Feasibility and safety of planned early discharge following laparotomy in gynecologic oncology with enhanced recovery protocol including opioid-sparing anesthesia

ObjectiveThis study aims to evaluate the feasibility and safety of planned postoperative day 1 discharge (PPOD1) among patients who undergo laparotomy (XL) in the department of gynecology oncology utilizing a modified enhanced recovery after surgery (ERAS) protocol including opioid-sparing anesthesia (OSA) and defined discharge criteria.MethodsPatients undergoing XL and minimally invasive surgery (MIS) were enrolled in this prospective, observational cohort study after the departmental implementation of a modified ERAS protocol. The primary outcome was quality of life (QoL) using SF36, PROMIS GI, and ICIQ-FLUTS at baseline and 2- and 6-week postoperative visits. Statistical significance was assessed using the two-tailed Student's t-test and non-parametric Mann–Whitney two-sample test.ResultsOf the 141 subjects, no significant demographic differences were observed between the XL group and the MIS group. The majority of subjects, 84.7% (61), in the XL group had gynecologic malignancy [vs. MIS group; 21 (29.2%), p < 0.001]. All patients tolerated OSA. The XL group required higher intraoperative opioids [7.1 ± 9.2 morphine milligram equivalents (MME) vs. 3.9 ± 6.9 MME, p = 0.02] and longer surgical time (114.2 ± 41 min vs. 96.8 ± 32.1 min, p = 0.006). No significant difference was noted in the opioid requirements at the immediate postoperative phase and the rest of the postoperative day (POD) 0 or POD 1. In the XL group, 69 patients (73.6%) were successfully discharged home on POD1. There was no increase in the PROMIS score at 2 and 6 weeks compared to the preoperative phase. The readmission rates within 30 days after surgery (XL 4.2% vs. MIS 1.4%, p = 0.62), rates of surgical site infection (XL 0% vs. MIS 2.8%, p = 0.24), and mean number of post-discharge phone calls (0 vs. 0, p = 0.41) were comparable between the two groups. Although QoL scores were significantly lower than baseline in four of the nine QoL domains at 2 weeks post-laparotomy, all except physical health recovered by the 6-week time point.ConclusionsPPOD1 is a safe and feasible strategy for XL performed in the gynecologic oncology department. PPOD1 did not increase opioid requirements, readmission rates compared to MIS, and patient-reported constipation and nausea/vomiting compared to the preoperative phase

Tillering as a trait to mitigate damages caused to maize by the main stem defoliation

O objetivo deste trabalho foi verificar se os perfilhos podem mitigar os prejuízos ocasionados pela desfolha do colmo principal em milho. Os experimentos foram implantados em Lages, SC, em 20/10/2006 e 31/10/2008. O delineamento experimental utilizado foi o de blocos ao acaso, com parcelas subdivididas. Na parcela principal, foram testados dois destinos dos perfilhos: manutenção até a colheita e remoção quando o colmo principal apresentava nove folhas expandidas (V9). Nas subparcelas, avaliaram-se quatro épocas de desfolha do colmo principal: V9, V15 (quinze folhas expandidas), VT (pendoamento) e folhas preservadas até a colheita. Avaliou-se o híbrido P30F53, à densidade de 55 mil plantas por hectare. Determinaram-se: a produtividade total, a do colmo principal e a dos perfilhos. As desfolhas realizadas em V15 e VT diminuíram a produtividade, em comparação ao tratamento sem desfolha, independentemente do destino dos perfilhos. Quando o milho foi desfolhado em V15 e VT, a produtividade total das parcelas em que os perfilhos foram mantidos foi maior do que daquelas em que eles foram removidos. Isto indica que os perfilhos foram benéficos ao colmo principal do milho, quando houve restrições à produção de carboidrato oriundas da perda de área foliar próximo do florescimento.The objective of this work was to verify if tillers can mitigate damages caused by the main stem defoliation in maize. The experiments were set up in Lages, SC, Brazil, on 10/20/2006 and 10/31/2008. The experimental design was a randomized block with split plots. Two tiller destinations were tested in the main plots: tillers preserved until harvesting, and tillers removed when the main stem had nine expanded leaves (V9). Four main stem defoliation times were assessed in the split plots: V9, V15 (15 expanded leaves), VT (tasseling), and leaf maintenance until harvesting. Hybrid P30F53 was tested at 55 thousand plants per hectare. Total grain yield, tiller grain yield and main stem grain yield were determined. Defoliations performed at V15 and VT decreased total productivity, in comparison to the control, regardless of tiller destination. When the main stem was defoliated at V15 and VT, plots where tillers were kept promoted higher total grain yield than those where tillers were removed. This indicates that tillers were instrumental to maize main stem when there were restrictions to the production of carbohydrates due to leaf area loss close to flowering

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

Response of maize hybrids grown at different eras to plant population and tassel removal

Os híbridos contemporâneos de milho são mais tolerantes à elevação da população de plantas do que os híbridos antigos. É possível que a melhor adaptação da cultura ao adensamento esteja relacionada com a menor dominância apical do pendão sobre a espiga. Este trabalho foi conduzido objetivando avaliar a evolução na tolerância de híbridos de milho liberados comercialmente em diferentes épocas à elevação na população de plantas, bem como observar se o progresso obtido esta associado à redução na dominância apical. O experimento foi conduzido no município de Lages, SC, durante os anos agrícolas de 1999/2000 e 2000/2001. Utilizou-se o delineamento experimental de parcelas subsubdivididas. Na parcela principal, foram testadas três populações de planta: 50.000, 75.000 e 100.000pl ha-1. Nas subparcelas, foram alocados quatro híbridos: Ag 12, Ag 28, Ag 303 e Ag 9012, liberados comercialmente para cultivo nas décadas de 60, 70, 80 e 90, respectivamente. Cada híbrido de milho foi analisado com pendões intactos e integralmente removidos durante o emborrachamento nas sub-subparcelas. Os ensaios foram implantados em 30/10/1999 e 2/11/2000. A por meio de análise de variância e de regressão polinomial. O híbrido Ag 9012, liberado comercialmente para cultivo na década de 90, foi mais exigente em população de plantas do que os híbridos antigos para otimizar o seu potencial produtivo em 1999/2000, quando as condições foram favoráveis à obtenção de rendimentos de grão superiores a 10.000kg ha-1. Neste ano agrícola, a interferência do pendão sobre o desenvolvimento das espigas foi pequena. Por outro lado, o rendimento de grãos de todos os híbridos respondeu positivamente ao despendoamento em 2000/2001, sob tetos produtivos mais baixos. Não houve associação entre maior tolerância ao adensamento e resposta ao despendoamento, indicando que a tolerância a altas densidades populacionais não esteve relacionada com a redução da dominância apical do pendão sobre as espigas.Current maize hybrids are more tolerant to the increasing of plant population than the hybrids used in the past. It is possible that modern hybrid’s better adaptation to crowding is related to the lower apical dominance of the tassel over the ear. This experiment was aimed at evaluating the evolution on maize hybrids commercially released in different times the increase in plant population and at detecting if this progress is related to the reduction of apical dominance. The experiment was carried out in Lages, SC, during the 1999/ 2000 and 2000/2001 growing seasons. A split-split plot design was used. Three plant populations were tested in the main plots: 50,000, 75,000 and 100,000pl ha-1. Four hybrids commercially released in the 60’s, 70’s, 80’s and 90’s, respectively, were assessed in the split plots. Each hybrid was analyzed with preserved tassels and with tassel removed at booting in the split-split plot. The trials were installed in 10/30/ 1999 and 11/02/2000. Grain yield was assessed using the variance and regression analyzes. The hybrid commercially released in the 90’s (Ag 9012) was more demanding in plant population to maximize grain yield when the conditions were favorable to yields higher than 10,000kg ha-1 (1999/2000). At this scenario, tassel interference on ear development was small. On the other hand, grain yield of all tested hybrids was increased by tassel removal under a lower yield plateau (2000/ 2001).There was no association between higher tolerance to crowding and greater response to detasseling, indicating that the tested hybrid higher endurance to dense stands was not related to the reduction in apical dominance of the tassel over the ear

Perfilhamento como característica mitigadora dos prejuízos ocasionados ao milho pela desfolha do colmo principal

O objetivo deste trabalho foi verificar se os perfilhos podem mitigar os prejuízos ocasionados pela desfolha do colmo principal em milho. Os experimentos foram implantados em Lages, SC, em 20/10/2006 e 31/10/2008. O delineamento experimental utilizado foi o de blocos ao acaso, com parcelas subdivididas. Na parcela principal, foram testados dois destinos dos perfilhos: manutenção até a colheita e remoção quando o colmo principal apresentava nove folhas expandidas (V9). Nas subparcelas, avaliaram-se quatro épocas de desfolha do colmo principal: V9, V15 (quinze folhas expandidas), VT (pendoamento) e folhas preservadas até a colheita. Avaliou-se o híbrido P30F53, à densidade de 55 mil plantas por hectare. Determinaram-se: a produtividade total, a do colmo principal e a dos perfilhos. As desfolhas realizadas em V15 e VT diminuíram a produtividade, em comparação ao tratamento sem desfolha, independentemente do destino dos perfilhos. Quando o milho foi desfolhado em V15 e VT, a produtividade total das parcelas em que os perfilhos foram mantidos foi maior do que daquelas em que eles foram removidos. Isto indica que os perfilhos foram benéficos ao colmo principal do milho, quando houve restrições à produção de carboidrato oriundas da perda de área foliar próximo do florescimento