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

Níveis séricos elevados de ácido araquidônico em indivíduos com periodontite crônica

Introdução: Ácidos graxos poli-insaturados estão sendo considerados uma valiosa abordagem para tratar as doenças periodontais. Objetivo: avaliar níveis plasmáticos dos ácidos: docosahexaenóico (DHA), eicosapentaenoico (EPA), docosapentanóico (DPA) e do ácido araquidônico (AA) em pacientes com periodontite crônica generalizada moderada e comparar com os níveis de pacientes que tinham apenas gengivite. Metodologia: Foram avaliados 10 indivíduos adultos com periodontite crônica (média de idade 42,5 ± 6,6 anos; 8 mulheres) e 10 indivíduos com gengivite (média de idade 32,8 ± 8,5 anos; 8 mulheres). O exame periodontal incluiu: índice de placa visível; índice de sangramento gengival, profundidade de sondagem, perda de inserção clínica e recessão gengival. Coleta de 20 ml de sangue após 12 horas de jejum foi realizada para avaliar os níveis de ácidos graxos poli-insaturados. Foram utilizados os testes estáticos T de Student e o qui quadrado. O nível de significância foi determinado em 5 % (p< 0.05). O programa SPSS 15.0 foi utilizado para a análise dos dados. Resultados: Os pacientes com periodontite apresentavam níveis significativamente mais altos de AA (1017,3 ±327,5mcmol/1) quando comparados aos indivíduos apenas com gengivite (609,0 ±257,2) (p<0,01). Em ambos os grupos as proporções AA/DPA e AA/EPA estavam mais altas do que a razão recomendada de 10:1, sugerindo que indivíduos com gengivite e periodontite apresentavam um desequilíbrio entre os ácidos ômega 3 e 6, o que pode prejudicar a resolução da inflamação nesses indivíduos. Conclusão: Esse estudo piloto demonstrou que indivíduos com periodontite crônica generalizada moderada apresentaram níveis plasmáticos mais elevados de AA do que indivíduos que tinham apenas gengivite. Os níveis plasmáticos de DHA, EPA e DPA foram similares entre os dois grupos avaliados

Receptor-Type Protein-Tyrosine Phosphatase ζ and Colony Stimulating Factor-1 Receptor in the Intestine: Cellular Expression and Cytokine- and Chemokine Responses by Interleukin-34 and Colony Stimulating Factor-1

<div><p>Differential intestinal expression of the macrophage growth factors colony stimulating factor-1 (CSF-1), interleukin (IL)-34, and their shared CSF-1 receptor (CSF-1R) in inflammatory bowel disease (IBD) has been shown. Diverse expression between CSF-1 and IL-34, suggest that IL-34 may signal via an alternate receptor. Receptor-type protein-tyrosine phosphatase ζ (PTPRZ1, RPTP-ζ), an additional IL-34 receptor, was recently identified. Here, we aimed to assess <i>PTPRZ1</i> expression in IBD and non-IBD intestinal biopsies. Further, we aimed to investigate cellular PTPRZ1 and CSF-1R expression, and cytokine- and chemokine responses by IL-34 and CSF-1. The expression of <i>PTPRZ1</i> was higher in non-IBD colon compared to ileum. <i>PTPRZ1</i> expression was not altered with inflammation in IBD, however, correlated to <i>IL34</i>, <i>CSF1</i>, and <i>CSF1R</i>. The expression patterns of PTPRZ1 and CSF-1R differed in peripheral blood mononuclear cells (PBMCs), monocytes, macrophages, and intestinal epithelial cell line. PBMCs and monocytes of the same donors responded differently to IL-34 and CSF-1 with altered expression of tumor-necrosis factor α (TNF-α), IL-1β, interferon γ (IFN-γ), IL-13, IL-8, and monocyte chemotactic protein-1 (MCP-1) levels. This study shows that <i>PTPRZ1</i> was expressed in bowel tissue. Furthermore, CSF-1R protein was detected in an intestinal epithelial cell line and donor dependently in primary PBMCs, monocytes, and macrophages, and first hints also suggest an expression in these cells for PTPRZ1, which may mediate IL-34 and CSF-1 actions.</p></div

Diverse regulation of IL-10, IL-1β, TNF-α and MCP-1 in macrophages differentiated in the presence of IL-34 and CSF-1.

<p><b>(A-C)</b><i>IL1B</i>, <i>TNFA</i> and <i>IL10</i> mRNA expression in IL-34 and/or CSF-1 differentiated macrophages and polarized to an M1-like phenotype, an M2-like phenotype or non-polarized were analysed by q-PCR and normalized to <i>GAPDH</i>. Data represent mean + SEM, *P<0.05; **P<0.01; ***P<0.001, ANOVA, n = 5–6 donors. <b>(D-F)</b> Secreted IL-10, MCP-1 and IL-1β in the supernatant from IL-34 and/or CSF-1 differentiated macrophages and polarized to an M1-like phenotype, an M2-like phenotype or non-polarized were analysed by ELISA. Data represent mean + SEM, *P<0.05; **P< 0.01; ***P<0.001, ANOVA, n = 9 donors.</p

PTPRZ1 is differentially expressed in normal human ileum and colon but not regulated with inflammation.

<p><b>(A)</b><i>PTPRZ1</i> relative mRNA expression in ileum and colon, presented as the mean per colon sites for each non-IBD subjects. <b>(B)</b> <i>PTPRZ1</i> relative mRNA in different sites of the colon from non-IBD subjects. <i>PTPRZ1</i> relative mRNA expression in <b>(C)</b> colon and <b>(D)</b> ileum from non-IBD, IBD, UC and CD patients. Comparisons between ileum and colon were calculated using Mann–Whitney <i>U</i> tests, and between different sites of colon by ANOVA with post-hoc LSD tests. N = 18 for ileum, n = 24 for colon. Results are means ± SEM *P<0.05; **P<0.01; ***P<0.001. <b>(E)</b> <i>PTPRZ1</i> relative mRNA expression compared between non-inflamed and inflamed in IBD patients. <i>PTPRZ1</i> relative mRNA expression in colon presented as the mean per colon sites for each patient in IBD patients subdivided into CD and UC. Correlations of <i>PTPRZ1</i> with <b>(F)</b> <i>IL34</i>, <b>(G)</b> <i>CSF1</i>, <b>(H)</b> <i>CSF1R</i>, <b>(I)</b> <i>TNFA</i> and <b>(J)</b> <i>CD68</i> in IBD patients. Comparisons were evaluated using Mann–Whitney U tests. Correlations were assessed by Spearman’s correlation coefficients. N = 18 for non-inflamed IBD, n = 23 for inflamed IBD, n = 6 for non-inflamed CD, n = 6 for inflamed CD, n = 11 for non-inflamed UC, n = 16 for inflamed UC. Results are mean ± SEM *P<0.05; **P<0.01; ***P<0.001.</p

Expression of CSF-1R and PTPRZ1 in PBMCs, monocytes, macrophages and colonic epithelial cells.

<p>Immunoblotting of lysates from PBMCs, monocytes, CSF-1 monocyte derived and non-polarized macrophages, Caco-2 and A549 cells analysed for <b>(A)</b> CSF-1R and <b>(B)</b> PTPRZ1. β-actin was used as a loading control (10 and 15 μg protein per lane, respectively).</p

CSF-1R dependent regulation of pro-inflammatory cytokines and chemokines in PBMCs and monocytes <i>IL1B</i>, <i>TNFA</i>, <i>IFNG</i>, <i>IL8</i> and <i>MCP1</i> relative mRNA expression from PBMCs.

<p><b>(A, B)</b> and monocytes <b>(C, D)</b> stimulated with IL-34, PBMCs <b>(E, F)</b> and monocytes <b>(G, H)</b> stimulated with CSF-1, after blocking CSF-1R for 6 h. IgG1 was used as a control. Gene expression was analysed by q-PCR and normalized to <i>GAPDH</i>. Data represent mean + SEM, *P<0.05; **P<0.01; ***P<0.001, Student’s T-test, n = 5–6 donors. (<b>I-J</b>) Secreted MCP-1 in supernatants from PBMCs <b>(I)</b> and monocytes <b>(J)</b> stimulated with IL-34 or CSF-1 after blocking CSF-1R for 24 h, IgG1 was used as a control, were analysed by ELISA. Data represent mean + SEM, *P<0.05; **P<0.01; ***P<0.001, Student’s T-test, n = 6 donors.</p

Regulation of pro—inflammatory cytokines and chemokines through IL-34 and CSF-1 in PBMCs and monocytes <i>IL1B</i>, <i>TNFA</i>, <i>IFNG</i>, <i>IL8</i> and <i>MCP1</i> relative mRNA expression in PBMCs.

<p><b>(A, B)</b> and monocytes <b>(C, D)</b> stimulated with IL-34, CSF-1 for 1 h or left untreated were analysed by q-PCR and normalized to <i>GAPDH</i>. <i>IL1B</i>, <i>TNFA</i>, <i>IFNG</i>, <i>IL8</i> and <i>MCP1</i> relative mRNA expression from PBMCs <b>(E, F)</b> and monocytes <b>(G, H)</b> stimulated with IL-34, CSF-1 for 6 h or left untreated were analysed by q-PCR and normalized to <i>GAPDH</i>. Data represent mean + SEM, *P<0.05; **P<0.01; ***P<0.001, Student’s T-test, n = 5–6 donors. <b>(I)</b> Secreted MCP-1 in supernatants from Caco-2 cells, PBMCs and monocytes stimulated with IL-34 or CSF-1 for 24 h, as analysed by ELISA. Data represent mean + SEM, *P< 0.05; **P< 0.01; ***P< 0.001, Student’s T-test, n = 5–6 donors. <b>(J)</b> Secreted MCP-1 in supernatants from PBMCs stimulated with IL-34 or CSF-1 (10 or 50 ng/ml for 24h) were analysed by ELISA. Data represent mean + SEM, *P<0.05; **P<0.01; ***P<0.001, Student’s T-test, n = 6 donors.</p

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