Efeito dos aditivos do tabaco na iniciação e manutenção do tabagismo

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the SMARTPARKS Project

UID/SOC/04647/2013Small Islands face particular challenges in their sustainable development, and therefore require specific tailored approaches for planning and management. Unsurprisingly, protected areas have a special role in the conservation of biodiversity and natural resources crucial to the sustainability of such territories. How should the management and planning system of protected areas in small islands be, therefore, structured and operated so it can face the threats and challenges falling upon the already fragile and vulnerable insular ecosystems? This is the central question of SMARTPARKS Project. The core objective of the project consists of the conceptual development of a planning and management system for protected areas that can be integrated with the territorial management instruments in force, and that takes into consideration the specificities of insular ecosystems, correcting or perfecting the insufficiencies or flaws already pointed out to traditional planning systems of protected areas. This paper presents the SMARTPARKS Project, its rationale and main outcomes. Taking Pico Island Natural Park (Azores, Portugal) as its case study, the SMARTPARKS Project has adopted the ecosystem approach and the conciliation of conservation objectives with human needs and activities. Throughout its five tasks several studies were developed, and contributed to the functional analysis (developed during the last task) of each protected area constituting the Island Natural Park, in terms of their conservation and development values. This innovative application allows not only an integrated assessment of the protected areas but also a sustained monitoring. PT | RESUMOAs pequenas ilhas oceânicas enfrentam desafios particulares com vista ao seu desenvolvimento sustentável, necessitando consequentemente de abordagens técnicas de base científica específicas no desenvolvimento das suas estratégias de planeamento e gestão territoriais. É inquestionável a relevância do papel das áreas protegidas quer na conservação da biodiversidade e dos recursos naturais, quer na sustentabilidade dos territórios por elas abrangidos. De que modo deve ser então definido o modelo de planeamento e gestão de áreas protegidas em pequenas ilhas oceânicas para poder fazer face a todas as ameaças e desafios com que se deparam estes frágeis e vulneráveis ecossistemas costeiros? Esta é a questão principal pela qual se rege o projecto SMARTPARKS. O objectivo nuclear deste projecto consiste no desenvolvimento conceptual de um sistema integrado de planeamento e gestão de áreas protegidas que possa integrar, complementar e fortalecer os instrumentos de gestão territorial vigentes, e que tenha em consideração as particularidades e especificidades destes ecossistemas insulares, corrigindo ou minimizando as falhas e insuficiências já identificadas das ferramentas e técnicas tradicionais de planeamento territorial de áreas protegidas. Este artigo apresenta o projecto SMARTPARKS, o seu contexto, a sua abordagem conceptual e os seus principais resultados. O Parque Natural de Ilha do Pico (Arquipélago dos Açores, Portugal) constitui o caso de estudo deste projecto, estando o desenvolvimento conceptual do SMARTPARKS especialmente focado numa sinergia definida pela abordagem ecossistémica e pela sua tentativa de conciliação com os objectivos de conservação com todas as necessidades e actividades humanas de cariz sócio-económico e cultural desenvolvidas no território abrangido. Ao longo do seu desenvolvimento metodológico dividido em 5 grandes tarefas, vários estudos específicos foram realizados, contribuindo nomeadamente para a análise funcional (em termos de valores para a conservação e desenvolvimento) que foi feita para cada área protegida que compõe o Parque Natural de Ilha do Pico. Esta abordagem metodológica inovadora permite não só uma avaliação integrada das áreas protegidas como também a sua monitorização sustentável.publishersversionpublishe

Identificação de Problemas e Propostas para Melhoria

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Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

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

Evaluation of KRAS Concomitant Mutations in Advanced Lung Adenocarcinoma Patients

Background and Objectives: One of the most frequently mutated oncogenes in cancer belongs to the Ras family of proto-oncogenes, which encode distinct key signaling events. RAS gain-of-function mutations are present in ~30% of all human cancers, with KRAS being the most frequently mutated isoform showing alterations in different cancer types including lung cancer. This study aimed to investigate the incidence of KRAS mutations, and concomitant mutations, in advanced non-small cell lung adenocarcinoma patients. Materials and Methods: This was a retrospective study, where genomic DNA extracted from paraffin-embedded tumor tissues from 121 Brazilian advanced non-small cell lung adenocarcinoma patients were analyzed to evaluate via Next Generation Sequencing (NGS) the incidence of KRAS mutations and co-occurring mutations and correlate, when possible, to clinicopathological characteristics. Statistical analyses were performed to calculate the prevalence of mutations and to investigate the association between mutational status, mutation type, and sex. Results: The results showed a prevalence of male (N = 63; 54.8%) compared to female patients (N = 52, 45.2%), and mutant KRAS was present in 20.86% (24/115) of all samples. Interestingly, 33.3% of the mutant KRAS samples showed other mutations simultaneously. Conclusions: This study revealed the presence of rare KRAS concomitant mutations in advanced lung adenocarcinoma patients. Further investigation on the importance of these genomic alterations in patient prognosis and treatment response is warranted