DESARROLLO DE UN MODELO COGNITIVO-CONDUCTUAL MOTIVACIONAL DE ATENCIÓN ESCALONADA PARA ESTUDIANTES UNIVERSITARIOS CON PROBLEMAS DE ALCOHOL

Resultados de encuestas internacionales en estudiantes universitarios documentan que los problemas de alcohol constituyen un problema emergente de salud pública. Se describe el desarrollo y evaluación de un modelo cognitivo-conductual motivacional de atención escalonada para estudiantes universitarios con problemas de alcohol, que incluye tres programas de tratamiento, “BASICS”, “GSC” y “SRP”, que forman parte del estado del arte de los tratamientos cognitivo-conductuales y motivacionales para el abordaje de un amplio espectro de problemas de alcohol, disponibles en centros y programas de la UNAM. Se empleó una versión modificada del enfoque de atención escalonada y una combinación de estrategias de igualación “cliente-tratamiento”, para la asignación de participantes a tratamientos específicos. Se describe el modelo y los resultados obtenidos en un estudio diseñado para evaluar su eficacia con un grupo de estudiantes universitarios que cubren un amplio espectro de problemas de alcohol

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Efecto de agonistas y antagonistas de la dopamina en ambientes de reforzamiento variables

The anhedonia hypothesis maintains that pleasure for food-reward is determined by dopamine activity in the brain. The cumulative body of empirical evidence shows that dopamine agonists and antagonists (e.g., Methylphenidate and Haloperidol, respectively) decrease operant behavior maintained by positive reinforcement. The present study used the generalized matching law (Baum, 1974) to assess effects of these drugs on the motor system and the organism’s motivation for food reinforcers. Thirty-two rats searched for food in a choice situation where the reinforcer ratio provided by two alternatives changed everyday. The results confirmed that the drugs do not impede the rats’ rapid adaptation to dynamic changes in the contingencies of reinforcement. Preference favored with more responses the alternative associated to the higher probability of reinforcement, showing an increment in sensitivity of behavior ratio to changes in food ratios. The alternative demanding the higher motor requirement showed a decrement in the number of responses, suggesting effects of the drugs in the organism’s motor systemSegún la hipótesis de la anhedonia el valor placentero de la comida está determinado por la actividad de dopamina en el cerebro. La evidencia empírica muestra que los agonistas y antagonistas a la dopamina (e.g., metilfenidato y haloperidol, respectivamente) disminuyen la conducta operante mantenida con reforzamiento positivo. Se utilizó la ley generalizada de igualación (Baum, 1974) para evaluar efectos de estas drogas en la motricidad y motivación del organismo por la comida. Treinta y dos ratas buscaron alimento en una situación de elección donde la razón de reforzamiento que proporcionaban dos alternativas cambia diariamente. Los resultados confirmaron que las drogas no impiden la rápida adaptación de las ratas a los cambios dinámicos en las contingencias de reforzamiento. Se evidenció un incremento en la sensibilidad de las razones de respuestas a los cambios en las razones de los reforzadores. La alternativa de mayor demanda motriz para el organismo mostró una reducción en el número de respuestas, sugiriendo efectos de las drogas en la motricidad del organism

Efecto de agonistas y antagonistas de la dopamina en ambientes de reforzamiento variables

The anhedonia hypothesis maintains that pleasure for food-reward is determined by dopamine activity in the brain. The cumulative body of empirical evidence shows that dopamine agonists and antagonists (e.g., Methylphenidate and Haloperidol, respectively) decrease operant behavior maintained by positive reinforcement. The present study used the generalized matching law (Baum, 1974) to assess effects of these drugs on the motor system and the organism’s motivation for food reinforcers. Thirty-two rats searched for food in a choice situation where the reinforcer ratio provided by two alternatives changed everyday. The results confirmed that the drugs do not impede the rats’ rapid adaptation to dynamic changes in the contingencies of reinforcement. Preference favored with more responses the alternative associated to the higher probability of reinforcement, showing an increment in sensitivity of behavior ratio to changes in food ratios. The alternative demanding the higher motor requirement showed a decrement in the number of responses, suggesting effects of the drugs in the organism’s motor systemSegún la hipótesis de la anhedonia el valor placentero de la comida está determinado por la actividad de dopamina en el cerebro. La evidencia empírica muestra que los agonistas y antagonistas a la dopamina (e.g., metilfenidato y haloperidol, respectivamente) disminuyen la conducta operante mantenida con reforzamiento positivo. Se utilizó la ley generalizada de igualación (Baum, 1974) para evaluar efectos de estas drogas en la motricidad y motivación del organismo por la comida. Treinta y dos ratas buscaron alimento en una situación de elección donde la razón de reforzamiento que proporcionaban dos alternativas cambia diariamente. Los resultados confirmaron que las drogas no impiden la rápida adaptación de las ratas a los cambios dinámicos en las contingencias de reforzamiento. Se evidenció un incremento en la sensibilidad de las razones de respuestas a los cambios en las razones de los reforzadores. La alternativa de mayor demanda motriz para el organismo mostró una reducción en el número de respuestas, sugiriendo efectos de las drogas en la motricidad del organism

Haloperidol, elección y requisitos de respuesta de cambio

En el laboratorio operante el haloperidol reduce la emisión de conductas requeridas para la obtención de comida. Este resultado se explica diciendo que la droga nulifica el efecto reforzante de la comida (hipótesis anhedónica). Otra explicación (hipótesis motriz) dice que el decremento en las respuestas se debe a que el haloperidol atrofia al sistema motriz. Las dos hipótesis sugieren que la droga impide una rápida adaptación del organismo a cambios dinámicos en contingencias de reforzamiento. Esta posibilidad se explor ó en una situación de elección que día con día cambiaba la razón de reforzadores (alimento) que otorgaban dos palancas y pedía cinco requisitos (costos) de respuesta para alternar entre ellas. Después de 140 días de línea base, el haloperidol se evaluó (ip) en un período de 42 días. La droga no impidió que las ratas se adaptaran a los cambios en las contingencias de reforzamiento; las distribuciones de respuestas favorecieron a la palanca de mayor probabilidad de reforzamiento. Con el haloperidol la ley de igualación mostró pendientes más inclinadas, indicando un aumento en la sensibilidad al reforzamiento