Factores de prognóstico do resultado do tratamento de doentes com síndrome de dependência do álcool: estudo de coorte prospectivo de 6 meses

Introdução: Uma das questões fundamentais para as políticas de saúde relacionadas com o tratamento e reabilitação de doentes com dependência de álcool, é identificar factores de prognóstico num curto prazo de tratamento ambulatório, de modo a se poderem optimizar as decisões de tratamento dos doentes. Assim, este estudo teve como objectivo identificar factores de prognóstico na admissão ao tratamento e factores de prognóstico durante o período de tratamento ambulatório. Materiais e métodos: Estudo observacional coorte de doentes com dependência de álcool observados num período de 6 meses de tratamento ambulatório. O estudo consistiu numa amostra de 209 doentes incluídos no estudo de acordo com os critérios do Diagnostic and Statistical Manual of Mental Disorders versão IV, tendo sido recolhida no Centro de Alcoologia do Sul (n=194) e no Hospital Nossa Senhora do Rosário (n=15). 8 médicos psiquiatras destes dois centros de tratamento foram responsáveis pelo tratamento dos doentes. O doente ter um co-responsável que acompanhasse a sua reabilitação e fizesse a supervisão da medicação para controlo do consumo de álcool era condição absolutamente necessária para inclusão do doente no estudo. Como factores de prognóstico foram medidos na admissão ao tratamento factores sócio demográficos, a história de uso de outras substâncias e indicadores de gravidade associados à história de consumo excessivo de álcool. Durante os 6 meses de tratamento foram medidos factores de prognóstico que respeitam os fármacos para controlo do consumo incluindo Dissulfiram e Acamprosato, os factores associados aos aspectos não farmacológicos do tratamento incluindo o número de consultas, os factores associados às características do médico e finalmente os fármacos para tratamento de depressão e ansiedade. As variáveis de resultado medidas no estudo envolveram o tempo até à primeira recaída pesada (variável de interesse primário para o estudo), a abstinência de consumo pesado, a abstinência de qualquer quantidade de álcool, o tempo cumulativo de abstinência acima da média dos doentes, o tempo máximo de recaída superior a 1 dia e o doente ter pelo menos um problema relacionado com o álcool aos 6 meses. Todas as variáveis resultado foram medidas através do calendário auto-reportado pelos doentes e seus co-responsáveis no que respeita os consumos diários Timeline Followback, à excepção da variável ter pelo menos 1 problema relacionado com o álcool aos 6 meses em que foi aplicado o instrumento Alcohol Related Problems Questionnaire. Foi estabelecido uma unidade padrão de consumo de álcool como uma garrafa de cerveja, um copo de vinho ou um cálice de bebida fortificada ou destilada que teriam aproximadamente 10 gramas de álcool, sendo considerado um consumo excessivo pesado de pelo menos 5 destas unidades padrão num dia típico de consumo, ou seja, pelo menos 50 gramas de álcool. Os dados recolhidos e validados foram analisados em Statistical Package for Social Sciences, tendo-se utilizado usuais métodos de estatística descritiva envolvendo tabulação de frequências e tabulação de medidas de tendência central e dispersão. Foram utilizados na análise bivariável entre os factores de prognóstico e as variáveis resultado o teste do Qui quadrado ou exacto de Fisher, o teste de Mann Whitney, o teste Kruskal Wallis, o coeficiente de correlação de Spearman e o coeficiente de concordância Kappa de Cohen. Foi ainda utilizado na análise bivariável a análise de sobrevivência de Kaplan Meier com teste log rank e a análise da área sob a curva ROC. Na análise multivariável foi utilizado a análise de regressão de Cox múltipla com razão de riscos medida pelo Hazard Ratio (HR) e a análise de regressão logística múltipla com razão de riscos medida pelo odds ratio (OR). O nível de significância foi estabelecido em 5%. Resultados: Dos doentes admitidos a tratamento, 84% eram homens, a idade mediana era 41 anos, o consumo mediano de álcool era 192 gramas/dia e a duração mediana de consumo excessivo pesado era 13 anos. Os anos completos de escolaridade em tendência situaram-se abaixo do 9º ano de escolaridade com uma mediana de 6 anos. 61% dos doentes pertenciam a classes sociais média/baixa e baixa. A taxa de Kaplan Meier de recaída em consumo pesado foi de 23% sendo a taxa de recaída em qualquer quantidade de álcool de 54%. O tempo médio cumulativo de abstinência foi 131 dias. Relativamente aos factores de prognóstico que se revelaram estatisticamente significativos após análise de regressão múltipla foram; na admissão ao tratamento, o sexo feminino associado a pior prognóstico de tempo máximo de recaída superior a 1 dia (OR=4,55; p<0,05), o nível sócio económico de graffar médio baixo e baixo associado a piores prognósticos relativamente à abstinência de consumo pesado (OR=0,32; p<0,05), abstinência de qualquer quantidade (OR=0,41; p<0,05) e tempo cumulativo de abstinência acima da média (OR=0,05; p<0,01), a situação profissional de emprego a tempo inteiro e vínculo associado a melhor prognóstico relativamente a menos problemas ligados ao álcool aos 6 meses (OR=0,37; p<0,05), a história de uso de cocaína associado a pior prognóstico relativamente à abstinência de consumo pesado (OR=0,11; 6 p<0,01) e abstinência de qualquer quantidade (OR=0,05; p<0,001), ter mais de 20 anos de consumo excessivo pesado associado a pior prognóstico relativamente à abstinência de qualquer quantidade (OR=0,20; p<0,05), tempo cumulativo de abstinência acima da média (OR=0,05; p<0,05), tempo máximo de recaída superior a 1 dia (OR=8,36; p<0,01) e ter pelo menos 1 problema ligado ao álcool aos 6 meses (OR=7,32; p<0,01), entrar em tratamento com menos tempo de abstinência, digamos até 7 dias sem beber, revelou-se associado a melhor prognóstico nomeadamente no tempo até à primeira recaída em consumo pesado (HR=0,32; p<0,05), mais gravidade da história de consumo indicada pelo doente consumir álcool de manhã e/ou antes do almoço revelou-se associado a melhor prognóstico, nomeadamente na abstinência de qualquer quantidade de álcool (OR=3,01; p<0,05), os doentes com valor de avaliação hepática GGT aumentada face ao limite normal revelaram pior prognóstico ao nível do tempo até à primeira recaída em consumo pesado (HR=2,48; p<0,05), os doentes com pelo menos 5 dos 11 problemas ligados ao álcool questionados no Alcohol Related Problems Questionnaire na admissão, revelaram pior prognóstico nomeadamente no tempo cumulativo de abstinência acima da média dos doentes (OR=0,04; p<0,01). Durante os 6 meses de tratamento, os factores de prognóstico que se revelaram estatisticamente significativos após análise de regressão múltipla foram; a toma de Dissulfiram por um período de pelo menos 120 dias, que se revelou associado a melhor prognóstico relativamente ao tempo cumulativo de abstinência acima da média dos doentes (OR=18,88; p<0,01) e o doente ter pelo menos 1 problema ligado ao álcool aos 6 meses (OR=0,16; p<0,001), o doente ter tomado Dissulfiram por um período inferior a 120 dias, que se revelou associado a pior prognóstico em todas as variáveis de resultado, ou sejam, o tempo até à primeira recaída em consumo pesado (HR=15,00; p<0,001), a abstinência de consumo pesado (OR=0,062; p<0,001), a abstinência de qualquer quantidade (OR=0,05; p<0,001), o tempo cumulativo de abstinência acima da média dos doentes (OR=0,08; p<0,05), o tempo máximo de recaída superior a 1 dia (OR=15,60; p<0,01) e ter pelo menos 1 problema ligado ao álcool aos 6 meses (OR=5,25; p<0,05), os doentes com indicação para Acamprosato tiveram pior prognóstico ao nível do tempo até à primeira recaída em consumo pesado (HR=2,60; p<0,05), os doentes que realizaram pelo menos 4 das 7 consultas previstas para os 6 meses tiveram melhor prognóstico relativamente à abstinência em consumo pesado (OR=9,10; p<0,001), abstinência de qualquer quantidade (OR=5,56; p<0,001), tempo cumulativo de abstinência acima da média (OR=177,50; p<0,001) e o doente ter pelo menos 1 problema ligado ao álcool aos 6 meses (OR=0,07; p<0,001), o doente ter pelo menos 2,5 de média nas fases da sua consulta (podendo variar as fases entre 1 e 4) têm melhor prognóstico ao nível do tempo até à primeira recaída em consumo pesado (HR=0,28; p<0,01), abstinência de consumo pesado (OR= 2,80; p<0,05), abstinência de qualquer quantidade (OR=3,24; p<0,05) e tempo máximo de recaída superior a 1 dia (OR=0,21; p<0,01), os doentes com indicação para ansiolíticos sejam eles Benzodiazepinas ou Buspirona tiveram pior prognóstico no tempo até à primeira recaída em consumo pesado (HR=2,12; p<0,05). Conclusões: em termos de políticas de saúde, este estudo permite concluir que durante o tratamento ambulatório devem ser valorizados o recurso farmacológico Dissulfiram com tempo de toma nunca inferior a 120 dias, a realização de um maior número de consultas previsto para o doente e a utilização de mais de duas fases nas consultas. Este estudo também revela que os prestadores de tratamento devem ter atenção aos doentes com indicação para a toma de ansiolíticos. Relativamente aos factores relevantes na admissão ao tratamento ambulatório, este estudo permite-nos concluir que deve haver maior preocupação dos prestadores de tratamento relativamente às mulheres alcoólicas, aos doentes com nível socioeconómico mais baixo e doentes sem emprego a tempo inteiro nem vínculo, pois são factores que se revelaram associados a pior prognóstico. Também, os prestadores de tratamento devem ter em especial atenção a história de consumo de outras substâncias, nomeadamente o consumo de cocaína, pois revelou-se associado a pior prognóstico. Em relação às variáveis da gravidade do consumo de álcool, os prestadores de tratamento devem tomar especial atenção que o prognóstico piora para os doentes que consomem álcool de modo excessivo pesado à mais de 20 anos, que tenham a avaliação laboratorial do GGT aumentada em relação ao normal e que revelem mais problemas ligados ao álcool no questionário Alcohol Related Problems Questionnaire. Este estudo também prova que se deve motivar o doente a iniciar o tratamento temporalmente o mais perto possível do início da abstinência. Mais concretamente, os doentes que iniciaram o tratamento até uma semana desde o início da abstinência tiveram melhor prognóstico. Curiosamente ainda uma informação útil para os prestadores de tratamento é que os doentes que consomem álcool pela manhã e/ou antes do almoço parecem estar mais motivados para recuperarem, tendo-se revelado um factor de bom prognóstico.Summary: Prognostic factors of outpatient treatment on alcohol dependent patients: cohort study with six months treatment follow upIntroduction: One important research question for healthpolitics concerning treatment and rehabilitation of alcoholic patients is to identify prognostic factors in a short treatment period.With this rational we set the general study objective as the identification of the most important prognostic factors in the admission to outpatient treatment as well asduring the outpatient treatment period. Methods: Observational cohort study of alcohol dependent patients in 6 months outpatient treatment (follow up period). The sample size was n=209 alcohol dependent patients selected according to Diagnostic and Statistical Manual of Mental DisordersIV in two hospital centres; Centro de Alcoologia do Sul(n=194) and Hospital Nossa Senhora do Rosário(n=15). 8 medical doctors from these two centreswere responsible for the patient treatment. Co-responsible participation on patient treatment and supervision of medication was a necessary condition for inclusion of the patient in the treatment. The prognostic factors observed on treatment admission were socio demographic factors, use of other drugs and severity indicators of alcohol consumption during the course of disease. During the 6 months treatment follow up we observed prognostic factors concerning medication for prevention of alcohol relapse including Disulfiram and Acamprosate, non pharmacological treatment factors as the number of sessions with the psychotherapist, therapist features and medication for depression and anxiety. The outcome variables were the time to first heavy relapse (primary variable), abstinence ofheavy alcohol consumption, abstinence of alcoholconsumption, cumulative abstinence duration above the mean, maximum relapse duration above one relapse day, patient with one or more alcohol problems at the end of six months follow up. The outcome variables that involve relapse, abstinence and alcohol quantity were measured with the Timeline Followbackauto reported every treatment day by the patient and co-responsible. Patient with one or more alcohol problems at the end of six months follow up was measured with the Alcohol Related Problems Questionnaire. We assumed that one standard unity of alcohol with 10 grams was a bottle of beer or a glass of wine or a little cup or shot of liquor or distilled alcohol beverage. Heavy alcohol relapse was defined as the consumption of 50 grams or more in one relapse day. The data was analyzed with the Statistical Package for Social Sciencesand the data analysis involved tabulation of descriptive statisticsas central and dispersion measures and counts and frequencies. The bivariable analysis between prognostic factors and outcome variables was done by Chi squaretest or Fisher exact test, Mann Whitney test and Kruskal Wallis test, Spearman’scorrelation, Kappa’sagreement of Cohen, Survival Kaplan Meier analysis with log rank test and area under the ROC curve analysis. The multivariable analysis between prognostic factors and outcome variables was done by multiple Cox regression with risk ratio measured by the hazard ratio (HR) and multiple logistic regression with risk ratio measured by the odds ratio (OR). The significance level was established as 5%.Results: On admission patients were 84% males, with 41 years median age, the median alcohol consumption in a typical day was 192 grams, with 13 years median time duration on heavy alcohol consumption in the course of the disease.Median education was 6 years with 61% of the patients with lower socio economic levels. The Kaplan Meier heavy relapse rate was 23% and the relapse rate in any alcohol quantity was 54%. The mean of the cumulative abstinence duration was 131 days. With multiple regression methods we found on treatment admission that female gender was a prognostic factor of worse outcome regarding maximum relapse duration above one relapse day (OR=4,55; p<0,05),the lower socio economic levels were prognostic factors of worse outcome regarding abstinence of heavy alcohol consumption (OR=0,32; p<0,05),abstinence of alcoholconsumption (OR=0,41; p<0,05), cumulative abstinence duration above the mean (OR=0,05; p<0,01),having a full time job with professional contract was a prognostic factor of better outcome regarding patient with one or more alcohol problems at the end of six months follow up (OR=0,37; p<0,05), cocaine use was a prognostic factor of worse outcome regarding abstinence of heavy alcohol consumption (OR=0,11; p<0,01)and abstinence of alcohol consumption (OR=0,05; p<0,001),more than 20 years of excessive alcohol consumption was a prognostic factor of worse outcome regarding abstinence of alcohol consumption (OR=0,20; p<0,05),cumulative abstinence duration abovethe mean (OR=0,05; p<0,05),maximum relapse duration above one relapse day (OR=8,36; p<0,01)and patient with one or more alcohol problems at the end of six months follow up (OR=7,32; p<0,01),patients with shorter abstinence time before treatment, say until 7 days, were more likely to have better outcome regarding time to first heavy relapse (HR=0,32; p<0,05),more alcohol severity indicated by morning or before lunch consumption was a prognostic factor of better outcome regarding abstinence of alcohol consumption (OR=3,01; p<0,05),more liver severity indicated by GGT values above de normal cut off was a prognostic factor of worse outcome regarding time to first heavy relapse (HR=2,48; p<0,05), patients with five or more alcohol related problems on Alcohol Related Problems Questionnairein admission showed worse outcome regarding cumulative abstinence duration above the mean (OR=0,04; p<0,01). During the 6 treatment months we found withmultiple regression methods that taking Disulfiram at least for 120 days was a prognostic factor of better outcome regarding cumulative abstinence duration above the mean (OR=18,88; p<0,01) and patient having one or more alcohol problems at the end of six months follow up (OR=0,16; p<0,001),taking Disulfiram for a periodlower than 120 days was a prognostic factor of worse outcome regarding all the 6 outcome variables; time to first heavy relapse (HR=15,00; p<0,001),abstinence of heavy alcohol consumption (OR=0,062; p<0,001), abstinence of alcohol consumption (OR=0,05; p<0,001), cumulative abstinence duration above the mean (OR=0,08; p<0,05),maximum relapse duration above one relapse day (OR=15,60; p<0,01)and patient having one or more alcohol problems at the end of six months follow up (OR=5,25; p<0,05), Acamprosate prescription was a prognostic factor of worse outcome regarding time to first heavy relapse (HR=2,60; p<0,05),patients with 4 or more of the 7 established therapy sessions had better outcome regarding abstinence of heavy alcohol consumption (OR=9,10; p<0,001),abstinence of alcohol consumption (OR=5,56; p<0,001), cumulative abstinence duration above the mean (OR=177,50; p<0,001)and patient with one or more alcohol problems at the end of six months follow up (OR=0,07; p<0,001),patients with a mean of 2,5 or more phases in a therapy session (with the phases between 1 and 4) had better outcome regarding time to first heavy relapse (HR=0,28; p<0,01), abstinence of heavy alcohol consumption (OR= 2,80; p<0,05), abstinence of alcohol consumption (OR=3,24; p<0,05), and maximum relapse duration above one relapse day (OR=0,21; p<0,01), the prescription of anxiety medication (Benzodiazepines or Buspirone) was a prognostic factor of worse outcome regarding time to first heavy relapse (HR=2,12; p<0,05).Conclusions: Concerning health politicson rehabilitation of alcohol dependent patients this epidemiologic research allows us to conclude that during short outpatient treatment period, say 6 months, Disulfiram is effective for periods of at least 120 days. The biggeradherence to therapy sessions and more than two phases involvingthe co-responsible in the therapy sessions are prognostic factors of better rehabilitation. This study allows us to conclude that moreattention must be made regarding patients with indication for anxiety medication.Considering prognostic factors on admission to outpatient treatment this research allows us to conclude that being women, having a lower socio economic level, and not having a full time job are prognostic factorsof worse outcome. The history of consumption of other drugs namely cocaine revealed worse prognosisas well. Concerning the severity of alcohol consumption, patients with heavy excessive drinking for more than 20 years are more likely to have worse prognosis, as well as patients with bigger GGT values (say above the normal cut off point) and patients with 5 or more alcohol related problems on Alcohol Related Problems Questionnaire. To have a better prognosisthis studyalso provesthat is very important to motivate the patient to start the outpatient treatmentas soon as possible after abstinence start, say until 7 days. Not so expected but even relevant was the better prognosisof patients with more alcohol severity indicated by morning and before lunch drinking. This result suggestthat these patients seem to be more motivated for treatment

COVID-19-related adolescent mortality and morbidity in nineteen European countries

Funding Information: Open access funding provided by FCT|FCCN (b-on). The present publication was funded by Fundação para a Ciência e Tecnologia, IP national support through CHRC (UIDP/04923/2020). FCT e a Unidade de I&D CHRC—Comprehensive Health Research Centre (UI/BD/150908/2021). GHTM (UID/Multi/04413/2019) is funded by the Portuguese Science Foundation (FCT). Publisher Copyright: © 2023, The Author(s).Prior to the COVID-19 pandemic, adolescents in most countries experienced a syndemic of malnutrition, obesity, deprivation, mental health problems, inequalities, and the effects of climate change. Today, other factors have added to this burden during the pandemic, and it is important to have an updated reflection. We aimed to assess the risk and protective factors for COVID-19-related adolescent mortality and morbidity in the European region. Three double models were fitted to analyze the relationship between different factors with the number of diagnosed cases and deaths. The 1a and 1b use a multiple Poisson regression. The 2a and 2b are optimized models that use the same variables as prior models but with backward selection with a p value < 0.05 as the limit. Finally, the 3a and 3b models (backward stepwise multivariable Poisson regression) include the variable “fully vaccinated.” All models used the at-risk population (15–19 years or total population) as a regression covariate (offset). Increased access to quality healthcare (IRR 0.68; CI 0.55–0.84), increased private sector involvement (IRR 0.86; CI 0.82–0.90), Gini coefficient (IRR 0.93; CI 0.88–0.99), and full vaccination (IRR 0.94; CI 0.90–0.99) represent protective factors of COVID-19 mortality in this population. Additionally, a positive association between pollution and mortality was found. Conclusion: Being fully vaccinated and having access to quality medical care are protective factors against COVID-19 mortality in this age group. Interestingly, the more the pollution, the greater the risk of dying from COVID-19. We stress the great importance of coordination between the public and private sectors to address crises such as the current one. What is Known: • Compared to other age groups, adolescents have been little studied, and most studies focused on mental health during the COVID-19 pandemic. What is New: • In this study, we show how in 19 European countries, different factors interact, such as socio-demographic, environmental, health system, and control measures with morbidity and mortality by COVID-19, in a very little studied age group as teenagers.publishersversioninpres

Physical distancing and mental well-being in youth population of Portugal and Brazil during the COVID-19 pandemic

Funding Information: This paper was made possible with the scholarship from FCT and to the Unidade de I&D CHRC – Comprehensive Health Research Centre (UI/BD/150908/2021). Also to CAPES (Code 001) and CNPQ (Research Productivity Scholarship Process 304483/2018-4). The databases are anonymous, guaranteeing data confidentiality. Funding Information: Fundação para a ciência e tecnologia (FCT) and the Unidade de I&D CHRC – Comprehensive Health Research Centre (UI/BD/150908/2021). Also to CAPES (Code 001) and CNPQ (Research Productivity Scholarship Process 304483/2018-4) Publisher Copyright: © 2022Background: The COVID-19 pandemic may affect youth's physical and mental well-being, partially because of the countries' rules to contain the virus from spreading. However, there is still uncertainty about the impact of physical distancing on youth's mental health. We aimed to estimate the prevalence of feeling agitated, anxious, down, sad, or low mood (FNF) due to physical distance measures and verify which factors are associated with young Portuguese and Brazilian people. Methods: We used cross-sectional data from the instrument "COVID-19 Barometer: Social Opinion"in Portugal (March 2020 and September 2021) and from "COVID-19 Social Thermometer"in Brazil (August 2020 to April 2021); these surveys included data regarding the health and socioeconomic impact on the population. The health and sociodemographic variables of the two countries were summarized as absolute and relative frequencies. A multivariable logistic regression model was fit by country to estimate the relation between FNF and selected variables of interest. Results: Approximately 36% of the sample studied reported anxiety, agitation, sadness, or low mood almost every day in Portugal and 52% in Brazil due to physical distancing. In Portugal, having more than two comorbidities represented a greater chance of experiencing FNF every day or almost every day (odds ratio [OR] = 1.51 [CI: 1.22-1.87]) than those without comorbidities. In contrast, having a university education level represented a protector factor (OR = 0.76 [CI: 0.67-0.88]). In Brazil, being unemployed increased the chance of FNF compared to students (OR = 11.2). Conclusions: Physical distancing measures have impacted the mental well-being of the young population in Portugal and Brazil. The countries must make a quick effort to attend to and protect young people's well-being and mental health in the changing context of the current pandemic.publishersversioninpres

Children and Adolescents during the COVID-19 Pandemic: Analysis of Some Protection Aspects of 10 Latin American and Caribbean Countries

Background: Latin America has registered cases in children under 14 years of age, which seem few compared to older age groups but are relevant since the child and youth population have been indirectly receiving the most decisive impact of the pandemic. Ensuring the most significant protection for this age group is essential. Methods: This is an ecological study of 10 Latin American and the Caribbean countries to study protecting children and adolescents during the COVID-19 pandemic. Using the information from UNICEF, a coverage analysis was done, and a new variable score was proposed. Also, a multiple linear regression model was tailored to evaluate the relationship between confirmed cases by 100k of COVID-19 (0–14 year population) and the performance of the countries and some key indicators. Results: A strong and statistically significant correlation (r = 0.79; p value 0.005) between the increased coverage of child helplines and a greater number of school closures. Relationship of confirmed cases by COVID-19 and stringency index with a coef B = −2163.6, [CI −3122.1; −1205.1]; p value = 0.010. Cases and healthcare access with a coef B = −17459.7, [CI −25630.1; −9289.5]. Conclusions: Experts say other pandemics will come, and this emergency must be turned into an opportunity. It is vital to strengthen protection programs for the population, especially vulnerable people, such as children and young people. Resum

Clinical information and its relationship with the quality of life of patients with head and neck cancer= La información clínica y su relación con la calidad de vida en pacientes con cáncer de cabeza y cuello

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