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

Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz.&nbsp

Design and baseline characteristics of the finerenone in reducing cardiovascular mortality and morbidity in diabetic kidney disease trial

Background: Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. Patients and Methods: The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate >= 25 mL/min/1.73 m(2) and albuminuria (urinary albumin-to-creatinine ratio >= 30 to <= 5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level alpha = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. Conclusions: FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. Trial Registration: EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049

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 &lt;= 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

Estimativa da taxa de produção urinária fetal através da ultrassonografia tridimensional

Objetivo: O objetivo principal do presente estudo foi desenvolver um modelo de predição para a estimativa da TPUF em gestações não complicadas entre 20 e 40 semanas, utilizando US 3D - VOCAL®, a partir da regressão com melhor desempenho estatístico. Métodos: A estimativa da TPUF foi calculada a partir da variação entre duas medidas do volume vesical na fase de enchimento (V1 - primeira aferição da bexiga fetal e V2 - segunda aferição da bexiga fetal) dividida pelo intervalo de tempo (em horas) entre as duas medidas. Análise dos resultados: Considerando que a TPUF é função da idade gestacional e da biometria fetal, os dados foram submetidos à análise de regressão, tendo como variável dependente, os valores da TPUF e como variável independente a idade gestacional em semanas e a biometria fetal, em milímetros, do fêmur, úmero, diâmetro biparietal e circunferência abdominal. Resultados: Foram avaliados de 160 fetos normais com idade gestacional entre 20-40 semanas; 9 deles foram excluídos porque a qualidade da imagem não foi suficiente para a visualização correta do contorno da bexiga. A análise da regressão linear da TPUF em função da idade gestacional, fêmur, úmero, circunferência abdominal, circunferência cefálica e diâmetro biparietal (DBP) geraram equações que representam o intervalo normal para a TPUF por estes parâmetros. Embora, o DBP tenha o maior coeficiente de determinação (R2 0,7066), não houve diferença estatísticamente significativa entre os parâmetros investigados para a previsão da TPUF. Conclusão: O uso de parâmetros biométricos para predição de TPUF fetal parece ser útil e pode evitar a necessidade de construir normogramas locais para diferentes populações. A mesma estratégia customização deve ser considerada a outros campos da medicina fetalObjective: The main objective of this study was to develop a predictive model to estimate the FUPR in uncomplicated pregnancies between 20 and 40 weeks using three-dimensional ultrasonography (3D U.S.) VOCAL® using the regression model with better statistical performance. Methods: The estimation of FUPR was calculated from the variation between two measurements of bladder volume on filling phase (V1 - the first measurement of the fetal bladder and V2 - the second measurement of fetal bladder) divided by time (in hours) between the two measures. Analysis of results: Since FUPR is a function of gestational age and fetal biometry, the data will be submitted to regression analysis, with the dependent variable, the values of FUPR and the independent variable gestational age in weeks and fetal biometry in milimeteres, of femur, humerus, biparietal diameter and abdominal circumference. Results: We evaluated 160 fetuses with gestational ages between 20-40 weeks, 5 were excluded because the image quality was not enough to properly display the outline of the bladder. The linear regression analysis FUPR by gestational age, femur, humerus, abdominal circumference, head circumference and biparietal diameter (BPD) generated equations that represent the normal range for FUPR by each of these parameters. Although DBP has the highest coefficient of determination (R2 0.7066), no statistically significant difference between the investigated parameters for predicting the FUPR. Conclusion: The use of biometric parameters for prediction of fetal FUPR seems to be useful and may avoid the need to construct nomograms for different populations. The same strategy of customization should be considered to other fields in fetal medicine69f

Avaliação da bexiga fetal através da ultra-sonografia tridimensional: reprodutibilidade da técnica rotacional

Objective: The aim of this study was to investigate the inter- and intraobserver reliability in measuring the fetal bladder volume by 3D ultrasound (US) imaging using the Virtual Organ Computed-aided Analysis (VOCALTM) comparing the 15° and 30° rotation steps calculation. Methods: We analysed 240 measurements of FB volume performed in 30 low-risk patients with gestation ages ranging from 22 to 39 weeks by two independent observers blind to each other. All fetuses were examined and no ultrasound detectable malformation was found. The volume of each FB was measured twice by each observer using the VOCALTM technique. Distinct sets of 12 and 6 planes were obtained after sequential rotations of 15° and 30°, respectively. The internal contour of the fetal bladder was manually and carefully determined as to exclude adjacent structures from volume calculation. Wilcoxon signed-rank test was used to compare the paired samples in the cases of replication within and between observers. Spearman s rank correlation was used to study the relationship among angles. Bland and Altman s graphical approach was used to investigate the agreement between observers. Results: The 3D VOCALTM technique showed itself as highly reliable in our sample. No significant difference was found between the measurements of FB volume with the VOCALTM technique either by varying the steps of rotation or the observers. Conclusion: Good correlations were found for both observers in the use of rotation angles of 15° and 30°. Since a significantly faster evaluation was obtained by using the 30° rotation step it must be preferred to assess the FB volume.Objetivo: O objetivo do presente estudo foi investigar a reprodutibilidade intra e inter-observador da aferição da BF utilizando a ultra-sonografia (US) tridimensional (3D) Virtual Organ Computed-aided Analysis (VOCAL®) comparando os ângulos de rotação de 15° e 30°. Métodos: Foram analisadas 240 aferições de volume da BF realizadas em 30 gestantes de baixo risco, com idade gestacional variando entre 22 e 39 semanas de gestação, por dois observadores independentes, cegos entre si. Todos os fetos foram examinados e nenhuma malformação detectável ao US foi observada. O volume de cada BF foi aferido duas vezes por cada observador utilizando a técnica 3D VOCAL®. Aferições de volume distintas através de 12 e 6 planos foram obtidas depois de rotações seqüencias de 15° e 30°, respectivamente. O contorno interno da BF foi determinado manualmente de forma cuidadosa para excluir do cálculo de volume as estruturas adjacentes. O teste do sinal ranqueado de Wilcoxon foi utilizado para a comparação de amostra pareada nos casos de replicação intra e inter-observador. A correlação ranqueada de Spearman foi utilizada para estudar a correlação entre os ângulos de 15° e 30°. O método de Bland-Altman foi usado para investigar a concordância entre os observadores. Resultados: A técnica 3D VOCAL® foi altamente reprodutível em nossa amostra. Não foi observada diferença significativa entre as medidas da BF através da técnica 3D VOCAL® variando por ângulo de rotação ou por observador. Conclusão: Boas correlações foram observadas para os dois observadores utilizando os ângulos de 15° e 30°. Considerando que uma avaliação significativamente mais rápida pode ser obtida utilizando o ângulo de 30°, essa deve ser preferida na avaliação de volume da BF