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 cmH2O 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 6430 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 metho

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

Preliminary study to characterize differences in potential immunomodulatory effects of cyclosporine A using BALB/c and ICR mouse splenocytes

Cyclosporine A (CsA) is widely used as an immunosuppressant for the treatment of autoimmune diseases and immune regulation in transplant patients. Due to its wide applicability, studies of unwanted side effects of CsA are imperative. It has been found that not all patients treated with CsA display the same types/patterns of adverse effects. To ascertain the bases for these differential responses, potential differing effects of CsA on B-lymphocytes were analyzed. This entailed an assessment of changes in CsA viability and mitotic activity within splenocyte populations from BALB/c and ICR mice. These particular strains were examined because: (1) in each of them, previously have been shown that differed in the respond to biological response modifiers, such as bacterial agents, and/or immunogens; (2) our own earlier studies showing strain-associated differences in ex vivo splenocyte/lymphocyte responses to other drug; and, (3) a potential immunomodulatory effect of any agent should be studied in at least two different strains during a broad toxicological evaluation. Splenocytes from each strain were treated with 200 &#956;g/mL CsA, and CD4+, CD8+, and CD19+ cell viabilities were monitored at various time points during the exposure period. In general, there appeared to be a trend toward greater decreases in viability among BALB/c B-lymphocytes than their ICR counterparts as incubation progressed. Differences related with T-lymphocyte sensitivity to drug associated to strains was not observed, because it was uniformly lethal throughout. With regard to mitotic activity, cells from ICR mice were more susceptible to inhibition of spontaneous cell division at low concentrations of CsA (relative to the rates of blastogenesis by BALB/c counterparts). At higher concentrations of the drug however, there were no differences in the sensitivity of each strain. This work provides new insight into the mechanism of action of CsA and illustrates the need for at least two different strains of mice/rodents for the evaluation of the overall toxicological potential of any test agent.<br>Ciclosporina A (CsA) é amplamente usada como imunossupressor para o tratamento de doenças autoimunes e regulação imune nos pacientes transplantados. Devido à alta aplicabilidade, são imperativos os estudos sobre seus efeitos colaterais indesejáveis. Descobriu-se que nem todos os pacientes tratados com CsA apresentam os mesmos tipos/padrões de efeitos adversos. Para averiguar as bases dessas respostas diferentes, analisaram-se efeitos potenciais diferentes da CsA nos linfócitos B. Isto envolveu a avaliação de alterações na viabilidade da CsA e da atividade mitótica dentro das populações de esplenócitos de camundongos BALB/c e ICR. Essas espécies, em particular, foram examinadas porque: (1) cada uma delas mostrou, previamente, respostas diferentes a modificadores de respostas biológicas, tais como agentes bacterianos e/ou imunogênicos; (2) nossos estudos anteriores mostraram diferenças associadas às espécies em respostas ex vivo de esplenócitos/linfócitos a outro fármaco e (3) qualquer efeito imunomodulatório potencial de um agente em teste deveria ser estudado, no mínimo, em duas espécies diferentes durante a avaliação toxicológica ampla. Esplenócitos de cada espécie foram tratados com 200 &#956;g/mL de CSA e a viabilidade das células CD4+, CD8+ e CD19+ foi monitorada em vários tempos durante o período de exposição. No geral, parece haver uma tendência em relação a aumentos maiores na viabilidade entre os linfócitos B de BALB/c do que no de ICR, à medida que a incubação progride. Não se observou diferenças na sensibilidade do linfócito T, uma vez que o fármaco foi uniformemente letal. Com relação à atividade mitótica, as células de camundongos ICR se mostraram mais suscetíveis à inibição da divisão celular espontânea em baixas concentrações de CsA (relativamente às taxas de blastogênese de BALB/c). Em concentrações maiores do fármaco, entretanto, não houve diferenças na sensibilidade em cada uma das espécies. Este trabalho propicia nova visão do mecanismo de ação de CsA e ilustra a necessidade de, pelo menos, duas espécies diferentes de camundongos/roedores para a avaliação da toxicidade potencial de qualquer agente em teste

Estresse e suporte social em mães de crianças com necessidades especiais Stress and social support for mothers of children with special needs

O objetivo do presente estudo foi avaliar a associação entre estresse e suporte social em mães de crianças com necessidades especiais e mães de crianças com desenvolvimento típico, em famílias de baixa renda. Trata-se de estudo quantitativo com 75 mães de crianças com idade entre quatro e 8 anos, com renda familiar de até quatro salários mínimos, alocadas em dois grupos: mães de crianças com desenvolvimento típico e mães de crianças com necessidades especiais. As participantes responderam ao Inventário de Sintoma de Stress e ao Questionário de Suporte Social. Os resultados indicaram, em ambos os grupos, elevada porcentagem de mães estressadas. Mães de crianças com necessidades especiais contam com um menor número de pessoas suportivas. Observou-se associação negativa entre stress e satisfação com o suporte social. Discute-se que o presente estudo confirma achados de pesquisas anteriores e identifica o papel do suporte social nos processos de adaptação familiar. A associação encontrada entre a satisfação com o suporte social e o estresse aponta para adequação de proposições e implantação de programas de intervenções em saúde para famílias de crianças com necessidades especiais.<br>The aim of this article is to assess the relationship between stress and social support in mothers of children with special needs, as contrasted with mothers of children with typical development, from low income families. In this quantitative study, participants included 75 mothers with children aged four to eight years, with income up to four minimum wages, divided in two groups: mothers of children with typical development and mothers of children with special needs. The mothers answered the Inventory of Stress Symptom and the Social Support Questionnaire. The results showed that mothers of both groups suffered stress. The mothers of children with special needs have a smaller number of people to support them. A negative relationship between stress and satisfaction with social support was observed. This study agrees with earlier research findings and confirms the importance of the role of social support in family adaptation processes. The association found between satisfaction with social support and the stress signals the importance of health intervention programs for families of children with special needs