Síndrome de abstinência em Unidade de Tratamento Intensivo Pediátrico: protocolo de revisão sistemática / Abstinence syndrome in Pediatric Intensive Care Unit: a systematic review protocol

OBJETIVO: Verificar qual o tratamento mais indicado para a prevenção e redução dos sinais e sintomas de abstinência em crianças criticamente doentes por meio de uma revisão sistemática da literatura mundial. MÉTODO: A revisão sistemática será conduzida conforme a metodologia PRISMA e Cochrane, com registro no PROSPERO, sob o número de ID CRD42021274670, nas respectivas bases de dados PubMed, LILACS, Embase, Web of Science, Cochrane, CINAHL, Cochrane Database Systematic Review e CENTRAL. As buscas serão realizadas por dois avaliadores independentes, um terceiro realizará o intermédio se necessário. Os dados serão inseridos no programa de software Zotero que irá excluir os artigos duplicados, após o material selecionado será transferido para planilha Excel em instrumento próprio. Os estudos serão classificados quanto ao seu nível de evidência, viés e fator de risco. Os resultados serão analisados e tabulados e discutidos a fim de melhor compreensão dos resultados. Se possível, serão realizadas meta-análises para os resultados agregados.

OBEJECTIVE: To verify the most appropriate treatment for the prevention and reduction of the signs and symptoms of abstinence in critically ill children through a systematic review of the world literature. METHOD: The systematic review will be conducted according to the PRISMA and Cochrane methodology, with registration at PROSPERO, under the ID number CRD42021274670, in the respective databases, PUBMed, LILACS, Embase, Web of Science, Cochrane, CINAHL, Cochrane Database Systematic Review, and CENTRAL, searches will be carried out by two independent evaluators, and a third party will perform the intermediate if necessary. The data will be entered into the Zotero software program that will delete duplicate articles after the selected material is transferred to an Excel spreadsheet on its instrument. The studies will be classified according to their level of evidence, bias, and risk factors. The results will be analyzed, tabulated, and discussed to understand the results better. If possible, meta-analyzes will be carried out for the aggregated results.

Dependencia y abstinencia de Zolpidem. Reporte de un caso de convulsiones generalizadas

El zolpidem es un agente hipnótico no benzodiacepínico utilizado con suma frecuencia en el tratamiento del insomnio e indicado para emplearlo en el corto plazo. No está indicado para el tratamiento crónico de los trastornos del sueño, pese a lo cual se evidencia en la práctica clínica que gran cantidad de pacientes lo reciben por arios. Si bien se ha descrito que presenta un mejor perfil de efectos adversos que las benzodiacepinas y que genera menos riesgo de dependencia y abstinencia que estas, existen sendos reportes de casos de dependencia y abstinencia de zolpidem. Se presenta el reporte de un caso de convulsiones tónico-clónicas generalizadas por abstinencia a dosis de 300 mg/día de Zolpidem y se realiza una breve revisión de la literatura.

Zolpidem is a non-benzodiazepine hypnotic agent used most frequently in the treatment of insomnia, indicated for short-term use. It is not indicated for the chronic treatment of sleep disorders, despite which there is evidence in clinical practice that a large number of patients receive it for years. Although it has been described that it presents a better profile of adverse effects than benzodiazepines and that it generates a lower risk of dependence and withdrawal than these, there are significant reports of cases of dependence and withdrawal from zolpidem. A report of a case of generalized tonic-clonic seizures due to with drawal at a dose of 300 mg per day of zolpidem is presented and a brief review of the literature is carried out.

Estratégias para manejo e prevenção da síndrome de abstinência em pacientes pediátricos críticos: revisão sistemática / Strategies for the management and prevention of withdrawal syndrome in critically ill pediatric patients: a systematic review

RESUMO Objetivo: Verificar as estratégias de prevenção e tratamento da síndrome de abstinência em unidade de terapia intensiva pediátrica. Métodos: Trata-se de revisão sistemática nas bases de dados PubMed®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review e CENTRAL. Uma estratégia de busca em três etapas foi utilizada para esta revisão. O protocolo da revisão foi aprovado no PROSPERO (CRD42021274670). Resultados: Foram incluídos na análise 12 artigos. Observou-se grande heterogeneidade entre os estudos incluídos, principalmente em se tratando de esquemas terapêuticos utilizados na sedação e na analgesia. As doses de midazolam variaram de 0,05mg/kg/hora a 0,3mg/kg/hora. A morfina também variou consideravelmente, de 10mcg/kg/hora a 30mcg/kg/hora entre os estudos. A escala mais utilizada para identificação da síndrome de abstinência, entre os 12 estudos selecionados, foi a Sophia Observational Widrawal Symptoms Scale. Em três estudos, houve diferença estatística relevante na prevenção e no manejo da síndrome de abstinência com a implantação de protocolos (p < 0,01 e p < 0,001). Conclusão: Observou-se grande variação entre o regime de sedoanalgesia utilizado entre os estudos e o método de desmame e avaliação de síndrome de abstinência. São necessários mais estudos para fornecer evidências mais robustas acerca do tratamento mais indicado para prevenção e redução dos sinais e sintomas de abstinência em crianças criticamente doentes. Registro PROSPERO:CRD 42021274670

ABSTRACT Objective: To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit. Methods: This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670). Results: Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001). Conclusion: There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children. PROSPERO register: CRD 42021274670

Delirium, catatonía y síndrome de abstinencia manifestados como agitación psicomotora en COVID-19: una propuesta de manejo farmacológico en el hospital general

Background: Neuropsychiatric symptoms can be part of the clinical spectrum of COVID-19 infections. Aim: To devise an evidence based clinical algorithm as a guide for clinicians, to identify and treat underlying clinical syndromes of psychomotor agitation, such as delirium, catatonia or substance withdrawal in patients who are hospitalized and infected with SARS-CoV-2. Material and Methods: A review of the literature about the pharmacological management of neuropsychiatric manifestations of COVID-19 at the general hospital, to develop a clinical protocol based on a consensus from an interdisciplinary expert panel at a Clinical Hospital. Results: A consensual clinical algorithm for the management of delirium, catatonia, and substance withdrawal, manifested as psychomotor agitation in patients hospitalized with COVID-19, was developed as a clinical proposal for physicians at different levels of complexity in health services. Conclusions: Cooperation among different clinical units in the general hospital facilitated the implementation of a clinical algorithm for clinicians for the management of psychomotor agitation in COVID-19 patients.

Adaptação cultural da withdrawal assesment tool version (wat ­ 1) para língua portuguesa falada no Brasil / Adaptación cultural de la evaluación de retiro versión de la herramienta (wat ­ 1) para el idioma portugués hablado en Brasil / Cultural adaptation of the version of the withdrawal assessement tool (wat-1) for portuguese language spoken in Brazil

Objetivo: Adaptar, para a língua portuguesa do Brasil, o instrumento Withdrawal Assessment Tool Version (WAT ­1). Métodos: Pesquisa metodológica, realizada no município de São Paulo/SP de março de 2017 a abril de 2019. O processo de adaptação cultural obedeceu às dez etapas definidas segundo o Report of the ISPOR Task Force for Translation and CulturalAdaptation, sendo realizado avaliação das equivalências semântica, idiomáticas, conceitual e cultural, por um comitê de nove juízes; avaliação da compreensibilidade do instrumento por 30 especialistas em Terapia Intensiva Pediátrica; revisão da avaliação da compreensibilidade; revisão final da tradução; relatório final. Resultados: A concordância entre os juízes na análise das equivalências apresentou escore médio de 96,9% na segunda rodada, devido a concordância de 80% na primeira etapa. Já, na avaliação da compreensibilidade, obteve-se 100% de compreensão dos especialistas. Conclusão: A tradução e adaptação cultural do instrumento wat-1 para língua portuguesa falada no Brasil foram consideradas satisfatórias(AU)

Objective: To adapt the Withdrawal Assessment Tool Version (WAT - 1) to the Portuguese language of Brazil. Methods: Methodological research, carried out in the city of São Paulo/SP from March 2017 to April 2019. The process of cultural adaptation followed the ten stages defined according to the Report of the ISPOR Task Force for Translation and Cultural Adaptation: authorization; translation, reconciliation, backtranslation; back-translation review; harmonization, with the evaluation of semantic, idiomatic, conceptual and cultural equivalences carried out by a committee of nine judges; evaluation of the comprehensibility of the instrument by 30 specialists in Pediatric Intensive Care TIP; review of the comprehensibility assessment; final translation review; final report. Results: The adapted instrument was divided into 35 sentences, being evaluated by nine judges regarding their equivalences. The agreement among the judges in the analysis of equivalences proved to be excellent, with an average score of 96.9% in these cond round. There was a need for two rounds, as some items did not show 80% agreement in the first stage. In the comprehensibility assessment, 100% of the specialists' understanding was obtained. Conclusion: The translation and cultural adaptation of the wat-1 instrument to the Portuguese language spoken in Brazil were considered satisfactory.(AU)

Objetivo: Adaptar la Versión de la Herramienta de Evaluación de Retiros (WAT - 1) al idioma portugués de Brasil. Métodos: Investigación metodológica, realizada en la ciudad de São Paulo/SP de marzo de 2017 a abril de 2019. Cuyo proceso de adaptación cultural siguió las diez etapas definidas según el Informe del Grupo de Trabajo ISPOR para la Traducción y Adaptación Cultural: autorización; traducción, reconciliación, retrotraducción; revisión de la retrotraducción; armonización, con la evaluación de equivalencias semánticas, idiomáticas, conceptuales y culturales realizada por un comité de nueve jueces; evaluación de la comprensibilidad del instrumento por 30 especialistas en Cuidados Intensivos Pediátricos TIP; revisión de la evaluación de comprensibilidad; revisión final de la traducción; informe final. Resultados: El instrumento adaptado se dividió en 35 sentencias, siendo evaluadas por nueve jueces en cuanto a sus equivalencias. La concordancia entre los jueces en el análisis de equivalencias resultó excelente, con una puntuación media de 96,9% en la segunda vuelta. Hubo necesidad de dos rondas, ya que algunos ítems no mostraron un 80% de acuerdo en la primera etapa. En la etapa de la evaluación de comprensibilidad, se obtuvo el 100% de la comprensión de los especialistas. Conclusión: La traducción y adaptación cultural del instrumento wat-1 al idioma portugués hablado en Brasil fue considerada satisfactoria.(AU)

Effects of naltrexone hydrochloride combined with trazodone on preventing relapse in heroin addicts after detoxification / 中国基层医药

Objective:To investigate the effects of naltrexone hydrochloride combined with trazodone on preventing relapse in heroin addicts after detoxification.Methods:A total of 274 opioid heroin addicts who received treatment in Beijing Gaoxin Hospital between June 2016 and January 2019 were included in this study. After detoxification with methadone, all patients were randomly assigned to receive either naltrexone hydrochloride combined with trazodone (group 1, n = 60) or naltrexone hydrochloride alone (group 2, n = 60) for preventing relapse in heroin addicts. The effects on relapse prevention were determined in each group. Results:There were no significant differences in age distribution, sex composition, marital status, and drug use between groups 1 and 2 (all P > 0.05). After 6 months of treatment, the non-relapse rate was 86.7% (52/60) and 6.7% (4/60) in groups 1 and 2 respectively, in the case of unchanged personal life status. There was significant difference in non-relapse rate between groups 1 and 2 ( χ2 = 77.1, P < 0.001). Conclusion:Naltrexone hydrochloride combined with trazodone exhibits superior efficacy in preventing relapse in opioid heroin addicts after detoxification to naltrexone hydrochloride alone.

Diferencia entre los signos y síntomas del consumo y la abstinencia por Basuco y Cocaína: estudio piloto en Manizales, Colombia / Difference between the signs and symptoms of consumption and abstinence by Basuco y cocaine: Pilot study in Manizales, Colombia

Objetivo: el Basuco es una sustancia psicoactiva derivada de la hoja de coca; hasta ahora no se ha descrito la sintomatología que genera su consumo ni su síndrome de abstinencia, por lo que suele incluirse en el mismo grupo sindromático de la cocaína. En este estudio se pretende determinar si existen signos y síntomas característicos del Basuco. Materiales y métodos: etudio piloto de carácter descriptivo y transversal, empleando una encuesta heteroaplicada a pacientes que consumieran exclusivamente Basuco, donde se les preguntaba si habían presentado determinados signos y síntomas durante su consumo o durante el síndrome de abstinencia por Basuco. Resultados: en el consumo se encontró predominio del insomnio, hiporexia, disminución de la sensación del cansancio, delirios y aislamiento social, mientras que durante la abstinencia predominó la depresión, irritabilidad, hipersominia e hiperfagia, asociado a sensación de deterioro y deseo de abandonar el consumo. Conclusiones: la sintomatología tanto del consumo como del síndrome de abstinencia por Basuco parece tener diferencias respecto a la generada por la cocaína..(AU)

Objetive: the Basuco is a psychoactive substance derived from the coca leaf, which has not been described the symptoms that generate the consumption or withdrawal syndrome, so they are included in the same syndromic group of cocaine. This study aims to identify if there are signs and symptoms characteristic of Basuco to improve diagnostic accuracy and facilitate syndromic management. Materials and methods: bservational and cross-sectional study, using a hetero-applied survey of patients who exclusively consumed Basuco, in which they were asked if they had presented certain signs and symptoms during the intoxication or during the withdrawal syndrome by Basuco. Results: during the consumption, the insomnia, hyporexia, decreased sensation of tiredness, delusions and social isolation were predominant, while during depression abstinence, irritability, hypersomnia and hyperphagia, associated with a sense of deterioration and desire to abandon the consume were more representative. Conclutions: the symptomatology of both intoxication and withdrawal syndrome by Basuco has important differences with respect to those generated by cocaine..(AU)

Motivação para primeira experiência do uso de drogas e recaídas de pessoas em tratamento / Motivation for first-time drug use and relapses of people in treatment

O objetivo deste estudo foi investigar a motivação para primeira experiência no uso de drogas e recaídas após abstinência por pessoas com dependência química induzida pelo crack. Estudo descritivo, de abordagem mista. Foram realizadas 600 entrevistas com a utilização de questionário estruturado, na etapa quantitativa, e oito grupos focais, na etapa qualitativa, com total de 39 participantes. Para análise de dados utilizou-se o software SPSS e o método de interpretação de sentidos. A curiosidade motivou a iniciação do uso de drogas, assim como a pressão dos amigos e problemas familiares. Já a dificuldade de ficar sem a droga, vontade de sentir o efeito novamente, pressão de amigos, problemas familiares, decepção pela desconfiança dos familiares e o uso de drogas na própria instituição de tratamento foram relatados como motivadores de recaída. Os dados em ambas as metodologias foram convergentes e ratificaram os resultados obtidos.

The aim of this study was to investigate the motivation for first-time drug use and relapses after abstinence of people with chemical dependency to crack cocaine. A descriptive study, with a mixed approach. In the quantitative phase, six hundred interviews were conducted using a structured questionnaire. In the qualitative phase, eight focus groups were created, with 39 total participants. SPSS software and the sense interpretation method were used to analyze the data. Curiosity, as well as peer pressure and family problems, motivated the initiation of drug use. Difficulty to live without the drug, desire to feel its effect again, peer pressure, family problems, disappointment in lack of trust of family members, and drug use at the rehabilitation institution were reported as relapse motivators. The data in both methodologies were convergent and confirmed the obtained results.

Cannabis Legalization: Perceptions of Psychiatrists and Recovering Users / Legalização da Maconha: Percepção de Psiquiatras e de Usuários em Recuperação / Legalización de la Marihuana: Percepción de Psiquiatras y de Usuarios en Recuperación

Abstract The legalization of cannabis in Brazil is a topic that is currently being discussed. As well as public health issues, it also involves social, legal and educational aspects. Accordingly, this study aimed to verify the perception of psychiatrists and recovering cannabis users regarding the legalization of cannabis in Brazil. This was an exploratory qualitative study. The study included 20 participants aged 26 to 71 (80% male), 10 composing the group of psychiatrists, and 10 the group of recovering cannabis users. Semi-structured interviews were performed and analyzed using content analysis. The majority of the participants (85%) were not in favor of cannabis legalization Brazil. The reports mentioned physical, psychic and social damage, as well as the absence and inefficiency of public policies. However, they were positive regarding cannabidiol treatments for refractory diseases. More studies are needed that contemplate this theme, encompassing other populations, in order to provide better explanations.

Resumo A legalização da maconha no Brasil é um tema que vem sendo discutido atualmente, pois além de questões sobre saúde pública, envolve também aspectos sociais, jurídicos e educacionais. Portanto, o estudo teve como objetivo verificar a percepção de médicos psiquiatras e usuários de maconha em recuperação sobre a legalização de maconha no Brasil. Trata-se de uma pesquisa qualitativa exploratória. O estudo foi composto por 20 participantes com idades entre 26 e 71 anos (80% do sexo masculino), 10 compondo o grupo de médicos psiquiatras, e 10 usuários de maconha em recuperação. Foi aplicada uma entrevista semiestruturada, e utilizada a análise de conteúdo. A maioria dos participantes se posicionaram de maneira desfavorável (85%) a legalização da maconha Brasil. Os relatos incluíram prejuízos físicos, psíquicos e sociais, bem como a ausência e ineficácia de políticas públicas. Porém, tiveram postura positiva aos tratamentos com canabidiol para doenças refratárias. Portanto, necessita-se de mais pesquisas que contemplem este tema, abarcando outras populações a fim de trazer melhores esclarecimentos.

Resumen La legalización de la marihuana en Brasil es un tema que viene siendo discutido actualmente, pues además de cuestiones sobre salud pública, involucra también aspectos sociales, jurídicos y educativos. Por lo tanto el estudio tuvo como objetivo verificar la percepción de médicos psiquiatras y usuarios de marihuana en recuperación sobre la legalización de marihuana en Brasil. Se trata de una investigación cualitativa exploratoria. El estudio fue compuesto por 20 participantes con edades entre 26 y 71 años (80% del sexo masculino), 10 componiendo el grupo de médicos psiquiatras, y 10 usuarios de marihuana en recuperación. Se aplicó una entrevista semiestructurada, y se utilizó el análisis de contenido. La mayoría de los participantes se posicionaron de manera desfavorable (85%) la legalización de la marihuana en Brasil. Los relatos incluyeron pérdidas físicas, psíquicas y sociales, así como la ausencia e ineficacia de políticas públicas. Pero tuvieron postura positiva a los tratamientos con canabidiol para enfermedades refractarias. Por lo tanto, se necesitan más investigaciones que contemplen este tema, abarcando otras poblaciones a fin de traer mejores aclaraciones.

Evaluación del uso de sedación y analgesia en niños con asistencia ventilatoria mecánica / Assessing the use of sedation and analgesia on children under mechanical ventilation / Avaliação do uso de sedação e analgesia em crianças com assistência ventilatória mecânica

Resumen: Objetivo: cuantificar el uso de sedoanalgesia en niños críticamente enfermos con asistencia ventilatoria mecánica (AVM) en la Unidad de Cuidados Intensivos (UCIN) del Centro Hospitalario Pereira Rossell (CHPR). Metodología: estudio observacional descriptivo y prospectivo realizado entre los meses de mayo a setiembre de 2017. Se incluyeron pacientes ingresados a UCIN que requirieron AVM y sedoanalgesia o mioparalización. Se registraron las siguientes variables: sexo, edad, peso, diagnóstico al ingreso. En relación con la sedación y analgesia se registraron dosis indicadas y recibidas de cada fármaco y las dosis acumulativas. Se las comparó con un estudio realizado en 2012 en UCIN. Resultados: se incluyeron 37 pacientes. El promedio de días de AVM fue de 3,7. La causa más frecuente de AVM fue patología respiratoria (n=34). Se observó discordancia entre dosis indicada y dosis recibida tanto de opiáceos, benzodiacepinas y paralizantes musculares, pero en menor medida que lo registrado en el año 2012. Las dosis acumulativas de midazolam, fentanyl y atracurio disminuyeron respecto al año 2012. Conclusión: se observó una disminución de las dosis promedio utilizadas de cada fármaco, de la duración de la AVM y una menor incidencia de síndrome de abstinencia. Las causas de esta observación pueden ser multifactoriales.

Summary: Objective: to quantify benzodiazepines and opioids dosages used in critically ill children under invasive mechanical ventilation (IMV) hospitalized in a Paediatric Intensive Care Unit (PICU). Methodology: an observational study was carried out from May to September 2017. It included children who under IMV hospitalized in a PICU and who were treated with benzodiazepines, opioids and/or neuromuscular blockers. These children key clinical features were recorded. Cumulative doses of benzodiazepines, opioids and neuromuscular blockers were recorded. Results were compared with the data obtained in a previous experience in the same PICU in 2012. Results: 37 children were included. IMV average duration of was 3.7 days. Cumulative doses and treatment duration of midazolam, fentanyl and atracurium decreased from 2012 to 2017. There were differences between the doses prescribed and the doses actually received in both periods. Conclusion: cumulative doses of benzodiazepines, opioids and neuromuscular blockers decreased in the 2012-2017 period.

Resumo: Objetivo: quantificar o uso da sedação e analgesia em crianças criticamente doentes com Assistência de Ventilação Mecânica (MAV) na Unidade de Terapia Intensiva (UTIN) do Centro Hospitalar Pediátrico Pereira Rossell (CHPR). Metodologia: estudo observacional descritivo e prospectivo realizado de maio a setembro de 2017. Incluíram-se pacientes internados em UTIN que necessitaram de MAV e sedação e analgesia e / ou bloqueadores neuromusculares. Registraram-se as seguintes variáveis: sexo, idade, peso, diagnóstico no momento da admissão. Foram registradas as doses indicadas e recebidas de cada droga de sedação e analgesia, assim como as doses cumulativas. Os resultados foram comparados com um estudo realizado em 2012 na UTIN. Resultados: incluíram-se 37 pacientes. O tempo médio de AVM foi de 3,7 dias. A causa mais frequente de MAV foi doença respiratória (n = 34). Observou-se dissonância entre a dose indicada e a dose recebida dos opiáceos, benzodiazepínicos e agentes paralisantes musculares, mas em grau menor do que o registrado em 2012. As doses cumulativas de midazolam, fentanil e atracúrio diminuíram em relação a 2012. Conclusão: observamos uma diminuição nas doses médias de cada droga utilizada, na duração da MAV e uma menor incidência de síndrome de abstinência. Esta observação pode ter causas multifatoriais.

fMRI observation on impact of protracted abstinence on large brain networks in heroin addicts on craving tasks / 中国医学影像技术

Objective: To investigate the impact of protracted abstinence on heroin addicts' psychological craving and brain network function under drug cue task. Methods: Totally 37 heroin addicts (protracted abstinence group) and 32 matched normal volunteers (control group) were recruited. Resting state and craving task fMRI data were acquired, and the psychological craving quantitative scoring was evaluated. Resting fMRI data were analyzed to obtain task negative correlation networks (TNN) and task positive correlation networks (TPN). After modeling task-state fMRI data and comparing with the control group, the abnormal activated brain areas in TNN and TPN in the protracted abstinence group were obtained, and the correlation with psychologic behavior was analyzed. Results: The craving scores of the protracted abstinence group were significantly higher than those of control group before and after the presentation of task cues (all P<0.01). Under the craving task, compared with control group, the right para-hippocampal gyrus was significantly activated in the protracted abstinence group in TNN, and the significantly enhanced networks in TPN included visual spatial network (bilateral anterior central gyrus and inferior frontal gyrus) and sensorimotor network (left posterior central gyrus). The activation intensity of bilateral inferior frontal gyrus in protracted abstinence group was negatively correlated with the duration of heroin use (right: r=-0.37, P=0.02; left: r=-0.41, P=0.01). Conclusion: The subjective craving of heroin addicts who are forced to quit is still increased, and the abnormal function of multiple large brain networks has not completely recovered, which may be the neuropathological basis of relapse.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review

SUMMARY OBJECTIVE: Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS: A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS: The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION: There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

RESUMO OBJETIVO: A síndrome de abstinência de opioides é comum no ambiente de terapia intensiva pediátrica porque a sedação é frequentemente necessária durante o tratamento das crianças. Não existe uma diretriz específica sobre o manejo desse paciente e, ultimamente, a metadona tem sido uma droga importante para a prevenção dos sintomas de abstinência durante o desmame dos opioides. Este estudo reúne as pesquisas disponíveis para estabelecer a dose inicial de metadona, taxa de redução e ferramentas para reconhecer essa síndrome e agir prontamente. MÉTODOS: Uma revisão sistemática foi feita a partir de dados de quatro diferentes bases de dados. Quarenta e nove artigos, de estudos observacionais e experimentais, foram selecionados com base nos critérios de inclusão (pacientes críticos pediátricos em uso de opioides agudamente) e critérios de exclusão (uso crônico prévio de opioides, outros medicamentos). Os dados referentes a temas específicos foram separados em seções: dose inicial de metadona, uso de protocolos na prática clínica, escalas de abstinência e drogas adjuvantes. RESULTADOS: Os artigos mostraram uma grande heterogeneidade de formas de calcular a dose inicial de metadona. As unidades de terapia intensiva pediátrica do estudo apresentaram diferentes protocolos de desmame, com menor incidência de abstinência quando foi utilizada uma sequência predefinida de redução gradual. A Ferramenta de Avaliação de Retirada - 1 foi a escala mais utilizada durante a redução dos opioides, com boa sensibilidade e especificidade para sinais e sintomas. CONCLUSÃO: Ainda há poucas evidências de outros medicamentos que possam ajudar a prevenir a síndrome de abstinência dos opioides. Este estudo tenta promover uma prática melhor durante o desmame dos opioides.

Motivos para el consumo de alcohol y tabaco en estudiantes de la licenciatura de enfermería / Reasons for the consumption of alcohol and tobacco in undergraduate nursing students

Resumen

Introducción: el consumo de alcohol y tabaco es un problema de salud pública. Los motivos para su consumo, en los estudiantes, frecuentemente están relacionados con ambientes estresantes y pueden de origen social, psicológico y físico.

Objetivo: describir la frecuencia de los motivos sociales, psicológicos y físicos que influyen en los estudiantes para el consumo de alcohol y tabaco.

Metodología: estudio descriptivo transversal en 216 estudiantes de licenciatura en enfermería. Se aplicaron dos escalas de motivos, una para el consumo de tabaco y otra para el consumo de alcohol.

Resultados: el 91.2% de los estudiantes consumen alcohol, el 22.4% son hombres y 77.6% son mujeres; más de la mitad (53.7%) de los estudiantes consumen tabaco, siendo, en su mayoría, mujeres (70.6%). Para el consumo de alcohol, el motivo que se presentó con mayor frecuencia fue el social, y para el consumo de tabaco fue el motivo psicológico.

Conclusiones: el consumo de alcohol y tabaco por los estudiantes, es mayor en mujeres que en hombres. Es relevante que el motivo con mayor frecuencia sea el de carácter social y psicológico.

Abstract

Introduction: The consumption of alcohol and tobacco is a public health problem. The reasons for its consumption in students are related to stressful environments and of social, psychological and physical origin.

Objective: To describe the frequency of social, psychological and physical reasons that influence students for alcohol and tobacco use.

Methods: Cross-sectional descriptive study in 216 undergraduate nursing students. Two scales of reasons were applied, one for the consumption of tobacco and another one for the consumption of alcohol.

Results: 91.2% of the students consume alcohol, 22.4% are men and 77.6% are women; more than half (53.7%) of students consumed tobacco, most of them women (70.6%). For the consumption of alcohol the reason that was presented with more frequency was the social and for the consumption of tobacco was the psychological reason.

Conclusions: The consumption of alcohol and tobacco by students is higher in women than in men. It is relevant that the most frequent reason is the social and psychological.

Effect of acupuncture in intervening heroin-induced brain damage via regulating ubiquitin-proteasome pathway / 针灸推拿医学（英文版）

Objective:To observe the effect of acupuncture in regulating ubiquitin-proteasome pathway (UPP),and discuss the action of acupuncture in intervening heroin-induced brain damage.Methods:Thirty male Sprague-Dawley (SD) rats were divided into a control group,a model group and an acupuncture group by using the random number table.Rats in the model and acupuncture groups received intramuscular heroin injection for successive 8 d at a progressively increased dose.Afterwards,the injection was suspended for 5 d for withdrawal.The heroin relapse rat model was established by repeating the drug addiction and withdrawal process for 3 times.The control group followed the step of the model establishment,but was given intramuscular injection of normal saline at the stage of addiction and no intervention at the stage of withdrawal;the model group was given intramuscular heroin injection at a progressively increased dose at the addiction stage and no intervention at the withdrawal stage;the acupuncture group was dealt in the same way as the model group at the addiction stage,but received acupuncture at Baihui (GV 20) and Dazhui (GV 14) at the withdrawal stage,with the needles retained for 30 min each time,1 session a day,for successive 5 d.On the 39th day,brain tissues were extracted from the hippocampus and ventral tegmental area (VTA) of the three groups of rats.The apoptosis of brain nerve cells was detected by using terminal deoxynucleotidyl transferase-mediated nick and labeling (TUNEL).The mRNA and protein expressions of ubiquitin (Ub),ubiquitin protein ligase (E3) and 26S were examined by immunohistochemistry and quantitative real-time polymerase chain reaction (RT-qPCR).Results:Compared with the model group,rat's hippocampus and VTA in the acupuncture group showed significantly fewer cells positively stained by TUNEL staining (P＜0.01),and its mRNA and protein expressions of Ub,E3,26S were significantly lower (P＜0.01).Conclusion:Reducing nerve cell apoptosis and regulating the mRNA and protein expressions of Ub,E3 and 26S in rat's hippocampus and VTA are possibly one of the action mechanisms of acupuncture in intervening heroin-induced brain damage.

Enfrentamiento del tabaquismo en el paciente hospitalizado / Smoking cessation in the hospitalized patient

Resumen La hospitalización es una oportunidad valiosa para el abandono del tabaquismo, desaprovechada en Chile. La necesidad de hospitalizarse está determinada por enfermedades muchas veces causadas por el consumo de tabaco, este escenario permite al paciente valorar no solo las consecuencias de esta adicción, si no también, la importancia de suspender el consumo. Es esperable que durante la hospitalización aparezca el síndrome de abstinencia de nicotina, cuyo reconocimiento y manejo es fundamental para evitar complicaciones habituales: ansiedad o delirium. Por todo lo anterior, resulta necesario el adecuado enfrentamiento del tabaquismo en el paciente hospitalizado, lo que es reconocido por organismos acreditadores internacionales como Joint Commission. Un metanálisis Cochrane 2012 concluyó que los dos pilares fundamentales de las intervenciones efectivas fueron el carácter multimodal (consejería y tratamiento farmacológico), y el seguimiento ambulatorio por más de un mes posterior al alta. Los elementos centrales de una consejería breve pueden resumirse en el ABC, siendo A: averiguar sobre el consumo de tabaco; B: dar un consejo breve indicando la importancia de dejar de fumar, y C: Ofrecer apoyo para la cesación a los pacientes que se muestren motivados. Si bien las intervenciones mencionadas involucran contar con recursos para apoyo farmacológico, no pareciera haber excusas para seguir sin implementar en los hospitales chilenos intervenciones sencillas como documentar el estado tabáquico de cada paciente y ofrecer consejería breve.

Hospitalization is a valuable opportunity for smoking cessation. In Chile this opportunity is wasted. The need to hospitalize is determined by diseases often caused by smoking, this scenario allows the patient to assess not only the consequences of this addiction, but also the importance of stopping tobacco consumption. During hospitalization, the nicotine withdrawal syndrome appears, whose recognition and management is essential to avoid habitual complications: anxiety or delirium. For all of the above mentioned reasons, it is necessary the adequate confrontation of smoking in the hospitalized patient, which is recognized by international accreditation bodies as Joint Commission. A Cochrane metaanalysis 2012 concluded that the two pillars of effective interventions were the multimodal character (counseling and pharmacological treatment), and ambulatory follow-up for more than one month after discharge. The central elements of a brief counseling can be summarized in ABC, where A: ask about smoking; B: give brief advice stating the importance of quitting, and C: provide support for cessation for motivated patients. Although the above-mentioned interventions involve resources for pharmacological support, there seems to be no excuse for implementing simple interventions in Chilean hospitals, such as documenting the smoking status of each patient and offering brief counseling.

Actividad Física y Tabaquismo / Physical activity and Smoking

Resumen En Chile, según la Encuesta Nacional de salud 2009-10, el 88,6% de la población general no realiza deporte o actividad física en su tiempo libre, y esta conducta de inactividad física aumenta con la edad y es mayor en los niveles educacionales bajos y en las mujeres. La evidencia reporta que utilizar la AF para la cesación del tabaquismo es débil, sin embargo, existe fuerte evidencia de que la actividad física reduce los síntomas de abstinencia, el deseo de fumar y el aumento de peso durante el abandono del tabaco. Los adultos de 18 a 64 años necesitan dedicar al menos 150 min semanales a la actividad física aeróbica, de intensidad moderada, o bien 75 min de actividad física aeróbica vigorosa cada semana, o bien una combinación equivalente de actividades moderadas y vigorosas para protegerse de mortalidad por diversas causas.

The Chilean National Health Survey 2009-10, evidences that 88.6% of the general population does not engage in sports or physical activity in their free time, and this behavior increases with age, low educational levels, and in women. According to evidence, using physical activity for smoking cessation has a weak. However, there is strong evidence that physical activity reduces withdrawal symptoms, craving, and weight gain during smoking cessation. Adults aged 18-64 need to spend at least 150 minutes a week on moderate intensity aerobic physical activity or 75 minutes of vigorous aerobic physical activity each week or an equivalent combination of moderate and vigorous activities to protect thenrselves against mortality from diverse causes.

Incidencia del síndrome de abstinencia en niños críticamente enfermos / Incidence of withdrawal syndrome in critically ill children

Objetivo: determinar la incidencia del síndrome de abstinencia (SA), describir presentación clínica e identificar la presencia de factores de riesgo. Metodología: se realizó un estudio prospectivo, observacional, de evaluaciones reiteradas usando la Sophia Observation Withdrawal Symptoms Scale (SOWS), en la Unidad de Cuidado Intensivo de Niños (UCIN) de 20 camas, del Centro Hospitalario Pereira Rossell (CHPR). Se incluyeron los niños ingresados en UCIN entre el 1 de noviembre de 2013 y el 30 de setiembre de 2014 tratados con benzodiacepinas y/o opiáceos por cinco días o más. Se registró: duración de la estadía, fármacos utilizados para sedación y analgesia, días de uso, máximo de dosis, dosis total acumulada. El diagnóstico de SA se realizó a través del uso de la SOWS. Los pacientes fueron divididos en dos grupos, con y sin SA. Se analizaron y compararon las características de ambos grupos. Resultados: se incluyeron 39 niños. La incidencia de SA fue 18% (7/39). Los ítems del SOWS más frecuentes fueron ansiedad y sueño menor a 1 hora. Los niños que desarrollaron SA presentaron dosis acumulativas más elevadas tanto de midazolam (54,1 mg/kg vs 44,2 mg/kg) como de fentanilo (464,2 mg/kg vs 380,1 mg/kg). Conclusiones: el SA fue frecuente en este grupo de niños. Las dosis acumulativas fueron mayores en el grupo con SA. La SOWS es una herramienta útil y de fácil aplicación para el diagnóstico de SA.

Objective: The study aims to determine the incidence of withdrawal syndrome, its clinical features and the presence of risk factors. Methodology: An observational and prospective study. Assessment was repeated and the Sophia Observation Withdrawal Symptoms Scale (SOWS) was used. The study was conducted at the Pediatric Intensive Care Unit (PICU) of Centro Hospitalario Pereira Rossell (CHPR). Hospitalized children in PICU between 1/11/2013- 30/9/2014 and treated with benzodiazepines and opioids during 5 days or more were included in the study. Days of stay at the PICU, agents used for sedation (dose, duration) and cumulative doses were recorded. Withdrawal syndrome diagnosis was done using the SOWS. Results: 39 children were included in the study. The incidence of withdrawal syndrome was 18% (7/39). Children who developed withdrawal syndrome presented higher cumulative doses of midazolam (54.1 mg/kg vs. 44.2 mg/kg) and fentanyl (464.2µg/kg vs. 380.1 µg/kg) than those without withdrawal syndrome. Conclusions: the withdrawal syndrome was frequent in this population. Cumulative doses of midazolam and fentanyl were higher in those with withdrawal symptoms. The SOWS is a useful resource for diagnosis.

Effect of reward alteration following acupuncture for morphine withdrawal rats on neuronal discharges in the ventral medial prefrontal cortex / 针灸推拿医学（英文版）

Objective:To observe the effect of reward alteration following acupuncture for morphine withdrawal rats on the behavior and neuronal discharges in the medial prefrontal cortex (mPFC). Methods:The Sprague-Dawley (SD) rats were randomly allocated into a model group, a confinement group, an electroacupuncture (EA) group, and a control group. Rats with morphine addiction were made by intraperitoneal injection of naloxone (same dose injection of saline for rats in the control group), followed by a 2-week morphine withdrawal. Acupuncture and confinement were completed during the morphine withdrawal period. Upon withdrawal, the rats received conditioned place preference (CPP) training and open field test. The multi-channel neural signal processor was used in the electrophysiological experiment to measure the neuronal discharges in different subareas of prefrontal cortex in CPP box and aversion box. Results:Rats in the model group and the confinement group spent longer period of time in CPP box than those in the EA group and the control group (allP<0.01); there was no statistically significant difference between the EA group and the control group. The total distances of movement by rats in the model group and the confinement group were longer than those in the EA group and the control group (allP<0.01). The mPFC neuronal discharge frequencies were compared between morphine preference box and aversion box. The mPFC neuronal discharge frequencies in the model group and the confinement group were higher than those in the EA group and the control group (allP<0.05); there was no statistically significant difference between the EA group and the control group. Conclusion:Acupuncture can effectively interfere with the reward alteration following morphine withdrawal, possibly because of its involvement with the mPFC neuronal discharges.

Effect of Acupoint Thread-embedding at Neiguan (PC6) and Zusanli (ST36) on Anxiety and Sleep Disorders After Heroin Withdrawal / 上海针灸杂志

Objective To observe the effect of acupoint thread-embedding at Neiguan (PC6) and Zusanli (ST36) on anxiety and sleep disorders after heroin withdrawal. Method Sixty-seven patients with heroin addiction were randomized into a Neiguan group (25 cases), a Zusanli group (22 cases) and a Neiguan plus Zusanli group (20 cases), to receive corresponding treatments once every 20 d, for 4 sessions in total. The Self-rating Anxiety Scale (SAS) and Pittsburgh Sleep Quality Index (PSQI) were adopted to observe the anxiety and sleep condition before and after the treatment. Result After 60 d thread-embedding treatment, the total and standard SAS scores, sleep initiation time and total PSQI score were significantly decreased in the 3 groups (P Neiguan group >Zusanli group (P0.05). Conclusion It's effective to use thread-embedding at Neiguan and Zusanli independently or together for anxiety and sleep disorders after heroin withdrawal, but the efficacy is more significant when the two points are used in combination, indicating the synergy of acupoints.

Clinical analysis of rhabdomyolysis syndrome caused by alcohol withdrawal syndrome / 中国医师进修杂志

Objective To analyze the characteristics of rhabdomyolysis (RM) caused by alcohol withdrawal syndrome (AWS). Methods The clinical data of 7 patients with RM induced by AWS were analyzed retrospectively. Results All 7 patients were male;the age was 38-63 (51.3 ± 9.8) years. All of the 7 patients showed obvious myalgia and fatigue, of whom 4 patients had limb swelling, and 3 patients had epigastric pain. Creatine kinase and myoglobin levels of 7 cases were significantly increased. One case had acute renal failure. Seven patients were improved after treatment with a large amount of fluid infusion. Conclusions For patients with AWS who have generalized withdrawal seizures and epileptic seizures, muscle cells can be damaged due to prolonged muscle contraction, which can cause RM. Changes of myoglobin, creatine kinase, renal function and liver function in patients with AWS should be monitored at clinical admissions. If RM occurs, the patients should be given early fluid therapy.