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

Hemoparasites of the genus Trypanosoma (Kinetoplastida: Trypanosomatidae) and hemogregarines in Anurans of the São Paulo and Mato Grosso do Sul States - Brazil

Wild animals are exposed to numerous pathogens, including hemoparasites. The Trypanosoma and hemogregarinegroup are frequently reported as parasites in anurans (frogs, tree frogs and toads). The identification of these hemoparasites is usually made through stage observation of their morphology in the peripheral blood of the host. There areno studies, however, based on the biological cycle of these hemoparasites. The objective of the present study was toevaluate the presence of hemogregarines and Trypanosoma spp. in anurans captured in the States of São Paulo andMato Grosso do Sul- Brazil and to perform the morphological and morphometric characterization of these hemoparasites. The species of anurans examined were: Dendropsophus nanus, D. minutus, Leptodactylus chaquensis L. podicipinus, L. labyrinthicus, L. fuscus, Bufo granulosus, B. schneideri, Phyllomedusa hypocondrialis, Trachicephalus venulosus, Scinax fuscovarius and Hypsiboas albopunctatus. Of the total of 40 animals studied, four (10%)were positive for hemogregarines and eight (20%) were positive for Trypanosoma spp. Hemogregarine gamontsshowed variable morphology and, in addition to intraerythrocytic forms, extraerythrocytic forms were also observed.Extremely different forms of Trypanosoma were observed, as described in the literature, with the broad and oval forms being the most common.<br>Os animais silvestres estão expostos a inúmeros patógenos,dentre eles estão os hemoparasitas. Podem-se destacar espécies do gênero Trypanosoma e do grupo das hemogregarinas,que ocorrem com freqüência parasitando anuros (rãs, pererecas e sapos). Normalmente, a descrição destes hemoparasitas é feita através da morfologia dos estágios observados nosangue periférico do hospedeiro e as pesquisas sobre o ciclobiológico desses hemoparasitas são escassas. Os objetivos dopresente estudo foram avaliar a presença de hemogregarinas eTrypanosoma spp. em anuros capturados nos Estados de São Paulo e Mato Grosso do Sul e fazer a caracterização morfológica e morfométrica dos seus hemoparasitas. As espécies deanuros examinadas foram: Dendropsophus nanus, D. minutus, Leptodactylus chaquensis, L. podicipinus, L. labyrinthicus, L. fuscus, Bufo granulosus, B. schneideri, Phyllomedusahypocondrialis, Trachicephalus venulosus, Scinax fuscovarius e Hypsiboas albopunctatus. Dos 40 animais estudados, foramencontrados quatro (10%) positivos para hemogregarinas e oito(20%) positivos para Trypanosoma spp. Foram observadosgamontes de hemogregarinas com morfologia variável e, alémdas formas intraeritrocíticas, também foram observados gamontes fora das hemácias. As formas de Trypanosoma encontradas eram muito polimórficas, conforme é descrito na literatura, sendo na sua maioria, larga e oval

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