En busca del buen morir / In search of a good death

La muerte siempre ha generado desconcierto, por lo que acompañar en este proceso de final de vida conlleva un alto compromiso existencial. Si a esta difícil tarea se le agregan los condicionantes hospitalarios o legales que sufren los enfermos en su agonía, estamos ante una muerte aterradora, muy distante de una partida que pueda ser considerada amorosa. Como sabemos, la palabra "clínica" hace referencia a la práctica de atender al pie de la cama del paciente, aliviando el dolor del que está por partir; sin embargo, el "corsé legal" de la muerte está alejando al médico de aquel que debiera recibir toda su atención y sus cuidados, atándole el brazo para acompañarlo en el buen morir. Deberíamos debatir y acordar una estrategia que enriquezca la experiencia del momento final de la vida, de modo que ese conjunto acotado de pacientes pueda elegir su forma de partir. Es de un valor incalculable despertar la compasión en este tema tan importante que preocupa al ser humano desde los inicios de la civilización. Sería muy fructífero que aprovechemos la transmisión de sabiduría de siglos de antiguas culturas que han sabido cuidar con humildad la vida hasta el instante de morir. (AU)

Death has always implied confusion, so accompanying this end-of-life process entails a highexistential commitment. If we add to this difficult task the hospital or legal constraints suffered bypatients in their agony, we are facing a terrifying death, very far from a departure that can be considered a loving one. As we know, the word "clinical" refers to the practice of caring for the patient very close to the bed, alleviating the pain of whom is about to leave; however, the "legal corset" of death is separating the doctor from the one who should receive all his attention and care, preventing him from accompanying the pacient in his/her good dying. We should discuss and agree on a strategy that enriches the experience of the end of life, so that patients could choose the way to leave. It is of incalculable value to awaken compassion on this important issue that has concerned human since the beggining of civilization. It would be very fruitful if we take advantage of the enormous wisdom of ancient cultures that have humbly cared for life until the moment of death. (AU)

Cefalea por abuso de medicamentos y sus marcadores clínicos / Medication overuse headache and its specific clinical markers

Resumen Introducción: Los marcadores clínicos de la cefalea por uso excesivo de medicación (CMA) se basan en la clasificación de las cefaleas desarrollada por la Sociedad Internacional de Cefaleas (IHS). Esta clasificación incluye sólo dos criterios: la frecuencia de los días de cefalea debe ser de 15 o más días al mes durante al menos tres o más meses; - y el número de días de uso excesivo de la medicación debe ser de 10 o 15 días al mes dependiendo del tipo de medicación. Sin embargo, los pacientes suelen tener otros marcadores clínicos asociados distintos, que la mayoría de los médicos pasan por alto durante la evaluación inicial. Metodología: Este estudio es un estudio prospectivo, longitudinal y observacional de 76 pacientes ingresados en la Unidad de Cefaleas del hospital DIPRECA. Todos ellos fueron diagnosticados de HMO según los criterios establecidos por su ICHD III beta.(1) Los pacientes recibieron un tratamiento estándar que incluía desintoxicación y medicación preventiva y fueron seguidos durante 6 meses. Se registraron los síntomas de interés en cada visita de seguimiento clínico y se administraron escalas de evaluación como Zung, MIDAS, HIT-6. Resultados: Los medicamentos sobreutilizados incluyeron antiinflamatorios no esteroideos (AINE), triptanes y cornezuelos. Los síntomas clínicos más significativos asociados fueron: despertar por la mañana con dolor de cabeza, despertar al paciente al amanecer por dolor de cabeza, dificultades de atención, depresión, dolor cervical y síndrome de dolor miofascial. Todos los síntomas mejoraron significativamente al iniciar el tratamiento, al igual que la calidad de vida medida por las escalas MIDAS y HIT-6. Discusión: Al evaluar a los pacientes con HMO, hay que tener en cuenta tanto los criterios diagnósticos de la ICHD III beta como los síntomas comunes y específicos que se observan en la mayoría de los casos de HMO.

Introduction: Clinical markers of medication overuse headache (MOH) are based on headache classification developed by the International Headache Society (IHS). This classification include only two criteria: frequency of headache days must be 15 or more days per month for at least three or more months; - and the number of days of overuse medication must be either 10 or 15 days per month depending on the type of medication. However, patients often have others distinct associated clinical markers, which are overlooked by most physicians during the initial evaluation. Methodology: This study is a prospective, longitudinal and observational study of 76 patients admitted to DIPRECA´s hospital Headache Unit. They were all diagnosed with, MOH according to the criteria established by the his ICHD III beta.(1) Patients were given standard treatment including detoxification and preventive medications and followed for 6 months. Symptoms of interest were recorded in at each clinical monitoring visit and assessment scales such as Zung, MIDAS, HIT-6 were administered. Results: Overused medications included nonsteroidal anti-inflammatory drugs (NSAIDs), triptans and ergots. The most significant clinical symptoms associated were: awaking in the morning with headache, awaking the patient at dawn by headache, attention difficulties, depression, cervical pain and myofascial pain syndrome. All symptoms significantly improved when treatment began, as did quality of life as measured by MIDAS and HIT-6 scales. Discussion: In evaluating patients with MOH consider both the ICHD III beta diagnostic criteria and the common and specific symptoms seen in most cases of MOH.

The Role of Stress in Bipolar Disorder.

Stress is a major risk factor for bipolar disorder. Even though we do not completely understand how stress increases the risk for the onset and poorer course of bipolar disorder, knowledge of stress physiology is rapidly evolving. Following stress, stress hormones - including (nor)adrenaline and corticosteroid - reach the brain and change neuronal function in a time-, region-, and receptor-dependent manner. Stress has direct consequences for a range of cognitive functions which are time-dependent. Directly after stress, emotional processing is increased at the cost of higher brain functions. In the aftermath of stress, the reverse is seen, i.e., increased executive function and contextualization of information. In bipolar disorder, basal corticosteroid levels (under non-stressed conditions) are generally found to be increased with blunted responses in response to experimental stress. Moreover, patients who have bipolar disorder generally show impaired brain function, including reward processing. There is some evidence for a causal role of (dysfunction of) the stress system in the etiology of bipolar disorder and their effects on brain system functionality. However, longitudinal studies investigating the functionality of the stress systems in conjunction with detailed information on the development and course of bipolar disorder are vital to understand in detail how stress increases the risk for bipolar disorder.

Cirugía con despertar operatorio para procesos expansivos cerebrales. Reporte de 20 casos

Resumen: Introducción: La cirugía de lesiones expansivas cerebrales con paciente despierto es una técnica que se usa de forma cada vez más frecuente. Esto se debe a que es una técnica costo efectiva para realizar resección de tumores cerebrales de forma amplia y segura. Resultado: Se presentan 20 pacientes operados con dicha técnica. Se trató de 13 hombres y 7 mujeres, rango etario 16 - 67 años, portadores de 17 lesiones tumorales y 3 lesiones vasculares (angiomas cavernosos). Se realizaron 22 cirugías ya que dos pacientes se intervinieron 2 veces. Se logró resección supra-máxima en 3 casos, completa en 9, subtotal en 5 y parcial en 2 pacientes. Un paciente no se pudo operar debido a que presentó un despertar inadecuado y el procedimiento se suspendió. En cuanto a las complicaciones, 18% de los pacientes presentaron crisis intra-operatorias, pero las mismas no impidieron el desarrolló del procedimiento con normalidad luego de yugulada la crisis. Dos pacientes (9% de los procedimientos) presentaron un despertar inadecuado. En un caso la lesión se resecó completamente de todas formas, en el otro se suspendió el procedimiento. 18% de los pacientes presentaron una peoría funcional transitoria y un 4.5% presentó una peoría definitiva (paresia severa). Un solo paciente (4.5%) presentó una infección del colgajo que requirió retiro de la plaqueta ósea y colocación de una placa de acrílico en diferido. Conclusiones: Las cifras presentadas por los autores están en concordancia con las de los centros regionales e internacionales de referencia.

Abstract: Introduction: Expansive brain injury surgery with awake patients is a technique that is being used more and more frequently. This is because it is a cost-effective technique for performing brain tumor resection widely and safely. Outcome: Twenty patients operated with this technique are presented. There were 13 men and 7 women, age range 16 - 67 years, carriers of 17 tumor lesions and 3 vascular lesions (cavernous angiomas). 22 surgeries were performed since two patients underwent surgery twice. Supra-maximal resection was achieved in 3 cases, complete in 9, subtotal in 5, and partial in 2 patients. One patient could not be operated on due to inadequate awakening and the procedure was suspended. Regarding complications, 18% of the patients presented intra-operative seizures, but they did not prevent the normal development of the procedure after the crisis was jugulated. Two patients (9% of the procedures) had inadequate awakening. In one case the lesion was completely resected anyway, in the other the procedure was suspended. 18% of the patients presented a transitory functional deterioration and 4.5% presented a definitive worsening (severe paresis). Only one patient (4.5%) had a flap infection that required removal of the bone plate and placement of a delayed acrylic plate. Conclusions: The figures presented by the authors are in accordance with those of the regional and international reference centers.

Resumo: Introdução: A cirurgia de lesão cerebral extensiva com pacientes acordados é uma técnica cada vez mais utilizada. Isso ocorre porque é uma técnica econômica para realizar a ressecção de tumor cerebral de forma ampla e segura. Resultado: São apresentados 20 pacientes operados com essa técnica. Eram 13 homens e 7 mulheres, com idades entre 16 e 67 anos, portadores de 17 lesões tumorais e 3 lesões vasculares (angiomas cavernosos). Foram realizadas 22 cirurgias, pois dois pacientes foram operados duas vezes. A ressecção supra-máxima foi alcançada em 3 casos, completa em 9, subtotal em 5 e parcial em 2 pacientes. Um paciente não pôde ser operado devido ao despertar inadequado e o procedimento foi suspenso. Em relação às complicações, 18% dos pacientes apresentaram convulsões no intra-operatório, mas não impediram o desenvolvimento normal do procedimento após a jugulação da crise. Dois pacientes (9% dos procedimentos) tiveram despertar inadequado. Em um caso a lesão foi totalmente ressecada de qualquer maneira, no outro o procedimento foi suspenso. 18% dos pacientes apresentaram uma deterioração funcional transitória e 4,5% apresentaram piora definitiva (paresia grave). Apenas um paciente (4,5%) apresentou infecção do retalho que exigiu a retirada da placa óssea e colocação de placa acrílica retardada. Conclusões: Os números apresentados pelos autores estão de acordo com os dos centros de referência regionais e internacionais.

Variability of anesthetic depth in total intravenous anesthesia vs balanced anesthesia using entropy indices: a randomized, crossover, controlled clinical trial / Variabilidad de la profundidad anestésica en anestesia total intravenosa vs. anestesia general balanceada usando índices de entropía. Un ensayo clínico aleatorizado, cruzado y controlado

Abstract Introduction: Total intravenous anesthesia (TIVA) and balanced anesthesia (BA) are the most commonly used anesthetic techniques. The differences are the variability of the depth of anesthesia between these techniques that might predict which one is safer for patients and presents a lower risk of intraoperative awakening. Objective: To determine whether a difference exists in the variability of depth of anesthesia obtained by response entropy (RE). Methods: A crossover clinical trial was conducted on 20 healthy patients receiving upper or lower limb ambulatory orthopedic surgery. Patients were randomly assigned to (a) target-controlled infusion of propofol using the Schnider model at a target concentration of 2.5 µg/mL for 15 minutes and a 10-minute washout, followed by sevoflurane administration at 0.8 minimal alveolar concentration (MAC) for the reminder of the surgery, or (b) the reverse sequence. Differences in the variability of the depth of anesthesia using RE were evaluated using paired t-test. Results: The treatment effect showed no significant difference in the average values of RE, during TIVA = 97.23 vs BA 97.04 (P = 0.39). Carry Over (-4.98 vs 4.08) and Period (100.3 vs 94.68) effects were not significantly different. Conclusion: The present study suggests that both anesthetic techniques are equivalent in terms of the stability of the depth of anesthesia. It is important to keep testing the determinants of the efficacy of different populations because the individual behaviors of patients might ultimately tip the scale.

Resumen Introducción: La anestesia total intravenosa (TIVA, por sus siglas en inglés) y la anestesia balanceada (AB) son las técnicas anestésicas más comúnmente utilizadas. La diferencia está en la variabilidad de la profundidad de la anestesia entre estas dos técnicas, lo cual pudiera predecir cuál es más segura para los pacientes y representar un menor riesgo de despertar intraoperatorio. Objetivo: Determinar si existe alguna diferencia en la variabilidad de la profundidad de la anestesia obtenida según los índices de entropía de respuesta (ER). Métodos: Se llevó a cabo un estudio clínico cruzado en 20 pacientes sanos que se sometieron a cirugía ortopédica ambulatoria de miembros superiores o inferiores. Los pacientes se asignaron aleatoriamente así: a) infusión controlada por objetivo (TCI, por sus siglas en inglés) de propofol, utilizando el modelo Schnider a una concentración objetivo de 2,5 µg/mL durante 15 min y un período de lavado de 10 minutos, seguido de la administración de sevoflurano a 0,8 de concentración alveolar mínima (CAM) durante el tiempo restante de la cirugía; o b) la secuencia inversa. Las diferencias en la variabilidad de la profundidad de la anestesia utilizando entropía de respuesta se evaluaron utilizando la prueba t pareada. Resultados: El efecto del tratamiento no mostró ninguna diferencia significativa en los valores promedio de entropía de respuesta (ER) durante TIVA = 97,23 vs. AB 97,04 (P = 0,39). Los efectos de arrastre (-4,98 vs. 4,08) y período (100,3 vs. 94,68) no fueron significativamente diferentes. Conclusiones: El presente estudio sugiere que ambas técnicas anestésicas son equivalentes en términos de estabilidad de la profundidad de la anestesia. Es importante continuar probando los factores determinantes de eficacia en las distintas poblaciones, ya que el comportamiento individual de cada paciente pudiera finalmente inclinar la balanza.

Changes in Cortisol but Not in Brain-Derived Neurotrophic Factor Modulate the Association Between Sleep Disturbances and Major Depression.

Sleep disturbance is a symptom consistently found in major depression and is associated with a longer course of illness, reduced response to treatment, increased risk of relapse and recurrence. Chronic insomnia has been associated with changes in cortisol and serum brain-derived neurotrophic factor (BDNF) levels, which in turn are also changed in major depression. Here, we evaluated the relationship between sleep quality, salivary cortisol awakening response (CAR), and serum BDNF levels in patients with sleep disturbance and treatment-resistant major depression (n = 18), and in a control group of healthy subjects with good (n = 21) and poor (n = 18) sleep quality. We observed that the patients had the lowest CAR and sleep duration of all three groups and a higher latency to sleep than the healthy volunteers with a good sleep profile. Besides, low CAR was correlated with more severe depressive symptoms and worse sleep quality. There was no difference in serum BDNF levels between groups with distinct sleep quality. Taken together, our results showed a relationship between changes in CAR and in sleep quality in patients with treatment-resistant depression, which were correlated with the severity of disease, suggesting that cortisol could be a physiological link between sleep disturbance and major depression.

O que resta da adolescência: despertar nas fronteiras e nos fronts / Lo que queda de la adolescencia: el despertar en las fronteras y en los frentes / What remains of adolescence: awakening at the borders and on the fronts

Os processos dos adolescentes diante dos dilemas humanos relativos à sexualidade, morte, pertença e transformação social contam a sua própria história, mas dizem também sobre o modo como cada sociedade concebe as modalidades de inscrição do sujeito no laço social, assim como da sua disponibilidade às transformações sociais. Neste artigo vamos demonstrar os impasses nos destinos da adolescência quando o outro social, em vez de interpelar, acompanhar e apostar no adolescente transforma suas fronteiras em opacidades intransponíveis, ao modo de um front de guerra, impondo impedimentos à sua pertença ao laço social. Vamos cotejar falas dos adolescentes da peça de teatro de Frank Wedekind, de 1891, O Despertar da Primavera, com falas de adolescentes das margens das grandes cidades brasileiras. Vamos demonstrar a articulação da sexualidade à cena social e política, assim como situar o estatuto do ato diante dos impasses do adolescente frente ao lugar que lhe é ofertado no discurso social. Pode-se escutar o que resta da adolescência: a construção de uma narrativa ficcional que permita construir e nortear a sua invenção de um lugar para existir.

Los procesos de los adolescentes frente a dilemas humanos relacionados con la sexualidad, la muerte, la pertenencia y la transformación social cuentan su propia historia, pero también cuentan la forma en que cada sociedad concibe las modalidades de inclusión del sujeto en el vínculo social, así como su disponibilidad para transformaciones sociales En este artículo, demostraremos los callejones sin salida en los destinos de la adolescencia cuando el otro social, en lugar de cuestionar, acompañar y apostar al adolescente transforma sus fronteras en opacidades insuperables, como un frente de guerra, imponiendo impedimentos para su pertenencia al vínculo social. Compararemos los discursos de los adolescentes en la obra de 1891 de Frank Wedekind, El Despertar de la Primavera, con los discursos de adolescentes de los márgenes de las grandes ciudades brasileñas. Vamos a demostrar la articulación de la sexualidad en la escena social y política, así como a situar el estatuto del acto en vista de los impases de los adolescentes en relación con el lugar que se les ofrece en el discurso social. Puedese escuchar lo que queda de la adolescencia: la construcción de una narrativa ficticia que te permite construir y guiar tu invención de un lugar para existir.

The processes of adolescents vis-à-vis human dilemmas related to sexuality, death, belonging and social transformation tell their own story, but they also tell about the way in which each society conceives the modalities of the subject's inclusion in the social bond, as well as its availability to social transformations. In this article we will demonstrate the impasses in the fates of adolescence when the social other, instead of questioning, accompanying and betting on the adolescent turns its borders into insurmountable opacities, like a war front, imposing impediments to their belonging to the social bond. We will compare the adolescents' speeches in Frank Wedekind's 1891 play, The Awakening of Spring, with speeches by adolescents from the margins of large Brazilian cities. We are going to demonstrate the articulation between sexuality and the social and political scene, as well as to situate the statute of the act in view of the adolescents' impasses in relation to the place offered to them in the social discourse. One can hear what remains of adolescence: the construction of a fictional narrative that allows building and guiding their invention of a place to exist.

Propuesta de protocolo en pacientes comatosos tras lesión cerebral traumática grave / Protocol proposal in comatose patients after severe traumatic brain injury

Resumen Introducción: Para analizar cuál es la mejor alternativa para la recuperación del paciente comatoso tras la lesión cerebral traumática grave en su contexto agudo, entre 1-6 semanas tras el evento traumático, se realizó una búsqueda bibliográfica sistemática. Metodología: La búsqueda empleó las principales bases de datos (Pubmed, Embase, Ovid y Cochrane) con la finalidad de discernir qué terapias son las más propicias para una correcta mejora neurocognitiva del enfermo. Se profundizará en la estimulación sensorial, las diversas instrucciones que se han recopilado sobre su aplicación clínica, el por qué de su efectividad, cuáles son los mejores tipos de estimulación y el fenómeno de habituación. Resultados: Este campo será el de la estimulación sensorial multimodal: por un lado, el uso de la estimulación sensorial que surge de los familiares y que se muestra ciertamente efectiva; y por otro lado, la realización de sesiones en las que intervenga personal del hospital y que estimule los diferentes sentidos. A partir de ciertos estudios se deducirá y comprobará que habrá un efecto positivo significativo al combinar ambas terapias. Esta unión sinérgica terapéutica será la que se pueda protocolizar y llevar a cabo en cualquier hospital. Conclusiones: Por tanto, se presenta el tratamiento terapéutico definitivo para pacientes clínicamente estables que han sufrido una LCT grave en un contexto agudo. Se debe destacar que el principal objetivo de la propuesta es aportar indicaciones a partir de la experiencia clínica sobre cómo se tienen que hacer los diferentes tipos de estimulación para obtener un resultado favorable.

Introduction: To analyze which is the best alternative for the recovery of the comatose patient after severe traumatic brain injury in its acute context, between 1-6 weeks after the traumatic event, a systematic bibliographic search was carried out. Methodology: The search used the main databases (Pubmed, Embase, Ovid and Cochrane) in order to discern which therapies are most conducive to a correct neurocognitive improvement of the patient. The sensory stimulation will be deepened, the various instructions that have been compiled about its clinical application, the why of its effectiveness, which are the best types of stimulation and the habituation phenomenon. Results: This field will be that of multimodal sensory stimulation: on the one hand, the use of sensory stimulation that emerges from the relatives and that is certainly effective; and on the other hand, the realization of sessions in which hospital personnel intervene and stimulate the different senses. From certain studies it will be deduced and verified that there will be a significant positive effect when combining both therapies. This synergistic therapeutic union will be the one that can be protocolized and carried out in any hospital. Conclusions: Therefore, definitive therapeutic treatment is presented for clinically stable patients who have suffered a severe TBI in an acute context. It should be noted that the main objective of the proposal is to provide indications based on clinical experience on how different types of stimulation have to be done in order to obtain a favorable result.

Monitorización automática de estados de sedación en señales electroencefalográficas / Automatic monitoring of sedation states in electroencephalographic signals

La anestesia general proporciona al paciente estados de inconciencia, amnesia y analgesia, sin embargo, se reportan casos de despertar intraoperatorio. Debido a la incidencia de este fenómeno y sus efectos psicosomáticos, el Centro de Estudios de Neurociencias, Procesamiento de Imágenes y Señales en la Universidad de Oriente, y el Hospital General Juan Bruno Zayas Alfonso ambos en Santiago de Cuba, Cuba, implementan una metodología que permita detectar automáticamente estados de sedación anestésica aplicando Inteligencia Artificial. Para esto se emplearon las señales registradas por el canal electroencefalográfico F4, nueve parámetros espectrales, las Máquinas de Soporte Vectorial y los Sistemas Neuro-Difusos. En el reconocimiento automático de los estados de Sedación Profunda, Moderada y Ligera se logró una Exactitud de 96.12 por ciento, 90.06 por ciento y 90.24 por ciento respectivamente con las Máquinas de Soporte Vectorial, por lo que se propone el uso del canal electroencefalográfico F4 en la detección de estados anestésicos(AU)

General anesthesia provide the patient states of unconsciousness, amnesia and analgesia, however, cases of intraoperative awareness are reported. Due to the incidence of this phenomenon and the psychosomatic effects it causes, the Neuroscience Studies Center, Images and Signals Processing at the University of Oriente, and the General Hospital Juan Bruno Zayas Alfonso both in Santiago de Cuba, Cuba, implement a methodology that allows the automatic detection of anesthetic sedation states applying Artificial Intelligence. For this, the signals recorded by the electroencephalographic channel F4, nine spectral parameters, the Support Vector Machines and the Neuro-Fuzzy Systems were used. In the automatic recognition of the Sedation States: Profound, Moderate and Mild an Accuracy of 96.12 percent, 90.06 percent and 90.24 percent respectively was achieved with the Support Vector Machines, so the use of the electroencephalographic channel F4 is proposed in the detection of anesthetic states(AU)

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study.

Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation. DESIGN: Multi-ICU proof-of-concept study and a single ICU before-after study. SETTING: University hospital ICUs. PATIENTS: Adult patients receiving mechanical ventilation. INTERVENTIONS: An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers. MEASUREMENTS AND MAIN RESULTS: We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application. CONCLUSIONS: Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

Effects of zolpidem and zaleplon on cognitive performance after emergent morning awakenings at Tmax: a randomized placebo-controlled trial.

STUDY OBJECTIVES: Prescription sleep aids are frequently used in the general population and even more frequently in spaceflight. To evaluate the risk to operational safety, a ground-based, double-blind, placebo-controlled study on the emergent awakening effects of zolpidem and zaleplon was conducted. METHODS: N = 34 participants (age M = 42.1 ± 9.7; 25 males; 9 Astronauts, 7 Astronaut candidates, and 18 Flight Controllers) were investigated for three nights separated by M = 10 days. They were randomized to ingestion of one of the following at lights out: placebo, 10 mg zaleplon, and either 5 mg (N = 20) or 10 mg (N = 14) zolpidem. They were awakened abruptly by alarm at the expected PK,max (1 hr after lights out for zaleplon; 1.5 hr for placebo/zolpidem). Participants were required to turn off the alarm and perform a cognitive test battery twice, separated by a 20-30 min reading break. They then returned to sleep and were awakened to perform the same cognitive tasks at an average of 6.7 hr after drug ingestion. RESULTS: Relative to placebo, the effects of 10 mg zaleplon and 5 mg zolpidem on cognitive performance were minor. In contrast, 10 mg zolpidem adversely affected cognitive throughput (p < 0.001), psychomotor vigilance (p < 0.001), working memory (p < 0.01), delayed word recall (p < 0.05), and subjective sleepiness (p < 0.01) at the first emergent awakening. At terminal awakening, neither cognitive performance nor subjective sleepiness was impaired after ingestion of zaleplon or zolpidem (5 mg and 10 mg) compared with placebo. CONCLUSIONS: Presleep ingestion of sleep medications, especially 10 mg zolpidem, poses a risk for performance errors after emergent awakenings near the expected PK,max. REGISTRATION: Optimize Astronaut Sleep Medication Efficacy and Individual Effects (clinicaltrials.gov ID NCT03526575).

Cortisol Modulation by Ayahuasca in Patients With Treatment Resistant Depression and Healthy Controls.

Major depression is a highly prevalent mood disorder, affecting about 350 million people, and around 30% of the patients are resistant to currently available antidepressant medications. Recent evidence from a randomized controlled trial (RCT) supports the rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression. The aim of this study was to explore the effect of ayahuasca on plasma cortisol and awakening salivary cortisol response, in the same group of treatment-resistant patients (MD) and in healthy volunteers (C). Subjects received a single dose of ayahuasca or placebo (dosing session), and both plasma and awakening salivary cortisol response were measured at baseline (before dosing session) and 48 h after the dosing session. Baseline assessment (D0) showed blunted awakening salivary cortisol response and hypocortisolemia in patients, with respect to healthy controls. Salivary cortisol was also measured during dosing session, and we observed higher increases for both C and MD that ingested ayahuasca than placebo. After 48 h from the dosing session with ayahuasca, patients' awakening salivary cortisol response is similar to the ones detected in controls. No significant changes in plasma cortisol levels were observed 48 h after the sessions. Therefore, these findings point to new evidence on the modulation of salivary cortisol levels as a result of an ayahuasca session, both in healthy and depressive volunteers. Considering that cortisol acts in regulation of distinct physiological pathways, emotional and cognitive processes, it is assumed to be critically involved to the etiology of depression and its regulation seems to be important for the treatment and remission of major depression, ayahuasca use as antidepressant should be further investigated. Moreover, this study highlights the importance of psychedelics in the treatment of human mental disorders.

Algunas posiciones subjetivas frente a lo pulsional en los sueños / Algumas posições subjetivas frente ao impulso nos sonhos / Some subjective positions in view of the drive in dreams / Quelques positions subjectives face à la pulsion dans les rêves

Este artículo trata sobre la inserción de la pulsión en el sueño y la posición subjetiva frente al mismo. Se distinguen tres posiciones: una defensiva, otra más abierta, y una posición decidida, propia de los análisis avanzados. Se utilizan textos freudianos para situar las dos primeras y textos sobre resultados del pase para la tercera. Se concluye que el análisis permite cambiar la forma de recepción de los propios sueños, favoreciendo otras funciones, diferentes de la de ser "el guardián del dormir ".

Este artigo aborda a inserção da pulsão no sonho e a posição do sujeito ante ela. Encontramos três posições diferentes: uma posição defensiva, uma posição mais aberta e uma posição decidida, típica da análise avançada. Os textos freudianos são usados para situar as duas primeiras, e os textos sobre os resultados, da passagem para a terceira. Conclui-se que a análise permite mudar a forma de receber os sonhos, favorecendo outras funções, além de ser "o guarda do dormir ".

This paper focuses on the point of insertion of Freudian drive (Trieb) into dreams and the position of the subject towards it. We distinguish three positions: a defensive one, another more open, and a third that is a position of determination, typical of advanced analysis. Freudian texts are used to describe the first two positions, and many texts to describe the passing into the third one. We conclude that the analysis allows changes in the way of receiving our own dreams, favoring other functions besides being "the guardian of sleep".

Cet article examine le surgissement de la pulsion dans le rêve et la position du sujet face à celle-ci. Trois positions sont différenciées: une défensive, une autre plus ouverte, et une troisième position, décidée, propre des analyses avancées. Les écrits freudiens sont utilisés pour situer les deux premières et les textes sur les résultats du passage pour la troisième. Nous parvenons à la conclusion que l'analyse permet d'altérer la façon de recevoir les rêves et ainsi de favoriser d'autres fonctions que celle du «gardien du sommeil¼.

Dieser Artikel beschäftigt sich mit der Manifestation des Triebs im Traum und der entsprechenden Positionierung des Subjekts dazu. Es werden drei Positionen unterschieden: eine defensive, eine offenere und eine entschiedene Position, wobei die letzte für die fortgeschrittene Analyse typisch ist. Freuds Texte werden als Referenz verwendet, um die ersten zwei in einen Zusammenhang zu stellen und Texte über die Ergebnisse des Überganges um die Dritte zu situieren. Wir kommen zum Schluss, dass die Analyse es ermöglicht, die Art und Weise wie die Träume empfangen werden zu ändern, wobei andere Funktionen begünstigt werden, in Ergänzung zu derjenigen des „Hüters des Schlafes ".

Inter-individual Differences in the Effects of Aircraft Noise on Sleep Fragmentation.

STUDY OBJECTIVES: Environmental noise exposure disturbs sleep and impairs recuperation, and may contribute to the increased risk for (cardiovascular) disease. Noise policy and regulation are usually based on average responses despite potentially large inter-individual differences in the effects of traffic noise on sleep. In this analysis, we investigated what percentage of the total variance in noise-induced awakening reactions can be explained by stable inter-individual differences. METHODS: We investigated 69 healthy subjects polysomnographically (mean ± standard deviation 40 ± 13 years, range 18-68 years, 32 male) in this randomized, balanced, double-blind, repeated measures laboratory study. This study included one adaptation night, 9 nights with exposure to 40, 80, or 120 road, rail, and/or air traffic noise events (including one noise-free control night), and one recovery night. RESULTS: Mixed-effects models of variance controlling for reaction probability in noise-free control nights, age, sex, number of noise events, and study night showed that 40.5% of the total variance in awakening probability and 52.0% of the total variance in EEG arousal probability were explained by inter-individual differences. If the data set was restricted to nights (4 exposure nights with 80 noise events per night), 46.7% of the total variance in awakening probability and 57.9% of the total variance in EEG arousal probability were explained by inter-individual differences. The results thus demonstrate that, even in this relatively homogeneous, healthy, adult study population, a considerable amount of the variance observed in noise-induced sleep disturbance can be explained by inter-individual differences that cannot be explained by age, gender, or specific study design aspects. CONCLUSIONS: It will be important to identify those at higher risk for noise induced sleep disturbance. Furthermore, the custom to base noise policy and legislation on average responses should be re-assessed based on these findings.

Robust evaluation of time since awakening using force platform posturography

INTRODUCTION: Sleepiness is responsible for a considerable proportion of traffic accidents. It is thus an important traffic safety issue to find a robust, objective and practical way to estimate the amount of time a person has been awake. To attempt to meet this goal, we investigated the relationship between sleepiness and posture control. METHODS: Subjects were kept awake for 36 hours and posturographic data during quiet standing were collected every two hours by means of a force platform. The standing surface (rigid surface or foam surface) and visual (eyes open or eyes closed) conditions were manipulated. RESULTS: In the more challenging conditions (with foam surface and/or eyes closed), the body sway variables derived from the center of the pressure measurement increased significantly when time since awakening became greater than 21 h in almost all subjects. CONCLUSION: Based on this result, we propose a practical protocol that could robustly assess whether time since awakening was greater than 21 h.

Retardo en el despertar de la anestesia / Retardation in awakening from anesthesia

Introducción: el retraso en el despertar de la anestesia es una complicación relativamente frecuente, observada en el post-operatorio inmediato, de origen multifactorial; dentro de sus causas se encuentra la presión intracraneal elevada como consecuencia de lesiones expansivas intracraneales, debido a procedimientos neuroquirúrgicos.Objetivo: exponer las características clínicas y la conducta post-operatoria que se realizó en paciente con despertar anestésico prolongado. Caso clínico: paciente intervenida de fístula de líquido cefalorraquídeo que presenta despertar anestésico prolongado en la Unidad de Recuperación Post-anestésica producto de un neumoencéfalo. Conclusiones: el neumoencéfalo constituye una causa poco frecuente de retardo en el despertar de la anestesia en el post-operatorio, pero debe tenerse en cuenta y descartarse en pacientes tratados mediante procedimientos neuroquirúrgicos(AU)

Introduction: the retardation when awakening from anesthesia is a relatively frequent complication observed in the immediate post operative period of multifactor origin; among the most important causes are: elevated intracranial pressure as a consequence of intracranial expansive lesions due to neurosurgical procedures. Objective: expose the clinical characteristics and post operative conduct carried out in patients with prolonged anesthetic awakening. Clinical case: patient who was operated on a fistula of cephalorachidial liquid who has a prolonged anesthetic awakening in the Post anesthetic Recovery Unit as a result of a neumoencephalom. Conclusiones: the neumoencephalom constitutes a cause less frequent in the retardation of awakening from anesthesia in post operative; it must be taken into account and ruled out in treated patients by jeans of neurosurgical procedures(AU)

Retardo en el despertar de la anestesia / Retardation in awakening from anesthesia

Introducción: el retraso en el despertar de la anestesia es una complicación relativamente frecuente, observada en el post-operatorio inmediato, de origen multifactorial; dentro de sus causas se encuentra la presión intracraneal elevada como consecuencia de lesiones expansivas intracraneales, debido a procedimientos neuroquirúrgicos. Objetivo: exponer las características clínicas y la conducta post-operatoria que se realizó en paciente con despertar anestésico prolongado. Caso clínico: paciente intervenida de fístula de líquido cefalorraquídeo que presenta despertar anestésico prolongado en la Unidad de Recuperación Post-anestésica producto de un neumoencéfalo. Conclusiones: el neumoencéfalo constituye una causa poco frecuente de retardo en el despertar de la anestesia en el post-operatorio, pero debe tenerse en cuenta y descartarse en pacientes tratados mediante procedimientos neuroquirúrgicos.

Introduction: the retardation when awakening from anesthesia is a relatively frequent complication observed in the immediate post operative period of multifactor origin; among the most important causes are: elevated intracranial pressure as a consequence of intracranial expansive lesions due to neurosurgical procedures. Objective: expose the clinical characteristics and post operative conduct carried out in patients with prolonged anesthetic awakening. Clinical case: patient who was operated on a fistula of cephalorachidial liquid who has a prolonged anesthetic awakening in the Post anesthetic Recovery Unit as a result of a neumoencephalom. Conclusiones: the neumoencephalom constitutes a cause less frequent in the retardation of awakening from anesthesia in post operative; it must be taken into account and ruled out in treated patients by jeans of neurosurgical procedures.

Duration effect of desflurane anesthesia and its awakening time and arterial concentration in gynecologic patients

OBJECTIVES: To determine the awakening arterial blood concentration of desflurane and its relationship with the end-tidal concentration during emergence from various durations of general anesthesia. METHOD: In total, 42 American Society of Anesthesiologists physical status class I-II female patients undergoing elective gynecologic surgery were enrolled. General anesthesia was maintained with fixed 6% inspiratory desflurane in 6 l min-1 oxygen until shutoff of the vaporizer at the end of surgery. One milliliter of arterial blood was obtained for desflurane concentration determination by gas chromatography at 20 and 10 minutes before and 0, 5, 10, 15, and 20 minutes after the discontinuation of desflurane and at the time of eye opening upon verbal command, defined as awakening. Concentrations of inspiratory and end-tidal desflurane were simultaneously detected by an infrared analyzer. RESULTS: The mean arterial blood concentration of desflurane was 1.20% at awakening, which correlated with the awakening end-tidal concentration of 0.96%. The mean time from the discontinuation of desflurane to eye opening was 5.2 minutes (SD = 1.6, range 3-10), which was not associated with the duration of anesthesia (60-256 minutes), total fentanyl dose, or body mass index (BMI). CONCLUSIONS: The mean awakening arterial blood concentration of desflurane was 1.20%. The time to awakening was independent of anesthetic duration within four hours. Using well-assisted ventilation, the end-tidal concentration of desflurane was proven to represent the arterial blood concentration during elimination and could be a clinically feasible predictor of emergence from general anesthesia. .