Prospective, randomized, controlled trial assessing the effects of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome due to community-acquired pneumonia (STAMINA trial): protocol and statistical analysis plan.

BACKGROUND: Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear. OBJECTIVE: To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia. METHODS: The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance. OUTCOMES: The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide. CONCLUSION: STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.

Association between religiosity/spirituality and substance use among homeless individuals.

BACKGROUND: Alcohol and illicit drug use are prevalent among homeless people. Religiosity and spirituality (RS) have been widely associated with lower consumption of substances. However, evidence of this relationship among homeless people is still scarce. AIMS: To evaluate the associations between RS and alcohol and illicit drug consumption among homeless people in a large Brazilian urban center. METHOD: This cross-sectional study was carried out in São Paulo city, Brazil. Aspects such as spirituality (FACIT-Sp12), religiosity (DUREL), spiritual-religious coping (Brief-RCOPE), and self-report questions concerning the current substance use (alcohol and illicit substances) were evaluated. Adjusted logistic regression models were used to assess the impact of RS beliefs on alcohol and illicit drug consumption. RESULTS: A total of 456 homeless people were included, of an average age of 44.5 (SD = 12.6) years. More than half of the participants consumed alcohol (55.7%) weekly and 34.2% used illicit drugs weekly. Adjusted logistic regression models identified that aspects of RS were associated with lower likelihood factors for alcohol and illicit drug use; conversely, negative spiritual religious coping (SRC) strategies were associated with a higher likelihood to use both. CONCLUSION: The prevalence of alcohol and illicit drug use among participants was high. RS and positive SRC were important protective factors for lower consumption of these substances. Conversely, negative SRC strategies were associated with risk factors.

Prospective, randomized, controlled trial assessing the effects of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome due to community-acquired pneumonia (STAMINA trial): protocol and statistical analysis plan / Estudo randomizado prospectivo e controlado de avaliação dos efeitos de uma estratégia de limitação da driving pressure em pacientes com síndrome do desconforto respiratório agudo devido à pneumonia adquirida na comunidade (estudo STAMINA): protocolo e plano de análise estatística

ABSTRACT Background: Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear. Objective: To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia. Methods: The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance. Outcomes: The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide. Conclusion: STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.

RESUMO Contexto: Em estudos observacionais sobre a síndrome do desconforto respiratório agudo, sugeriu-se que a driving pressure é o principal fator de lesão pulmonar induzida por ventilador e de mortalidade. Não está claro se uma estratégia de limitação da driving pressure pode melhorar os desfechos clínicos. Objetivo: Descrever o protocolo e o plano de análise estatística que serão usados para testar se uma estratégia de limitação da driving pressure envolvendo a titulação da pressão positiva expiratória final de acordo com a melhor complacência respiratória e a redução do volume corrente é superior a uma estratégia padrão envolvendo o uso da tabela de pressão positiva expiratória final baixa do protocolo ARDSNet, em termos de aumento do número de dias sem ventilador em pacientes com síndrome do desconforto respiratório agudo devido à pneumonia adquirida na comunidade. Métodos: O estudo STAMINA (ventilator STrAtegy for coMmunIty acquired pNeumoniA) é randomizado, multicêntrico e aberto e compara uma estratégia de limitação da driving pressure com a tabela de pressão positiva expiratória final baixa do protocolo ARDSnet em pacientes com síndrome do desconforto respiratório agudo moderada a grave devido à pneumonia adquirida na comunidade internados em unidades de terapia intensiva. Esperamos recrutar 500 pacientes de 20 unidades de terapia intensiva brasileiras e duas colombianas. Eles serão randomizados para um grupo da estratégia de limitação da driving pressure ou para um grupo de estratégia padrão usando a tabela de pressão positiva expiratória final baixa do protocolo ARDSnet. No grupo da estratégia de limitação da driving pressure, a pressão positiva expiratória final será titulada de acordo com a melhor complacência do sistema respiratório. Desfechos: O desfecho primário é o número de dias sem ventilador em 28 dias. Os desfechos secundários são a mortalidade hospitalar e na unidade de terapia intensiva e a necessidade de terapias de resgate, como suporte de vida extracorpóreo, manobras de recrutamento e óxido nítrico inalado. Conclusão: O STAMINA foi projetado para fornecer evidências sobre se uma estratégia de limitação da driving pressure é superior à estratégia da tabela de pressão positiva expiratória final baixa do protocolo ARDSnet para aumentar o número de dias sem ventilador em 28 dias em pacientes com síndrome do desconforto respiratório agudo moderada a grave. Aqui, descrevemos a justificativa, o desenho e o status do estudo.

The role of spirituality and religiosity on suicidal ideation of homeless people in a large Brazilian urban center.

BACKGROUND: Suicidal ideation is an important mental health issue among homeless people. Despite the fact that spirituality and religiousness (S/R) have been associated with lower levels of suicide behavior, there is little evidence on this relationship among homeless individuals. Thus, this study aims to investigate the association between S/R and suicidal ideation among homeless people living in a large Brazilian city. METHODS: This cross-sectional study included 456 homeless individuals living in Sao Paulo, Brazil. Logistic and linear regression models were used to determine the role of religious and spiritual beliefs (Duke Religion Index, FACIT SP-12 and Brief-RCOPE) on suicidal ideation, after adjustements. RESULTS: Most participants were male (75%) with a mean age of 44.53(SD 12.62) years. A total of 49.6% had significant depressive symptoms and the prevalence of suicidal ideation was 29.8%. In the adjusted logistic regression, higher levels of religiousness (organizational, nonorganizational and intrinsic), positive religious/spiritual coping, peace and meaning were associated with a lower suicidal ideation. The same results were found when using linear regression models. LIMITATIONS: Long questionnaires can be factors of inhibition and fatigue for the participants. Suicidal ideation was based on a single question. CONCLUSION: Our results revealed a high prevalence of suicidal ideation and depression in our sample. Religiousness and spirtuality were important factors in the life of homeless individuals, being negatively associated with suicidal ideation. These results could make healthcare professionals aware of the importance of addressing S/R issues in this vulnerable population.

Brazilian Society of Hepatology and Brazilian Society of Infectious Diseases Guidelines for the Diagnosis and Treatment of Hepatitis B.

Chronic hepatitis B is an important health problem that can progress to cirrhosis and complications such as hepatocellular carcinoma. There is approximately 290 million of people with chronic hepatitis B virus (HBV) infection worldwide, however only 10% of patients are currently identified. Most part of Brazil is considered of low prevalence of HBV infection but there are some regions with higher frequency of carriers. Unfortunately, many infected patients are not yet identified nor evaluated for treatment. The Brazilian Society of Infectious Diseases (SBI) and the Brazilian Society of Hepatology worked together to elaborate a guideline for diagnosis and treatment of hepatitis B. The document includes information regarding the population to be tested, diagnostic tools, indications of treatment, therapeutic schemes and also how to handle HBV infection in specific situations (pregnancy, children, immunosuppression, etc). Delta infection is also part of the guideline, since it is an important infection in some parts of the country.

Role of noninvasive ventilation in perioperative patients with neuromuscular disease: a clinical case / Papel da ventilação não invasiva no período perioperatório de doentes com patologia neuromuscular: caso clínico

The inclusion body myositis is an inflammatory myopathy that leads to chronic muscle inflammation associated with muscle weakness. It is characterized by a restrictive ventilatory syndrome requiring ventilatory support under non-invasive ventilation. The authors describe a clinical case and the anaesthetic management of a patient with inclusion body myopathy candidate for vertebroplasty, which highlights the importance of locoregional anaesthesia and of noninvasive ventilation and includes assisted cough techniques, maintained throughout the perioperative period.

A miosite por corpos de inclusão é uma miopatia inflamatória que cursa com inflamação crônica muscular associada à fraqueza muscular. Caracteriza-se por uma síndrome ventilatória restritiva com necessidade de suporte ventilatório sob ventilação não invasiva. Os autores descrevem caso clínico e respectivo manuseio anestésico de paciente com miopatia por corpos de inclusão proposta para vertebroplastia que realça a importância da anestesia locorregional e da ventilação não invasiva e inclui as técnicas de tosse assistida, mantidas durante todo o período perioperatório.

Role of noninvasive ventilation in perioperative patients with neuromuscular disease: a clinical case.

The inclusion body myositis is an inflammatory myopathy that leads to chronic muscle inflammation associated with muscle weakness. It is characterized by a restrictive ventilatory syndrome requiring ventilatory support under non-invasive ventilation. The authors describe a clinical case and the anaesthetic management of a patient with inclusion body myopathy candidate for vertebroplasty, which highlights the importance of locoregional anaesthesia and of noninvasive ventilation and includes assisted cough techniques, maintained throughout the perioperative period.

Preparation of Cellulose Nanofibrils from Bamboo Pulp by Mechanical Defibrillation for Their Applications in Biodegradable Composites.

There is a growing interest in cellulose nanofibrils from renewable sources for various industrial applications. However, there is a lack of information on cellulose arising from bamboo pulps. Nanofibrils from refined bamboo pulps, including bleached, unbleached, and unrefined/unbleached, were obtained by mechanical defibrillation for use in biodegradable composites. The influence of industrial processes, such as pulping and refining of unbleached pulps, as well as of alkali pretreatments and bleaching of refined pulps, on the chemical composition of the samples was analyzed. Morphological, structural, thermal, optical and viscometric properties were investigated as a function of the number of passages of refined/bleached suspensions through a defibrillator. For the unbleached suspensions, the effects of refining and bleaching on the properties of nanofibrils were evaluated, fixing the number of passages through the defibrillator. Microscopic studies demonstrated that nanoscale cellulose fibers were obtained from both pulps, with a higher yield for the refined/bleached and refined/unbleached pulp, at the expense of the unbleached/unrefined pulps. The study showed that, in addition to the effectiveness of the pre-treatments, there was an increase in the production efficiency of nanofibrils, as well as in the transparency of the bleached suspensions, while viscosity, thermal stability and crystallinity had reduced levels as the number of passages through the defibrillator increased, showing a gradual improvement in the transition from the micro- to the nano-scale. The present study contributed to the different methods that are available for the production of bamboo cellulose nanofibrils, which can be used in the production of biodegradable composites for various applications.

Incidence rates of healthcare-associated infection in a pediatric home healthcare service.

We describe the incidence rates of home healthcare-associated infections (HHAIs) in a pediatric home healthcare service (PHHCS). The overall incidence density of HHAIs was 11.1 infections per 1,000 patient-days. Average incidence density of ventilator-associated pneumonia (VAP) was 6.8 per 1,000 ventilator-days. Strategies for control of VAP should be prioritized in PHHCSs.

[Food-borne botulism: review of five cases]. / Botulismo alimentar. Estudo retrospectivo de cinco casos.

Food-borne botulism is a disease caused by the ingestion of food contaminated with botulinum toxin, often present in smoked meat, canned food and preserved food; it can occur as sporadic case or as an outbreak. In the last decades there has been an increasing incidence of food-borne botulism in Portugal. The authors do a review of five cases of food-borne botulism, three isolated cases and 2 familiar. Four were associated with the ingestion of smoked ham and one of canned tunafish. The incubation period was 48 hours in one patient and 4 days in another, in the remaining patients it was not possible to determine this period. The clinical picture was dominated in all patients by diplopy, dysphagia, dizziness, blurred vision, dry mouth and constipation, and in two patients there were gastrointestinal complains. In one patient the electromyography findings were compatible with pre-synaptic neuromuscular blockage. A toxin type B was found in the serum of one patient and in the food involved in the two familiar cases. All patients experienced complete recovery with only symptomatic treatment. With this article the authors intend to call attention to this diagnosis, which is not rare, but difficult for someone not familiar with its presentation, being of notice that the diagnosis is essentially clinic with a strong epidemiological history, confirmed by typical electromyography findings and by the identification of the toxin involved. In Portugal there is only descriptions of clinical cases associated with the type B and the type E toxins, not being necessary the resource to the antitoxin therapy.

Lipoaspiraçäo e luxaçäo do ombro; relato de caso / Lipossuction procedure and luxation of the articulatio humeri; case report

Os autores fazem uma breve descriçäo anatômica da articulaçäo do ombro e, após, relatam um caso em que ocorreu luxaçäo da mesma, no período transoperatório de uma lipoaspiraçäo. Dissertam sobre o tratamento instituído para a lesäo e sobre sua profilaxia. Alertam, ainda, sobre as graves consequências de um tratamento mal orientado, o que contrasta com a boa evoluçäo de um tratamento bem conduzido