DINÂMICA DA COBERTURA DO SOLO NA MICROBACIA E ZONA RIPÁRIA DO RIO BELA VISTA, AMAZÔNIA OCIDENTAL, BRASIL

For an efficient environmental planning and management from the point of view of conservation of natural resources it is necessary to know the dynamics of soil cover in the watershed. Thus, the objective of this work was to provide information on the spatial and temporal dynamics of soil cover in the watershed and riparian zone of the Bela Vista River. Geotechnologies and satellite images were used for dynamics analysis. The watershed has an area of 7.78 km2, and in 1984, the cover was formed by agriculture (55.14%) and native forest (44.86%). The riparian area has an area of 2.27 km2, and in 1984, the cover was formed by agriculture (57.27%) and native forest (42.73%). In the period from 1984 to 2010, there was a steady growth of the agricultural area in the watershed (4.29 to 7.36 km2) and in the riparian zone (1.3 to 2.13 km2), but in the period from 2010 to 2022 there was a small decrease in both (7.36 to 7.28 km2 and 2.13 to 2.04 km2, respectively). In 2022, the main land cover was agriculture, covering 93.57% of the watershed area and 89.87% of the riparian area area. It is concluded that the agricultural area dominated the soil cover from 1984 to 2022, and the advance of this cover over virtually the entire area of the watershed and riparian area in the last year compromises the conservation of water resources and, consequently, the sustainable development of the region.Para una planificación y gestión ambiental eficiente desde el punto de vista de la conservación de los recursos naturales es necesario conocer la dinámica de la cobertura del suelo en la cuenca. Por lo tanto, el objetivo de este trabajo fue proporcionar información sobre la dinámica espacial y temporal de la cobertura del suelo en la cuenca y la zona ribereña del río Bela Vista. Se utilizaron geotecnologías e imágenes satelitales para el análisis dinámico. La cuenca tiene una superficie de 7,78 km2, y en 1984, la cobertura estaba formada por la agricultura (55,14%) y el bosque nativo (44,86%). El área ribereña tiene una superficie de 2,27 km2, y en 1984, la cobertura estaba formada por la agricultura (57,27%) y el bosque nativo (42,73%). En el período de 1984 a 2010, hubo un crecimiento constante del área agrícola en la cuenca (4,29 a 7,36 km2) y en la zona ribereña (1,3 a 2,13 km2), pero en el período de 2010 a 2022 hubo una pequeña disminución en ambos (7,36 a 7,28 km2 y 2,13 a 2,04 km2, respectivamente). En 2022, la principal cobertura del suelo fue la agricultura, cubriendo el 93,57% del área de la cuenca y el 89,87% del área ribereña. Se concluye que el área agrícola dominó la cobertura del suelo desde 1984 hasta 2022, y el avance de esta cobertura sobre prácticamente toda el área de la cuenca y el área ribereña en el último año compromete la conservación de los recursos hídricos y.Para um planejamento e gestão ambiental eficiente do ponto de vista de conservação dos recursos naturais é necessário conhecer a dinâmica da cobertura do solo na microbacia. Assim, objetivou-se com o presente trabalho fornecer informações sobre a dinâmica espacial e temporal da cobertura do solo na microbacia e zona ripária do rio Bela Vista. Para a análise da dinâmica foram utilizadas geotecnologias e imagens de satélites. A microbacia tem área de 7,78 km2, e no ano de 1984, a cobertura era formada por agropecuária (55,14%) e floresta nativa (44,86%). A zona ripária tem área de 2,27 km2, e no ano de 1984, a cobertura era formada por agropecuária (57,27%) e floresta nativa (42,73%). No período de 1984 a 2010, ocorreu o crescimento constante da área de agropecuária na microbacia (4,29 para 7,36 km2) e na zona ripária (1,3 para 2,13 km2), porém, no período de 2010 a 2022 ocorreu um pequeno decréscimo em ambas (7,36 para 7,28 km2 e 2,13 para 2,04 km2, respectivamente). No ano de 2022, a principal cobertura do solo era de agropecuária, abrangendo 93,57% da área da microbacia e 89,87% da área da zona ripária. Conclui-se que a área de agropecuária dominou a cobertura do solo de 1984 a 2022, e o avanço desta cobertura sobre praticamente toda área da microbacia e zona ripária no último ano compromete a conservação dos recursos hídricos e, consequentemente, o desenvolvimento sustentável da região.Para um planejamento e gestão ambiental eficiente do ponto de vista de conservação dos recursos naturais é necessário conhecer a dinâmica da cobertura do solo na microbacia. Assim, objetivou-se com o presente trabalho fornecer informações sobre a dinâmica espacial e temporal da cobertura do solo na microbacia e zona ripária do rio Bela Vista. Para a análise da dinâmica foram utilizadas geotecnologias e imagens de satélites. A microbacia tem área de 7,78 km2, e no ano de 1984, a cobertura era formada por agropecuária (55,14%) e floresta nativa (44,86%). A zona ripária tem área de 2,27 km2, e no ano de 1984, a cobertura era formada por agropecuária (57,27%) e floresta nativa (42,73%). No período de 1984 a 2010, ocorreu o crescimento constante da área de agropecuária na microbacia (4,29 para 7,36 km2) e na zona ripária (1,3 para 2,13 km2), porém, no período de 2010 a 2022 ocorreu um pequeno decréscimo em ambas (7,36 para 7,28 km2 e 2,13 para 2,04 km2, respectivamente). No ano de 2022, a principal cobertura do solo era de agropecuária, abrangendo 93,57% da área da microbacia e 89,87% da área da zona ripária. Conclui-se que a área de agropecuária dominou a cobertura do solo de 1984 a 2022, e o avanço desta cobertura sobre praticamente toda área da microbacia e zona ripária no último ano compromete a conservação dos recursos hídricos e, consequentemente, o desenvolvimento sustentável da região

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

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

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

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research