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

Táticas caminhantes: cinema marginal e flanâncias juvenis pela cidade

Este trabalho baseia-se na análise de filmes em formato não-comercial e reflete sobre as tensões existentes entre a cidade visível, configurada no discurso urbanista, e as cidades subjetivas, expressas nas práticas cotidianas de seus consumidores. O centro do argumento consiste na idéia de que os filmes em estudo configuram uma guerrilha semântica que objetivou efetuar novas leituras do espaço urbano com base na localização e ocupação dos lugares da cidade por meio de movimentos táticos. O corpo de fontes é composto por seis filmes do "espectro Torquato Neto" rodados entre 1972 e 1974 em Teresina (PI) e no Rio de Janeiro.<br>This work, from the analysis of film in not-commercial format, reflects about the existing tensions between the visible city, configured in the talk town planner, and the express, subjective cities in the routine practices of his consumers. The center of the argument consists of the idea of that the film in study configure a semantic guerrilla that planned to perform news readings of the urban space from the location and occupation of the places of the city by means of tactical movements. The body of springs is composed for six film of the "spectrum Torquato Neto" rolled between 1972 and 1974 in the cities of Teresina (PI) and Rio de Janeiro

Contribuições da Sociologia na América Latina à imaginação sociológica: análise, crítica e compromisso social Sociology's contribution in Latin America to sociological imagination: analysis, critique, and social commitment

O artigo aborda o papel desempenhado pela Sociologia na análise dos processos de transformação das sociedades latino-americanas, no acompanhamento do processo de construção do Estado e da Nação, na problematização das questões sociais na América Latina. São analisados seis períodos na Sociologia na América Latina e no Caribe: I) a herança intelectual da Sociologia ; II) a sociologia da cátedra; III) O período da "Sociologia Científica" e a configuração da "Sociologia Crítica"; IV) a crise institucional, a consolidação da "Sociologia Crítica" e a diversificação da sociologia; V) a sociologia do autoritarismo, da democracia e da exclusão; VI) a consolidação institucional e a mundialização da sociologia da América Latina (desde o ano de 2000), podendo-se afirmar que os traços distintivos do saber sociológico no continente foram: o internacionalismo, o hibridismo, a abordagem crítica dos processos e conflitos das sociedades latino-americanas e o compromisso social do sociólogo.<br>The article focuses on the role played by Sociology in the analysis of processes of change in Latin American societies, in the process of construction of Nation and State, in the debate of social issues in Latin America and the Caribbean. Six periods in Sociology in Latin America and the Caribbean are examined: I) sociology's intellectual legacy; II) sociology as a cathedra; III) the period of "Scientific Sociology"; IV) the institutional crisis, the consolidation of "Critical Sociology", and the diversifying of sociology; V) sociology of authoritarianism, democracy and exclusion; VI) institutional consolidation and globalization of Latin American sociology (since 2000). It may be said that the distinctive features of sociological knowledge in the continent were: internationalism, hybridism, the critical approach to processes and conflicts of Latin American societies, and the sociologist social commitment

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

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p &lt; 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p &lt; 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p &lt; 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease