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.

Acupuncture for treatment of tobacco withdrawal syndrome: systematic review and Meta-analysis / 中国针灸

OBJECTIVE@#To systematically review the efficacy of acupuncture for the treatment of tobacco withdrawal syndrome.@*METHODS@#The randomized controlled trials (RCTs) regarding acupuncture for treatment of tobacco withdrawal syndrome were searched in CNKI, Wanfang, VIP, SinoMed, PubMed, Cochrane, Medline and EMbase databases. The search period was from January 1st of 2011 to December 31st of 2021. After data extraction and bias risk assessment of the included literature, the Meta-analysis was performed using RevMan5.4.1 software.@*RESULTS@#Totally 23 RCTs were included, including 2 120 patients. The Meta-analysis results showed that compared with medication, acupuncture showed no significant difference at improving Fagerström test for nicotine dependence (FTND) score (MD=0.16, 95%CI: -0.08, 0.41), heaviness of smoking index (HSI) score (MD=0.11, 95%CI: -0.13, 0.36), Minnesota nicotine withdrawal scale (MNWS) score (MD=0.12, 95%CI: -0.11, 1.35), questionnaire of smoking urges (QSU) score (MD=-0.30, 95%CI: -2.78, 2.18), Hamilton depression scale (HAMD) score (MD=0.76, 95%CI: -1.54, 3.06), abstinence rate (RR=0.95, 95% CI: 0.82, 1.10) and effective rate (RR=1.01, 95%CI: 0.95, 1.07). Acupuncture was superior to sham acupuncture in reducing MNWS score (MD=-4.88, 95%CI: -5.21, -4.55, P<0.000 01). Acupuncture was superior to cognitive behavioral therapy in reducing FTND score (MD=-1.41, 95%CI: -1.74, -1.08), MNWS score (MD=-4.28, 95%CI: -5.31, -3.25) and increasing abstinence rate (RR=2.19, 95%CI: 1.39, 3.45, P<0.000 01, P<0.001).@*CONCLUSION@#Acupuncture could effectively improve tobacco withdrawal syndrome, increase abstinence rate and effective rate. Limited by the quantity and quality of the included studies, this conclusion needs to be verified by more studies.

A Case of Withdrawal Syndrome after Opioid Discontinuation Following Pain Relief of Bone Metastases

Introduction: In patients receiving opioids, relief of cancer pain by palliative radiation therapy or other means can lead to opioid discontinuation and subsequent withdrawal symptoms, such as agitation, insomnia, and diarrhea, due to opioid-related physical dependence. Appropriate steps should be taken to prevent these symptoms. Case: A 72-year-old man underwent surgery for esophageal cancer. He developed low back pain and right lower limb pain, and was diagnosed with sacral and right iliac bone metastases. His pain was resistant to oxycodone (OXC), so he was simultaneously treated with methadone (MDN) and palliative radiotherapy. His pain gradually decreased, and MDN was tapered and switched to OXC, which was in turn discontinued at 20 mg/day at the patient's strong request. After OXC discontinuation, akathisia, anxiety, and diarrhea appeared as withdrawal symptoms. These were treated with immediate-release OXC, transdermal fentanyl, and suvorexant. Discussion: When discontinuing opioids, dose reduction below 10% per week is recommended, de-escalation to the lowest possible dose should be followed by cessation. In case of withdrawal symptoms, immediate-release opioids may be used, and opioid tapering should be attempted in parallel with symptom control.

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

Clinical perspectives on the management of common psychiatric disorders in India

Psychiatric disorders are common health problems in patients of all age groups, under-diagnosis and under-treatment of these disorders can result in disability and serious complications. With an objective of creating a comprehensive evidence-based consensus on common mental health disorders and their management in the Indian setting, 10 expert groups meetings involving 98 psychiatrists across India were conducted in the month of May 2020. Clinical insights related to burden, signs and symptoms, diagnosis and management were summarized based on the discussions during these meetings. Experts agreed that depressive disorders and anxiety disorders represent two important psychiatric disorders in India. Selective serotonin reuptake inhibitors (SSRIs) are commonlyused for the treatment of depression. Benzodiazepines are effective for the treatment of comorbid anxiety in patients with depression, but their long-term use causes adverse events such as dependence and withdrawal reaction. Obsessive compulsive disorder (OCD), bipolar disorder, substance use especially alcohol withdrawal syndrome, and sleep disorders are other common psychiatric disorders found among Indian patients. Lithium and valproate represent the commonly used and effective pharmacological treatments for bipolar disorder. SSRIs are preferred drugs in the treatment of OCD,whereas benzodiazepines such as chlordiazepoxide and diazepam represent important pharmacological treatment optionsfor alcohol withdrawal. Early identification and timely and effective treatment of psychiatric disorders is important for prevention of complications. Treatment should be individualized based on efficacy, tolerability profile of the medicine, risk of drug interactions, and cost. This consensus may be useful to psychiatrists and general practitioners treating common psychiatric conditions in Indian patients.

Recién nacidos hijos de madres adictas. Formas de presentación: no todo se trata de síndrome de abstinencia

RESUMEN El consumo de drogas ilegales por la mujer gestante puede ocasionar morbilidades potencialmente graves en el feto y recién nacido. Las manifestaciones en el niño pueden ser diversas, por lo que es necesario un alto índice de sospecha a fin de realizar el diagnóstico y tratamiento apropiados. Se presentan tres casos de recién nacidos, hijos de madres adictas, con variadas expresiones clínicas.

ABSTRACT Illegal drug consumption by pregnant women can cause potentially serious morbidities in the fetus and newborn. Manifestations in children can be diverse, so a high index of suspicion is necessary in order to appropriately diagnose and treat this condition. Three cases of newborns, born to mothers with substance-abuse disorder, with various clinical presentations are reviewed.

Delirium, catatonía y síndrome de abstinencia manifestados como agitación psicomotora en COVID-19: una propuesta de manejo farmacológico en el hospital general / Delirium, catatonia and substance withdrawal syndrome manifested as psychomotor agitation in COVID-19: a pharmacological management approach for the general hospital setting

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.

Effect of auricular acupuncture on reduction of sertraline hydrochloride in patients with depression: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the effect of auricular acupuncture on reduction rate of sertraline hydrochloride, and to explore the long-term efficacy of auricular acupuncture in patients with depression.@*METHODS@#Seventy-two patients with depression were randomly divided into an observation group (36 cases, 1 case dropped off) and a control group (36 cases, 2 cases dropped off). The patients in the control group were treated with conventional dosage reduction method, that is, the dosage of sertraline hydrochloride was reduced by 25% every week until the dosage was stopped completely on the premise of no aggravation of depressive symptoms. Based on the conventional dosage reduction method used in the control group, the patients in the observation group were treated with auricular acupuncture at Xin (CO@*RESULTS@#The dosage of sertraline hydrochloride in the observation group was less than that in the control group after 2, 3, 4 weeks of dosage reduction and during follow-up (@*CONCLUSION@#Auricular acupuncture could effectively reduce the dosage of sertraline hydrochloride, improve the dosage reduction rate, reduce the incidence of withdrawal syndrome and reduce the risk of long-term recurrence in patients with depression.

A study of alanine aminotransferase - aspartate aminotransferase as a marker of advanced alcoholic liver disease

Background: Alcohol is one of the most common etiology for chronic liver disease. There are several enzymes which remain elevated in both excessive Alcohol consumption and Alcohol induced liver cirrhosis1. But none is sensitive or specific. The ratio of Aspartate transaminase (AST) with Alanine transaminase (ALT) is one of the best marker for alcohol liver disease. Current study mainly compares the ratio of AST/ALT with both Alcoholic liver disease and excessive Alcohol consumption patients.Methods: Observational, cross sectional study conducted on 50 patients diagnosed with alcoholic liver disease and 50 patients of alcohol withdrawal syndrome. Either admitted or seen on outpatient basis at Bangalore medical college and research institute and data was compared among the groups and appropriate statistical methods are applied.Results: The mean ratio of AST/ALT ratio in 50 patients of alcoholic liver disease group was 3.45, whereas the mean ratio in 50 patient of alcohol withdrawal was about 99. When compared statistically this ratio was significant in chronic liver disease group.Conclusions: Most of the patients with heavy alcohol drinking had high AST and alt levels. But ratio of AST/ALT levels was significant high and suggest chronic liver disease secondary to alcohol.

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.

Statin withdrawal syndrome in patients with coronary heart disease / 中华全科医师杂志

Statins, as the first-line anti-atherosclerosis drugs, are of significant benefit in reducing the risk for cardiovascular and cerebrovascular events. However, many studies have shown that the patient adherence to statin is poor in clinical practice, and many cardiovascular patients abruptly discontinue therapy. Acute withdrawal of statin therapy may have a rebound effect on patient outcomes, and clinicians should pay attention to statin withdrawal syndrome to avoid its occurence.

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.

Efeito do álcool na ilusão da máscara côncava: uma revisão / Effect of alcohol on the hollow-face illusion: a review / Efecto del alcohol en la ilusión de la máscara cóncava: una revisión

A ilusão da máscara côncava ocorre quando o observador a determinada distância percebe uma máscara facial côncava como convexa. Isso pode ser explicado pela sobreposição dos processos de alta ordem da percepção visual sobre os de baixa ordem. Pesquisas com indivíduos intoxicados e em Síndrome de Abstinência do Álcool (SAA) revelaram um prejuízo em perceber essa ilusão. O objetivo foi realizar uma revisão da literatura sobre o tema. Após buscas em bases indexadas, cinco pesquisas foram encontradas. Os resultados para os alcoolistas em SAA moderada revelaram uma menor frequência nas respostas de percepção da ilusão. Os resultados foram contraditórios quanto ao grupo de alcoolistas com SSA leve. Pesquisas futuras com metodologias diferentes são necessárias para testar as hipóteses explicativas da ilusão da máscara côncava em alcoolistas. É importante considerar os processos de tomada de decisão do observador diante da observação dos objetos como base a Teoria de Detecção de Sinal (TDS)

The hollow-face illusion happens when the observer perceives a concave facial mask as convex, at a given distance. This can be explained by the overlap of top-down on bottom-up visual processes. Researches demonstrated that intoxicated and Alcohol Withdrawal Syndrome (AWS) individuals had deficit in perceiving this illusion. This study aimed to review the literature on this topic. A survey of indexed databases found five studies. The results for alcoholics with moderate AWS were similar and showed a lower frequency in the answers of illusion perception. However, results were contradictory to the alcoholic group with mild AWS. Future researches with different methodologies are necessary to test the hollow-face illusion hypotheses in alcoholics. Therefore, it is also important to consider the observer's decision-making processes in the objects observation based on the Signal Detection Theory (SDT)

La ilusión de la máscara cóncava ocurre cuando el observador a cierta distancia percibe una máscara facial cóncava como convexa. Esto puede ser explicado por la superposición de los procesos de alto orden de la percepción visual sobre los de bajo orden. Las investigaciones con individuos intoxicados y en el Síndrome de Abstinencia del Alcohol (SAA) revelaron un perjuicio en percibir esa ilusión. El objetivo fue realizar una revisión de la literatura sobre el tema. Después de buscar en bases indexadas, se encontraron cinco encuestas. Los resultados para los alcohólicos en SAA moderada revelaron una menor frecuencia en las respuestas de percepción de la ilusión. Los resultados fueron contradictorios en cuanto al grupo de alcohólicos con SSA leve. Las investigaciones futuras con metodologías diferentes son necesarias para probar las hipótesis explicativas de la ilusión de la máscara cóncava en alcohólicos. Es importante considerar los procesos de toma de decisión del observador ante la observación de los objetos como base la Teoría de Detección de Señal (TDS)

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.