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Maia IS, Medrado FA, Tramujas L, Tomazini BM, Oliveira JS, Sady ERR, Barbante LG, Nicola ML, Gurgel RM, Damiani LP, Negrelli KL, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Fernandes RP, Zandonai CL, Pincelli MP, Figueiredo RC, Bustamante CLS, Norbin LF, Boschi E, Lessa R, Romano MP, Miura MC, de Alencar MS, Dantas VCDS, Barreto PA, Hernandes ME, Grion CMC, Laranjeira AS, Mezzaroba AL, Bahl M, Starke AC, Biondi RS, Dal-Pizzol F, Caser EB, Thompson MM, Padial AA, Veiga VC, Leite RT, Araújo G, Guimarães M, Martins PDA, Lacerda FH, Hoffmann CR, Melro L, Pacheco E, Ospina-Táscon GA, Ferreira JC, Freires FJC, Machado FR, Cavalcanti AB, Zampieri FG. 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. Crit Care Sci 2024; 36:e20240210en. [PMID: 38775567 PMCID: PMC11098077 DOI: 10.62675/2965-2774.20240210-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/12/2024] [Indexed: 05/25/2024]
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.
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Affiliation(s)
- STAMINA Study Group Investigators
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Universidade de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade de São Paulo - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Centro Hospitalar Unimed JoinvilleJoinvilleSCBrazilCentro Hospitalar Unimed Joinville - Joinville (SC), Brazil.
- Hospital Nereu RamosFlorianópolisSCBrazilHospital Nereu Ramos - Florianópolis (SC), Brazil.
- Hospital e Maternidade São JoséColatinaESBrazilHospital e Maternidade São José - Colatina (ES), Brazil.
- Linhares Medical CenterLinharesESBrazilLinhares Medical Center - Linhares (ES), Brazil.
- Hospital Geral de Caxias do SulCaxias do SulRSBrazilHospital Geral de Caxias do Sul - Caxias do Sul (RS), Brazil.
- Hcor-Hospital do CoraçãoSão PauloSPBrazilHcor-Hospital do Coração - São Paulo (SP), Brazil.
- Hospital São Vicente de PauloBarbalhaCEBrazilHospital São Vicente de Paulo - Barbalha (CE), Brazil.
- Hospital Marcílio DiasRio de JaneiroRJBrazilHospital Marcílio Dias - Rio de Janeiro (RJ), Brazil.
- Santa Casa de VotuporangaVotuporangaSPBrazilSanta Casa de Votuporanga - Votuporanga (SP), Brazil.
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrazilHospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brazil.
- Hospital Araucária de LondrinaLondrinaPRBrazilHospital Araucária de Londrina - Londrina (PR), Brazil.
- Universidade Federal de Santa CatarinaHospital UniversitárioFlorianópolisSCBrazilHospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil.
- Hospital BrasíliaBrasíliaDFBrazilHospital Brasília - Brasília (DF), Brazil.
- Hospital São JoséCriciúmaSCBrazilHospital São José - Criciúma (SC), Brazil.
- Hospital Unimed VitóriaVitóriaSCBrazilHospital Unimed Vitória - Vitória (SC), Brazil.
- Hospital Evangélico de Cachoeiro de ItapemirimCachoeiro de ItapemirimESBrazilHospital Evangélico de Cachoeiro de Itapemirim - Cachoeiro de Itapemirim (ES), Brazil.
- Instituto Baía SulFlorianópolisSCBrazilInstituto Baía Sul - Florianópolis (SC), Brazil.
- BP - A Beneficência Portuguesa de São PauloSão PauloSPBrazilBP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.
- Imperial Hospital de CaridadeFlorianópolisSCBrazilImperial Hospital de Caridade - Florianópolis (SC), Brazil.
- Santa Casa de Misericórdia de BarretosBarretosSPBrazilSanta Casa de Misericórdia de Barretos - Barretos (SP), Brazil.
- Hospital Estadual Dr. Jayme Santos NevesSerraESBrazilHospital Estadual Dr. Jayme Santos Neves - Serra (ES), Brazil.
- Hospital OtoclínicaFortalezaCEBrazilHospital Otoclínica - Fortaleza (CE), Brazil.
- Hospital Regional Hans Dieter SchmidtJoinvilleSCBrazilHospital Regional Hans Dieter Schmidt - Joinville (SC), Brazil.
- Hospital SamaritanoSão PauloSPBrazilHospital Samaritano, São Paulo (SP), Brazil.
- Hospital SepacoSão PauloSPBrazilHospital Sepaco - São Paulo (SP), Brazil.
- Universidad ICESIFundación Valle del LiliColombiaCOFundación Valle del Lili - Universidad ICESI - Colombia, CO.
- Universidade de São PauloHospital das ClínicasDepartment of PneumologySão PauloSPBrazilDepartment of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
- Universidade Federal de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
- University of Alberta and Alberta Health Services - EdmontonFaculty of Medicine and DentistryDepartment of Critical Care MedicineAlbertaCanadaDepartment of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services - Edmonton, Alberta, Canada.
| | - Israel Silva Maia
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Universidade de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade de São Paulo - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
| | - Fernando Azevedo Medrado
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Lucas Tramujas
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Bruno Martins Tomazini
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
| | - Júlia Souza Oliveira
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Erica Regina Ribeiro Sady
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Letícia Galvão Barbante
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Marina Lazzari Nicola
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Rodrigo Magalhães Gurgel
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Lucas Petri Damiani
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Karina Leal Negrelli
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Tamiris Abait Miranda
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Eliana Santucci
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Nanci Valeis
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Ligia Nasi Laranjeira
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Glauco Adrieno Westphal
- Centro Hospitalar Unimed JoinvilleJoinvilleSCBrazilCentro Hospitalar Unimed Joinville - Joinville (SC), Brazil.
| | - Ruthy Perotto Fernandes
- Centro Hospitalar Unimed JoinvilleJoinvilleSCBrazilCentro Hospitalar Unimed Joinville - Joinville (SC), Brazil.
| | - Cássio Luis Zandonai
- Hospital Nereu RamosFlorianópolisSCBrazilHospital Nereu Ramos - Florianópolis (SC), Brazil.
| | | | - Rodrigo Cruvinel Figueiredo
- Hospital e Maternidade São JoséColatinaESBrazilHospital e Maternidade São José - Colatina (ES), Brazil.
- Linhares Medical CenterLinharesESBrazilLinhares Medical Center - Linhares (ES), Brazil.
| | | | - Luiz Fernando Norbin
- Linhares Medical CenterLinharesESBrazilLinhares Medical Center - Linhares (ES), Brazil.
| | - Emerson Boschi
- Hospital Geral de Caxias do SulCaxias do SulRSBrazilHospital Geral de Caxias do Sul - Caxias do Sul (RS), Brazil.
| | - Rafael Lessa
- Hospital Geral de Caxias do SulCaxias do SulRSBrazilHospital Geral de Caxias do Sul - Caxias do Sul (RS), Brazil.
| | - Marcelo Pereira Romano
- Hcor-Hospital do CoraçãoSão PauloSPBrazilHcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Mieko Cláudia Miura
- Hcor-Hospital do CoraçãoSão PauloSPBrazilHcor-Hospital do Coração - São Paulo (SP), Brazil.
| | - Meton Soares de Alencar
- Hospital São Vicente de PauloBarbalhaCEBrazilHospital São Vicente de Paulo - Barbalha (CE), Brazil.
| | | | - Priscilla Alves Barreto
- Hospital Marcílio DiasRio de JaneiroRJBrazilHospital Marcílio Dias - Rio de Janeiro (RJ), Brazil.
| | - Mauro Esteves Hernandes
- Santa Casa de VotuporangaVotuporangaSPBrazilSanta Casa de Votuporanga - Votuporanga (SP), Brazil.
| | - Cintia Magalhães Carvalho Grion
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrazilHospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brazil.
- Hospital Araucária de LondrinaLondrinaPRBrazilHospital Araucária de Londrina - Londrina (PR), Brazil.
| | - Alexandre Sanches Laranjeira
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrazilHospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brazil.
| | - Ana Luiza Mezzaroba
- Hospital Araucária de LondrinaLondrinaPRBrazilHospital Araucária de Londrina - Londrina (PR), Brazil.
| | - Marina Bahl
- Universidade Federal de Santa CatarinaHospital UniversitárioFlorianópolisSCBrazilHospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil.
| | - Ana Carolina Starke
- Universidade Federal de Santa CatarinaHospital UniversitárioFlorianópolisSCBrazilHospital Universitário, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil.
| | - Rodrigo Santos Biondi
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Hospital BrasíliaBrasíliaDFBrazilHospital Brasília - Brasília (DF), Brazil.
| | - Felipe Dal-Pizzol
- Hospital São JoséCriciúmaSCBrazilHospital São José - Criciúma (SC), Brazil.
| | | | - Marlus Muri Thompson
- Hospital Evangélico de Cachoeiro de ItapemirimCachoeiro de ItapemirimESBrazilHospital Evangélico de Cachoeiro de Itapemirim - Cachoeiro de Itapemirim (ES), Brazil.
| | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- BP - A Beneficência Portuguesa de São PauloSão PauloSPBrazilBP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.
| | - Rodrigo Thot Leite
- BP - A Beneficência Portuguesa de São PauloSão PauloSPBrazilBP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.
| | - Gustavo Araújo
- Imperial Hospital de CaridadeFlorianópolisSCBrazilImperial Hospital de Caridade - Florianópolis (SC), Brazil.
| | - Mário Guimarães
- Santa Casa de Misericórdia de BarretosBarretosSPBrazilSanta Casa de Misericórdia de Barretos - Barretos (SP), Brazil.
| | - Priscilla de Aquino Martins
- Hospital Estadual Dr. Jayme Santos NevesSerraESBrazilHospital Estadual Dr. Jayme Santos Neves - Serra (ES), Brazil.
| | | | - Conrado Roberto Hoffmann
- Hospital Regional Hans Dieter SchmidtJoinvilleSCBrazilHospital Regional Hans Dieter Schmidt - Joinville (SC), Brazil.
| | - Livia Melro
- Hospital SamaritanoSão PauloSPBrazilHospital Samaritano, São Paulo (SP), Brazil.
| | - Eduardo Pacheco
- Hospital SepacoSão PauloSPBrazilHospital Sepaco - São Paulo (SP), Brazil.
| | | | - Juliana Carvalho Ferreira
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Universidade de São PauloHospital das ClínicasDepartment of PneumologySão PauloSPBrazilDepartment of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Fabricio Jocundo Calado Freires
- Universidade Federal de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- Universidade Federal de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
| | - Alexandre Biasi Cavalcanti
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Universidade de São PauloDepartment of Anesthesiology, Pain, and Intensive CareSão PauloSPBrazilDepartment of Anesthesiology, Pain, and Intensive Care, Universidade de São Paulo - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
| | - Fernando Godinho Zampieri
- Hcor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, Hcor-Hospital do Coração - São Paulo (SP), Brazil.
- Brazilian Research in Intensive Care NetworkSão PauloSPBrazilBrazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil.
- University of Alberta and Alberta Health Services - EdmontonFaculty of Medicine and DentistryDepartment of Critical Care MedicineAlbertaCanadaDepartment of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services - Edmonton, Alberta, Canada.
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2
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de Barros E Silva PGM, Furtado RHM, de Alcântara Chaud MS, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, Suiama MA, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Berwanger O, Cavalcanti AB, Lopes RD. Predictors of bleeding and thrombotic events among patients admitted to the hospital with COVID-19 and elevated D-dimer: insights from the ACTION randomized clinical trial. J Thromb Thrombolysis 2024:10.1007/s11239-024-02995-y. [PMID: 38762708 DOI: 10.1007/s11239-024-02995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/20/2024]
Abstract
Therapeutic anticoagulation showed inconsistent results in hospitalized patients with COVID-19 and selection of the best patients to use this strategy still a challenge balancing the risk of thrombotic and hemorrhagic outcomes. The present post-hoc analysis of the ACTION trial evaluated the variables independently associated with both bleeding events (major bleeding or clinically relevant non-major bleeding) and the composite outcomes thrombotic events (venous thromboembolism, myocardial infarction, stroke, systemic embolism, or major adverse limb events). Variables were assessed one by one with independent logistic regressions and final models were chosen based on Akaike information criteria. The model for bleeding events showed an area under the curve of 0.63 (95% confidence interval [CI] 0.53 to 0.73), while the model for thrombotic events had an area under the curve of 0.72 (95% CI 0.65 to 0.79). Non-invasive respiratory support was associated with thrombotic but not bleeding events, while invasive ventilation was associated with both outcomes (Odds Ratio of 7.03 [95 CI% 1.95 to 25.18] for thrombotic and 3.14 [95% CI 1.11 to 8.84] for bleeding events). Beyond respiratory support, creatinine level (Odds Ratio [OR] 1.01 95% CI 1.00 to 1.02 for every 1.0 mg/dL) and history of coronary disease (OR 3.67; 95% CI 1.32 to 10.29) were also independently associated to the risk of thrombotic events. Non-invasive respiratory support, history of coronary disease, and creatinine level may help to identify hospitalized COVID-19 patients at higher risk of thrombotic complications.ClinicalTrials.gov: NCT04394377.
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Affiliation(s)
- Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Hcor Research Institute, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
- Centro Universitario São Camilo, São Paulo, Brazil
| | - Remo H M Furtado
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto Do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Luiz Eduardo Fonteles Ritt
- Instituto D'Or de Pesquisa E Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
- Escola Bahiana de Medicina, Salvador, Brazil
| | - Ana Thereza Rocha
- Instituto D'Or de Pesquisa E Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
- Escola Bahiana de Medicina, Salvador, Brazil
- Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Hospital Universitário da Universidade Estadual de Londrina, Londrina, Brazil
| | | | | | | | | | | | | | - Lilia Nigro Maia
- Pain and Intensive Care Department, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Flávia Ribeiro Machado
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Instituto Socrates Guanaes, São Paulo, Brazil
| | - Alexandre de Matos Soeiro
- Instituto Do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Patrícia O Guimarães
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Regis G Rosa
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Luciano C P Azevedo
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC, 27705, USA
| | | | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Imperial College London, London, UK
- The George Institute for Global Health UK, London, UK
| | - Alexandre B Cavalcanti
- Hcor Research Institute, São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil.
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC, 27705, USA.
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Suzuki DA, Morelle AM, de Brito ML, Paes FR, Mattar A, Leal JHS, Simon SD, Lima EMA, Werutsky G, Piotto GHM, Bines J, Damiani LP, Macedo A, Campos L, Buehler AM. Real-World Evidence of Ribociclib Plus Aromatase Inhibitors as First-Line Treatment in Advanced Breast Cancer: The BrasiLEEira Study. JCO Glob Oncol 2024; 10:e2300484. [PMID: 38603658 DOI: 10.1200/go.23.00484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/31/2024] [Indexed: 04/13/2024] Open
Abstract
PURPOSE Cyclin inhibitors plus endocrine therapy represent the reference standard for hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) locally advanced or metastatic breast cancer (ABC). Efficacy results on hard end points such as overall survival come from well-designed randomized clinical trials (RCTs). However, a limitation of RCTs is the low external results validity, and their extrapolation to a broader population may not be appropriate. Real-world studies can overcome these limitations, also increasing the reliability of RCTs. MATERIALS AND METHODS The BrasiLEEira was an observational, longitudinal, retrospective, multicenter study to evaluate the effectiveness and safety of ribociclib plus nonsteroidal aromatase inhibitors in Brazilian women age 18 years or older with HR+/HER2- ABC. The study was approved by the institutional review boards of all 11 hospitals. Data were collected anonymously from medical records using an electronic case report form designed by an independent academic research organization, which conducted the study considering all recommendations of international guidelines. The primary end point was 1-year progression-free survival (PFS) rate. Secondary end points included mortality, dose reduction, and safety. RESULTS The mean age of 76 patients was 57 years, and 28.9% were Black/Brown. The most prevalent comorbidity was arterial hypertension (34.7%). About 26.0% had endocrine-resistant disease, and 54.1% had more than three metastatic sites. The PFS rate was 77.6%. Three patients died (3.9%). Dose reductions occurred in 37.7% of patients. The most common adverse event was neutropenia (68.4%). CONCLUSION The high-quality evidence from the BrasiLEEira study corroborates the RCTs' findings, expanding its validity to a broader spectrum and underrepresented population who may benefit from ribociclib treatment.
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Affiliation(s)
| | | | | | - Flavia Rocha Paes
- Oncoclínicas do Brasil Serviços Médicos S.A., Belo Horizonte, Brazil
| | - André Mattar
- Clínica de Pesquisa e Centro de Estudos em Oncologia Ginecológica e Mamária LTDA, São Paulo, Brazil
| | - Jorge H Santos Leal
- IPD-CAM Instituto de Pesquisa e Desenvolvimento Carlos Aristides Maltez, Salvador, Brazil
| | | | | | - Gustavo Werutsky
- União Brasileira de Educação e Assistência-Hospital São Lucas da PUCRS, Porto Alegre, Brazil
| | | | - José Bines
- Oncologia Rede D'OR S.A., Rio de Janeiro, Brazil
| | | | - Ariane Macedo
- Brazilian Clinical Research Institute, Alameda Campinas, São Paulo, Brazil
| | - Lígia Campos
- Local Medical Affairs-Oncology, Novartis Biociências S.A., São Paulo, Brazil
| | - Anna Maria Buehler
- Local Medical Affairs-Oncology, Novartis Biociências S.A., São Paulo, Brazil
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4
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Tavares CDAM, de Azevedo LCP, Rea-Neto Á, Campos NS, Amendola CP, Bergo RR, Kozesinski-Nakatani AC, David-João PG, Westphal GA, Guimarães Júnior MRR, Lobo SMA, Tavares MS, Dracoulakis MDA, de Souza GM, de Almeida GMB, Gebara OCE, Tomba PO, Albuquerque CSN, Silva MCR, Pereira AJ, Damiani LP, Corrêa TD, Serpa-Neto A, Berwanger O, Zampieri FG. Dapagliflozin in patients with critical illness: rationale and design of the DEFENDER study. Crit Care Sci 2023; 35:256-265. [PMID: 38133155 PMCID: PMC10734800 DOI: 10.5935/2965-2774.20230129-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated. METHODS DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study. CONCLUSION DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients. CLINICALTRIALS.GOV REGISTRY NCT05558098.
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Affiliation(s)
| | | | - Álvaro Rea-Neto
- Centro de Estudos e de Pesquisas em Terapia Intensiva - Curitiba
(PR), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
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5
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Silveira MAD, Menezes MDA, de Souza SP, Galvão EBDS, Berretta AA, Caldas J, Teixeira MB, Gomes MMD, Damiani LP, Bahiense BA, Cabral JB, De Oliveira CWLM, Mascarenhas TR, Pinheiro PCG, Alves MS, de Melo RMV, Leite FM, Nonaka CKV, Souza BSDF, Baptista NU, Teles F, da Guarda SF, Mendes AVA, Passos RDH. Standardized Brazilian green propolis extract (EPP-AF®) in COVID-19 outcomes: a randomized double-blind placebo-controlled trial. Sci Rep 2023; 13:18405. [PMID: 37891178 PMCID: PMC10611696 DOI: 10.1038/s41598-023-43764-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
SARS-CoV-2 and its different variants caused a "wave and wave" pandemic pattern. During the first wave we demonstrated that standardized Brazilian green propolis extract (EPP-AF®) reduces length of hospital stay in adult patients with COVID-19. Afterwards, we decided to evaluate the impact of EPP-AF in hospitalized patients during the third wave of the pandemic. BeeCovid2 was a randomized, double-blind, placebo-controlled clinical trial in hospitalized COVID-19 adult patients. Patients were allocated to receive an oral dose of 900 mg/day of EPP-AF® or placebo for 10 days. The primary outcome was length of hospital stay. Secondary outcomes included safety, secondary infection rate, duration of oxygen therapy dependency, acute kidney injury and need for intensive care. Patients were followed up for 28 days after admission. We enrolled 188 patients; 98 were assigned to the propolis group and 90 to the placebo group. The post-intervention length of hospital stay was of 6.5 ± 6.0 days in the propolis group versus 7.7 ± 7.1 days in the control group (95% CI - 0.74 [- 1.94 to 0.42]; p = 0.22). Propolis did not have significant impact on the need for oxygen supplementation or frequency of AKI. There was a significant difference in the incidence of secondary infection between groups, with 6.1% in the propolis group versus 18.9% in the control group (95% CI - 0.28 [0.1-0.76], p = 0.01). The use of EPP-AF was considered safe and associated with a decrease in secondary infections. The drug was not associated with a significant reduction in length of hospital stay. ClinicalTrials.gov (NCT04800224).
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Affiliation(s)
- Marcelo Augusto Duarte Silveira
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil.
| | - Matheus de Alencar Menezes
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Sergio Pinto de Souza
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Erica Batista Dos Santos Galvão
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Andresa Aparecida Berretta
- Development and Innovation Department, Apis Flora Indl. Coml. Ltda, Rua Triunfo 945, Subsetor Sul 3, Ribeirão Preto, SP, 14020-670, Brazil
| | - Juliana Caldas
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Maurício Brito Teixeira
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Marcel Miranda Dantas Gomes
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Lucas Petri Damiani
- Academic Research Organization, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Morumbi, São Paulo, SP, 05652-000, Brazil
| | - Bruno Andrade Bahiense
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Julia Barros Cabral
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | | | - Talita Rocha Mascarenhas
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Priscila Carvalho Guedes Pinheiro
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Milena Souza Alves
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Rodrigo Morel Vieira de Melo
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
- School of Medicine, Federal University of Bahia, Rua Augusto Viana s/n, Canela, Salvador, BA, 40110-909, Brazil
| | - Flávia Mendes Leite
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Carolina Kymie Vasques Nonaka
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Bahia, 40296-710, Brazil
| | - Bruno Solano de Freitas Souza
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Bahia, 40296-710, Brazil
| | - Nathália Ursoli Baptista
- Development and Innovation Department, Apis Flora Indl. Coml. Ltda, Rua Triunfo 945, Subsetor Sul 3, Ribeirão Preto, SP, 14020-670, Brazil
| | - Flávio Teles
- School of Medicine, Federal University of Alagoas, Av. Lourival de Melo Mota S/N, Tabuleiro do Martins, Maceió, Alagoas, 57072-900, Brazil
| | - Suzete Farias da Guarda
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
- School of Medicine, Federal University of Bahia, Rua Augusto Viana s/n, Canela, Salvador, BA, 40110-909, Brazil
| | - Ana Verena Almeida Mendes
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
| | - Rogério da Hora Passos
- D'Or Institute for Research and Education (IDOR), Hospital São Rafael, Avenida São Rafael 2152, São Marcos, Salvador, BA, 41253-190, Brazil
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Lopes RD, de Barros E Silva PGM, Filho CRH, Cavalvante MA, Miranda CM, Esper RB, de Lima GG, Ritt LEF, da Silva RMFL, Nakazone MA, Almeida AP, Pavanello R, de Lima CEB, Backes LM, Oliveira LH, de Souza OF, Filho AML, God EMG, Jorge JCM, de Almeida Luiz A, Martins SFPP, Dantas RC, D Oliveira Vieira R, Zimerman LI, Júnior ÁRA, de Oliveira Figueiredo MJ, do Carmo Gomes SP, de Lima LM, Damiani LP, Teixeira RA, Fagundes AA, Saad EB. The First Brazilian Cardiovascular Registry of Atrial Fibrillation: Primary Results of the RECALL Study. Am Heart J 2023; 264:97-105. [PMID: 37330162 DOI: 10.1016/j.ahj.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND It is estimated that atrial fibrillation (AF) affects approximately 1.5 million people in Brazil; however, epidemiological data are limited. We sought to evaluate the characteristics, treatment patterns, and clinical outcomes in patients with AF in Brazil by creating the first nationwide prospective registry. METHODS RECALL was a multicenter, prospective registry that included and followed for 1 year 4,585 patients with AF at 89 sites across Brazil from April 2012 to August 2019. Patient characteristics, concomitant medication use, and clinical outcomes were analyzed using descriptive statistics and multivariable models. RESULTS Of 4,585 patients enrolled, the median age was 70 (61, 78) years, 46% were women, and 53.8% had permanent AF. Only 4.4% of patients had a history of previous AF ablation and 25.2% had a previous cardioversion. The mean (SD) CHA2DS2-VASc score was 3.2 (1.6); median HAS-BLED score was 2 (2, 3). At baseline, 22% were not on anticoagulants. Of those taking anticoagulants, 62.6% were taking vitamin K antagonists and 37.4% were taking direct oral anticoagulants. The primary reasons for not using an oral anticoagulant were physician judgment (24.6%) and difficulty in controlling (14.7%) or performing (9.9%) INR. Mean (SD) TTR for the study period was 49.5% (27.5). During follow-up, the use of anticoagulants and INR in the therapeutic range increased to 87.1% and 59.1%, respectively. The rates/100 patient-years of death, hospitalization due to AF, AF ablation, cardioversion, stroke, systemic embolism, and major bleeding were 5.76 (5.12-6.47), 15.8 (14.6-17.0), 5.0 (4.4-5.7), 1.8 (1.4-2.2), 2.77 (2.32-3.32), 1.01 (0.75-1.36), and 2.21 (1.81-2.70). Older age, permanent AF, New York Heart Association class III/IV, chronic kidney disease, peripheral arterial disease, stroke, chronic obstructive pulmonary disease, and dementia were independently associated with increased mortality while the use of anticoagulant was associated with lower risk of death. CONCLUSIONS RECALL represents the largest prospective registry of patients with AF in Latin America. Our findings highlight important gaps in treatment, which can inform clinical practice and guide future interventions to improve the care of these patients.
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Affiliation(s)
- Renato D Lopes
- Brazilian Clinical Research Institute, Sao Paulo, SP, Brazil; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Pedro G M de Barros E Silva
- Brazilian Clinical Research Institute, Sao Paulo, SP, Brazil; HCOR Research Institute, São Paulo, SP, Brazil; Hospital Samaritano Paulista, São Paulo, SP, Brazil
| | | | | | | | | | | | - Luiz Eduardo Fonteles Ritt
- D'or Research Institute, Hospital Cardio Pulmomar, Salvador, BA, Brazil; Bahiana School of Medicine and Public Health, Salvador, BA, Brazil
| | | | - Marcelo A Nakazone
- Faculdade de Medicina de Sao José do Rio Preto, Sao José do Rio Preto, SP, Brazil
| | | | | | | | | | | | | | | | | | | | - Alcirley de Almeida Luiz
- Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brazil; Hospital Universitário do Oeste do Paraná, Cascavel, PR, Brazil
| | | | | | | | | | | | | | | | | | - Lucas Petri Damiani
- Brazilian Clinical Research Institute, Sao Paulo, SP, Brazil; HCOR Research Institute, São Paulo, SP, Brazil
| | - Ricardo Alkmim Teixeira
- Sociedade Brasileira de Arritmias Cardíacas, Sao Paulo, SP, Brazil; Hospital Renascentista, Pouso Alegre, MG, Brazil; Universidade do Vale do Sapucaí, Pouso Alegre, MG, Brazil
| | | | - Eduardo Benchimol Saad
- Sociedade Brasileira de Arritmias Cardíacas, Sao Paulo, SP, Brazil; Hospital Pró-Cardíaco, Rio de Janeiro, RJ, Brazil; Hospital Samaritano Botafogo, Rio de Janeiro, RJ, Brazil
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7
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Maia IS, Kawano-Dourado L, Damiani LP, Fitzgerald M, Lewis RJ, Cavalcanti AB. Update in statistical analysis plan of the RENOVATE trial. CRIT CARE RESUSC 2023; 25:113-114. [PMID: 37876375 PMCID: PMC10581258 DOI: 10.1016/j.ccrj.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- I S Maia
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Division of Anesthesiology, Medical School, University of Sao Paulo, Sao Paulo, Brazil
- Brazilian Research in Intensive Care Network - BricNet
| | - L Kawano-Dourado
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Pulmonary Division, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - L P Damiani
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
| | | | - R J Lewis
- Berry Consultants, LLC, Austin, TX, USA
- David Geffen School of Medicine at UCLA Los Angeles, California, USA
| | - A B Cavalcanti
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil
- Division of Anesthesiology, Medical School, University of Sao Paulo, Sao Paulo, Brazil
- Brazilian Research in Intensive Care Network - BricNet
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8
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Lin‐Wang HT, Damiani LP, Farias EDS, Bajgelman MC, Gun C. Longitudinal study comparing IgG antibodies induced by heterologous prime-boost COVID-19 vaccine. J Med Virol 2023; 95:e28379. [PMID: 36478244 PMCID: PMC9877967 DOI: 10.1002/jmv.28379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/08/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Abstract
Vaccines are critical cost-effective tools to control the COVID-19 pandemic. The heterologous prime-boost vaccination has been used by many countries to overcome supply issues, so the effectiveness and safety of this strategy need to be better clarified. This study aims to verify the effect of heterologous prime-boost COVID-19 vaccination on healthcare professionals from Dante Pazzanese Hospital in Brazil. It was performed serological assays of vaccinated individuals after 2-dose of CoronaVac (Sinovac; n = 89) or ChAdOx1 nCoV-19 (Oxford-AstraZeneca; n = 166) followed by a BNT162b2 booster (Pfizer-BioNTech; n = 255). The serum antibodies anti-S (spike), anti-N (nucleocapsid), and anti-RBD (receptor binding domain) were assessed by enzyme-linked immunosorbent assay. The heterologous booster dose induced a 10-fold higher anti-Spike antibody regardless of the 2-dose of a prime vaccine. It was strikingly observed that BNT162b2 enhanced levels of anti-spike antibodies, even in those individuals who did not previously respond to the 2-dose of CoronaVac. In conclusion, the heterologous scheme of vaccination using mRNA as a booster vaccine efficiently enhanced the antibody response against SARS-CoV-2, especially benefiting those elderly who were seronegative with a virus-inactivated vaccine.
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Affiliation(s)
- Hui Tzu Lin‐Wang
- Laboratory of Molecular Biology, Research DivisionDante Pazzanese Institute of CardiologySão PauloBrazil
| | - Lucas Petri Damiani
- Statistics and Epidemiology Department, Research DivisionDante Pazzanese Institute of CardiologySão PauloBrazil,Academic Research OperationsAlbert Einstein Israelite HospitalSão PauloBrazil
| | - Eduardo da Silva Farias
- Statistics and Epidemiology Department, Research DivisionDante Pazzanese Institute of CardiologySão PauloBrazil
| | - Marcio Chaim Bajgelman
- Brazilian National Laboratory for Biosciences (LNBio)Center for Research in Energy and Materials (CNPEM)CampinasBrazil
| | - Carlos Gun
- Teaching and Research DivisionDante Pazzanese Institute of CardiologySão PauloBrazil
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9
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Barros E Silva PG, Lopes RD, Furtado RHM, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, Morata JA, Ramacciotti E, Martins PA, De Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L. Variables associated with bleeding and thrombotic outcomes among patients admitted to the hospital with COVID-19 and elevated D-dimer: insights from the ACTION randomised clinical trial. Eur Heart J 2022. [PMCID: PMC9619581 DOI: 10.1093/eurheartj/ehac544.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background In the ACTION trial, therapeutic anticoagulation did not show benefit on mortality, days of hospitalization and oxygens therapy at 30 days among patients with COVID19. However, this strategy was associated with higher rate of bleeding and a potential reduction in the rate of clinical thrombotic events. The current analysis evaluated which variables were independently associated with both outcomes in order to help the identification of the risk for thrombotic and hemorrhagic events among patients with COVID19. Methods A total of 615 patients hospitalized with COVID-19 and elevated D-dimer levels were randomly assigned to prophylactic anticoagulation (mainly in-hospital heparin) or a therapeutic strategy that used in-hospital rivaroxaban 20 mg daily for stable patients, or enoxaparin 1 mg/kg twice daily for unstable patients, followed by rivaroxaban through 30 days. One patient withdrew consent and was not included in the analysis. The current analysis tested baseline clinical characteristics and laboratorial exams one by one with independent logistic regressions for the composite of bleeding (major bleeding and clinically relevant nonmajor bleeding) and thrombotic events (venous thromboembolism, myocardial infarction, stroke, systemic embolism, and major adverse limb events). Significant variables (p<0.05) were selected to adjust several multiple logistic models. Final models were chosen based on Akaike information criterion and therapeutic anticoagulation was included in the final model based on the primary results of the trial. Results The model for bleeding events showed an accuracy of area under the curve (AUC) of 0.635 (table 1) while the model for thrombotic events had an AUC of 0.725 (table 2). Level of respiratory support (especially invasive ventilation) was associated with both outcomes in the multivariable analysis (tables 1 and 2). Beyond respiratory support, level of creatinine and history of coronary disease were also independently associated to the risk of thrombotic events. When the utilization of therapeutic anticoagulation (mainly with rivaroxaban) was included in the multivariable analysis, this variable was strongly associated with higher risk of bleeding (model AUC of 0.718) but was not associated with lower rate of thrombotic events (Tables 1 and 2). Conclusion Since the variables associated with higher risk of thrombotic events are similar to the variables associated to bleeding complications, the selection of patients with better balance of risk vs. benefit to use therapeutic anticoagulation in COVID-19 still a challenging decision. Coronary disease and creatine may help to identify patients at higher risk of thrombotic complications while the use of therapeutic dose of direct oral anticoagulant increased the risk of bleeding in almost 4 times among patients hospitalized due to COVID19. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Investigator initiated research with financial support of Bayer
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Affiliation(s)
| | - R D Lopes
- Duke Clinical Research Institute , Durham , United States of America
| | - R H M Furtado
- Hospital Israelita Albert Einstein , Sao Paulo , Brazil
| | - A V S Macedo
- Brazilian Clinical Research Institute (BCRI) , Sao Paulo , Brazil
| | - B Bronhara
- Brazilian Clinical Research Institute (BCRI) , Sao Paulo , Brazil
| | - L P Damiani
- Brazilian Clinical Research Institute (BCRI) , Sao Paulo , Brazil
| | - L M Barbosa
- Brazilian Clinical Research Institute (BCRI) , Sao Paulo , Brazil
| | - J A Morata
- Brazilian Clinical Research Institute (BCRI) , Sao Paulo , Brazil
| | - E Ramacciotti
- Loyola University , Chicago , United States of America
| | - P A Martins
- Hospital Estadual Dr Jayme Santos Neves , Serra , Brazil
| | | | - V S Nunes
- Hospital Estadual Dr Jayme Santos Neves , Serra , Brazil
| | - L E F Ritt
- Cardio Pulmonary Hospital , Salvador , Brazil
| | - A T Rocha
- Cardio Pulmonary Hospital , Salvador , Brazil
| | - L Tramujas
- HCor Hospital do Coracao , Sao Paulo , Brazil
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10
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Zampieri FG, Damiani LP, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Serpa-Neto A, Manoel ALDO, Miranda TA, Corrêa TD, Azevedo LCPD, Silva NBD, Machado FR, Cavalcanti AB. Effects of balanced solution on short-term outcomes in traumatic brain injury patients: a secondary analysis of the BaSICS randomized trial. Rev Bras Ter Intensiva 2022; 34:410-417. [PMID: 36888820 PMCID: PMC9987002 DOI: 10.5935/0103-507x.20220261-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/18/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To describe the effects of balanced solution use on the short-term outcomes of patients with traumatic brain injury enrolled in BaSICS trial. METHODS Patients were randomized to receive either 0.9% saline or balanced solution during their intensive care unit stay. The primary endpoint was 90-day mortality, and the secondary outcomes were days alive and free of intensive care unit stay at 28 days. The primary endpoint was assessed using Bayesian logistic regression. The secondary endpoint was assessed using a Bayesian zero-inflated beta binomial regression. RESULTS We included 483 patients (236 in the 0.9% saline arm and 247 in the balanced solution arm). A total of 338 patients (70%) with a Glasgow coma scale score ≤ 12 were enrolled. The overall probability that balanced solutions were associated with higher 90-day mortality was 0.98 (OR 1.48; 95%CrI 1.04 - 2.09); this mortality increment was particularly noticeable in patients with a Glasgow coma scale score below 6 at enrollment (probability of harm of 0.99). Balanced solutions were associated with -1.64 days alive and free of intensive care unit at 28 days (95%CrI -3.32 - 0.00) with a probability of harm of 0.97. CONCLUSION There was a high probability that balanced solutions were associated with high 90-day mortality and fewer days alive and free of intensive care units at 28 days.ClinicalTrials.gov: NCT02875873.
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Affiliation(s)
- Fernando Godinho Zampieri
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | | | | | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,BP-A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | | | | | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | | | - Flavia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Alexandre Biasi Cavalcanti
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
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11
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Silveira MAD, de Souza SP, dos Santos Galvão EB, Teixeira MB, Gomes MMD, Damiani LP, Bahiense BA, Cabral JB, De Oliveira CWLM, Mascarenhas TR, Pinheiro PCG, Alves MS, de Melo RMV, Berretta AA, Leite FM, Nonaka CKV, de Freitas Souza BS, Mendes AVA, da Guarda SF, da Hora Passos R. The use of standardized Brazilian green propolis extract (EPP-AF) as an adjunct treatment for hospitalized COVID-19 patients (BeeCovid2): a structured summary of a study protocol for a randomized controlled trial. Trials 2022; 23:255. [PMID: 35379306 PMCID: PMC8978159 DOI: 10.1186/s13063-022-06176-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 03/16/2022] [Indexed: 11/29/2022] Open
Abstract
Background The 2019 coronavirus disease (COVID-19) pandemic continues to spread and affects large numbers of people with unprecedented impacts. Experimental evidence has already been obtained for use of the standardized extract of Brazilian green propolis (EPP-AF) against viral targets, and clinical rationality has been demonstrated for testing this extract as an adjunct to treatment in patients affected by COVID-19. The BeeCovid2 study aims to assess whether EPP-AF has an impact on the improvement of patients hospitalized with COVID-19 by reducing the length of hospital stay. Methods BeeCovid2 is a randomized, double-blinded, placebo-controlled clinical study being conducted in Brazil to provide further evidence on the effectiveness of standardized green propolis extract as an adjunctive treatment for adults hospitalized with COVID-19. Hospitalized patients over 18 years of age with a confirmed diagnosis of COVID-19 and up to 14 days of symptoms were included. Patients under mechanical ventilation at randomization, pregnant women, cancer patients, transplanted or using immunosuppression, HIV patients, patients who used propolis in the last 30 days, bacterial or fungal infection at randomization, impossibility of using medication orally or enterally, and advanced chronic diseases (e.g., advanced heart failure, severe liver disease, and end-stage chronic kidney disease). Enrolled patients are randomized at a 1:1 ratio to receive placebo or standardized propolis extract (900 mg/day) for 10 days. The study treatments are administered in a double-blinded manner, and patients are followed for 28 days. The primary outcome is the difference in length of hospital stay in days between groups. Secondary outcomes include the need for mechanical ventilation, the rate of secondary infection, rate of acute kidney injury, the need for renal replacement therapy, the requirement for vasoactive drugs, the use of an intra-aortic balloon pump (IABP), and the use of extracorporeal membrane oxygenation (ECMO). Discussion This trial is very useful and will provide more data on the effectiveness of using the standardized Brazilian green propolis extract as an adjunctive treatment in association with standard care in adults hospitalized with moderate to severe acute COVID-19. Trial registration ClinicalTrials.gov NCT04800224. Registered on March 16, 2021.
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12
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Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, de Alencar Filho MS, Hamamoto VA, Hernandes ME, Golin NA, de Olinda RT, Machado FR, Rosa RG, Veiga VC, de Azevedo LCP, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022. [PMID: 35766657 PMCID: PMC9345580 DOI: 10.5935/0103-507x.20220002-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Israel Silva Maia
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Division of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Corresponding author: Israel Silva Maia HCor-Hospital do Coração Rua Abílio Soares, 250, 12º andar ZIP code: 04005-002 - São Paulo (SP), Brazil E-mail:
| | - Aline Marcadenti
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | - Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | - Eliana Santucci
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | - Nanci Valeis
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Department of Anaesthesiology, Pain and Intensive Care Medicine, Universidade Federal de São Paulo (SP), Brazil
| | - Régis Goulart Rosa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil
| | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Research and Education Institute, Hospital Sírio-Libanês - São Paulo (SP), Brazil
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brazil
| | - Renato Delascio Lopes
- Brazilian Clinical Research Institute (BCRI) - São Paulo (SP), Brazil
- Duke University Medical Center, Duke Clinical Research Institute - Durham, North Carolina, United States
| | - Tiago Moreno L Souza
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brazil
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations, Center for Technological Development in Health, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brazil
| | | | - Alexandre Biasi Cavalcanti
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Division of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
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13
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Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, Alencar Filho MSD, Hamamoto VA, Hernandes ME, Golin NA, Olinda RTD, Machado FR, Rosa RG, Veiga VC, Azevedo LCPD, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022; 34:44-55. [PMID: 35766657 DOI: 10.5935/0103-507x.20220002-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 11/20/2022] Open
Abstract
Repurposed drugs are important in resource-limited settings because the interventions are more rapidly available, have already been tested safely in other populations and are inexpensive. Repurposed drugs are an effective solution, especially for emerging diseases such as COVID-19. The REVOLUTIOn trial has the objective of evaluating three repurposed antiviral drugs, atazanavir, daclatasvir and sofosbuvir, already used for HIV- and hepatitis C virus-infected patients in a randomized, placebo-controlled, adaptive, multiarm, multistage study. The drugs will be tested simultaneously in a Phase II trial to first identify whether any of these drugs alone or in combination reduce the viral load. If they do, a Phase III trial will be initiated to investigate if these medications are capable of increasing the number of days free respiratory support. Participants must be hospitalized adults aged ≥ 18 years with initiation of symptoms ≤ 9 days and SpO2 ≤ 94% in room air or a need for supplemental oxygen to maintain an SpO2 > 94%. The expected total sample size ranges from 252 to 1,005 participants, depending on the number of stages that will be completed in the study. Hence, the protocol is described here in detail together with the statistical analysis plan. In conclusion, the REVOLUTIOn trial is designed to provide evidence on whether atazanavir, daclatasvir or sofosbuvir decrease the SARS-CoV-2 load in patients with COVID-19 and increase the number of days patients are free of respiratory support. In this protocol paper, we describe the rationale, design, and status of the trial. ClinicalTrials.gov identifier: NCT04468087.
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Affiliation(s)
- Israel Silva Maia
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Aline Marcadenti
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Fernando Godinho Zampieri
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | - Eliana Santucci
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Nanci Valeis
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Dor e Medicina Intensiva, Universidade Federal de São Paulo (SP), Brasil
| | - Régis Goulart Rosa
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Viviane Cordeiro Veiga
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | - Luciano César Pontes de Azevedo
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa e Educação, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Alvaro Avezum
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Renato Delascio Lopes
- Brazilian Clinical Research Institute (BCRI) - São Paulo (SP), Brasil.,Duke University Medical Center, Duke Clinical Research Institute - Durham, North Carolina, United States
| | - Tiago Moreno L Souza
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil.,Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas, Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil. Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Alexandre Biasi Cavalcanti
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
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14
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Zampieri FG, Damiani LP, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Serpa-Neto A, Manoel ALDO, Miranda TA, Corrêa TD, Azevedo LCPD, Silva NBD, Machado FR, Cavalcanti AB, BRICNet BRICN. Effects of balanced solution on short-term outcomes in traumatic brain injury
patients: a secondary analysis of the BaSICS randomized trial. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220261-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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15
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Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, Alencar Filho MSD, Hamamoto VA, Hernandes ME, Golin NA, Olinda RTD, Machado FR, Rosa RG, Veiga VC, Azevedo LCPD, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB, BRICNet CIXIAT. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Ospina-Tascón GA, Calderón-Tapia LE, García AF, Zarama V, Gómez-Álvarez F, Álvarez-Saa T, Pardo-Otálvaro S, Bautista-Rincón DF, Vargas MP, Aldana-Díaz JL, Marulanda Á, Gutiérrez A, Varón J, Gómez M, Ochoa ME, Escobar E, Umaña M, Díez J, Tobón GJ, Albornoz LL, Celemín Flórez CA, Ruiz GO, Cáceres EL, Reyes LF, Damiani LP, Cavalcanti AB. Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial. JAMA 2021; 326:2161-2171. [PMID: 34874419 PMCID: PMC8652598 DOI: 10.1001/jama.2021.20714] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE The effect of high-flow oxygen therapy vs conventional oxygen therapy has not been established in the setting of severe COVID-19. OBJECTIVE To determine the effect of high-flow oxygen therapy through a nasal cannula compared with conventional oxygen therapy on need for endotracheal intubation and clinical recovery in severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label clinical trial conducted in emergency and intensive care units in 3 hospitals in Colombia. A total of 220 adults with respiratory distress and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 200 due to COVID-19 were randomized from August 2020 to January 2021, with last follow-up on February 10, 2021. INTERVENTIONS Patients were randomly assigned to receive high-flow oxygen through a nasal cannula (n = 109) or conventional oxygen therapy (n = 111). MAIN OUTCOMES AND MEASURES The co-primary outcomes were need for intubation and time to clinical recovery until day 28 as assessed by a 7-category ordinal scale (range, 1-7, with higher scores indicating a worse condition). Effects of treatments were calculated with a Cox proportional hazards model adjusted for hypoxemia severity, age, and comorbidities. RESULTS Among 220 randomized patients, 199 were included in the analysis (median age, 60 years; n = 65 women [32.7%]). Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR, 11-19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047). Suspected bacterial pneumonia occurred in 13 patients (13.1%) randomized to high-flow oxygen and in 17 (17.0%) of those randomized to conventional oxygen therapy, while bacteremia was detected in 7 (7.1%) vs 11 (11.0%), respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04609462.
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Affiliation(s)
- Gustavo A. Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Luis Eduardo Calderón-Tapia
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Alberto F. García
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Virginia Zarama
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | | | | | | | | | - Mónica P. Vargas
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - José L. Aldana-Díaz
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Ángela Marulanda
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | | | - Janer Varón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Mónica Gómez
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - María E. Ochoa
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Elena Escobar
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Mauricio Umaña
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Julio Díez
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Gabriel J. Tobón
- Department of Pathology and Laboratory Medicine, Fundación Valle del Lili–Universidad Icesi, Cali, Colombia
| | - Ludwig L. Albornoz
- Department of Pathology and Laboratory Medicine, Fundación Valle del Lili–Universidad Icesi, Cali, Colombia
| | | | - Guillermo Ortiz Ruiz
- Departamento de Cuidado Crítico, SubRed Centro-Oriente, Universidad del Bosque, Bogotá, Colombia
| | | | - Luis Felipe Reyes
- Department of Critical Care, Clínica de la Universidad de La Sabana, Chía, Colombia
- Department of Infectious Diseases, Universidad de La Sabana, Chía, Colombia
| | - Lucas Petri Damiani
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre B. Cavalcanti
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Ospina-Tascón GA, Calderón-Tapia LE, García AF, Zarama V, Gómez-Álvarez F, Álvarez-Saa T, Pardo-Otálvaro S, Bautista-Rincón DF, Vargas MP, Aldana-Díaz JL, Marulanda Á, Gutiérrez A, Varón J, Gómez M, Ochoa ME, Escobar E, Umaña M, Díez J, Tobón GJ, Albornoz LL, Celemín Flórez CA, Ruiz GO, Cáceres EL, Reyes LF, Damiani LP, Cavalcanti AB. Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial. JAMA 2021. [PMID: 34874419 DOI: 10.1001/jama.2021.20714,pubmed:34874419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
IMPORTANCE The effect of high-flow oxygen therapy vs conventional oxygen therapy has not been established in the setting of severe COVID-19. OBJECTIVE To determine the effect of high-flow oxygen therapy through a nasal cannula compared with conventional oxygen therapy on need for endotracheal intubation and clinical recovery in severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label clinical trial conducted in emergency and intensive care units in 3 hospitals in Colombia. A total of 220 adults with respiratory distress and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 200 due to COVID-19 were randomized from August 2020 to January 2021, with last follow-up on February 10, 2021. INTERVENTIONS Patients were randomly assigned to receive high-flow oxygen through a nasal cannula (n = 109) or conventional oxygen therapy (n = 111). MAIN OUTCOMES AND MEASURES The co-primary outcomes were need for intubation and time to clinical recovery until day 28 as assessed by a 7-category ordinal scale (range, 1-7, with higher scores indicating a worse condition). Effects of treatments were calculated with a Cox proportional hazards model adjusted for hypoxemia severity, age, and comorbidities. RESULTS Among 220 randomized patients, 199 were included in the analysis (median age, 60 years; n = 65 women [32.7%]). Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR, 11-19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047). Suspected bacterial pneumonia occurred in 13 patients (13.1%) randomized to high-flow oxygen and in 17 (17.0%) of those randomized to conventional oxygen therapy, while bacteremia was detected in 7 (7.1%) vs 11 (11.0%), respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04609462.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia.,Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Luis Eduardo Calderón-Tapia
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia.,Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Alberto F García
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia.,Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Virginia Zarama
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | | | | | | | | | - Mónica P Vargas
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - José L Aldana-Díaz
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia.,Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Ángela Marulanda
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia.,Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | | | - Janer Varón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Mónica Gómez
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - María E Ochoa
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Elena Escobar
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia.,Translational Medicine Laboratory in Critical Care (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Mauricio Umaña
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Julio Díez
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | - Gabriel J Tobón
- Department of Pathology and Laboratory Medicine, Fundación Valle del Lili-Universidad Icesi, Cali, Colombia
| | - Ludwig L Albornoz
- Department of Pathology and Laboratory Medicine, Fundación Valle del Lili-Universidad Icesi, Cali, Colombia
| | | | - Guillermo Ortiz Ruiz
- Departamento de Cuidado Crítico, SubRed Centro-Oriente, Universidad del Bosque, Bogotá, Colombia
| | | | - Luis Felipe Reyes
- Department of Critical Care, Clínica de la Universidad de La Sabana, Chía, Colombia.,Department of Infectious Diseases, Universidad de La Sabana, Chía, Colombia
| | - Lucas Petri Damiani
- HCor Research Institute-Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute-Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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18
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Lopes RD, de Barros E Silva PGM, Furtado RHM, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, de Aveiro Morata J, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, de Alcântara Chaud MS, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Cavalcanti AB, Berwanger O. Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial. Lancet 2021; 397:2253-2263. [PMID: 34097856 PMCID: PMC8177770 DOI: 10.1016/s0140-6736(21)01203-4] [Citation(s) in RCA: 306] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. Whether therapeutic anticoagulation improves outcomes in patients hospitalised with COVID-19 is unknown. We aimed to compare the efficacy and safety of therapeutic versus prophylactic anticoagulation in this population. METHODS We did a pragmatic, open-label (with blinded adjudication), multicentre, randomised, controlled trial, at 31 sites in Brazil. Patients (aged ≥18 years) hospitalised with COVID-19 and elevated D-dimer concentration, and who had COVID-19 symptoms for up to 14 days before randomisation, were randomly assigned (1:1) to receive either therapeutic or prophylactic anticoagulation. Therapeutic anticoagulation was in-hospital oral rivaroxaban (20 mg or 15 mg daily) for stable patients, or initial subcutaneous enoxaparin (1 mg/kg twice per day) or intravenous unfractionated heparin (to achieve a 0·3-0·7 IU/mL anti-Xa concentration) for clinically unstable patients, followed by rivaroxaban to day 30. Prophylactic anticoagulation was standard in-hospital enoxaparin or unfractionated heparin. The primary efficacy outcome was a hierarchical analysis of time to death, duration of hospitalisation, or duration of supplemental oxygen to day 30, analysed with the win ratio method (a ratio >1 reflects a better outcome in the therapeutic anticoagulation group) in the intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding through 30 days. This study is registered with ClinicalTrials.gov (NCT04394377) and is completed. FINDINGS From June 24, 2020, to Feb 26, 2021, 3331 patients were screened and 615 were randomly allocated (311 [50%] to the therapeutic anticoagulation group and 304 [50%] to the prophylactic anticoagulation group). 576 (94%) were clinically stable and 39 (6%) clinically unstable. One patient, in the therapeutic group, was lost to follow-up because of withdrawal of consent and was not included in the primary analysis. The primary efficacy outcome was not different between patients assigned therapeutic or prophylactic anticoagulation, with 28 899 (34·8%) wins in the therapeutic group and 34 288 (41·3%) in the prophylactic group (win ratio 0·86 [95% CI 0·59-1·22], p=0·40). Consistent results were seen in clinically stable and clinically unstable patients. The primary safety outcome of major or clinically relevant non-major bleeding occurred in 26 (8%) patients assigned therapeutic anticoagulation and seven (2%) assigned prophylactic anticoagulation (relative risk 3·64 [95% CI 1·61-8·27], p=0·0010). Allergic reaction to the study medication occurred in two (1%) patients in the therapeutic anticoagulation group and three (1%) in the prophylactic anticoagulation group. INTERPRETATION In patients hospitalised with COVID-19 and elevated D-dimer concentration, in-hospital therapeutic anticoagulation with rivaroxaban or enoxaparin followed by rivaroxaban to day 30 did not improve clinical outcomes and increased bleeding compared with prophylactic anticoagulation. Therefore, use of therapeutic-dose rivaroxaban, and other direct oral anticoagulants, should be avoided in these patients in the absence of an evidence-based indication for oral anticoagulation. FUNDING Coalition COVID-19 Brazil, Bayer SA.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Brazilian Clinical Research Institute, São Paulo, Brazil.
| | - Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil; Hospital Samaritano Paulista, São Paulo, Brazil
| | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil
| | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Lucas Petri Damiani
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil
| | | | | | - Eduardo Ramacciotti
- Brazilian Clinical Research Institute, São Paulo, Brazil; Science Valley Research Institute, São Paulo, Brazil; Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | | | | | | | | | - Ana Thereza Rocha
- Hospital Cárdio Pulmonar, Salvador, Brazil; Escola Bahiana de Medicina, Salvador, Brazil; Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | - Gilson Soares Feitosa-Filho
- Escola Bahiana de Medicina, Salvador, Brazil; Santa Casa de Misericórdia da Bahia-Hospital Santa Izabel, Salvador, Brazil; Centro Universitário Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | | | | | | | - Lilia Nigro Maia
- Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Regis G Rosa
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
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19
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Tomazini BM, Maia IS, Bueno FR, Silva MVAO, Baldassare FP, Costa ELV, Moura RAB, Honorato MO, Costa AN, Cavalcanti AB, Rosa RG, Avezum Á, Veiga VC, Lopes RD, Damiani LP, Machado FR, Berwanger O, de Azevedo LCP. COVID-19-associated ARDS treated with DEXamethasone (CoDEX): study design and rationale for a randomized trial. Rev Bras Ter Intensiva 2020; 32:354-362. [PMID: 33053024 PMCID: PMC7595716 DOI: 10.5935/0103-507x.20200063] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/18/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads worldwide and is considered a pandemic. The most common manifestation of SARS-CoV-2 infection (coronavirus disease 2019 - COVID-19) is viral pneumonia with varying degrees of respiratory compromise and up to 40% of hospitalized patients might develop acute respiratory distress syndrome. Several clinical trials evaluated the role of corticosteroids in non-COVID-19 acute respiratory distress syndrome with conflicting results. We designed a trial to evaluate the effectiveness of early intravenous dexamethasone administration on the number of days alive and free of mechanical ventilation within 28 days after randomization in adult patients with moderate or severe acute respiratory distress syndrome due to confirmed or probable COVID-19. METHODS This is a pragmatic, prospective, randomized, stratified, multicenter, open-label, controlled trial including 350 patients with early-onset (less than 48 hours before randomization) moderate or severe acute respiratory distress syndrome, defined by the Berlin criteria, due to COVID-19. Eligible patients will be randomly allocated to either standard treatment plus dexamethasone (Intervention Group) or standard treatment without dexamethasone (Control Group). Patients in the intervention group will receive dexamethasone 20mg intravenous once daily for 5 days, followed by dexamethasone 10mg IV once daily for additional 5 days or until intensive care unit discharge, whichever occurs first. The primary outcome is ventilator-free days within 28 days after randomization, defined as days alive and free from invasive mechanical ventilation. Secondary outcomes are all-cause mortality rates at day 28, evaluation of the clinical status at day 15 assessed with a 6-level ordinal scale, mechanical ventilation duration from randomization to day 28, Sequential Organ Failure Assessment Score evaluation at 48 hours, 72 hours and 7 days and intensive care unit -free days within 28.
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Affiliation(s)
- Bruno Martins Tomazini
- Hospital Sírio-Libanês - São Paulo (SP), Brazil
- Universidade de São Paulo - São Paulo (SP), Brazil
| | - Israel Silva Maia
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | - Alexandre Biasi Cavalcanti
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | - Álvaro Avezum
- Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brazil
| | | | - Renato Delascio Lopes
- Brazilian Clinical Research Institute (BCRI) - São Paulo (SP), Brazil
- Duke Clinical Research Institute, Duke University Medical Center - Durham, Estados Unidos
| | | | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Universidade Federal de São Paulo - São Paulo (SP), Brazil
| | | | - Luciano César Pontes de Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brazil
- Universidade de São Paulo - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
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20
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de Farias DLC, Prats J, Cavalcanti AB, Rosa RG, Machado FR, Berwanger O, de Azevedo LCP, Lopes RD, Avezum Á, Kawano-Dourado L, Damiani LP, Rojas SSO, de Oliveira CZ, Andrade LEC, Sandes AF, Pintão MC, de Castro Júnior CG, Scheinberg P, Veiga VC. Rationale and design of the "Tocilizumab in patients with moderate to severe COVID-19: an open-label multicentre randomized controlled" trial (TOCIBRAS). Rev Bras Ter Intensiva 2020; 32:337-347. [PMID: 32965395 PMCID: PMC7595725 DOI: 10.5935/0103-507x.20200060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Pro-inflammatory markers play a significant role in the disease severity of patients with COVID-19. Thus, anti-inflammatory therapies are attractive agents for potentially combating the uncontrolled inflammatory cascade in these patients. We designed a trial testing tocilizumab versus standard of care intending to improve the outcomes by inhibiting interleukin-6, an important inflammatory mediator in COVID-19. METHODS AND ANALYSIS This open-label multicentre randomized controlled trial will compare clinical outcomes of tocilizumab plus standard of care versus standard of care alone in patients with moderate to severe COVID-19. Two of the following four criteria are required for protocol enrolment: D-dimer > 1,000ng/mL; C reactive protein > 5mg/dL, ferritin > 300mg/dL, and lactate dehydrogenase > upper limit of normal. The primary objective will be to compare the clinical status on day 15, as measured by a 7-point ordinal scale applied in COVID-19 trials worldwide. The primary endpoint will be assessed by an ordinal logistic regression assuming proportional odds ratios adjusted for stratification variables (age and sex). ETHICS AND DISSEMINATION The TOCIBRAS protocol was approved by local and central (national) ethical committees in Brazil following current national and international guidelines/directives. Each participating center had the study protocol approved by their institutional review boards before initiating protocol enrolment. The data derived from this trial will be published regardless of the results. If proven active, this strategy could alleviate the consequences of the inflammatory response in COVID-19 patients and improve their clinical outcomes.
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Affiliation(s)
| | - João Prats
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | | | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Hospital Sírio-Libanês - São Paulo (SP), Brazil
| | - Renato Delascio Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, Estados Unidos
- Brazilian Clinical Research Institute - São Paulo (SP), Brazil
| | - Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | - Claudio Galvão de Castro Júnior
- Academic Research Organization, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Santa Casa de Porto Alegre - Porto Alegre (RS), Brazil
| | | | - Viviane Cordeiro Veiga
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
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21
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Machline-Carrion MJ, Soares RM, Damiani LP, Campos VB, Sampaio B, Fonseca FH, Izar MC, Amodeo C, Pontes-Neto OM, Santos JY, Gomes SPDC, Saraiva JFK, Ramacciotti E, Barros E Silva PGDM, Lopes RD, Brandão da Silva N, Guimarães HP, Piegas L, Stein AT, Berwanger O. Effect of a Multifaceted Quality Improvement Intervention on the Prescription of Evidence-Based Treatment in Patients at High Cardiovascular Risk in Brazil: The BRIDGE Cardiovascular Prevention Cluster Randomized Clinical Trial. JAMA Cardiol 2020; 4:408-417. [PMID: 30942842 DOI: 10.1001/jamacardio.2019.0649] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Studies have found that patients at high cardiovascular risk often fail to receive evidence-based therapies in community practice. Objective To evaluate whether a multifaceted quality improvement intervention can improve the prescription of evidence-based therapies. Design, Setting, and Participants In this 2-arm cluster randomized clinical trial, patients with established atherothrombotic disease from 40 public and private outpatient clinics (clusters) in Brazil were studied. Patients were recruited from August 2016 to August 2017, with follow-up to August 2018. Data were analyzed in September 2018. Interventions Case management, audit and feedback reports, and distribution of educational materials (to health care professionals and patients) vs routine practice. Main Outcomes and Measures The primary end point was prescription of evidence-based therapies (ie, statins, antiplatelet therapy, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) using the all-or-none approach at 12 months after the intervention period in patients without contraindications. Results Of the 1619 included patients, 1029 (63.6%) were male, 1327 (82.0%) had coronary artery disease (843 [52.1%] with prior acute myocardial infarction), 355 (21.9%) had prior ischemic stroke or transient ischemic attack, and 197 (12.2%) had peripheral vascular disease, and the mean (SD) age was 65.6 (10.5) years. Among randomized clusters, 30 (75%) were cardiology sites, 6 (15%) were primary care units, and 26 (65%) were teaching institutions. Among eligible patients, those in intervention clusters were more likely to receive a prescription of evidence-based therapies than those in control clusters (73.5% [515 of 701] vs 58.7% [493 of 840]; odds ratio, 2.30; 95% CI, 1.14-4.65). There were no differences between the intervention and control groups with regards to risk factor control (ie, hyperlipidemia, hypertension, or diabetes). Rates of education for smoking cessation were higher among current smokers in the intervention group than in the control group (51.9% [364 of 701] vs 18.2% [153 of 840]; odds ratio, 11.24; 95% CI, 2.20-57.43). The rate of cardiovascular mortality, acute myocardial infarction, and stroke was 2.6% for patients from intervention clusters and 3.4% for those in the control group (hazard ratio, 0.76; 95% CI, 0.43-1.34). Conclusions and Relevance Among Brazilian patients at high cardiovascular risk, a quality improvement intervention resulted in improved prescription of evidence-based therapies. Trial Registration ClinicalTrials.gov identifier: NCT02851732.
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Affiliation(s)
| | | | | | | | - Bruna Sampaio
- HCor Research Institute, Hospital do Coração, São Paulo, São Paulo, Brazil
| | | | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, São Paulo, Brazil.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nilton Brandão da Silva
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Airton T Stein
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Otávio Berwanger
- HCor Research Institute, Hospital do Coração, São Paulo, São Paulo, Brazil
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22
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Lopes RD, de Barros E Silva PGM, Damiani LP, Santos RHN, Alexander JH, Granger CB, Berwanger O. Major Adverse Cardiovascular Events After 12 Months Among Patients With Acute Coronary Syndrome Receiving Loading Doses of Atorvastatin Prior to Planned PCI. JAMA 2020; 323:787-789. [PMID: 32096839 DOI: 10.1001/jama.2020.0118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina
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23
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Damiani LP, Cavalcanti AB, Biondi RS, Freitas FGRD, Figueiredo RC, Lovato WJ, Amêndola CP, Serpa Neto A, Paranhos JLDR, Veiga VC, Guedes MAV, Lúcio EDA, Oliveira Júnior LC, Lisboa TC, Lacerda FH, Miranda TA, Maia IS, Grion CMC, Machado FR, Zampieri FG. Statistical analysis plan for the Balanced Solution versus Saline in Intensive Care Study (BaSICS). Rev Bras Ter Intensiva 2020; 32:493-505. [PMID: 33263702 PMCID: PMC7853670 DOI: 10.5935/0103-507x.20200081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/07/2020] [Indexed: 01/18/2023] Open
Abstract
Objective To report the statistical analysis plan (first version) for the Balanced Solutions versus Saline in Intensive Care Study (BaSICS). Methods BaSICS is a multicenter factorial randomized controlled trial that will assess the effects of Plasma-Lyte 148 versus 0.9% saline as the fluid of choice in critically ill patients, as well as the effects of a slow (333mL/h) versus rapid (999mL/h) infusion speed during fluid challenges, on important patient outcomes. The fluid type will be blinded for investigators, patients and the analyses. No blinding will be possible for the infusion speed for the investigators, but all analyses will be kept blinded during the analysis procedure. Results BaSICS will have 90-day mortality as its primary endpoint, which will be tested using mixed-effects Cox proportional hazard models, considering sites as a random variable (frailty models) adjusted for age, organ dysfunction and admission type. Important secondary endpoints include renal replacement therapy up to 90 days, acute renal failure, organ dysfunction at days 3 and 7, and mechanical ventilation-free days within 28 days. Conclusion This manuscript provides details on the first version of the statistical analysis plan for the BaSICS trial and will guide the study’s analysis when follow-up is finished.
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Affiliation(s)
| | | | - Rodrigo Santos Biondi
- Instituto de Cardiologia do Distrito Federal, Fundação Universitária de Cardiologia - Brasília (DF), Brasil
| | | | | | - Wilson José Lovato
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | | | - Ary Serpa Neto
- Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | | | | | - Eraldo de Azevedo Lúcio
- Hospital São Francisco, Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | | | - Thiago Costa Lisboa
- Hospital Santa Rita, Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | | | | | | | | | - Flavia Ribeiro Machado
- Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
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24
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Lopes RD, de Barros E Silva PGM, de Andrade Jesuíno I, Santucci EV, Barbosa LM, Damiani LP, Nakagawa Santos RH, Laranjeira LN, Dall Orto FTC, Beraldo de Andrade P, de Castro Bienert IR, Alexander JH, Granger CB, Berwanger O. Timing of Loading Dose of Atorvastatin in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes: Insights From the SECURE-PCI Randomized Clinical Trial. JAMA Cardiol 2019; 3:1113-1118. [PMID: 30264159 DOI: 10.1001/jamacardio.2018.3408] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Loading doses of atorvastatin did not show reduction on clinical outcomes in the overall population of patients with acute coronary syndrome (ACS) enrolled in the Statins Evaluation in Coronary Procedures and Revascularization (SECURE-PCI) trial, but a potential benefit was identified in patients who subsequently underwent percutaneous coronary intervention (PCI). Objectives To determine whether periprocedural loading doses of atorvastatin are associated with decreased 30-day major adverse cardiovascular events (MACE) in patients with ACS undergoing PCI according to type of ACS and timing of atorvastatin administration before PCI. Design, Setting, and Participants Secondary analysis of a multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites that enrolled 4191 patients with ACS intended to be treated with PCI between April 18, 2012, and October 06, 2017. Interventions Patients were randomized to 2 loading doses of 80 mg of atorvastatin or matching placebo before and 24 hours after a planned PCI. By protocol, all patients (regardless of treatment group) received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. Main Outcomes and Measures The primary outcome was MACE through 30 days, composed by all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization. Cox regression models adjusting for key baseline characteristics were used to assess the association between atorvastatin and MACE in patients undergoing PCI. Results From the overall trial population, 2710 (64.7%) underwent PCI (650 women [24.0%]; mean [SD] age, 62 [11.3] years). Loading atorvastatin was associated with reduced MACE at 30 days by 28% in the PCI group (adjusted hazard ratio [HR], 0.72; 95% CI 0.54-0.97; P = .03). Loading dose of atorvastatin was administered less than 12 hours before PCI in 2548 patients (95.3%) (45.1% < 2 hours and 54.3% between 2 and 12 hours). There was no significant interaction between treatment effect and timing of study drug administration. The treatment effect of loading atorvastatin was more pronounced in patients with ST-segment elevation myocardial infarction than in patients with non-ST-segment elevation ACS (adjusted HR, 0.59; 95% CI, 0.38-0.92; P = .02; HR, 0.85; 95% CI, 0.58-1.27; P = .43, respectively). Conclusions and Relevance In patients with ACS undergoing PCI, periprocedural loading doses of atorvastatin appeared to reduce the rate of MACE at 30 days, most clearly in patients with ST-segment elevation myocardial infarction. This beneficial effect seemed to be preserved and consistent, irrespective of the timing of atorvastatin administration, including within 2 hours before PCI. Trial Registration clinicaltrials.gov Identifier: NCT01448642.
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Affiliation(s)
- Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil.,Duke Clinical Research Institute, Durham, North Carolina
| | - Pedro G M de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil.,Research Institute-Heart Hospital, São Paulo, Brazil
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25
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Machline-Carrion MJ, Santucci EV, Damiani LP, Bahit MC, Málaga G, Pontes-Neto OM, Martins SCO, Zétola VF, Normilio-Silva K, Rodrigues de Freitas G, Gorgulho A, De Salles A, Pacheco da Silva BG, Santos JY, de Andrade Jesuíno I, Bueno PRT, Cavalcanti AB, Guimarães HP, Xian Y, Bettger JP, Lopes RD, Peterson ED, Berwanger O. Effect of a Quality Improvement Intervention on Adherence to Therapies for Patients With Acute Ischemic Stroke and Transient Ischemic Attack: A Cluster Randomized Clinical Trial. JAMA Neurol 2019; 76:932-941. [PMID: 31058947 DOI: 10.1001/jamaneurol.2019.1012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. Objective To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. Design, Setting and Participants This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. Interventions The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. Main Outcomes and Measures The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). Results A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). Conclusions and Relevance A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. Trial Registration ClinicalTrials.gov identifier: NCT02223273.
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Affiliation(s)
| | | | | | - M Cecilia Bahit
- Fundacion Instituto de Neurología Cognitiva Rosario, Grupo Argentino Colaborativo en Investigación Clínica, Rosario, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ying Xian
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Miura MC, Ribeiro de Carvalho CR, Yamada da Silveira LT, de Moraes Regenga M, Damiani LP, Fu C. Recruitment maneuver might be an option for patients with hypoxemia and atelectasis. J Thorac Cardiovasc Surg 2019; 157:e178-e179. [PMID: 33198032 DOI: 10.1016/j.jtcvs.2018.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Mieko Claudia Miura
- Hospital do Coração-HCor, São Paulo, Brazil; Department of Physiotherapy, Communication Science & Disorders, Occupational Therapy, Medical School, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Roberto Ribeiro de Carvalho
- Cardio-Pulmonary Department-Respiratory ICU/Pulmonary Division, Heart Institute (InCor), Medical School, Universidade de São Paulo, São Paulo, Brazil
| | - Leda Tomiko Yamada da Silveira
- Department of Physiotherapy, Communication Science & Disorders, Occupational Therapy, Medical School, Universidade de São Paulo, São Paulo, Brazil; University Hospital, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Carolina Fu
- Department of Physiotherapy, Communication Science & Disorders, Occupational Therapy, Medical School, Universidade de São Paulo, São Paulo, Brazil
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Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA 2019; 321:654-664. [PMID: 30772908 PMCID: PMC6439620 DOI: 10.1001/jama.2019.0071] [Citation(s) in RCA: 386] [Impact Index Per Article: 77.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. OBJECTIVE To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. INTERVENTIONS Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. RESULTS Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. CONCLUSIONS AND RELEVANCE Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03078712.
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Affiliation(s)
- Glenn Hernández
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Gustavo A. Ospina-Tascón
- Fundación Valle del Lili, Universidad ICESI, Department of Intensive Care Medicine, Cali, Colombia
| | - Lucas Petri Damiani
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Arnaldo Dubin
- Sanatorio Otamendi, Buenos Aires, Argentina
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Javier Hurtado
- Intensive Care Unit, Hospital Español–ASSE, Montevideo, Uruguay
- Department of Pathophysiology, School of Medicine Universidad de la República, Montevideo, Uruguay
| | - Gilberto Friedman
- Post-Graduation Program in Pneumological Sciences, Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ricardo Castro
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Leyla Alegría
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hopital Bicetre, Hopitaux Universitaires Paris–Sud, Paris, France
- Assistance Publique Hôpitaux de Paris, Université Paris–Sud, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Manuel Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Escuela de Medicina, Universidad Internacional del Ecuador, Quito
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Paula Fernández
- Unidad de Pacientes Críticos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Diego Barahona
- Unidad de Cuidados Intensivos, Hospital General Docente de Calderón, Universidad Central del Ecuador, Quito
| | - Vladimir Granda-Luna
- Unidad de Cuidados Intensivos, Hospital San Francisco, Pontificia Universidad Católica de Quito, Quito, Ecuador
| | - Alexandre Biasi Cavalcanti
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jan Bakker
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, New York
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
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Machline-Carrion MJ, Soares RM, Damiani LP, Campos VB, Sampaio B, Yamashita J, Fonseca FH, Izar MC, Amodeo C, Pontes-Neto OM, de Melo Barros PG, Lopes RD, Brandão da Silva N, Guimarães HP, Piegas L, Stein AT, Berwanger O. Rationale and design for a cluster randomized quality-improvement trial to increase the uptake of evidence-based therapies for patients at high cardiovascular risk: The BRIDGE-Cardiovascular Prevention trial. Am Heart J 2019; 207:40-48. [PMID: 30415082 DOI: 10.1016/j.ahj.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Translating evidence into clinical practice in the management of high cardiovascular risk patients is challenging. Few quality improvement interventions have rigorously evaluated their impact on both patient care and clinical outcomes. OBJECTIVES The main objectives are to evaluate the impact of a multifaceted educational intervention on adherence to local guidelines for the prescription of statins, antiplatelets and angiotensin converting enzyme inhibitors or angiotensin II receptor blockers for high cardiovascular risk patients, as well as on the incidence of major cardiovascular events. DESIGN We designed a pragmatic two arm cluster randomized trial involving 40 clusters. Clusters are randomized to receive a multifaceted quality improvement intervention or to routine practice (control). The multifaceted intervention includes: reminders, care algorithms, training of a case manager, audit and feedback reports, and distribution of educational materials to health care providers. The primary endpoint is the adherence to combined evidence-based therapies (statins, antiplatelet therapy and angiotensin converting enzyme inhibitors or angiotensin receptor blockers) at 12 months after the intervention period in patients without contra-indications for these medications. All analyses follow the intention-to-treat principle and take the cluster design into account using linear mixed logistic regression modeling. SUMMARY If proven effective, this multifaceted intervention would have wide utility as a means of promoting optimal usage of evidence-based interventions for the management of high cardiovascular risk patients.
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Machline-Carrion MJ, Santucci EV, Damiani LP, Bahit C, Málaga G, Pontes-Neto OM, Martins SCO, Zétola VF, Normilio-Silva K, de Freitas GR, Gorgulho A, De Salles A, da Silva BGP, Santos JY, de Andrade Jesuíno I, Bueno PRT, Cavalcanti AB, Guimarães HP, Xian Y, Bettger JP, Lopes RD, Peterson ED, Berwanger O. An international cluster-randomized quality improvement trial to increase the adherence to evidence-based therapies for acute ischemic stroke and transient ischemic attack patients: Rationale and design of the BRIDGE STROKE Trial. Am Heart J 2019; 207:49-57. [PMID: 30415083 DOI: 10.1016/j.ahj.2018.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/21/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging especially in low- and middle-income countries. OBJECTIVES The aim of this study is to assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for AIS and TIA patients care. DESIGN We designed a pragmatic, 2-arm cluster-randomized trial involving 36 clusters and 1624 patients from Brazil, Argentina, and Peru. Hospitals are randomized to receive a multifaceted quality improvement intervention (intervention group) or to routine care (control group). The BRIDGE Stroke multifaceted quality improvement intervention includes case management, reminders, health care providers' educational materials (including treatment algorithms), interactive workshops, and audit and feedback reports. Primary outcome is a composite adherence score to AIS and TIA performance measures. Secondary outcomes include an "all or none" composite end point to performance measures, the individual components of the composite end points, and clinical outcomes at 90 days following admission (stroke recurrence, death, and disability measured by the modified Rankin scale). SUMMARY The BRIDGE Stroke Trial is an international pragmatic evaluation of a multifaceted quality improvement intervention. If effective, this intervention could be potentially extended widely to improve the quality of care and outcomes of patients with AIS or TIA.
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Miura MC, Ribeiro de Carvalho CR, Yamada da Silveira LT, de Moraes Regenga M, Petri Damiani L, Fu C. The effects of recruitment maneuver during noninvasive ventilation after coronary bypass grafting: A randomized trial. J Thorac Cardiovasc Surg 2018; 156:2170-2177.e1. [DOI: 10.1016/j.jtcvs.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 04/23/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022]
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Sganzerla D, Teixeira C, Robinson CC, Kochhann R, Santos MMS, de Moura RM, Barbosa MG, da Silva DB, Ribeiro T, Eugênio C, Schneider D, Mariani D, Jeffman RW, Bozza F, Cavalcanti AB, Azevedo LCP, Machado FR, Salluh JI, Pellegrini JAS, Moraes RB, Damiani LP, da Silva NB, Falavigna M, Rosa RG. Statistical analysis plan for a cluster-randomized crossover trial comparing the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units (the ICU Visits Study). Trials 2018; 19:636. [PMID: 30454019 PMCID: PMC6245900 DOI: 10.1186/s13063-018-3006-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. METHODS/DESIGN The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data. DISCUSSION This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field. TRIAL REGISTRATION ClinicalTrials.gov, NCT02932358 . Registered on 11 October 2016.
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Affiliation(s)
- Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Cassiano Teixeira
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Caroline Cabral Robinson
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Renata Kochhann
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Mariana Martins Siqueira Santos
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Rafaela Moraes de Moura
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Mirceli Goulart Barbosa
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Daiana Barbosa da Silva
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Tarissa Ribeiro
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Cláudia Eugênio
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Daniel Schneider
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Débora Mariani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Rodrigo Wiltgen Jeffman
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Fernando Bozza
- Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rua Diniz Cordeiro, 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil
| | | | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91, Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Flávia Ribeiro Machado
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 737, Vila Clementino, São Paulo, SP, 04024-900, Brazil
| | - Jorge Ibrain Salluh
- HCor Research Institute, Rua Abílio Soares, 250, Paraíso, São Paulo, SP, 04005-909, Brazil
| | - José Augusto Santos Pellegrini
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Santa Cecília, Porto Alegre, RS, 90035-903, Brazil
| | - Rafael Barberena Moraes
- Institute for Education and Research, HMV, Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Lucas Petri Damiani
- HCor Research Institute, Rua Abílio Soares, 250, Paraíso, São Paulo, SP, 04005-909, Brazil
| | - Nilton Brandão da Silva
- Department of Internal Medicine, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Rua Sarmento Leite, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, HMV, Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Regis Goulart Rosa
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil.
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Hernández G, Cavalcanti AB, Ospina-Tascón G, Dubin A, Hurtado FJ, Damiani LP, Friedman G, Castro R, Alegría L, Cecconi M, Teboul JL, Bakker J. Statistical analysis plan for early goal-directed therapy using a physiological holistic view - the ANDROMEDA-SHOCK: a randomized controlled trial. Rev Bras Ter Intensiva 2018; 30:253-263. [PMID: 30066731 PMCID: PMC6180476 DOI: 10.5935/0103-507x.20180041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/11/2018] [Indexed: 01/13/2023] Open
Abstract
Background ANDROMEDA-SHOCK is an international, multicenter, randomized controlled trial
comparing peripheral perfusion-targeted resuscitation to lactate-targeted
resuscitation in patients with septic shock in order to test the hypothesis
that resuscitation targeting peripheral perfusion will be associated with
lower morbidity and mortality. Objective To report the statistical analysis plan for the ANDROMEDA-SHOCK trial. Methods We describe the trial design, primary and secondary objectives, patients,
methods of randomization, interventions, outcomes, and sample size. We
describe our planned statistical analysis for the primary, secondary and
tertiary outcomes. We also describe the subgroup and sensitivity analyses.
Finally, we provide details for presenting our results, including mock
tables showing baseline characteristics, the evolution of hemodynamic and
perfusion variables, and the effects of treatments on outcomes. Conclusion According to the best trial practice, we report our statistical analysis plan
and data management plan prior to locking the database and initiating the
analyses. We anticipate that this procedure will prevent analysis bias and
enhance the utility of the reported results.
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | | | - Gustavo Ospina-Tascón
- Departamento de Medicina Intensiva, Fundación Valle del Lili, Universidad ICESI - Cali, Colômbia
| | - Arnaldo Dubin
- Serviço de Terapia Intensiva, Sanatorio Otamendi y Miroli - Ciudad Autónoma de Buenos Aires, Argentina
| | - Francisco Javier Hurtado
- Centro de Terapia Intensiva, Hospital Español, Escuela de Medicina, Universidad de la República - Montevidéu, Uruguai
| | | | - Gilberto Friedman
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | - Maurizio Cecconi
- St George's University Hospitals NHS Foundation Trust - Londres, Reino Unido
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris - Paris, França
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center - Nova Iorque, Estados Unidos.,Erasmus MC University Medical Center, Department Intensive Care Adults - Rotterdam, CA, Holanda.,Division of Pulmonary, and Critical Care Medicine, New York University - Langone - Nova Iorque, Estados Unidos
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Damiani LP, Berwanger O, Paisani D, Laranjeira LN, Suzumura EA, Amato MBP, Carvalho CRR, Cavalcanti AB. Statistical analysis plan for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART). A randomized controlled trial. Rev Bras Ter Intensiva 2018; 29:142-153. [PMID: 28977255 PMCID: PMC5496748 DOI: 10.5935/0103-507x.20170024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/01/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) is an international multicenter randomized pragmatic controlled trial with allocation concealment involving 120 intensive care units in Brazil, Argentina, Colombia, Italy, Poland, Portugal, Malaysia, Spain, and Uruguay. The primary objective of ART is to determine whether maximum stepwise alveolar recruitment associated with PEEP titration, adjusted according to the static compliance of the respiratory system (ART strategy), is able to increase 28-day survival in patients with acute respiratory distress syndrome compared to conventional treatment (ARDSNet strategy). OBJECTIVE To describe the data management process and statistical analysis plan. METHODS The statistical analysis plan was designed by the trial executive committee and reviewed and approved by the trial steering committee. We provide an overview of the trial design with a special focus on describing the primary (28-day survival) and secondary outcomes. We describe our data management process, data monitoring committee, interim analyses, and sample size calculation. We describe our planned statistical analyses for primary and secondary outcomes as well as pre-specified subgroup analyses. We also provide details for presenting results, including mock tables for baseline characteristics, adherence to the protocol and effect on clinical outcomes. CONCLUSION According to best trial practice, we report our statistical analysis plan and data management plan prior to locking the database and beginning analyses. We anticipate that this document will prevent analysis bias and enhance the utility of the reported results. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01374022.
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Affiliation(s)
| | | | | | | | | | - Marcelo Britto Passos Amato
- Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Carlos Roberto Ribeiro Carvalho
- Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Berwanger O, Santucci EV, de Barros e Silva PGM, Jesuíno IDA, Damiani LP, Barbosa LM, Santos RHN, Laranjeira LN, Egydio FDM, Borges de Oliveira JA, Dall Orto FTC, Beraldo de Andrade P, Bienert IRDC, Bosso CE, Mangione JA, Polanczyk CA, Sousa AGDMR, Kalil RAK, Santos LDM, Sposito AC, Rech RL, Sousa ACS, Baldissera F, Nascimento BR, Giraldez RRCV, Cavalcanti AB, Pereira SB, Mattos LA, Armaganijan LV, Guimarães HP, Sousa JEMR, Alexander JH, Granger CB, Lopes RD. Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial. JAMA 2018; 319. [PMID: 29525821 PMCID: PMC5876881 DOI: 10.1001/jama.2018.2444] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. OBJECTIVE To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. INTERVENTIONS Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. MAIN OUTCOMES AND MEASURES The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. RESULTS Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. CONCLUSIONS AND RELEVANCE Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01448642.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Carlos Eduardo Bosso
- Santa Casa de Presidente Prudente/Instituto do Coração de Presidente Prudente, Presidente Prudente, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - John Hunter Alexander
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | | | - Renato Delascio Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
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Lima DB, Damiani LP, Fujimori E. DEFICIÊNCIA DE VITAMINA A EM CRIANÇAS BRASILEIRAS E VARIÁVEIS ASSOCIADAS. Rev paul pediatr 2018; 36:176-185. [PMID: 29617474 PMCID: PMC6038778 DOI: 10.1590/1984-0462/;2018;36;2;00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/27/2017] [Indexed: 11/21/2022]
Abstract
RESUMO Objetivo: Analisar variáveis associadas à deficiência de vitamina A (DVA) em crianças brasileiras de 6 a 59 meses de idade, considerando um modelo hierárquico de determinação. Métodos: Trata-se de um recorte da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS), realizada em 2006. A análise dos dados incluiu 3.417 crianças de seis a 59 meses com dados de retinol. A DVA foi definida como retinol sérico <0,7 mmol/L. Realizaram-se análises univariada e ajustada por regressão múltipla de Poisson, com nível de significância de 5%, utilizando-se modelo hierárquico de determinação que considerou três blocos de variáveis: vinculadas aos processos estruturais da sociedade (variáveis socioeconômicas e demográficas); ao ambiente imediato da criança (variáveis maternas, de segurança e consumo alimentar); e individuais (características biológicas da criança). Os dados foram expressos em razão de prevalência (RP). Resultados: Após ajuste para variáveis de confusão, permaneceram associadas à DVA: residir no Sudeste [RP=1,59; IC95% 1,19-2,17] e no Nordeste [RP=1,56; IC95% 1,16-2,15]; em zona urbana [RP=1,31; IC95% 1,02-1,72]; ter mãe com idade ≥36 anos [RP=2,28; IC95% 1,37-3,98]; sendo proteção consumir carne pelo menos uma vez nos últimos sete dias [RP=0,24; IC95% 0,13-0,42]. Conclusões: As principais variáveis associadas à DVA no país relacionam-se aos processos estruturais da sociedade e ao ambiente imediato da criança, e não aos individuais.
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Schiavon CA, Bersch-Ferreira AC, Santucci EV, Oliveira JD, Torreglosa CR, Bueno PT, Frayha JC, Santos RN, Damiani LP, Noujaim PM, Halpern H, Monteiro FLJ, Cohen RV, Uchoa CH, de Souza MG, Amodeo C, Bortolotto L, Ikeoka D, Drager LF, Cavalcanti AB, Berwanger O. Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). Circulation 2017; 137:1132-1142. [PMID: 29133606 PMCID: PMC5865494 DOI: 10.1161/circulationaha.117.032130] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/24/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent research efforts on bariatric surgery have focused on metabolic and diabetes mellitus resolution. Randomized trials designed to assess the impact of bariatric surgery in patients with obesity and hypertension are needed. METHODS In this randomized, single-center, nonblinded trial, we included patients with hypertension (using ≥2 medications at maximum doses or >2 at moderate doses) and a body mass index between 30.0 and 39.9 kg/m2. Patients were randomized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. The primary end point was reduction of ≥30% of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure <140 mm Hg and 90 mm Hg, respectively, at 12 months. RESULTS We included 100 patients (70% female, mean age 43.8±9.2 years, mean body mass index 36.9±2.7 kg/m2), and 96% completed follow-up. Reduction of ≥30% of the total number of antihypertensive medications while maintaining controlled blood pressure occurred in 41 of 49 patients from the gastric bypass group (83.7%) compared with 6 of 47 patients (12.8%) from the control group with a rate ratio of 6.6 (95% confidence interval, 3.1-14.0; P<0.001). Remission of hypertension was present in 25 of 49 (51%) and 22 of 48 (45.8%) patients randomized to gastric bypass, considering office and 24-hour ambulatory blood pressure monitoring, respectively, whereas no patient submitted to medical therapy was free of antihypertensive drugs at 12 months. A post hoc analysis for the primary end point considering the SPRINT (Systolic Blood Pressure Intervention Trial) target reached consistent results, with a rate ratio of 3.8 (95% confidence interval, 1.4-10.6; P=0.005). Eleven patients (22.4%) from the gastric bypass group and none in the control group were able to achieve SPRINT levels without antihypertensives. Waist circumference, body mass index, fasting plasma glucose, glycohemoglobin, low-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, and 10-year Framingham risk score were lower in the gastric bypass than in the control group. CONCLUSIONS Bariatric surgery represents an effective strategy for blood pressure control in a broad population of patients with obesity and hypertension. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT01784848.
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Affiliation(s)
- Carlos Aurelio Schiavon
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Angela Cristine Bersch-Ferreira
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Eliana Vieira Santucci
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Juliana Dantas Oliveira
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Camila Ragne Torreglosa
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Priscila Torres Bueno
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Julia Caldas Frayha
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Renato Nakagawa Santos
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Lucas Petri Damiani
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | | | | | | | | | - Carlos H Uchoa
- Heart Institute, Hypertension Unit, São Paulo, Brazil (C.H.U., L.B., L.F.D.)
| | - Marcio Gonçalves de Souza
- Department of Hypertension, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil (M.G.d.S., C.A.)
| | - Celso Amodeo
- Department of Hypertension, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil (M.G.d.S., C.A.)
| | - Luiz Bortolotto
- Heart Institute, Hypertension Unit, São Paulo, Brazil (C.H.U., L.B., L.F.D.)
| | - Dimas Ikeoka
- Intensive Unit (D.I.), Heart Hospital, São Paulo, Brazil
| | - Luciano F Drager
- Heart Institute, Hypertension Unit, São Paulo, Brazil (C.H.U., L.B., L.F.D.)
| | - Alexandre Biasi Cavalcanti
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
| | - Otavio Berwanger
- Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.)
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Cavalcanti AB, Suzumura ÉA, Laranjeira LN, Paisani DDM, Damiani LP, Guimarães HP, Romano ER, Regenga MDM, Taniguchi LNT, Teixeira C, Pinheiro de Oliveira R, Machado FR, Diaz-Quijano FA, Filho MSDA, Maia IS, Caser EB, Filho WDO, Borges MDC, Martins PDA, Matsui M, Ospina-Tascón GA, Giancursi TS, Giraldo-Ramirez ND, Vieira SRR, Assef MDGPDL, Hasan MS, Szczeklik W, Rios F, Amato MBP, Berwanger O, Ribeiro de Carvalho CR. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2017; 318:1335-1345. [PMID: 28973363 PMCID: PMC5710484 DOI: 10.1001/jama.2017.14171] [Citation(s) in RCA: 550] [Impact Index Per Article: 78.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. OBJECTIVE To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. INTERVENTIONS An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. RESULTS A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. CONCLUSIONS AND RELEVANCE In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01374022.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Flavia Ribeiro Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Mirna Matsui
- Hospital Universitário da Universidade Federal da Grande Dourados, Dourados, Brazil
| | | | | | | | | | | | | | - Wojciech Szczeklik
- Jagiellonian University Medical College; Department of Intensive Care and Perioperative Medicine, Krakow, Poland
| | - Fernando Rios
- Hospital Nacional Alejandro Posadas, Moron, Argentina
| | - Marcelo Britto Passos Amato
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
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Gomes JGR, Gorgulho AA, de Oliveira López A, Saraiva CWC, Damiani LP, Pássaro AM, Salvajoli JV, de Oliveira Siqueira L, Salvajoli BP, De Salles AAF. The role of diffusion tensor imaging tractography for Gamma Knife thalamotomy planning. J Neurosurg 2016; 125:129-138. [DOI: 10.3171/2016.7.gks161553] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe role of tractography in Gamma Knife thalamotomy (GK-T) planning is still unclear. Pyramidal tractography might reduce the risk of radiation injury to the pyramidal tract and reduce motor complications.METHODSIn this study, the ventralis intermedius nucleus (VIM) targets of 20 patients were bilaterally defined using Iplannet Stereotaxy Software, according to the anterior commissure–posterior commissure (AC-PC) line and considering the localization of the pyramidal tract. The 40 targets and tractography were transferred as objects to the GammaPlan Treatment Planning System (GP-TPS). New targets were defined, according to the AC-PC line in the functional targets section of the GP-TPS. The target offsets required to maintain the internal capsule (IC) constraint of < 15 Gy were evaluated. In addition, the strategies available in GP-TPS to maintain the minimum conventional VIM target dose at > 100 Gy were determined.RESULTSA difference was observed between the positions of both targets and the doses to the IC. The lateral (x) and the vertical (z) coordinates were adjusted 1.9 mm medially and 1.3 mm cranially, respectively. The targets defined considering the position of the pyramidal tract were more medial and superior, based on the constraint of 15 Gy touching the object representing the IC in the GP-TPS. The best strategy to meet the set constraints was 90° Gamma angle (GA) with automatic shaping of dose distribution; this was followed by 110° GA. The worst GA was 70°. Treatment time was substantially increased by the shaping strategy, approximately doubling delivery time.CONCLUSIONSRoutine use of DTI pyramidal tractography might be important to fine-tune GK-T planning. DTI tractography, as well as anisotropy showing the VIM, promises to improve Gamma Knife functional procedures. They allow for a more objective definition of dose constraints to the IC and targeting. DTI pyramidal tractography introduced into the treatment planning may reduce the incidence of motor complications and improve efficacy. This needs to be validated in a large clinical series.
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Affiliation(s)
- João Gabriel Ribeiro Gomes
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
- 2Department of Neurosurgery, Real Hospital Português, Recife-PE, Brazil
| | - Alessandra Augusta Gorgulho
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | | | - Crystian Wilian Chagas Saraiva
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Lucas Petri Damiani
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Anderson Martins Pássaro
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - João Victor Salvajoli
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Ludmila de Oliveira Siqueira
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Bernardo Peres Salvajoli
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Antônio Afonso Ferreira De Salles
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
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Kawano-Dourado L, Zampieri F, Cavalcanti AB, Damiani LP, Kairalla RA. Unfavourable effects of medically indicated oral anticoagulants on survival in idiopathic pulmonary fibrosis: methodological concerns. Eur Respir J 2016; 48:1523-1524. [PMID: 27799398 DOI: 10.1183/13993003.01283-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 07/01/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Leticia Kawano-Dourado
- Research Institute - Heart Hospital (Hospital do Coração - HCor), São Paulo, Brazil .,Interstitial Lung Disease Unit, Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Fernando Zampieri
- Research Institute - Heart Hospital (Hospital do Coração - HCor), São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Lucas Petri Damiani
- Research Institute - Heart Hospital (Hospital do Coração - HCor), São Paulo, Brazil
| | - Ronaldo Adib Kairalla
- Interstitial Lung Disease Unit, Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
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Zardo KM, Damiani LP, Matera JM, Fonseca-Pinto ACBDC. Recurrent and non-recurrent feline injection-site sarcoma: computed tomographic and ultrasonographic findings. J Feline Med Surg 2016. [DOI: 10.1177/1098612x15596200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives This study describes the sonographic and computed tomographic (CT) characteristics of primary and recurrent feline injection-site sarcomas (FISSs). Methods Between 2005 and 2013, 32 cats were selected for prospective and retrospective studies. Tumor shape and margins, presence of thickening of the adipose tissue, muscular and bone involvement, pre- and postcontrast attenuation, blurring of fat planes, calcification and liquefactive necrosis, intratumoral areas and skip metastasis were analyzed in CT scans. Echogenicity, echotexture, tumor margins and peritumoral tissue characteristics were analyzed by ultrasound (US). Results Irregular shape (62.5%) with digitiform projections (100.0%), mixed (peripheral and intratumoral) contrast enhancement (67.7%), blurring of fat planes (68.8%) and signs of liquefactive intratumoral necrosis (68.8%) were the prevailing CT findings. Ultrasonography revealed irregular tumor margins, peripheral hyperechoic capsule-like rim, heterogeneous echotexture, and hyperechoic tissue contiguous with the formations and thickening of adjacent subcutaneous tissues in all cases. Mixed echogenicity with areas suggestive of tumor liquefactive necrosis was documented in 83.3% of cases. Skip metastases were highly correlated with tumor recurrence ( P = 0.001). The incidence of muscular involvement tended to be higher ( P = 0.003) in tumors presenting with thickening of adjacent adipose tissue. Conclusions and relevance CT and US features common to FISS lesions were highlighted in this study. The imaging modalities employed allowed assessment of peritumoral inflammation, particularly adipose tissue inflammation. Imaging data may contribute to FISS diagnosis, therapeutic planning and patient follow-up.
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Affiliation(s)
- Karen Maciel Zardo
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Lucas Petri Damiani
- Statistics Department, Institute of Mathematics and Statistics, University of São Paulo, São Paulo, Brazil
| | - Julia Maria Matera
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
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Cavalcanti AB, Bozza FA, Machado FR, Salluh JIF, Campagnucci VP, Vendramim P, Guimaraes HP, Normilio-Silva K, Damiani LP, Romano E, Carrara F, Lubarino Diniz de Souza J, Silva AR, Ramos GV, Teixeira C, Brandão da Silva N, Chang CCH, Angus DC, Berwanger O. Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients: A Randomized Clinical Trial. JAMA 2016; 315:1480-90. [PMID: 27115264 DOI: 10.1001/jama.2016.3463] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The effectiveness of checklists, daily goal assessments, and clinician prompts as quality improvement interventions in intensive care units (ICUs) is uncertain. OBJECTIVE To determine whether a multifaceted quality improvement intervention reduces the mortality of critically ill adults. DESIGN, SETTING, AND PARTICIPANTS This study had 2 phases. Phase 1 was an observational study to assess baseline data on work climate, care processes, and clinical outcomes, conducted between August 2013 and March 2014 in 118 Brazilian ICUs. Phase 2 was a cluster randomized trial conducted between April and November 2014 with the same ICUs. The first 60 admissions of longer than 48 hours per ICU were enrolled in each phase. INTERVENTIONS Intensive care units were randomized to a quality improvement intervention, including a daily checklist and goal setting during multidisciplinary rounds with follow-up clinician prompting for 11 care processes, or to routine care. MAIN OUTCOMES AND MEASURES In-hospital mortality truncated at 60 days (primary outcome) was analyzed using a random-effects logistic regression model, adjusted for patients' severity and the ICU's baseline standardized mortality ratio. Exploratory secondary outcomes included adherence to care processes, safety climate, and clinical events. RESULTS A total of 6877 patients (mean age, 59.7 years; 3218 [46.8%] women) were enrolled in the baseline (observational) phase and 6761 (mean age, 59.6 years; 3098 [45.8%] women) in the randomized phase, with 3327 patients enrolled in ICUs (n = 59) assigned to the intervention group and 3434 patients in ICUs (n = 59) assigned to routine care. There was no significant difference in in-hospital mortality between the intervention group and the usual care group, with 1096 deaths (32.9%) and 1196 deaths (34.8%), respectively (odds ratio, 1.02; 95% CI, 0.82-1.26; P = .88). Among 20 prespecified secondary outcomes not adjusted for multiple comparisons, 6 were significantly improved in the intervention group (use of low tidal volumes, avoidance of heavy sedation, use of central venous catheters, use of urinary catheters, perception of team work, and perception of patient safety climate), whereas there were no significant differences between the intervention group and the control group for 14 outcomes (ICU mortality, central line-associated bloodstream infection, ventilator-associated pneumonia, urinary tract infection, mean ventilator-free days, mean ICU length of stay, mean hospital length of stay, bed elevation to ≥30°, venous thromboembolism prophylaxis, diet administration, job satisfaction, stress reduction, perception of management, and perception of working conditions). CONCLUSIONS AND RELEVANCE Among critically ill patients treated in ICUs in Brazil, implementation of a multifaceted quality improvement intervention with daily checklists, goal setting, and clinician prompting did not reduce in-hospital mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01785966.
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Affiliation(s)
| | | | - Fernando Augusto Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil3Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | | | | | | | | | | | - Edson Romano
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil
| | | | | | - Aline Reis Silva
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | | | | | | | | | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania8Associate Editor, JAMA
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Cavalcanti AB, Bozza FA, Machado FR, Salluh JIF, Campagnucci VP, Vendramim P, Guimarães HP, Normílio-Silva K, Chiattone VC, Damiani LP, Romano ER, Carrara F, Lubarino J, Silva AR, Viana G, Teixeira C, Silva NB, Chang CCH, Angus DC, Berwanger O. A Cluster Randomised Trial of a Multifaceted Quality Improvement Intervention in Brazilian Intensive Care Units. Intensive Care Med Exp 2015. [PMCID: PMC4798127 DOI: 10.1186/2197-425x-3-s1-a24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Background: Nonelective removal of peripherally inserted central catheters (PICCs) due to complications continues to be a major concern in neonatal intensive care units (NICUs) around the world. Nonelective removal results in interruption of intravenous therapy, added costs, stress, and negative impacts on infant’s health. Identification of predictors of complications that lead to nonelective removal of PICCs would allow for the initiation of preventive strategies to improve the quality of care. Aim: To identify predictors of nonelective removal of PICCs in neonates. Methods: A prospective cohort study with a sample of 524 PICC lines inserted in 436 neonates admitted to a tertiary-level NICU of a Brazilian hospital. Data were collected on all neonates between August 31, 2010, and August 30, 2012. Neonates were monitored daily from insertion of the catheter until its removal. Bivariate analysis and a logistic regression were conducted in order to identify predictors of nonelective removal. Results: A diagnosis of a transitory metabolic disorder (hypoglycemia; disorders of calcium, magnesium, sodium, or potassium; or dehydration), previous PICC line insertion, insertion of dual-lumen polyurethane PICC, noncentral tip position, and multiple intravenous solutions in a single-lumen silicone PICC were predictors of nonelective removal of PICC lines. Conclusion: The avoidance of repeated PICC insertions, noncentral tip position, and placement of single-lumen silicone PICCs for administration of four or more intravenous solutions is suggested. Interventions should be explored that facilitate PICC insertion success and correct tip placement.
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Affiliation(s)
- Priscila Costa
- Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of Sao Paulo, Sao Paulo, Brazil
| | - Amélia Fumiko Kimura
- Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Lucas Petri Damiani
- Statistics and Mathematics Institute, University of Sao Paulo, Sao Paulo, Brazil
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Cavalcanti AB, Machado F, Bozza F, Ibrain J, Salluh F, Campagnucci VP, Guimarães HP, Normilio-Silva K, Chiattone VC, Vendramim P, Carrara F, Lubarino J, da Silva AR, Viana G, Damiani LP, Romano E, Teixeira C, da Silva NB, Chang CCH, Angus DC, Berwanger O. A cluster randomized trial of a multifaceted quality improvement intervention in Brazilian intensive care units: study protocol. Implement Sci 2015; 10:8. [PMID: 25928627 PMCID: PMC4342101 DOI: 10.1186/s13012-014-0190-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/09/2014] [Indexed: 01/01/2023] Open
Abstract
Background The uptake of evidence-based therapies in the intensive care environment is suboptimal, particularly in limited-resource countries. Checklists, daily goal assessments, and clinician prompts may improve compliance with best practice processes of care and, in turn, improve clinical outcomes. However, the available evidence on the effectiveness of checklists is unreliable and inconclusive, and the mechanisms are poorly understood. We aim to evaluate whether the use of a multifaceted quality improvement intervention, including the use of a checklist and the definition of daily care goals during multidisciplinary daily rounds and clinician prompts, can improve the in-hospital mortality of patients admitted to intensive care units (ICUs). Our secondary objectives are to assess the effects of the study intervention on specific processes of care, clinical outcomes, and the safety culture and to determine which factors (the processes of care and/or safety culture) mediate the effect of the study intervention on mortality. Methods/design This is a cluster randomized trial involving 118 ICUs in Brazil conducted in two phases. In the observational preparatory phase, we collect baseline data on processes of care and clinical outcomes from 60 consecutive patients with lengths of ICU stay longer than 48 h and apply the Safety Attitudes Questionnaire (SAQ) to 75% or more of the health care staff in each ICU. In the randomized phase, we assign ICUs to the experimental or control arm and repeat data collection. Experimental arm ICUs receive the multifaceted quality improvement intervention, including a checklist and definition of daily care goals during daily multidisciplinary rounds, clinician prompting, and feedback on rates of adherence to selected care processes. Control arm ICUs maintain usual care. The primary outcome is in-hospital mortality, truncated at 60 days. Secondary outcomes include the rates of adherence to appropriate care processes, rates of other clinical outcomes, and scores on the SAQ domains. Analysis follows the intention-to-treat principle, and the primary outcome is analyzed using mixed effects logistic regression. Discussion This is a large scale, pragmatic cluster-randomized trial evaluating whether a multifaceted quality improvement intervention, including checklists applied during the multidisciplinary daily rounds and clinician prompting, can improve the adoption of proven therapies and decrease the mortality of critically ill patients. If this study finds that the intervention reduces mortality, it may be widely adopted in intensive care units, even those in limited-resource settings. Trial registration ClinicalTrials.gov NCT01785966 Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0190-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandre Biasi Cavalcanti
- Research Institute - Hospital do Coração (IEP- HCor), Rua Abílio Soares 250, 12th floor, CEP: 04005-000 - São Paulo, SP, Brazil.
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Alvarenga MB, Francisco AA, de Oliveira SMJV, da Silva FMB, Shimoda GT, Damiani LP. Episiotomy healing assessment: Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability. Rev Lat Am Enfermagem 2015; 23:162-8. [PMID: 25806645 PMCID: PMC4376045 DOI: 10.1590/0104-1169.3633.2538] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 09/26/2014] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE to analyse the Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability when evaluating perineal healing after a normal delivery with a right mediolateral episiotomy. METHOD observational study based on data from a clinical trial conducted with 54 randomly selected women, who had their perineal healing assessed at four time points, from 6 hours to 10 days after delivery, by nurses trained in the use of this scale. The kappa coefficient was used in the reliability analysis of the REEDA scale. RESULTS the results indicate good agreement in the evaluation of the discharge item (0.75< Kappa ≥0.88), marginal and good agreement in the first three assessments of oedema (0.16< Kappa ≥0.46), marginal agreement in the evaluation of ecchymosis (0.25< Kappa ≥0.42) and good agreement regarding redness (0.46< Kappa ≥0.66). For the item coaptation, the agreement decreased from excellent in the first assessment to good in the last assessment. In the fourth evaluation, the assessment of all items displayed excellent or good agreement among the evaluators. CONCLUSION the difference in the scores among the evaluators when applying the scale indicates that this tool must be improved to allow an accurate assessment of the episiotomy healing process.
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Affiliation(s)
- Marina Barreto Alvarenga
- MSc, Laboratory Technician, Escola de Artes, Ciências e Humanidades da
Universidade de São Paulo, São Paulo, SP, Brasil
| | - Adriana Amorim Francisco
- Doctoral student, Escola de Enfermagem, Universidade de São Paulo, São
Paulo, SP, Brazil. Scholarship holder from Fundação de Amparo à Pesquisa do Estado de
São Paulo (FAPESP), Brazil
| | | | | | | | - Lucas Petri Damiani
- MSc, Statistician, Instituto de Ensino e Pesquisa do Hospital do
Coração, São Paulo, SP, Brazil
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Alvarenga MB, Francisco AA, de Oliveira SMJV, da Silva FMB, Shimoda GT, Damiani LP. Episiotomy healing assessment: Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability. Rev Lat Am Enfermagem 2015; 23:162-168. [PMID: 25806645 DOI: 10.21203/rs.3.rs-1659930/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 09/26/2014] [Indexed: 05/23/2023] Open
Abstract
OBJECTIVE to analyse the Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability when evaluating perineal healing after a normal delivery with a right mediolateral episiotomy. METHOD observational study based on data from a clinical trial conducted with 54 randomly selected women, who had their perineal healing assessed at four time points, from 6 hours to 10 days after delivery, by nurses trained in the use of this scale. The kappa coefficient was used in the reliability analysis of the REEDA scale. RESULTS the results indicate good agreement in the evaluation of the discharge item (0.75< Kappa ≥0.88), marginal and good agreement in the first three assessments of oedema (0.16< Kappa ≥0.46), marginal agreement in the evaluation of ecchymosis (0.25< Kappa ≥0.42) and good agreement regarding redness (0.46< Kappa ≥0.66). For the item coaptation, the agreement decreased from excellent in the first assessment to good in the last assessment. In the fourth evaluation, the assessment of all items displayed excellent or good agreement among the evaluators. CONCLUSION the difference in the scores among the evaluators when applying the scale indicates that this tool must be improved to allow an accurate assessment of the episiotomy healing process.
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Costa P, Dorea EP, Kimura AF, Yamamoto LY, Damiani LP. Incidence of Nonelective Removal of Single-Lumen Silicone and Dual-Lumen Polyurethane Percutaneously Inserted Central Catheters in Neonates. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.java.2013.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Objective: To compare the incidence of nonelective removal of single-lumen silicone and dual-lumen polyurethane percutaneously inserted central catheters (PICCs).
Study Design: A prospective cohort study was conducted with neonates in whom 247 PICC lines had been successfully inserted. Patients were assigned to either the single-lumen silicone group or the dual-lumen polyurethane group and nonelective removal incidence was compared using a logistic regression model.
Results: Incidence of nonelective removal in dual-lumen polyurethane PICCs (n =91) was 48.3% versus 34% in single-lumen silicone PICCs (n =156). Thus, dual-lumen polyurethane catheters had a significantly increased chance of nonelective removal compared with single-lumen silicone PICCs (P =.004). The most usual complication in dual-lumen polyurethane PICCs was suspected catheter-related bloodstream infection; in single-lumen silicone PICCs it was external rupture.
Conclusions: Dual-lumen polyurethane PICCs are associated with higher rates of nonelective removal and complications such as suspected catheter-related bloodstream infection. Cautious nursing care is necessary to prevent complications.
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Affiliation(s)
- Priscila Costa
- Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil
| | - Eny Paiva Dorea
- Department of Maternal-Child Nursing, School of Nursing, Federal Fluminense University, Rio de Janeiro, Brazil
| | - Amélia Fumiko Kimura
- Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil
| | | | - Lucas Petri Damiani
- Statistics and Mathematics Institute, University of São Paulo, São Paulo, Brazil
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de Moraes Vieira EB, de Góes Salvetti M, Damiani LP, de Mattos Pimenta CA. Self-efficacy and fear avoidance beliefs in chronic low back pain patients: coexistence and associated factors. Pain Manag Nurs 2013; 15:593-602. [PMID: 23891180 DOI: 10.1016/j.pmn.2013.04.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/26/2013] [Accepted: 04/04/2013] [Indexed: 10/26/2022]
Abstract
A cross sectional study was conducted with the objective to assess the coexistence of self-efficacy and fear avoidance beliefs and establish the associated factors. Data collection was performed (215 individuals with lower back pain at three health services and two industries). The following instruments were used: Tampa Scale for Kinesiophobia, Beck's Depression Inventory, Piper's Fatigue Scale, Oswestry Disability Index, and the Chronic Pain Self-Efficacy Scale. Wilks' lambda test was performed, followed by MANOVA model to assess the effect of self-efficacy beliefs and fear avoidance on independent variables. Most subjects were women (65.1%), 45 years of age or younger (50.7%), with a family income between $450 and $1,350 per month (49.3%). Depression was present in 21.4%, fatigue in 29.3%, and disability in 68%. The average (standard deviation) of self-efficacy was 180.8 (60.4), and fear avoidance was 42.0 (11.5). A significant negative correlation was observed between the total score of both beliefs. The Wilks' lambda test showed that gender, income, depression, disability, and fatigue were significant and were included in the model. In the Manova analysis, low self-efficacy was associated with lower income, fatigue, depression, and level of disability (p < .001). High fear avoidance was associated to the male gender, lower income, depression, and level of disability (p < .001). The analysis of the confidence areas showed that a reduced self-efficacy and increased fear avoidance are related to an increased level of disability (p < .001). Specific intervention strategies must be implemented change these beliefs.
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