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

Células simples e complexas no wulst visual da coruja

Exportado OPUSMade available in DSpace on 2019-08-12T07:05:18Z (GMT). No. of bitstreams: 1 jo_o_paulo_machado_de_sousa___tese.pdf: 3022850 bytes, checksum: 1cd2394aebb286311aca5de818035b2a (MD5) Previous issue date: 7O wulst visual é o alvo das projeções retinotalamofugais no telencéfalo de aves. Em corujas, esta área é conhecida por possuir semelhanças funcionais com o córtex visual primário (V1) de mamíferos. Em seu estudo pioneiro, Pettigrew relatou que tais semelhanças também se estendiam a dois tipos celulares básicos que inicialmente foram descritos por Hubel e Wiesel (em V1): células simples, caracterizadas por suas seletividade espacial aproximadamente linear à polaridade do contraste do estímulo, e uma população muito mais diversificada de células denominadas complexas, as quais não exibem esta propriedade de resposta. Neste trabalho, os achados de Pettigrew foram reavaliados usando métodos de classificação mais quantitativos oriundos da teoria de sistemas lineares. O método calcula o índice de linearidade do somatório espacial baseado na resposta dos disparos da célula a uma grade senoidal em movimento. Os estímulo utilizados foram otimizados em termos de frequências espaciais e temporais, orientação, tamanho e direção do movimento, dependendo do protocolo de registro. A modulação da resposta evocada ($F_{1}/F_{0}$) é obtida por meio da divisão da amplitude da oscilação da resposta na frequência temporal do estímulo ($F_{1}$) pela média da resposta acima da atividade espontânea ($F_{0}$). Células que possuem $F_{1}/F_{0}$ $>$ 1 são classificadas como simples; as outras como complexas. A confiabilidade neste método de classificação se baseia em duas linhas de evidências: 1) concordância geral com outros métodos de mapeamento; 2) distribuição bimodal de $F_{1}/F_{0}$ com um vale bem definido entre os neurônios de V1 na maioria das espécies de mamíferos estudadas até hoje. Fui analisado um total de 369 neurônios, amostrados aleatoriamente ao longo de diferentes profundidades no wulst visual de dezesseis corujas buraqueiras acordadas. Os resultados obtidos até o momento mostram que a distribuição da modulação ($F_{1}/F_{0}$) foi unimodal (mediana $F_{1}/F_{0}$ = 0,43) sem evidência clara de um mínimo local (P=0,997 teste dip de Hartigan). Adotando o critério de classificação convencionalmente utilizado em mamíferos (descrito acima), 83\% das células amostradas foram classificadas como complexas (mediana $F_{1}/F_{0}$ = 0,36). A proporção de células simples (mediana $F_{1}/F_{0}$ = 1,33) foi apenas ligeiramente menor que o relatado por Pettigrew em corujas {\it Tyto alba } anestesiadas (21\%, 126/579). Os neurônios classificados como simples e complexos apresentaram valores de atividade espontânea mediana similares (3,43 e 4,24 disparos/s, respectivamente) e a modulação da resposta evocada não mostrou correlação estatisticamente significativa com a atividade espontânea. Conforme nossos dados, foi encontrada uma grande variação na modulação das respostas evocadas para baixo e alto contrastes, 7,5\% e 98\% respectivamente. Algumas células do wulst (aproximadamente 1/4 das células avaliadas, n = 120) apresentaram classificações variadas para diferentes contrastes. De acordo com um trabalho anterior de nosso grupo, os neurônios do wulst (86/111) apresentam uma supressão da resposta quando uma grade senoidal em movimento é expandida além do seu campo receptivo clássico (CRF). Aqui, mostramos que este efeito é muitas vezes acompanhado por um aumento de $F_{1}/F_{0}$ (aproximadamente 2/3 das células avaliadas, n = 86). Metodologias de mapeamento das subunidades do campo receptivo dos neurônios utilizando a correlação reversa foram desenvolvidas e aplicadas com o objetivo de caracterizar suas estruturas internas. Os mapeamentos das subunidades dos campos receptivos mostraram que a localização espacial das subunidades {\it ON} e {\it OFF} podem se alterar ao longo do tempo ou se configurar de forma diferente dependendo do estímulo utilizado em sua estimulação. Os campos receptivos se mostraram mais 'complexos' quando estimulados com um ruído esparso e mais 'simples' quando estimulados com um ruído denso. Portanto, de modo geral, nossos resultados não apóiam a existência de duas classes distintas de células simples/complexas no wulst visual. Os resultados sugerem ainda que o grau com que cada neurônio do wulst atua como um filtro espaço temporal linear depende da combinação específica dos atributos do estímulo.The visual wulst is the avian telencephalic target of the retinothalamofugal pathway. In owls, this area is known to have a close functional resemblance with mammalian primary visual cortex (V1). In his pioneering study, Pettigrew reports that this resemblance also extends to two basic cell types initially described by Hubel and Wiesel: simple cells, characterized by approximately linear spatial selectivity to stimulus contrast polarity, and a much more diverse population of so-called complex cells, which do not exhibit this response property. Here, we reassess Pettigrew's finding using a more quantitative classification method derived from linear system theory. The method computes a linearity index of spatial summation based on the spiking response of a cell to moving sinusoidal gratings optimized in terms of spatial as well as temporal frequencies, orientation and direction of motion. The index ($F_{1}/F_{0}$) is obtained by dividing the amplitude of response oscillation at the fundamental frequency of the stimulus ($F_{1}$) by the mean response of the cell above spontaneous discharge ($F_{0}$). Cells yielding a $F_{1}/F_{0}$ $>$ 1 are classified as simple cells; the others as complex cells. The reliability of this classification method is supported by two lines of evidence: 1) general agreement with other mapping methods; 2) Bimodal distribution of $F_{1}/F_{0}$ with a pronounced dip close to unity across V1 neurons of most mammalian species investigated to date. We analyzed a total of 369 neurons randomly sampled along different depths of the visual wulst of sixteen awake burrowing owls. Unexpectedly, the $F_{1}/F_{0}$ frequency distribution was found to be unimodal (median $F_{1}/F_{0}$ = 0.43) with no clear evidence of local minimum at unity (P = 0.997, Hartigan's dip test). Adopting the classification criterion conventionally used in mammals (see above), 83\% of our sampled cells were classified as complex (median $F_{1}/F_{0}$ = 0.36). The proportion of simple cells (median $F_{1}/F_{0}$ = 1.33) was however only slightly lower than that reported by Pettigrew in anesthetized barn owls (21\%, 126/579). Neurons classified as simple and complex had similar median spontaneous rates (3.43 and 4.24, respectively) and $F_{1}/F_{0}$ was not significantly correlated with spontaneous activity. According to our data, it was found a considerable variability of $F_{1}/F_{0}$ for low and high contrast, 7.5\% and 98\%, respectively. Some wulst's cells (about 1/4 of evaluated cells, n = 120) showed different classification for both contrasts. Most wulst's neurons exhibit marked response suppression when a drifting grating is expanded beyond their classical receptive field (CRF). Here, we found that this suppressive effect is actually often accompanied by a significant increase in $F_{1}/F_{0}$ (about 2/3 of evaluated cells, n = 86). Receptive field subunits mapping methodologies were developed and applied using the reverse correlation in order to characterize its internal structures. The receptive field subunits maps showed a dynamic behavior in the spatial localization of receptive field subunits ON and OFF during time and a receptive field reconfigurability depending on the stimulus statistics. The receptive field was more 'complex' like when stimulated by a sparse noise and more 'simple' like when stimulated by a dense noise. Altogether, our results do not support the existence of two discrete simple/complex cell classes within the visual wulst. They further suggest that the degree with which a wulst neuron operates as a spatiotemporal linear filter dependents on specific combinations of stimulus attributes

Porous membranes of the polycaprolactone (PCL) containing calcium silicate fibers for guided bone regeneration

Porous membranes of polycaprolactone containing calcium silicate fibers for guided bone regeneration were prepared by a controlled humidity method. The results indicated the development of the novel membrane microstructure with porosity and surface roughness increased. The pore size varied between 4.76-14.28 mu m and the roughness increase 72.8% compared with control. These characteristics can provide a better interaction with the biological medium combined to the osteoconduction properties of the calcium silicate fibers and biocompatibility of the PCL. Therefore, the porous PCL/CaSiO3 membranes are promising biomaterial for guided bone regeneration. (C) 2017 Elsevier B.V. All rights reserved.Sao Paulo Research Foundation - FAPESP BrazilFed Univ Sao Paulo UNIFESP, 330 Talim St, BR-2231280 Sao Jose Dos Campos, SP, BrazilNatl Inst Space Res INPE, 1758 Astronautas Ave, BR-2227010 Sao Jose Dos Campos, SP, BrazilUniv Fed Sao Carlos, Rod Washington Luis,Km 235, BR-13565905 Sao Carlos, SP, BrazilFed Univ Sao Paulo UNIFESP, 330 Talim St, BR-2231280 Sao Jose Dos Campos, SP, BrazilFAPESP: 2015/24659-7Web of Scienc

Age and gender influence on maximal bite force and masticatory muscles thickness

The present study aimed investigate the age and gender influence on maximal molar bite force and at outlining the criteria for normal masticatory muscle development in a sample of 177 Brazilian Caucasian dentate individuals aged 7-80 years divided into five age groups: I(7-12 years), II (13-20 years), III (21-40 years), IV (41-60 years), and V (61-80 years). Except for Group V, which comprised nine women and eight men, all groups were equally divided in respect to gender (20 M/20 F). Bite force was recorded with a mouth-adapted 1000 N dynamometer and the highest out of three records was regarded as the maximal bite force. The data were submitted to multivariate statistical analysis (SPSS 17.0 p < 0.05). Effects of group and gender were found, but no interactions between them. The ANOVA showed significant differences between groups bilaterally. Bonferroni`s test showed that group I had significantly lower bite force means at both sides as compared to all groups, except group V. No differences were found between the left and right sides. In all the groups, gender was found to be a significant factor associated with maximal bite force. A global comparison including all the subjects and measures showed that the means of men were approximately 30% higher than those of women, within-group comparisons yielded similar results in all groups. Muscle thickness was measured with a SonoSite Titan ultrasound tool using a high-resolution real-time 56 mm/10 MHz linear-array transducer. Three ultrasound images were obtained from the bilateral masseter and temporal muscles at rest and at maximal voluntary contraction. The means of the three measures in each clinical condition were analyzed with multivariate statistical analysis (SPSS 17.0 p < 0.05). A gradual increase in thickness of the masseter and temporal muscles was found both at rest and maximal voluntary contraction for groups I to IV, whereas a decrease in muscle thickness was observed in group V. Multivariate analysis showed that in both conditions there was an effect of group and gender. The study of the development of the stomatognathic system in relation to age and gender can provide useful data for the identification of normal and impaired functioning patterns. The results of this study indicate that age and gender are associated with structural and functional alterations in the muscles of the stomatognathic system. (C) 2010 Elsevier Ltd. All rights reserved.Fundacao de Amparo a Pesquisa - FAPESP[2006/60965-6

Validity of a Brazilian version of the Zung self-rating depression scale for screening of depression in patients with Parkinson`s disease

Introduction: Parkinson`s disease (PD) is a neurodegenerative disorder with prominent motor manifestations and many other non-motor symptoms that significantly decrease quality-of-life and are frequently under-recognized, for example depression. Objective: To study the validity of a Brazilian version of the Zung Self-rating Depression Scale (SDS) for the diagnosis of depression in patients with PD. Methods: We evaluated 78 consecutive non demented patients over the age of 40 with diagnosis of PD at a Movement Disorders Outpatient Clinic, who could read and understand questionnaires. They completed the SIDS and the Geriatric Depression Scale with 15 items (GDS-15). The diagnosis of depression was made after a structured clinical interview based on DSM-IV criteria for the diagnosis of major depression (SCID-CV). Results: The prevalence of major depression was 23.1%. Cronbach`s alpha was 0.73 and the area under the ROC curve was 0.93 for the SDS. The score index of 55 had a sensitivity of 88.9% and a specificity of 83.3% for the diagnosis of depression. The total scores of the SDS and GDS-15 were highly correlated (0.652, p < 0.0001) and correlated weakly with the scores of a motor scale. Discussion: The SIDS is a valid too] for screening depression in patients with PD since the specific SDS index of 55 is adopted. Two shortened versions could be used with good results. (C) 2009 Published by Elsevier Ltd.Conselho Nacional de Pesquisa (CNPq, Brasilia, Brazil)CAPES (Brasilia, Brazil)FAPESP (Sao Paulo, Brazil

Acupuncture and Temporomandibular Disorders: A 3-Month Follow-up EMG Study

Objectives: The purpose of this study was to investigate the levels of electromyographic (EMG) activation and maximal molar bite force before and after a 3-month acupuncture therapy in individuals with temporomandibular disorder (Helkimo Index) from a pool of subjects attending the Special Care Course of the Ribeirao Preto Dental School, Sao Paulo University, Brazil. Design: All 17 patients, aged between 37 and 50 years (44.2 +/- 4.84 years), with an average weight of 71 +/- 9.45 kg and height of 1.64 +/- 0.07 m, were clinically examined with regard to pain and dysfunctions of the masticatory system. The temporomandibular acupuncture points of needling were IG4, E6, E7, B2, VB14, VB20, ID18, ID19, F3, E36, VB34, E44, R3, and HN3. EMG measures were acquired before and after the treatment using a MyoSystem-BR1 electromyographer. The data collected at rest, protrusion, left and right laterality, and clenching were normalized by maximum voluntary contraction. Maximal bite force in right and left molar regions were registered using a dynamometer with a capacity of up to 1000 N, adapted for oral conditions. The highest value out of three recordings was considered to be the individual's maximal bite force. The results were statistically analyzed using the paired t test (SPSS version 15.0) during the comparison before and after treatment. Results: We found decreased EMG activity at rest, protrusion, left and right laterality, and clenching; as well as increased values of maximal bite force after acupuncture treatment. Conclusions: Acupuncture promoted alterations in the EMG activity of masticatory muscles, increased maximal molar bite force, and led to remission of the subjects' painful symptomatology.FAPESP[2006/55567-1

Altered gray matter morphometry and resting-state functional and structural connectivity in social anxiety disorder

In social anxiety disorder (SAD), impairments in limbic/paralimbic structures are associated with emotional dysregulation and inhibition of the medial prefrontal cortex (MPFq. Little is known, however, about alterations in limbic and frontal regions associated with the integrated morphometric, functional, and structural architecture of SAD. Whether altered gray matter volume is associated with altered functional and structural connectivity in SAD. Three techniques were used with 18 SAD patients and 18 healthy controls: voxel-based morphometry; resting-state functional connectivity analysis; and diffusion tensor imaging tractography. SAD patients exhibited significantly decreased gray matter volumes in the right posterior inferior temporal gyrus (ITG) and right parahippocampal/hippocampal gyrus (PHG/HIP). Gray matter volumes in these two regions negatively correlated with the fear factor of the Liebowitz Social Anxiety Scale. In addition, we found increased functional connectivity in SAD patients between the right posterior ITG and the left inferior occipital gyrus, and between the right PHF/HIP and left middle temporal gyms. SAD patients had increased right MPFC volume, along with enhanced structural connectivity in the genu of the corpus callosum. Reduced limbic/paralimbic volume, together with increased resting-state functional connectivity, suggests the existence of a compensatory mechanism in SAD. Increased MPFC volume, consonant with enhanced structural connectivity, suggests a long-time overgeneralization of structural connectivity and a role of this area in the mediation of clinical severity. Overall, our results may provide a valuable basis for future studies combining morphometric, functional and anatomical data in the search for a comprehensive understanding of the neural circuitry underlying SAD. (C) 2011 Elsevier B.V. All rights reserved.Natural Science Foundation of China[61035006]Natural Science Foundation of China[90820006]Natural Science Foundation of China[30625024]863 Program[2008AA02Z408]973 Project[2008CB517407]Flanders Research Foundation[A4/5-SDS15387]CNPq (Brazil

Late-onset social anxiety disorder following traumatic brain injury

Background: Neuropsychiatric sequelae are the predominant long-term disability after traumatic brain injury (TBI). This study reports a case of late-onset social anxiety disorder (SAD) following TBI. Case report: A patient that was spontaneous and extroverted up to 18-years-old started to exhibit significant social anxiety symptoms. These symptoms became progressively worse and he sought treatment at age 21. He had a previous history of traumatic brain injury (TBI) at age 17. Neuroimaging investigations (CT, SPECT and MRI) showed a bony protuberance on the left frontal bone, with mass effect on the left frontal lobe. He had no neurological signs or symptoms. The patient underwent neurosurgery with gross total resection of the lesion and the pathological examination was compatible with intradiploic haematoma. Conclusions: Psychiatric symptoms may be the only findings in the initial manifestation of slowly growing extra-axial space-occupying lesions that compress the frontal lobe from the outside. Focal neurological symptoms may occur only when the lesion becomes large. This case report underscores the need for careful exclusion of general medical conditions and TBI history in cases of late-onset SAD and may also contribute to the elucidation of the neurobiology of this disorder