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

La dinámica de flujo de salida en un sistema francés de los humedales verticales que funcionan con un ciclo de alimentación extendida

La posibilidad de utilizar la primera etapa del Sistema francés (FS) de humedales verticales compuestos de solo dos unidades en paralelo requiere investigaciones hidráulicas para permitir una mejor comprensión de su funcionamiento en entornos climáticos tropicales. Este estudio evaluó el patrón del hidrograma de salida a lo largo de un ciclo extendido de operación (siete días de alimentación) y la influencia del depósito de lodo, la ocurrencia de lluvia y la duración de la aplicación del pulso en el hidrograma de salida en un FS modificado a escala completa en Brasil. Los resultados indicaron que, a medida que aumentaban los días del ciclo de alimentación, había un aumento en el tiempo de filtración y el almacenamiento interno del volumen de líquido, probablemente debido a una reducción en la permeabilidad del filtro. Mayor gradiente hidráulico favoreció la velocidad de infiltración, disminuyó la cantidad de líquido almacenado dentro del sistema, y ​​retrasó la pérdida de permeabilidad. La capa de lodo contribuyó a una retención momentánea de líquido y también permitió una mayor evapotranspiración, reduciendo el volumen de líquido a tratar. El depósito de lodo parecía dificultar la filtración líquida, especialmente al final del ciclo, modificando la conductividad hidráulica del filtro en su conjunto. Los intensos eventos de lluvia demostraron que la precipitación podría modificar la dinámica del flujo dentro del sistema.The possibility of using the first stage of the French System (FS) of vertical wetlands composed of only two units in parallel requires hydraulic investigations to allow a better understanding of its operation under tropical climatic environments. This study evaluated the pattern of the outflow hydrograph along an extended cycle of operation (seven days of feeding) and the influence of the sludge deposit, rainfall occurrence and duration of pulse application on the outflow hydrograph in a modified full-scale FS in Brazil. The results indicated that, as the feeding cycle days increased, there was an increase in the time of filtration and the internal storage of the liquid volume, probably due to a reduction in the filter permeability. Greater hydraulic gradient favoured the infiltration velocity, decreased the amount of liquid stored within the system, and delayed the loss of permeability. The sludge layer contributed to a momentary liquid retention, and also allowed greater evapotranspiration, reducing the liquid volume to be treated. The sludge deposit seemed to hinder the liquid percolation, especially at the end of the cycle, modifying the hydraulic conductivity of the filter as a whole. Intense rainfall events demonstrated that precipitation could modify the flow dynamics within the system

A ludicidade no desenvolvimento da criança: uma experiência de iniciação científica

The play activity in education, represented by plays and games, can develop a child’s learning in the classroom. The playful poses as a teaching tool for performance and full development of children, providing moments of joy, learning and commitment to learning. Article and results of undergraduate research activities developed by the Group of Studies and Research in Education, Childhood and Philosophy - GEPEIF / CNPq/UFPA coordinated by professors Waldir Ferreira de Abreu and Damião Bezerra Oliveira and the bond extension project: The playful as teaching resource in the education of children. Aims to discuss the importance of playfulness in the process of child development, especially in kindergarten and provide recreational activities developed with the school children and the rivers Quianduba and Ajuaí in a workshop on playful.A atividade lúdica na educação, representada por jogos e brincadeiras, pode desenvolver o aprendizado da criança na sala de aula. O lúdico se apresenta como ferramenta de ensino para o desempenho e o desenvolvimento integral das crianças, proporcionando momentos de alegria, aprendizado e comprometimento com o aprender. O artigo é resultado das atividades de iniciação científica desenvolvidas pelo Grupo de Estudos e Pesquisas em Educação, Infância e Filosofia – GEPEIF/CNPq/UFPA, vinculado ao projeto de extensão, coordenado pelos professores Waldir Ferreira de Abreu e Damião Bezerra Oliveira: O lúdico como recurso didático na formação da criança. Tem como objetivo discutir a importância do lúdico no processo de desenvolvimento da criança, sobretudo na Educação Infantil, e apresentar as atividades lúdicas desenvolvidas com as crianças das escolas dos rios Quianduba e Ajuaí, em uma oficina sobre o lúdico.UFPA - Universidade Federal do Par

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