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

Light and dark cells in the lumbar sensory ganglia of pre and post-hatching domestic fowl

Clear and dark satellite cell classes were identified by electron microscopy in the lumbar sensory ganglia of domestic fowl in 8 pre and 4 post-hatching stages of development. Some cytologic differences found between the two classes relating to the rough-endoplasmic reticulum, ribosomes, Golgi apparatus and junctional complexes suggest the existence of distinct functional features for both types of satellite cells

Correlative scanning and transmission electron microscopic study on the ependymal surface of Bradypus Tridactylus

Topographical variations of the ependymal surface of the whole brain ventricular system of Bradypus tridactylus were studied at the scanning electron microscope after CO2 critical point drying and carbon-gold coating. Certain selected areas were also studied at the transmission electron microscope, following standard technical procedures. We observed distinct patterns in the distribution of cilia, microvilli and supraependymal structures (nerve-like and fibrous astrocyte fibers), and also a small number of blebs. It the lateral transition zone between the floor and roof of the lateral ventricle were found interconrected stellate bulgings measuring an average 98 x 190 mm, constituted by a complex meshwork of processes from fibrous astrocytes, without ependymal lining and with few cell bodies. In the junction between these formations and the underlying neuropil, ciliated ependymal-cell-like glial cells were found to delimit complex labyrinthic spaces. Based on the morphological findings, morpho-functional considerations are made

A freeze-fracture study on the developing satellite cells of spinal ganglia in the chick embryo

A freeze-fracture analysis of the satellite cells of spinal ganglia of the chick embryo was performed in 8 successive stages of development, from the 5th incubation day to hatching. The characteristic laminar disposition of the cells were first observed on the 7th day. Tight junctions were found at the 20th incubation day. Small groups or irregular aggregates of particles, but not gap junctions, were described on the 7th and 8th days. Pinocytotic vesicles were pointed out in the different stages considered