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 cmH2O 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 6430 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 metho

Uso da adubação verde na recuperação de solos degradados por mineração na floresta amazônica

O presente trabalho teve como objetivo avaliar: (a) Uso de leguminosas e gramíneas utilizadas na adubação verde; (b) Incorporação de matéria orgânica pela adição de compostos orgânicos e (c) Efeitos da adubação química e calagem na recuperação de áreas degradadas pela mineração de cassiterita na FLONA do Jamari (RO). O experimento foi instalado em dezembro de 1999. O delineamento experimental adotado foi em blocos casualizados com 24 tratamentos no esquema fatorial 6 X 4, constando de seis tipos de coberturas vegetais (Brachiaria humidicula (Braquiária), Cajanus cajan (Feijão guandu), Mucuma aterrima (Mucuna preta), Cajanus cajan (Feijão guandu) + Brachiaria humidicula (Braquiária); Mucuma aterrima (Mucuna preta)+ Brachiaria humidicula (Braquiária) e solo nu e quatro tipos de adubação na cova (NPK 10-10-10; 50% rejeito + 50% composto; 50% rejeito + 50% composto + NPK 10-10-10; 50% rejeito + 50% composto + NPK 10-10-10 + calcário dolomítico). As amostras de solo foram coletadas superficialmente (0-20 cm) para fins de análises químicas e físicas, 15 meses após o plantio, logo após as chuvas. Os resultados foram submetidos à análise de variância (p < 0,05) e, nos casos em que o teste F foi significativo, aplicou-se o teste Tukey para a comparação das médias de seis repetições Apenas nas características químicas foram observadas diferenças significativas entre os tratamentos. As adubações química e orgânica e a calagem contribuíram para essas diferenças, e os tratamentos que receberam calcário proporcionaram como esperado aumento no pH, nos teores de Ca, Mg, na CTC, SB e V% e diminuição no H+Al quando comparados aos demais. Porém, quando se analisa o teor de matéria orgânica e os parâmetros físicos estudados não houve diferenças entre os tratamentos, mesmo naqueles onde a adubação foi intensiva associada ao plantio de adubos verde e a gramíneas indicando que as melhorias nos atributos físicos do solo em áreas de deposição de rejeito deve ocorrer de forma mais lenta

Sombric horizon: five decades without evolution

The sombric horizon is a diagnostic subsurface horizon defined in the soil classification system of the United States (Soil Taxonomy) and FAO (WRB), used to classify the soil at different categorical levels. The sombric horizon has a soil color darker than the overlying surface(s) horizon(s), and must show illuvial humus accumulation features, though they are not associated with aluminum (Al), as in the spodic horizon, nor associated with sodium (Na), as in the natric horizon. There are also criteria to distinguish it from buried A horizons. However, since the first references and proposed concept of the sombric horizon in African soils made by Sys and co-workers in the 1960s, and adopted by the Soil Taxonomy edition of 1975, few modifications have been made to its definition. Moreover, the pedogenic process involved in illuvial humus accumulation in these horizons remains inadequately clarified, making the distinction between the sombric and spodic or buried A horizon difficult and unclear. This review reports the historical evolution of the sombric horizon concept, its definition and inconsistencies under different soil classification systems, and the current hypothesis, together with its fragilities, proposed to explain the soil illuvial humus accumulation. Although it is recognized that further research is necessary, alternative criteria are proposed for the definition of the sombric horizon in the Brazilian System of Soil Classification

Histopathological, immunohistochemical, and molecular study of BHV-5 infection in the central nervous system of experimentally infected calves

Bovine meningoencephalitis caused by BHV-5, a double-stranded DNA enveloped virus that belongs to the family Herpesviridae and subfamily Alphaherpesvirinae, is an important differential diagnosis of central nervous diseases. The aim of this study was to describe the histological changes in the central nervous system of calves experimentally infected with BHV-5 and compare these changes with the PCR and IHC results. Formalin-fixed paraffin-embedded central nervous system samples from calves previously inoculated with BHV-5 were microscopically evaluated and tested using IHC and PCR. All the animals presented with nonsuppurative meningoencephalitis. From 18 evaluated areas of each calf, 32.41% and 35.19% were positive by IHC and PCR, respectively. The telencephalon presented more accentuated lesions and positive areas in the PCR than other encephalic areas and was the best sampling area for diagnostic purposes. Positive areas in the IHC and PCR were more injured than IHC and PCR negative areas. The animal with neurological signs showed more PCR- and IHC-positive areas than the other animals

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 &lt;= 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