III Diretriz Brasileira de Insuficiência Cardíaca Crônica

Universidade de São Paulo Faculdade de Medicina Hospital das ClínicasUniversidade Federal do Rio Grande do Sul Hospital de Clínicas de Porto AlegreUniversidade de Pernambuco Faculdade de Ciências Médicas de PernambucoUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de Minas Gerais Faculdade de MedicinaFaculdade de Medicina de São José do Rio PretoFundação Universitária de Cardiologia do Rio Grande do Sul Instituto de CardiologiaRede Labs D'OrUniversidade Federal FluminenseUniversidade do Estado do Rio de Janeiro Faculdade de Ciencias MédicasInstituto Dante Pazzanese de CardiologiaSanta Casa de MisericórdiaUniversidade de Pernambuco Pronto Socorro Cardiológico de PernambucoHospital Pró CardíacoHospital de MessejanaPontifícia Universidade Católica do ParanáUniversidade Federal de Goiás Faculdade de MedicinaUniversidade de São Paulo Faculdade de Medicina de Ribeirão PretoReal e Benemerita Sociedade de Beneficência PortuguesaFaculdade de Ciências Médicas de Minas GeraisUNIFESP, EPMSciEL

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

Electro-oxidation of ethanol on PtSn/CeO(2)-C electrocatalyst

PtSn/CeO(2)-C electrocatalyst was prepared in a single step by an alcohol-reduction process using ethylene glycol as solvent and reducing agent and CeO(2) (15 wt%) and Vulcan XC72 (85 wt%) as supports. The performance for ethanol oxidation was investigated by cyclic voltammetry and in situ FTIR spectroscopy. The electrocatalytic activity of the PtSn/CeO(2)-C electrocatalyst was higher than that of the PtSn/C electrocatalyst. FTIR studies for ethanol oxidation on PtSn/C electrocatalyst showed that acetaldehyde and acetic acid were the principal products formed, while on PtSn/CeO(2)-C electrocatalyst the principal products formed were CO(2) and acetic acid.FINEP-ProH<INF>2</INF>Financiadora de Estudos e Projetos (FINEP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)CNPqFAPESPFundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Pacientes com infecção por vírus A (H1N1) admitidos em unidades de terapia intensiva do Estado do Paraná, Brasil Outcome of influenza A (H1N1) patients admitted to intensive care units in the Paraná state, Brazil

OBJETIVO: Analisar a evolução, características clínico-epidemiológicas e fatores de gravidade em pacientes adultos admitidos com diagnóstico de infecção por vírus A(H1N1) em unidades de terapia intensiva públicas e privadas no Estado do Paraná, sul do Brasil. MÉTODOS: Estudo coorte de análise de prontuários de pacientes com idade superior a 12 anos admitidos em 11 unidades de terapia intensiva de 6 cidades no Estado do Paraná (Brasil), durante um período de 45 dias, com diagnóstico de gripe suína. O diagnóstico de infecção por vírus A(H1N1) foi feito através de real time -polimerase chain reaction (RT-PCR) da secreção nasofaríngea, ou de forte suspeita clínica quando descartadas outras causas (mesmo com RT-PCR negativo). Foi feita estatística descritiva e análise com teste chi quadrado, para comparação entre porcentagens e teste t de student para variáveis continuas, com análise univariada, admitindo-se como significante um p30). A média do escore Acute Physiologic Chronic Heatlh Evaluation II (APACHE II) foi de 15,0 ± 8,1. A mortalidade na unidade de terapia intensiva foi de 39,7%. Os principais fatores associados a essa mortalidade foram exame positivo no teste RT-PCR, níveis baixos de relação PaO2/FiO2 inicial, níveis elevados de uréia e desidrogenase lática iniciais, nível de pressão expiratória final positiva necessária, necessidade de posição prona e de drogas vasopressoras. CONCLUSÕES: Pacientes admitidos em unidades de terapia intensiva com infecção por vírus A(H1N1) apresentaram alto risco de óbito, particularmente devidos ao comprometimento respiratório. O exame RT-PCR positivo, níveis de uréia e de desidrogenase láctica, além baixa PaO2/FiO2 e necessidades de PEEP alta, foram relacionados com uma maior mortalidade.OBJECTIVE: This study aimed to analyze outcome, clinical and epidemiological characteristics and severity factors in adult patients admitted with a diagnosis of infection by virus A (H1N1) to public and private intensive care units, in Paraná, Brazil. METHODS: Cohort study of medical charts of patients older than 12 years admitted to 11 intensive care units in 6 cities in the state of Parana, Brazil, during a period of 45 days, with diagnosis of swine influenza. The diagnosis of infection with A (H1N1) was made by real time polymerase chain reaction (RT-PCR) of nasopharyngeal secretion, or strong clinical suspicion when other causes had been ruled out (even with negative RT-PCR). Descriptive statistics were performed, analysis by the Chi square test was used to compare percentages and the Student's t test for continuous variables with univariate analysis, assuming a significance level of p 30). Mean of the Acute Physiologic Chronic Health Evaluation II (APACHE II) score was 15.0 + 8.1. Mortality in the intensive care unit was 39.7%. The main factors associated with mortality were: positive RT-PCR, low levels of initial PaO2/FiO2, high initial levels of urea and lactate dehydrogenase, required level of positive end expiratory pressure, need for the prone position and vasopressors. CONCLUSIONS: Adult patients with A (H1N1) virus infection admitted to intensive care units had a high risk of death, particularly due to respiratory impairment. Positive RT-PCR, urea and lactic dehydrogenase, low initial PaO2/FiO2 and high levels of PEEP were correlated with higher mortality

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