Empaglifozina no tratamento de portadores de diabetes tipo 2: proteção cardiovascular

Introdução: Indivíduos com diabetes mellitus tipo 2 (DM2) têm risco para doença cardiovascular (DCV) de duas a três vezes maior que a população sem essa condição. O estudo IRIS (Insulin Resistance Intervention after Stroke), comprovou que enquanto a hiperglicemia é um fator de risco fraco para DCV, a síndrome de resistência à insulina é o principal fator. Considerando isso, vários estudos têm demonstrado que as mais novas medicações para controle de DM2 reduzem o risco cardiovascular de forma independente da redução de glicose e por meio da ação em outros fatores de risco relacionados à resistência à insulina como obesidade, dislipidemia e hipertensão. Entre esses medicamentos se destaca a empaglifozina, um inibidor do cotransportador sódio-glicose 2 (iSGLT2) que diminui a reabsorção de glicose do filtrado glomerular de volta para a circulação, resultando em um aumento da excreção urinária de glicose e em uma diminuição da glicemia. Objetivo: analisar o efeito de proteção cardiovascular da empaglifozina em indivíduos com DM2 e os prováveis mecanismos responsáveis por essa proteção. Material e Método: trata-se de uma revisão integrativa da literatura. A busca foi feita nas bases de dados Public Medlines (Pubmed) e Literatura Latino-americana do Caribe em Ciências da Saúde (LILACS) utilizando os descritores “type 2 diabetes mellitus”, “empaglifozin” e “cardiovascular outcomes”. Foram obtidos 178 resultados, dos quais foram incluídos para análise aqueles publicados a partir de 2015 e com maior rigor científico, obtendo-se 10 artigos. Resultados: O estudo EMPA-REG OUTCOME, mostrou que entre os pacientes com DM2 e alto risco cardiovascular, o grupo recebendo empaglifozina, em comparação com o grupo recebendo placebo, obteve taxas significantemente menores de morte por causas cardiovasculares (redução de 38 % no risco relativo), de hospitalização por insuficiência cardíaca (redução de 35 % no risco relativo) e de morte por qualquer causa (redução de 32% no risco relativo). Não houve diferenças significativas entre os grupos nas taxas de infarto do miocárdio ou acidente vascular cerebral. A empaglifozina reduz a rigidez arterial possivelmente pela redução no estresse oxidativo ou pela supressão da inflamação. Além disso, seu efeito diurético com a consequente redução do volume intravascular reduz a pressão aórtica central e produz uma redução na pós-carga que melhora a função do ventrículo esquerdo, reduz a carga de trabalho do coração e diminui a demanda de oxigênio do miocárdio. Acredita-se que esses efeitos hemodinâmicos são responsáveis por reduzir os eventos cardíacos, particularmente em indivíduos com doença cardíaca isquêmica, melhorar a função do ventrículo esquerdo e a insuficiência cardíaca congestiva. Houve um aumento na taxa de infecção genital, mas nenhum outro efeito adverso. Conclusão: O uso de empaglifozina em indivíduos com DM2 e alto risco cardiovascular leva a redução de desfecho primário de eventos cardíacos adversos principais, principalmente pela redução das taxas de morte por causas cardiovasculares. Seu uso não exerce nenhum efeito sobre as taxas de infarto do miocárdio e acidente vascular cerebral. Também produz uma menor taxa de morte por qualquer causa e hospitalização por insuficiência cardíaca. Os principais mecanismos de ação que explicam isso são os efeitos hemodinâmicos, responsáveis por reduzir os eventos cardíacos

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

Adaptação transcultural e análise das propriedades psicométricas da versão brasileira do instrumento Motor Activity Log Cross-cultural adaptation and analysis of the psychometric properties of the Brazilian version of the Motor Activity Log

OBJETIVO: Traduzir para o português brasileiro e adaptar transculturalmente o Motor Activity Log (MAL), instrumento específico que avalia a função do membro superior mais afetado (MSMA) em hemiplégicos. MÉTODOS: O MAL foi traduzido e adaptado seguindo instruções padronizadas e submetido a exame de confiabilidade teste-reteste (coeficiente de correlação intraclasse, CCI). As demais propriedades psicométricas foram investigadas pela análise de Rasch em 77 hemiplégicos crônicos (41 homens, média de idade = 57,5 ± 12,4 anos). RESULTADOS: Tanto a escala de quantidade como a escala de qualidade do MAL obtiveram excelente CCI (0,98) para as pontuações totais. Quanto ao grau de dificuldade, "usar a chave para destrancar a porta" foi o item mais difícil na escala quantitativa, sendo "lavar as mãos" o item mais fácil. Na escala qualitativa, o mais difícil foi "utilizar o controle remoto da TV", e o mais fácil, "secar as mãos". A análise mostrou que o conjunto dos itens enquadrou-se no modelo; entretanto, quatro itens não se encaixaram nas expectativas do modelo nas escalas quantitativa (itens 21, 16, 14 e 13) e qualitativa (itens 9, 21, 23 e 22). Foram localizadas pessoas com padrão errático de respostas, e cinco indivíduos tiveram pontuação mínima. Constatou-se discrepância entre dificuldade dos itens e habilidade da amostra, indicando que as habilidades dos indivíduos estavam abaixo da dificuldade dos itens. Houve correlação significativa entre a força de preensão do MSMA e as medidas de habilidade dos indivíduos na escala quantitativa (r = 0,51; P & lt; 0,0001) e qualitativa (r = 0,57; P OBJECTIVE: To describe the translation into Brazilian Portuguese and cross-cultural adaptation of the Motor Activity Log (MAL), an instrument specifically designed to assess function of the more severely affected upper limb in hemiplegics. METHODS: The MAL was translated and adapted according to standardized procedures and submitted to test-retest reliability assessment (intraclass correlation coefficient, ICC). Other psychometric properties were investigated using Rasch analysis in 77 chronic hemiplegics (41 men, mean age = 57.5 ± 12.4 years). RESULTS: An excellent ICC (0.98) was obtained for the total scores of both the quantity and quality MAL scales. When assessing degree of difficulty, "using a key to unlock the door" was the most difficult item on the quantity scale, whereas "washing hands" was the easiest one. On the quality scale, the most difficult item was "using the TV remote control," and the easiest one was "drying hands." The analyses showed that the set of items as a whole fit into the model; however, the individual analyses indicated that four items did not meet the expectations of the model in both the quantity (items 21, 16, 14, and 13) and quality (items 9, 21, 23, and 22) scales. Irregular response patterns were observed, and five subjects obtained the minimum score. There was disagreement between item difficulty and sample ability, suggesting that the abilities of individuals were below the degree of difficulty of the assessed items. A significant correlation was observed between grip strength of the more severely affected upper limb and motor skill measurement among individuals on the quantity (r = 0.51, P < 0.0001) and quality scales (r = 0.57, P < 0.0001), and also between the two scales when measuring the individuals' motor skills (r = 0.97, P < 0.0001). CONCLUSIONS: MAL-Brazil is potentially useful to evaluate the more severely affected upper limb in Brazilian patients with chronic hemiplegia. However, the instrument has limitations for use with individuals with severe limb impairments. Also, construct validity was affected by the presence of irregular score patterns. MAL-Brazil should be applied to additional samples to further investigate its validity

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

Brazilian Flora 2020: Leveraging the power of a collaborative scientific network

International audienceThe shortage of reliable primary taxonomic data limits the description of biological taxa and the understanding of biodiversity patterns and processes, complicating biogeographical, ecological, and evolutionary studies. This deficit creates a significant taxonomic impediment to biodiversity research and conservation planning. The taxonomic impediment and the biodiversity crisis are widely recognized, highlighting the urgent need for reliable taxonomic data. Over the past decade, numerous countries worldwide have devoted considerable effort to Target 1 of the Global Strategy for Plant Conservation (GSPC), which called for the preparation of a working list of all known plant species by 2010 and an online world Flora by 2020. Brazil is a megadiverse country, home to more of the world's known plant species than any other country. Despite that, Flora Brasiliensis, concluded in 1906, was the last comprehensive treatment of the Brazilian flora. The lack of accurate estimates of the number of species of algae, fungi, and plants occurring in Brazil contributes to the prevailing taxonomic impediment and delays progress towards the GSPC targets. Over the past 12 years, a legion of taxonomists motivated to meet Target 1 of the GSPC, worked together to gather and integrate knowledge on the algal, plant, and fungal diversity of Brazil. Overall, a team of about 980 taxonomists joined efforts in a highly collaborative project that used cybertaxonomy to prepare an updated Flora of Brazil, showing the power of scientific collaboration to reach ambitious goals. This paper presents an overview of the Brazilian Flora 2020 and provides taxonomic and spatial updates on the algae, fungi, and plants found in one of the world's most biodiverse countries. We further identify collection gaps and summarize future goals that extend beyond 2020. Our results show that Brazil is home to 46,975 native species of algae, fungi, and plants, of which 19,669 are endemic to the country. The data compiled to date suggests that the Atlantic Rainforest might be the most diverse Brazilian domain for all plant groups except gymnosperms, which are most diverse in the Amazon. However, scientific knowledge of Brazilian diversity is still unequally distributed, with the Atlantic Rainforest and the Cerrado being the most intensively sampled and studied biomes in the country. In times of “scientific reductionism”, with botanical and mycological sciences suffering pervasive depreciation in recent decades, the first online Flora of Brazil 2020 significantly enhanced the quality and quantity of taxonomic data available for algae, fungi, and plants from Brazil. This project also made all the information freely available online, providing a firm foundation for future research and for the management, conservation, and sustainable use of the Brazilian funga and flora

Growing knowledge: an overview of Seed Plant diversity in Brazil

Abstract An updated inventory of Brazilian seed plants is presented and offers important insights into the country's biodiversity. This work started in 2010, with the publication of the Plants and Fungi Catalogue, and has been updated since by more than 430 specialists working online. Brazil is home to 32,086 native Angiosperms and 23 native Gymnosperms, showing an increase of 3% in its species richness in relation to 2010. The Amazon Rainforest is the richest Brazilian biome for Gymnosperms, while the Atlantic Rainforest is the richest one for Angiosperms. There was a considerable increment in the number of species and endemism rates for biomes, except for the Amazon that showed a decrease of 2.5% of recorded endemics. However, well over half of Brazillian seed plant species (57.4%) is endemic to this territory. The proportion of life-forms varies among different biomes: trees are more expressive in the Amazon and Atlantic Rainforest biomes while herbs predominate in the Pampa, and lianas are more expressive in the Amazon, Atlantic Rainforest, and Pantanal. This compilation serves not only to quantify Brazilian biodiversity, but also to highlight areas where there information is lacking and to provide a framework for the challenge faced in conserving Brazil's unique and diverse flora