Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

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

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Correlations and long-range interactions in disordered media: shorelines and Anderson transition

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgicoMuitos fenÃmenos fÃsicos tÃm forte dependÃncia da desordem do meio no qual ocorrem. A teoria de localizaÃÃo de Anderson, por exemplo, estabelece que a introduÃÃo de desordem em sistemas eletrÃnicos pode promover a transiÃÃo metal-isolante, tambÃm conhecida como transiÃÃo de Anderson. Contudo, para sistemas de baixa dimensionalidade, segundo essa mesma teoria, qualquer grau finito de desordem pode promover a localizaÃÃo exponencial de todas as funÃÃes eletrÃnicas. No entanto, foi mostrado que a teoria geral de localizaÃÃo de Anderson à violada quando correlaÃÃes e interaÃÃes de longo alcance sÃo utilizadas. Nesse cenÃrio, a transiÃÃo metal-isolante ocorre tambÃm para sistemas de baixa dimensionalidade. Nos problemas relacionados com redes, as ligaÃÃes de longo alcance sÃo responsÃveis pela pequena distÃncia mÃdia entre indivÃduos pertencentes à mesma rede social. Esse fenÃmeno à popularmente conhecido como os seis graus de separaÃÃo. AlÃm disso, Kleinberg mostrou que a introduÃÃo de uma distribuiÃÃo em lei de potÃncia de ligaÃÃes de longo alcance em uma rede substrato gera um mÃnimo no tempo de envio de uma informaÃÃo de um sÃtio fonte a um sÃtio alvo da rede. Nesta tese, investigamos como a desordem de longo alcance altera a classe de universalidade de dois modelos matemÃticos que representam os seguintes problemas fÃsicos: o processo de erosÃo na costa de paisagens correlacionadas e a transiÃÃo deslocalizaÃÃo-localizaÃÃo dos modos normais de vibraÃÃo de uma cadeia harmÃnica com ligaÃÃes de longo alcance restritas por uma funÃÃo custo. No primeiro modelo, mostramos que correlaÃÃes espaciais de longo alcance nas propriedades geolÃgicas da costa, no regime crÃtico do nosso modelo, gera um espectro de linhas costeiras fractais cujas dimensÃes fractais variam entre D=1.33 e 1.00 quando variamos o expoente de Hurst no intervalo 0<H<1. AlÃm disso, quando utilizamos superfÃcies nÃo correlacionadas, as linha costeiras, para erosÃes marÃtimas muito intensas, sÃo autoafins e pertencem à mesma classe de universalidade das interfaces descritas pela equaÃÃo de Kardar-Parisi-Zhang (KPZ). No segundo modelo, mostramos que ligaÃÃes de longo alcance inseridas em uma cadeia harmÃnica com uma probabilidade decaindo com o tamanho da ligaÃÃo, p ~ r -&#945;, restritas por uma funÃÃo custo proporcional ao tamanho da cadeia, promovem uma transiÃÃo deslocalizaÃÃo-localizaÃÃo dos modos normais de vibraÃÃo para o expoente &#945; &#8776; 1.25.Many physical phenomena have strong dependence on the disorder of the medium in which they occur. The {it Anderson} theory localization, for example, states that the introduction of disorder in electronic systems can promote the metal-insulator transition, also known as {it Anderson} transition. However, for low dimensional systems, according to the same theory, any finite degree of uncorrelated disorder is able to promote the exponential localization of all electronic functions. The general {it Anderson} theory localization is violated when long-range correlations and long-range interactions are used. In this scenario, the metal-insulator transition also occurs for low dimensional systems. In network problems, the long-range connections are responsible for the short average distance between individuals belonging to the same social network. This phenomenon is popularly known as six degrees of separation. Furthermore, {it Kleinberg} showed that the introduction of a power-law distribution of long-range links in a network produces a minimum in the transmission time information from a source site to a target site network . In this thesis, we investigate how the long-range disorder changes the universality class of two mathematical models that represent the following physical problems: the erosion process in correlated landscapes and the delocalization-localization transition of the normal modes of a harmonic chain with long range connections restricted by a cost function. In the first model, we show that long-range spatial correlations in the geological properties of the coast, in the critical regime of our model, generates a spectrum of fractals shorelines whose fractal dimensions vary between {it D} = 1.33 and 1.00 when we vary the {it Hurst} exponent in the range $0< H <1$. Furthermore, when we use uncorrelated surfaces, the shoreline, for very intense sea erosion, are self-affine and belong to the same universality class of the interfaces described by the equation of {it Kardar-Parisi-Zhang} ({it KPZ}). In the second model, we show that long-range links in a chain harmonic inserted with a probability with decreasing size of the bond, $p sim r^{-alpha}$, restricted by a cost function proportional to chain length, promotes a delocalization-localization transition of the normal modes for the exponent $alpha simeq 1.25$

Estudo de novos processos de empacotamento em duas dimensões

O processo de amassamento de fios em cavidades bidimensionais leva à formação de padrões complexos de laços interagentes controlados por interações de auto-exclusão e descritos por leis de escala robustas. A partir da análise de imagens de configurações de fios de cobre amassados em uma cavidade circular, estudamos a geometria individual dos laços. Entre outras propriedades, calculamos médias do ângulo de torção(b) e da relação perímetro/(área) 1 2 (k). Os valores médios de b e k obtidos obedecem consistentemente as relações para polígonos regulares para um número de lados n fracionário. Experimentos de empacotamento foram realizados utilizando o laço médio e obtivemos a fração de ocupação máxima pmax = 0,8752 em uma rede, valor intermediário entre a fração de ocupação de empacotamento máxima de discos pmax = 0,9068 e a fração de ocupação de empacotamento aleatório de discos paleat = 0, 8