of FLH in the B16F10 mouse melanoma model does not require priming.

<p>(<b>A</b>). Schedule of the bioassay. (<b>B</b>). Effect of FLH on melanoma growth. Tumor growth was followed every 3 days, and each group contained 7 mice; ***p<0.001 between FLH and PBS. (<b>C</b>). Effect of FLH on the survival of mice. The log-rank test was used to compare the curves; *p<0.05 between FLH and PBS. (<b>D</b>). Kinetics of tumor appearance in mice. The percentages of mice bearing tumors were determined visually and by palpation. (<b>E</b>). Tumor-infiltrating immune cells. The quantitative analysis of tumor infiltration by CD8/CD3+, CD11c+, NK1.1+, F4/80+, CD4/CD3+ and CD19+-positive cells in single-cell suspensions derived from B16F10 tumors was performed on day 18 of the bioassay. The results are expressed as the percentages of total viable immune cells. Each group consisted of 3–4 mice; *p<0.05. (<b>F</b>). IFN-γ measurements from mouse sera were obtained on day 18 of the bioassay (same mice and day as the experiment shown in E); *p<0.05 FLH <i>versus</i> PBS.</p