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

Microstructural, Mechanical, and Electrochemical Analysis of Duplex and Superduplex Stainless Steels Welded with the Autogenous TIG Process Using Different Heat Input

Duplex Stainless Steels (DSS) and Superduplex Stainless Steels (SDSS) have a strong appeal in the petrochemical industry. These steels have excellent properties, such as corrosion resistance and good toughness besides good weldability. Welding techniques take into account the loss of alloying elements during the process, so this loss is usually compensated by the addition of a filler metal rich in alloying elements. A possible problem would be during the welding of these materials in adverse conditions in service, where the operator could have difficulties in welding with the filler metal. Therefore, in this work, two DSS and one SDSS were welded, by autogenous Tungsten Inert Gas (TIG), i.e., without addition of a filler metal, by three different heat inputs. After welding, microstructural, mechanical, and electrochemical analysis was performed. The microstructures were characterized for each welding condition, with the aid of optical microscopy (OM). Vickers hardness, Charpy-V, and cyclic polarization tests were also performed. After the electrochemical tests, the samples were analyzed by scanning electron microscopy (SEM). The SDSS welded with high heat input kept the balance of the austenite and ferrite, and toughness above the limit value. The hardness values remain constant in the weld regions and SDSS is the most resistant to corrosion

I Diretriz Brasileira de Cardio-Oncologia da Sociedade Brasileira de Cardiologia

Inst Canc Estado Sao Paulo, BR-01246 Sao Paulo, BrazilUniv Sao Paulo, Hosp Clin, Fac Med, Inst Coracao, BR-05508 Sao Paulo, BrazilUniv Fed Sao Paulo, Escola Paulista Med, Inst Cardiol, Sao Paulo, BrazilUniv Fed Rio Grande do Sul, Hosp Clin Porto Alegre, Serv Cardiol, BR-90046900 Porto Alegre, RS, BrazilUniv Hosp, Brasilia, DF, BrazilHosp Procardiaco, Ctr Insuficiencia Cardiaca, Rio De Janeiro, BrazilUniv Pernambuco, Recife, PE, BrazilUniv Fed Amazonas, Fdn Ctr Oncol Amazonas, Manaus, Amazonas, BrazilMonte Tabor Hosp Sao Rafael, Salvador, BA, BrazilFdn Beneficencia Hosp & Cirurgia, Clin Coracao, Aracaju, SE, BrazilHosp Socor, Ecoctr, Belo Horizonte, MG, BrazilUniv Fed Sao Paulo, Escola Paulista Med, Inst Cardiol, Sao Paulo, BrazilWeb of Scienc

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery

Background: Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. Methods: This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min -2 · m -2) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 μg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. Results: A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. Conclusions: The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

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