Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities

Background: Mechanical ventilation is common in critically ill patients. This life-saving treatment can cause complications and is also associated with long-term sequelae. Patient-ventilator asynchronies are frequent but underdiagnosed, and they have been associated with worse outcomes.Main body: Asynchronies occur when ventilator assistance does not match the patient's demand. Ventilatory overassistance or underassistance translates to different types of asynchronies with different effects on patients. Underassistance can result in an excessive load on respiratory muscles, air hunger, or lung injury due to excessive tidal volumes. Overassistance can result in lower patient inspiratory drive and can lead to reverse triggering, which can also worsen lung injury. Identifying the type of asynchrony and its causes is crucial for effective treatment.Mechanical ventilation and asynchronies can affect hemodynamics. An increase in intrathoracic pressure during ventilation modifies ventricular preload and afterload of ventricles, thereby affecting cardiac output and hemodynamic status. Ineffective efforts can decrease intrathoracic pressure, but double cycling can increase it. Thus, asynchronies can lower the predictive accuracy of some hemodynamic parameters of fluid responsiveness.New research is also exploring the psychological effects of asynchronies. Anxiety and depression are common in survivors of critical illness long after discharge. Patients on mechanical ventilation feel anxiety, fear, agony, and insecurity, which can worsen in the presence of asynchronies. Asynchronies have been associated with worse overall prognosis, but the direct causal relation between poor patient-ventilator interaction and worse outcomes has yet to be clearly demonstrated.Critical care patients generate huge volumes of data that are vastly underexploited. New monitoring systems can analyze waveforms together with other inputs, helping us to detect, analyze, and even predict asynchronies. Big data approaches promise to help us understand asynchronies better and improve their diagnosis and management.Conclusions: Although our understanding of asynchronies has increased in recent years, many questions remain to be answered. Evolving concepts in asynchronies, lung crosstalk with other organs, and the difficulties of data management make more efforts necessary in this field

The Treaty of Alfred and Guthrum

Alfred the Great lived from 849-899, and is largely remembered as being one of the most influential rulers in English history. This is partially due to how effective his policies proved to be during a time of instability and uncertainty. Alfred met challenges in a pragmatic manner that enabled him to restore threatened institutions within England and bolster political stability. The innovative nature of Alfred's policies is perhaps most notably exemplified in the Treaty of Alfred and Guthrum, which was initiated in 878. At the time of Alfred's rule, England was not a politically united entity, but was rather a conglomeration of Anglo-Saxon kingdoms. The reign of Alfred, however, is widely recognized as having laid the groundwork for the eventual political unification of England in the generations to come. Alfred came to be recognized as the most powerful of the kings of England, and his descendants eventually held power in all of England. Recognition of Alfred's importance however, was not limited to England; as is shown by his daughters' strategic marriages to kings on the European continent

MOÇAMBIQUE SOB A MIRA DOS IMPÉRIOS: O PROSAVANA E A QUESTÃO DA TERRA

A interpretação territorial do espaço agrário moçambicano supõe reconhecer as forças que odominam, a dimensão histórica do país e o modo pelo qual a geopolítica da produção e dos negócios dealimentos, na escala mundial, se efetivam atualmente. Cabe reconhecer que os acordos e os programas,como o ProSAVANA, desenvolvido pelo pacto entre Brasil e Moçambique com mediação do Japão, éuma forma de instituir a modernização predatória das terras e dos modos de vida campesinos deMoçambique. Por meio de missões científicas, trabalhos de campo, tanto no Brasil quanto emMoçambique; organização de seminários e colóquios, estágios e orientações de pesquisas, eespecialmente, mediante o projeto de pesquisa “Sementes crioulas, quintais agroecológicos e cooperaçãopopular: troca de saberes e experiências de economia criativa do Cerrado brasileiro as savanas emInhambane/Moçambique”, nos foi possível edificar uma leitura territorial da situação da terra emMoçambique ao sabor das imposições econômicas e geopolíticas dos impérios agroalimentares dos paísesricos.Palavras-chave: produção de alimentos; modernização predatória; geopolítica; interpretação territoria