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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

BIOMETRIA TESTICULAR DE CORDEIROS EM DIFERENTES IDADES E ALIMENTADOS COM NÍVEIS CRESCENTES DE FIBRA EM DETERGENTE NEUTRO ORIUNDA DA FORRAGEM

The experiment was conducted at the Federal University of Lavras. We used 64 lambs, which, after birth, were divided into four treatments: Diet A - 8.67; Diet B - 17.34, Diet C - 26.01 and Diet D - 34.68% neutral detergent fiber from forage (NDFf) in the diet. At three days of age, lambs were separated from their mothers and began receiving sheep milk replacer until weaning at 55 days. The experimental diets were isonitrogenous, formulated to meet the nutritional requirements of growing lambs, except for energy. Four digestibility diet essays were conducted for determining of metabolizable energy (ME) at different ages (43, 83, 123 and 173 days of life). The biometric variables analyzed were weight, testis weight, scrotal circumference and volume. The experimental design was in randomized blocks (DBC), in a 4 x 4 factorial arrangement (four levels of dietary NDFf and four slaughter ages), with 4 replicates per treatment. The estimation of scrotal circumference by weight proved to be more efficient than in function of age. The prediction of the size and weight of the testes through scrotal circumference was more efficient than by the age and body weight. Animals fed diets with less fiber from forage, that is, with greater amount of energy, showed better results of testis biometry compared to the animals fed smaller amounts of energy

CONSUMO, DIGESTIBILIDADE E CURVA GLICÊMICA DE OVELHAS EM FINAL DE GESTAÇÃO RECEBENDO DIFERENTES RELAÇÕES VOLUMOSO:CONCENTRADO

This research was carried out to investigate the effect of different levels of forage and concentrate in the diet offered to pregnant ewes on the intake, glucose level and apparent digestibility. A study of in vivo digestibility was done to determine the intake and the apparent digestibility and blood samples were collected to determine the glucose concentration. Sixteen adult, pregnant, non- lactating, Santa Inês ewes, weighting 54.10 ± 5.89 kg, were used. The experimental design used was a completely randomized arrangement, with four treatments (10%; 20%; 30% and 40% of roughage). The intake of DM, digestible energy, metabolizable energy and digestible protein was not influenced by treatments. The apparent digestibility of DM, CE and neutral detergent fiber (NDF) was not influenced by treatments. The apparent digestibility of CP and the intake of NDF were influenced by treatments. The glucose level was influenced by treatments and the times of collection

Consumo, digestibilidade aparente e balanço de nitrogênio em ovelhas alimentadas com diferentes níveis de fibra em detergente neutro

This research was carried to investigate the effect of different levels of forage neutral detergent fiber (fNDF) in the diet offered to ewe on the intake and apparent digestibility of the diet and on nitrogen balance. Sixteen adult, non-pregnant and non-lactating Santa Ines ewes, weighting 45.01 ± 5.15 kg, were used. The experimental design used was a 4x4 latin square, with four treatments (8.67%; 17.34%; 26.01% and 34.69% of fNDF) four animals and four periods. The intake of dry matter (DM), organic matter (OM), gross energy (GE), digestible energy (DE), metabolizable energy (ME), crude protein (CP), digestible protein (DP), neutral detergent fiber (NDF) and acid detergent fiber (ADF) were influenced positively by the levels of fNDF of the treatments. The apparent digestibility of DM, OM, GE and ADF wereinfluenced by treatments. Nitrogen balances were positive at all levels of forage NDF. This study made it clear that there is a physiological limit to the use of concentrate in diets offered to ewe, being necessary a minimum amount of forage NDF in the diet to reach the maximum efficiency of nutrients use; however, this limit seems to be inferior at the lowest level of fNDF of the current study.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

O processo tributário: do administrativo ao judicial

- Divulgação dos SUMÁRIOS das obras recentemente incorporadas ao acervo da Biblioteca Ministro Oscar Saraiva do STJ. Em respeito à Lei de Direitos Autorais, não disponibilizamos a obra na íntegra.- Localização na estante: 336.2:35.077.3(81) P963