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

A priori choice of hybrid parents in plants

Não encontrei o DOI do artigo.Plant breeding deals with high-yielding genotypes. However, how best to choose parents of these genotypes remains an unsolved question. Here, we focus on a priori choice based on parental distances by means of agronomic and molecular data. Despite numerous theoretical and empirical studies, a priori choice continues to be a controversial procedure. Both success and failure are commonly reported. We looked at these ambiguous results in order to investigate their possible causes. A total of 139 articles on genetic divergence were sampled to examine aspects such as type and number of markers utilized. We suggest that the mean number of 160, 281 and 25 for RAPD and RFLP markers, and SSR loci, respectively, which we found in these papers, should be increased for accurate analysis. A second sample composed of 54 articles was used to evaluate the divergence-heterosis association. Most of them (28) detected positive divergence-heterosis association, whereas 26 revealed negative or inconclusive results. We examined several causes that influence a priori choice positively and negatively

Impunidade no Brasil: Colônia e Império

A IMPUNIDADE está no centro do debate político brasileiro. Um olhar retrospectivo para a história do Brasil, tendo como referência a aplicação da pena de morte para delitos comuns (em contraposição a delitos políticos, militares e religiosos), a partir de documentos legais e do relato de historiadores, cronistas e viajantes, mostra que a impunidade sempre esteve na ordem do dia. A despeito da violência repressiva, marcante em diversos momentos, a ausência de efetividade do direito penal tal como escrito, seja pela prática do perdão, seja pela falta de vontade política, seja pela dificuldade de meios, é uma constante nos períodos colonial e imperial.<br>IMPUNITY is at the core of the Brazilian political debate. A retrospective look at legal documents and accounts by historians, travelers and chroniclers for references to the application of the death penalty for common crimes (as opposed to political, military and religious offenses) shows that impunity has always been the order of the day in the history of Brazil. Despite the repressive violence, evident at several moments, a constant feature of both Colonial and Imperial periods was the ineffectiveness of the penal law as it was written, made so either by the granting of pardons, the lack of political will or by practical impediments

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