Discurso y micropoder en la intervención con personas mayores con delirium hospitalizadas: reflexión en torno a las narrativas ausentes / Discourse and micropower in the intervention with hospitalized elderly people with delirium: reflection on absent narratives

Resumen Este ensayo analiza ¿cómo son las interacciones entre las personas mayores (PM) hospitalizadas con delirium y el personal de salud? Para reflexionar en la construcción de estas interacciones, nos basamos en el filósofo Michel Foucault, en su presentación y libro del "Orden del Discurso", donde consideramos como las relaciones sociales de micropoder pueden presentarse en diversos contextos, dialogando la interacción descrita desde las estrategias y tácticas de exclusión del discurso. Enfocamos sobre i) la razón y la locura, al identificar en las PM hospitalizadas con delirium, una narrativa desde el trastorno neurocognitivo, presentando una experiencia de aislamiento y por otro lado ii) el personal de salud, que se basa en determinar lo verdadero de lo falso, utilizando su conocimientos y tácticas desde el proceso de diagnóstico e intervención, el cual no logra recoger las experiencias de las PM con delirium. Por último, proponemos desde el realismo agencial una nueva construcción del fenómeno, que integre el conocimiento del personal de salud y la experiencia de las PM con delirium.

Abstract In this essay, we analyze the interactions between elderly people (EP) hospitalized with delirium and the health team. To reflect on the construction of these interactions we rely on the philosopher Michel Foucault, in his presentation and book "Order of Discourse", where we consider how micro-power social relations can be presented in various contexts, landing the interaction described from the strategies and discourse exclusion tactics. It is emphasized mainly i) reason and insanity, identified in EP hospitalized with delirium, which may have a narrative from the neurocognitive disorder, presenting an experience of isolation; on the other hand ii) the health team is based on determining what is true from what is false, using its knowledge and tactics from the process of diagnosis and intervention, which cannot collect the experiences of EP with delirium. Finally, we propose a new construction of the phenomenon from agency realism that integrates the knowledge of the health team and the experience of the EP with delirium.

Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile / Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units

Background: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). Aim: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. Material and Methods: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. Results: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. Conclusions: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Risk factors for dental caries in Latin American and Caribbean countries

Abstract Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

Delirium en el adulto mayor hospitalizado / Delirium in elderly hospitalized patients

El delirium corresponde a un síndrome clínico frecuente y relevante en el adulto mayor hospitalizado. Su incidencia e impacto han sido reconocidos desde hace más de 30 años y su importancia en la atención del adulto mayor hospitalizado es creciente debido a que abarca diferentes escenarios clínicos (atención de urgencia, en pacientes hospitalizados por patologías médicas o quirúrgicas, en pacientes admitidos a unidades de cuidados intensivos, entre otros), y al envejecimiento poblacional, que ha conducido a que la atención hospitalaria moderna concentre cada vez una mayor cantidad de adultos mayores portadores de diversas condiciones crónicas, con grados diversos de fragilidad y discapacidad que requieren de nuestra mejor atención, de forma de reducir la aparición u optimizar el manejo de esta condición que puede ser devastadora para la evolución del adulto mayor posterior al egreso hospitalario. El presente capítulo pretende resumir el estado del arte de esta condición señalando, cuando corresponda, algunos de los elementos en controversia y donde nos parece necesario que la investigación nos señale innovadoras respuestas que permitan reducir su impacto.

Delirium is a frequent and relevant clinical syndrome in the elderly hospitalized. Incidence and impact has been recognized for more than 30 years, and its importance in the care of hospitalized older adults is increasing because it occurs in different clinical units (patients admitted in units of emergency, medical or surgical rooms, to intensive care units, among others), and the ageing population, which has led to modern hospital care concentrating a greater number of older adults with various chronic conditions, with varying degrees of frailty and disability that require our better attention, in order to reduce the occurrence or optimize the management of this condition, that can be devastating for the evolution of the elderly after hospital discharge. This chapter aims to summarize the state of the art of this condition, pointing out some controversial elements and where it seems necessary that the research shows us innovative answers that reduce its impact

Estimulação cognitiva e terapia ocupacional para prevenção de delirium / Cognitive stimulation and occupational therapy for delirium prevention

RESUMO O delirium é uma condição importante em pacientes críticos, com impactos em longo prazo em termos de mortalidade, condição cognitiva e funcional, e qualidade de vida. Apesar do progresso ocorrido nos anos recentes em seu diagnóstico, prevenção e tratamento, seu impacto continua relevante, de forma que é necessário explorar novas estratégias de prevenção e tratamento. Dentre as estratégias preventivas não farmacológicas, relatos recentes sugerem o papel da terapia ocupacional por meio de uma série de intervenções que podem ter impacto no desenvolvimento do delirium. O objetivo desta revisão é avaliar os estudos que discutem o papel da terapia ocupacional na prevenção do delirium em populações de pacientes críticos, além de sugerir perspectivas para pesquisas nesta área.

ABSTRACT Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

Efecto de Lepidium meyenii (maca) sobre la producción de tres citoquinas hematopoyéticas en esplenocitos de ratones inmunosuprimidos / Effect of Lepidium meyenii (maca) on the production of three hematopoietic cytokines in splenocytes from immunosuppressed mice

Lepidium meyenii Walp, Brassicaceae (Maca) is a plant native to Peru to conferring immunostimulatory activity. The objective was to evaluate the immunomodulatory effect of the aqueous extract (EAc) of yellow ecotype on gene expression of three hematopoietic cytokines (IL-3, GM-CSF and IL-7) in splenocytes from Balb/c mice immunosuppressed with cyclophosphamide. Levels of mRNA were measured by RT-PCR. Two days after immunosuppression (IS), in splenocytes from mice treated with EAc increased expression of mRNA was demonstrated for IL-3, GM-CSF e IL-7 (p < 0.05) compared to the untreated group. Five days after IS, in mice treated with EAc found higher cell counts in bone marrow, peripheral blood and endogenous colonies formed units in spleen compared to the untreated group. It is concluded that administration of EAc in immunocompromised mice can reverse the suppressive effects of cyclophosphamide.

Lepidium meyenii Walp., Brassicaceae (Maca) es una planta oriunda del Perú a la que se atribuye actividad inmunoestimuladora. El objetivo fue evaluar el efecto inmunomodulador del extracto acuoso (EAc) del ecotipo amarillo sobre la expresión génica de tres citoquinas hematopoyéticas (IL-3, GM-CSF e IL-7) en esplenocitos de ratones Balb/c inmunosuprimidos con ciclofosfamida. Los niveles de mRNA se midieron por RT-PCR. Dos días después de la inmunosupresión (IS), en los esplenocitos de los ratones tratados con EAc se evidenció mayor expresión de mRNA para IL-3, GM-CSF e IL-7 (p<0.05) respecto al grupo no tratado. Cinco días después de la IS, en los ratones tratados con EAc se encontró mayor recuento de células en la médula ósea, sangre periférica y unidades formadoras de colonias endógenas en el bazo respecto al grupo no tratado. Se concluye que la administración de EAc a ratones inmunocomprometidos puede revertir los efectos supresores de la ciclofosfamida.

Impacto de intervención temprana a cuidadores de pacientes secuelados de un accidente cerebrovascular: estudio piloto / Impact of early intervention for stroke caregivers: a pilot study

Introducción: Los cuidadores de personas secueladas de un Accidente Cerebro Vascular (ACV), perciben que durante los primeros meses carecen de la información necesaria sobre el proceso de su familiar, afectando sobre su estado afectivo y percepción de estrés. Objetivo: Evaluar la intervención realizada a cuidadores de pacientes secuelados de un ACV como factor protector en el estado afectivo y de carga en los cuidadores. Sujetos y métodos: Se reclutaron cuidadores directos, de personas con secuelas de ACV, según Escala de Rankin durante el período hospitalario. Se realizo un taller teórico práctico, consistentes en 4 sesiones; 3 durante el periodo hospitalario del usuario y 1 dentro del primer mes posterior al alta, los temas tratados eran organización y distribución de la rutina, integración de rutinas de tiempo libre y relajación y manejo del paciente en el hogar. Se evalúo a los cuidadores con escalas diagnósticas de carga emocional (Zarit, Indice de Esfuerzo del Cuidador) y ansiedad (Goldberg). Resultados: Luego del taller hubo una reducción significativa de 20 por ciento en el número de cuidadores con depresión (p=0,036) y 37 por ciento en el número de cuidadores con ansiedad (p=0,034.). Asimismo hubo una disminución significativa en el puntaje de sobrecarga emocional del cuidador medido mediante la escala de Zarit (p = 0,044). Conclusiones: La intervención evaluada en el presente estudio piloto parece ser una medida que contribuye en disminuir la sobrecarga emocional y ansiedad del cuidador.

Background: Caregivers of ischemic stoke damaged patients feels during the first months after the event a lack of information on how to help their relative, affecting the sense of stress and anxiety. We made an intervention to caregivers of the stroke unit of the University of Chile Hospital, in 2008.Objective: Determine whether the intervention to caregivers of stroke damaged patients is a protective factor in their emotional state and stress on caregivers. Subjects and methods: Direct healthy caregivers were recruited with a severe impaired family member within the hospitalization period. Intervention was conducted in 4 sessions, 3 during the hospital period and 1 in his home within the first month after discharge, where the issues discussed with caregiver was self-care and patient management. To measure the intervention we evaluated before the workshop and 2 months after the last session with some standardized tests (Zarit, Caregiver Stress Index) and anxiety (Goldberg). Results: After the intervention there was a significant 20 percent reduction in the number of caregivers with depression (p=0.036) and 37percent in the number of caregivers with anxiety (p=0.034.). There was also a significant decrease in the score of caregiver's emotional overload measured by the Zarit scale (p=0.044). Conclusions: The intervention evaluated in this pilot study appears to be an effective measure in reducing the emotional overload and anxiety of the caregiver, with an evident improvement in their mood.

Definición y desarrollo del concepto de ocupación: ensayo sobre la experiencia de construcción teórica desde una identidad local / Concept of occupation: definition and development: essay about an experience of theoretical construction from a local ident

En el proceso de construcción teórica, al que se ha dedicado el Comité de Ciencia de la Ocupación, se ha hecho necesaria una aproximación a conceptos, ya definidos por la Ciencia Ocupacional con una visión que provea identidad al grupo de investigadores, por sobre los elementos de universalidad que se han usado previamente. Si bien todo proceso de generación de conocimiento debe considerar la investigación, este comité comenzó su trabajo de desarrollo teórico a través de una construcción colectiva, basada en lectura y análisis profundo. El presente ensayo refleja ese proceso colectivo.

In the process of theoretical construction, on which the Committee of Occupational Science (of the School of Occupational Therapy of University of Chile) has been devoted, it was needed an approach to concepts, already defined by Occupational Science, from a view that provides identity to this recent group of study and research. Even though generation of knowledge requires research, this committee began its work of theoretical development through a collective construction; reading and discussion based. The present essay reflects that collective process, and the authors took the task of giving to it the written form.