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

Produção e qualidade de azevém-anual submetido a adubação nitrogenada sob pastejo por cordeiros Production and quality of annual ryegrass submitted to nitrogen fertilization under grazing by lambs

O objetivo neste trabalho foi verificar como a adubação nitrogenada pode afetar a produção e a qualidade da massa de forragem em pastagem de azevém-anual (Lolium multiflorum Lam.) sob lotação contínua de cordeiros de corte. O azevém foi implantado em 6 de junho de 2006, em sistema de plantio direto com densidade de semeadura de 45 kg de sementes/ha. A adubação de base foi de 300 kg/ha, sem nitrogênio, com 60 kg/ha P2O5 e 60 kg/ha K2O. As adubações corresponderam a quatro doses de nitrogênio (N) na forma de ureia (45% de N) em aplicação de cobertura após 35 dias do plantio: 0; 75; 150; ou 225 kg/ha de N. O período de avaliação foi de 84 dias. Para cada kg de nitrogênio aplicado na pastagem de azevém, verificaram-se aumentos lineares de 2,82 kg/ha de massa de forragem, 1,28 kg/ha de massa seca de folhas verdes, 2,47 perfilhos/m² e 15,84 kg/ha de massa de forragem total. As doses de nitrogênio aplicadas não influenciaram os teores de proteína bruta (21,21%), fibra detergente ácido (25,90%) e fibra detergente neutro (54,93%) da forragem colhida por meio da simulação do pastejo. O aumento nas doses de nitrogênio interferem positivamente na taxa de acúmulo, o que proporciona maior massa de forragem total.<br>The aim of this work was to evaluate how nitrogen fertilization can affect forage mass production and quality on annual Italian ryegrass (Lolium multiflorum Lam.) pasture under continuous stocking of beef lambs. Ryegrass was established on June 6th, 2006, on no-tillage cropping system with seed density of 45 kg seeds/ha. Base fertilization was 300 kg/ha without N, with 60 kg/ha P2O5 and 60 kg/ha K2O. Fertilization consisted on four doses of nitrogen (N) using urea fertilizer (45% de N) in covering application 35 days after seeding: 0; 75; 150; or 225 kg/ha N. Periods of evaluations lasted 84 days. For each kg of nitrogen applied on ryegrass pasture, it was observed linear increases of 2.82 kg/ha of forage mass, 1.28 kg/ha of green leaf dry mass, 2.47 tillers/m² and 15.84 kg/ha of total forage mass. Doses of applied nitrogen did not affect crude protein contents (21.21%), acid detergent fiber (25.90%) and neutral detergent fiber (54.93%) of forage harvested through grazing simulation. The increase on nitrogen doses interfere positively in the accumulation rate, providing greater total forage mass

Laços familiares e aspectos materiais da dinâmica mercantil na cidade de São Paulo (séculos XVIII e XIX)

Based on the family ties established within the active merchant community of the city of São Paulo through the 18th and 19th centuries, the author sets out to tell the life story of nine merchants involved in matrimonial alliances, with a focus on the transactions carried out, their sociopolitical engagement and the fortunes of their descendants. Having done that, she seeks out connections between the urban development of the city center and the activities of these businessmen by means of analyses centered on the material aspects of their lives, particularly those related to their homes and home furniture