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

Sequential feeding for pigs and poultry : effect on perfomance, energetic and protein metabolism

Dois experimentos foram realizados para avaliar o efeito da alimentação sequencial (AS) no desempenho e metabolismo energético e proteico de frangos de corte e suínos em crescimento. No primeiro experimento foram utilizados 144 frangos de corte com 21 dias de idade, alojados em baterias de metabolismo. As dietas A e B foram formuladas para atender 100% e 80% das recomendações de aminoácidos digestíveis, respectivamente. Os tratamentos utilizados foram: Tratamento AA, dieta A, fornecida durante todo o ciclo de 24 horas; Tratamento AB, dieta A fornecida durante o dia e dieta B fornecida durante a noite; Tratamento BA, dieta B fornecida durante o dia e dieta A fornecida durante a noite e; Tratamento BB, dieta B fornecida durante todo o ciclo de 24 horas. No experimento com suínos foram utilizados 16 animais com peso inicial de 30 kg, alojados em gaiolas metabólicas. Os tratamentos e as dietas experimentais seguiram as mesmas proposições do experimento com aves, porém com parâmetros nutricionais ajustados para suínos. Os frangos submetidos à AS apresentaram desempenho semelhante à dieta completa, com ligeira piora na conversão alimentar. Os frangos de corte dos tratamentos com AS ingeriram menos energia, nitrogênio (N) e lisina comparadas aos animais alimentados exclusivamente com a dieta A. Os valores de retenção e excreção de N nos frangos alimentados sob regime de AS compararam-se ao tratamento AA. O tratamento BA excretou menos N e obteve uma relação de retenção de N por quilograma de peso vivo equivalente ao tratamento AA. Em suínos, não foram detectados efeitos da AS sobre o peso final, consumo de ração diário, ganho de peso diário e conversão alimentar. A ingestão de N foi influenciada pela AS, mas não houve diferença na excreção e retenção de N, comparado ao tratamento AA. Os programas de AS apresentam desempenhos similares com reduzida ingestão de nutrientes e retenções de N similares a programas de alimentação convencionais em frangos de corte. AAS mantém o potencial de retenção de nitrogênio de uma dieta convencional, sem alterar os coeficientes de digestibilidade da dieta e o desempenho zootécnico. O fornecimento da dieta deficiente em aminoácidos durante o período da noite parece ser a melhor escolha para otimizar retenção de nitrogênio ao aplicar a estratégia de alimentação sequencial em suínos.Two experiments were carried out to evaluate the effect of sequential feeding (AS) on performance and energy and protein metabolism of broiler chickens to growing pigs. In the experiment in birds were used 144 broiler chickens with 21 days of age, housed in metabolism batteries. Diets A and B were formulated to meet 100% and 80% of digestible amino acid recommendations, respectively. The treatments utilized were: Treatment AA, diet A, provided throughout the 24-hour cycle; AB treatment, A diet provided during the day and diet B provided overnight; Treatment BA, diet B provided during the day and diet A provided at night and; Treatment BB, diet B provided throughout the 24 hour cycle. In the experiment with pigs were used 16 animals with initial weight of 30 kg, housed in metabolic cages. The treatments and the experimental diets followed the same propositions of the experiment with birds, however with nutritional parameters adjusted for pigs. The birds submitted to AS presented similar performance to the complete diet, with a slight worsening in feed conversion. The birds in the AS treatments ingested less energy, nitrogen (N) and lysine compared to birds fed exclusively on diet A. The N retention and excretion values in the birds fed under AS regimen were compared to the AA treatment. The BA treatment excreted less N and had a N retention ratio per kilogram live weight equivalent to the AA treatment. In pigs, no effects of AS and final weight, daily feed intake, daily weight gain and feed conversion were detected. N intake was influenced by AS, but there was no difference in N excretion and retention compared to AA treatment. AS programs perform similar performances with reduced nutrient intakes and N retention similar to conventional feeding programs in broilers. AS maintains the nitrogen retention potential of a conventional diet without altering the digestibility coefficients of the diet and the zootechnical performance. The supply of the amino acid deficient diet over night appears to be the best choice to optimize nitrogen retention by applying the sequential dietary strategy

Modelagem da ingestão, retenção e excreção de nitrogênio e fósforo pela suinocultura gaúcha: interface vegetal Ingestion, retention and excretion modeling of nitrogen and phosphorus by pigs in Rio Grande do Sul, Brazil: vegetable interface

Um modelo foi desenvolvido com o objetivo de simular as dinâmicas de Nitrogênio e Fósforo pela suinocultura gaúcha associadas às produções de milho e soja do Rio Grande do Sul. O modelo é constituído por um submodelo animal (SMA) e outro vegetal (SMV). Os princípios gerais do SMA foram baseados em sistemas tecnológicos (ST), categorias animais, concentrações de N e P das dietas e suas eficiências digestiva e metabólica. O SMA integra três níveis de agregação, sendo constituído de 10 compartimentos para N e P e 300 subcompartimentos relacionados aos ST e às categorias animais. Os dados da suinocultura gaúcha foram divididos em sete mesorregiões de acordo com as definições fisiográficas. Os ST foram definidos pelo número de suínos terminados/porca/ano. O SMV é constituído pelos subcompartimentos milho e soja. Os parâmetros do SMV foram baseados nas áreas cultivadas e nas produções de milho e soja de cada município. De acordo com o balanço entre a produção e o consumo, todas as mesorregiões possuem excedente de milho e soja. O consumo anual de milho e farelo de soja pela suinocultura gaucha é em média de 1,14 e 0,39 milhões de toneladas, respectivamente. O volume anual de N e P ingeridos pelos suínos é de aproximadamente 36 e 5,7 mil toneladas. Desse volume, cerca de 41% do N e 71% do P retornam ao meio ambiente. Os valores simulados dos diferentes cenários de oferta/demanda de milho e soja no Rio Grande do Sul mostram autosuficiência das sete mesorregiões. Os fluxos de nutrientes entre solo-planta-animal-solo simulados mostram que as mesorregiões do Rio Grande do Sul têm níveis de nitrogênio e fósforo lançados ao meio ambiente pelos suínos abaixo dos limites determinados pela União Europeia. O modelo simula adequadamente as transferências de N e P entre as interfaces animal e vegetal na produção suína, no Rio Grande do Sul.A model was developed to simulate the Nitrogen and Phosphorus dynamics of pigs in the Rio Grande do Sul state, Brazil associated with corn and soybean production. The model is constituted by an animal sub-model (SMA) and a vegetable one (SMV). The general approaches of SMA are based on technological systems (ST), animal categories, N and P concentrations in diets and its digestive and metabolic efficiencies. The SMA integrates three aggregation levels, constituted by ten compartments for N and P and 300 sub-compartments related to ST and animal categories. The pig production data were divided in seven mesorregions in agreement with the physiographic definitions. The SMV is constituted by corn and soybean sub-compartments. The SMV parameters were based on the cultivated area and in the corn and soybean production of each municipal district. The simulated data show a surplus of corn and soybean in all mesorregions. Annual consumption of corn and soybean meal by pigs on the state is nearly to 1.14 and 0.39 million tons, respectively. Annual volume intake of N and P by the pigs is nearly 36 and 5.7 thousand tons, which 41% of N and 71% of P return to the environment. The simulated values of the different offer/demand sceneries of corn and soybean in Rio Grande do Sul show self-sufficiency of seven mesorregions. The flows of nutrients among soil-plant-animal-soil simulated show that Rio Grande do Sul mesorregions has levels of nitrogen and phosphorus released into the environment by the pigs below the limits imposed by the European Union. The model simulates appropriately the transfers of N and P between animal and vegetable interfaces in pig production in Rio Grande do Sul

Application of a precision nutrition tool for growing and finishing pigs

The objective of this study was to evaluate a growth model applied to adjust nutritional programs for growing and finishing pigs, in a commercial production context. The phase I (calibration) was conducted in a commercial pig production unit. The data were collected from a nutritional program, a feed program, and an animal profile. In experimental phase II, these data were entered in the InraPorc® model for simulations and to propose adjustments to the commercial nutritional program. Afterwards, the conventional nutritional program (CNP) and the adjusted nutritional program (ANP) were compared with InraPorc® simulation. Animal profile was collected by weighing 30% of pigs per stall and monitoring their feed intake in each stage. Four hundred and thirty-two pigs with an average initial body weight of 21.9 kg were used in a completely randomized design. There were no differences between treatments, the pig performance was affected by temperature conditions, and the fat thickness was 8% higher for CNP than ANP. In conclusion, the model has advantages to adjust growing and finishing pig nutrition programs and improve environmental and economic aspects

Application of a precision nutrition tool for growing and finishing pigs

ABSTRACT The objective of this study was to evaluate a growth model applied to adjust nutritional programs for growing and finishing pigs, in a commercial production context. The phase I (calibration) was conducted in a commercial pig production unit. The data were collected from a nutritional program, a feed program, and an animal profile. In experimental phase II, these data were entered in the InraPorc® model for simulations and to propose adjustments to the commercial nutritional program. Afterwards, the conventional nutritional program (CNP) and the adjusted nutritional program (ANP) were compared with InraPorc® simulation. Animal profile was collected by weighing 30% of pigs per stall and monitoring their feed intake in each stage. Four hundred and thirty-two pigs with an average initial body weight of 21.9 kg were used in a completely randomized design. There were no differences between treatments, the pig performance was affected by temperature conditions, and the fat thickness was 8% higher for CNP than ANP. In conclusion, the model has advantages to adjust growing and finishing pig nutrition programs and improve environmental and economic aspects

Dietas ajustadas para suínos através do modelo InraPorc®: desempenho, características de carcaça e impacto econômico Diets for pigs fitted through the model InraPorc®: performance, carcass traits and economic impact

O objetivo deste trabalho foi avaliar o desempenho animal, as características de carcaça e os custos para suínos alimentados com dietas ajustadas, para condições brasileiras, através do modelo InraPorc®. Foram utilizados 36 suínos castrados e 36 fêmeas, nas fases de crescimento e terminação, em um delineamento inteiramente casualizado. Os tratamentos foram dietas controles e dietas ajustadas para machos e fêmeas. O programa alimentar e o perfil animal foram adicionados ao modelo para parametrização e definição das estratégias nutricionais e alimentares nas dietas ajustadas. O desempenho e as características de carcaça não foram influenciados pelos tratamentos. O custo médio de alimentação para os animais que receberam a dieta controle foi 3,4% e 2,4% superior para os machos e para as fêmeas, respectivamente. Na comparação entre as dietas, o custo médio de alimentação para os animais que receberam a dieta controle foi 2,9% superior. A receita líquida foi R$0,19 e R$0,66 superior para os machos e fêmeas que receberam a dieta ajustada, respectivamente. As dietas ajustadas através do InraPorc® para suínos em crescimento e terminação não influenciam no desempenho e nas características de carcaça, contudo reduzem os custos de alimentação, o que gera aumento da receita líquida de produção.The objective of this study was to evaluate animal performance, carcass characteristics and costs for pigs fed diets adjusted to Brazilian conditions, through the model InraPorc®. We used 36 barrows and 36 females, during the growing and finishing in a completely randomized design. The treatments were control diets and diets adjusted for both males and females. The feeding program and the animal profile were added to the model parameterization and define strategies and nutritional feed in the diets adjusted. The performance and carcass traits were not affected by treatments. The average cost to feed the animals that received the control diet was higher in 3.4% and 2.4% for the males and females respectively. Comparing the diets, the average cost to feed the animals that received the control diet was 2.9% higher. Net income was R$0.19 and R$0.66 higher for males and females which received the diet adjusted, respectively. Diets adjusted through InraPorc® for the growing and finishing pigs did not influence the performance and carcass traits, however reduced feed costs which generates higher net production

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