Autolesiones y conducta suicida en niños y adolescentes. Lo que la pandemia nos ha desvelado / Self-injury and suicidal behavior in children and youth population: Learning from the pandemic

Introducción: Las conductas suicidas y las autolesiones están aumentando en niños y adolescentes. Las autolesiones no suicidas suponen un método disfuncional de regulación emocional. Es importante aprender a distinguirlas de las conductas suicidas. Material y métodos: Revisión narrativa de la situación actual sobre suicidio y autolesiones en España. Estudio descriptivo conductas suicidas en urgencias pediátricas. Resultados: En un estudio multicéntrico de la Sociedad Española de Urgencias Pediátricas (SEUP) se analizaron las consultas por salud mental (marzo-2019 a marzo-2020 y marzo-2020 a marzo-2021), encontrándose un aumento del 122% del diagnóstico «intoxicación no accidental por fármacos» y del 56% en «suicidio/intento de suicidio/ideación autolítica». En otro análisis prospectivo, se registraron 281 tentativas, siendo el perfil de paciente: sexo femenino (90,1%), 14,8 años, el 34,9% sin diagnóstico psiquiátrico previo, el 57,7% con conductas suicidas anteriormente. La presencia de trastornos psiquiátricos, en especial de depresión, y de intentos previos, son los factores de riesgo más implicados en la conducta suicida, aunque existen otros de índole diversa (familiares, personales o sociales). Los pediatras deben estar formados para atender consultas sobre suicidio, y adquirir habilidades para realizar una entrevista con actitud de apoyo y empatía. En España los planes de prevención de suicidio son heterogéneos y no existe un plan nacional de prevención del suicidio. Conclusiones: Se deben reforzar los recursos de atención primaria, hospitalaria y de salud mental de la población pediátrica. Los centros escolares y la formación en psiquiatría infantil y adolescente para médicos y enfermeras resultan cruciales en la prevención del suicidio en niños y adolescentes. (AU)

Introduction: Suicidal behavior and self-harm are increasing in children and adolescents. Non-suicidal self-harm are a dysfunctional method of emotional regulation, and it must be distinguished from suicidal behaviors. Methods: Narrative review of the current situation on suicide and self-harm in Spain. Descriptive study of suicidal behaviors in pediatric emergencies. Results: Mental health consultations were analyzed (March-2019 to March-2020 and March-2020 to March-2021) in a multicentric study of the Spanish Society of Pediatric Emergencies (SEUP), finding a 122% increase of the diagnosis of «non-accidental drug intoxication» and 56% of «suicide/suicide attempt/suicidal ideation». In another prospective analysis, 281 attempts were recorded, with the patient profile being: female (90.1%), 14.8 years old, 34.9% without previous psychiatric diagnosis; 57.7% with previous suicidal behavior. The presence of psychiatric disorders, especially depression, and previous attempts, are the best-known risk factors for suicidal behavior, although other factors are involved (family, personal or social). Pediatricians should be trained to deal with questions about suicide and acquire the skills to conduct an interview with a supportive and empathetic attitude. In Spain, suicide prevention plans are heterogeneous among communities, and there is not a unified national suicide prevention plan. Conclusions: Primary, hospital and mental health care resources for pediatric population should be strengthened to prevent suicidal behaviors. Specific training for school staff, and child and adolescent psychiatry training for pediatricians and nurses are crucial in the prevention of suicide in children and adolescent population. (AU)

Self-injury and suicidal behavior in children and youth population: Learning from the pandemic.

INTRODUCTION: Suicidal behaviour and self-harm are increasing in children and adolescents. Non-suicidal self-harm are a dysfunctional method of emotional regulation, and it must be distinguished from suicidal behaviours. METHODS: Narrative review of the current situation on suicide and self-harm in Spain. Descriptive study of suicidal behaviours in paediatric emergencies. RESULTS: Mental health consultations were analysed (March-2019 to March-2020 and March-2020 to March-2021) in a multicentric study of the SEUP (Spanish Society of Pediatric Emergencies), finding a 122 % increase of the diagnosis of "non-accidental drug intoxication" and 56 % of "suicide/suicide attempt/suicidal ideation". In another prospective analysis, 281 attempts were recorded, with the patient profile being: female (90.1 %), 14.8 years old, 34.9 % without previous psychiatric diagnosis; 57.7% with previous suicidal behaviour. The presence of psychiatric disorders, especially depression, and previous attempts, are the best-known risk factors for suicidal behaviour, although other factors are involved (family, personal or social). Pediatricians should be trained to deal with questions about suicide and acquire the skills to conduct an interview with a supportive and empathetic attitude. In Spain, suicide prevention plans are heterogeneous among communities, and there is not a unified national suicide prevention plan. CONCLUSIONS: Primary, hospital and mental health care resources for paediatric population should be strengthened to prevent suicidal behaviours. Specific training for school staff, and child and adolescent psychiatry training for paediatricians and nurses are crucial in the prevention of suicide in children and adolescent population.

Overcoming Stigma and Discrimination: Challenges for Reinsertion of Gang Members in Developing Countries.

This article is an effort to better understand the discrimination mechanisms that ex-gang members perceive upon leaving the gang and seeking to reinsert themselves into a society marked by high levels of violence and inequality, as in Central America. Based on 24 in-depth interviews with former members of MS-13, the 18th Street gang, and other street gangs in El Salvador, this article analyzes the different mechanisms of discrimination perceived by respondents as a result of the stigma of past gang membership. This article also documents how these perceptions of discrimination can affect individuals who are searching for employment opportunities and seeking to reinsert themselves into society.

The status of support for cannabis regulation in Uruguay 4 years after reform: Evidence from public opinion surveys.

INTRODUCTION AND AIMS: The objective of this study was to measure the public support for marijuana legalisation in Uruguay, both overall and in its provisions, in nearly 4 years after its implementation. DESIGN AND METHODS: Three separate cross-national surveys were conducted in early 2014, late 2015 and mid-2017 with national representative samples of adults. The first study was carried out during the initial months of implementation of the law and used face-to-face interviews (N = 1490); the second survey was conducted using a computer-assisted telephone interviewing system (N = 703); and the third study (N = 1515), using face-to-face interviews, was completed just before the implementation of pharmacy sales. RESULTS: About 60.7% of respondents in 2014 were against marijuana legalisation; in 2017, 54.1% remained opposed to the marijuana law. In 2015, half of the people interviewed (49.9%) supported access to marijuana through self-cultivation, while 38.6% favoured the provision of cannabis clubs and 33.1% agreed with the pharmacy retail provision. Support for medical cannabis was high in 2015, with 74.5% favouring it. DISCUSSION AND CONCLUSIONS: This study shows a change in the public opinion toward legalisation of marijuana although most people still remain opposed to the law. However, the data do not provide indication of a significant change in its use. Results suggest that opposition to legalisation may be focused on the pharmacy retail provision.

Cannabis clubs in Uruguay: The challenges of regulation.

BACKGROUND: The Uruguayan Cannabis Clubs (UCCs) constitute one of three ways to obtain cannabis under the new cannabis regulation laws. These organizations, formed by up to 45 adults and with a legal limit to grow up to 99 plants, appear to provide a safe method of procuring cannabis in a country that is trying to regulate aspects of cannabis production and distribution. This article describes the operations of the UCCs and the challenges these organizations face. METHODS: The paper draws on data from in-depth interviews conducted with representatives of UCCs and conversations with government officials conducted between March and August of 2015. We collected information about membership, facilities and forms of organization, methods of cannabis cultivation and distribution, and activities within the community. RESULTS: This article describes how UCCs are formed, their resources, rules for cannabis production and distribution; and their relationships with government institutions and the community. Data show that UCCs face four main challenges: compliance with the extant regulation, financial sustainability, tolerance from the community, and collective action dilemmas. CONCLUSIONS: Organizational challenges are as frequent in Uruguay as in other country where cannabis clubs exist, however this paper shows that in order to be sustainable, UCCs need to address issues of collective action, financial sustainability, and possible competition with cannabis distribution via pharmacies that could diminish membership. In the case of Uruguay, UCCs are part of a regulation effort, though they may not be preferred over other legal alternatives already in place.

Cannabis consumption patterns among frequent consumers in Uruguay.

BACKGROUND: In 2013, Uruguay became the first country to fully regulate the cannabis market, which now operates under state control. Cannabis can be legally acquired in three ways: growing it for personal use (self-cultivation), cannabis club membership, and from pharmacies (not yet implemented). Users must be entered into a confidential official registry to gain access. METHODS: This article presents findings of a Respondent Driven Sample survey of 294 high-frequency cannabis consumers in the Montevideo metropolitan area. RESULTS: Frequent consumers resort to more than one method for acquiring cannabis, with illegal means still predominating after 1 year of the new regulation law. Cannabis users overwhelmingly support the current regulation, but many of them are reluctant to register. CONCLUSIONS: Some of the attitudes and behaviors of the high-frequency consumers pose a challenge to the success of the cannabis law. Individuals relying on more than one method of access defy the single access clause, a prerequisite for legal use, while the maximum amount of cannabis individuals can access monthly seems too high even for most frequent consumers, which might promote the emergence of a grey market. Reluctance to register among a significant proportion of high-frequency consumers raises doubts about the law's ability to achieve its stated objectives.

Lack of appetite in haemodialysis patients--associations with patient characteristics, indicators of nutritional status and outcomes in the international DOPPS.

BACKGROUND: Identification of haemodialysis patients with problems related to lack of appetite should help prevent adverse outcomes. We studied whether a single question about being bothered by lack of appetite within the prior 4 weeks is related to nutritional status, inflammation and risks of death and hospitalization. Additionally, we assessed associations of lack of appetite with depression, dialysis dose and length of haemodialysis. METHODS: This study is an analysis of baseline and longitudinal data from 14 406 patients enrolled in the Dialysis Outcomes and Practice Pattern Study. Cox regression was used to assess whether the degree (not, somewhat, moderately, very much, extremely) that patients were bothered by lack of appetite is an independent predictor of death and hospitalization. Logistic regression was used to identify baseline characteristics associated with being bothered by lack of appetite. RESULTS: The risk of death was more than 2-fold higher [relative risk (RR) = 2.23; 95% confidence interval (CI) = 1.90-2.62] and the risk of hospitalization 33% higher (RR = 1.33; 95% CI = 1.19-1.48) among patients extremely bothered, compared with not bothered, by lack of appetite. These associations followed a dose-response fashion and remained statistically significant after adjustments for 14 comorbidities. Depression, shorter haemodialysis session, hypoalbuminaemia, lower concentration of serum creatinine and normalized protein catabolic rate, lower body mass index and higher leucocyte and neutrophil counts were independently associated with higher odds of being bothered by lack of appetite. CONCLUSIONS: The data suggest that a single question about lack of appetite helps identify haemodialysis patients with poorer nutritional status, inflammation, depression and higher risks of hospitalization and death. The study calls attention to a possible beneficial effect of longer haemodialysis on appetite.

Diuretic use, residual renal function, and mortality among hemodialysis patients in the Dialysis Outcomes and Practice Pattern Study (DOPPS).

BACKGROUND: Information about residual renal function (RRF) and outcomes associated with practices of diuretic use in patients with end-stage renal disease is not available worldwide. METHODS: Diuretic use was investigated in 16,420 hemodialysis patients from the Dialysis Outcomes and Practice Patterns Study, a prospective observational study of hemodialysis patients selected from nationally representative facilities on 3 continents. Logistic regressions were used to investigate associations between diuretic use and patient characteristics. Outcomes of interdialytic weight gain, increased serum potassium and phosphorus levels, and odds of retaining RRF after 1 year were investigated. Cox regression was used to analyze the association between mortality and diuretic use. RESULTS: Facility diuretic use varied substantially from 0% to 83.9% of patients. Diuretic use decreased sharply after the start of dialysis therapy. Loop diuretic use ranged from 9.2% in the United States to 21.3% in Europe, whereas use within 90 days of starting dialysis therapy ranged from 25.0% in the United States to 47.6% in Japan. Diuretic use was associated with lower interdialytic weight gain and lower odds of hyperkalemia (potassium > 6.0 mmol/L). Patients with RRF on diuretic therapy had almost twice the odds of retaining RRF after 1 year in the study versus patients not on diuretic therapy. Patients administered diuretics had a 7% lower all-cause mortality risk (P = 0.12) and 14% lower cardiac-specific mortality risk (P = 0.03) versus patients not administered diuretics. CONCLUSION: Variation exists in facility practices of diuretic use. In patients with RRF, there may be benefit associated with continuing diuretic use rather than automatically discontinuing diuretic therapy at dialysis initiation.

Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS.

BACKGROUND: Worldwide statistics on practice patterns regarding "do not resuscitate" (DNR) orders and patient withdrawal from hemodialysis have not been uniformly collected or analyzed. METHODS: Using data concerning adult hemodialysis patients randomly selected from 308 representative dialysis facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States participating in the Dialysis Outcomes and Practice Patterns Study, DNR orders were tabulated at study entry from a prevalent cross-section of patients (N = 8615), using multivariate logistic regression to investigate characteristics associated with DNR status, Cox models to identify risk factors for withdrawal from hemodialysis, and scores from the mental component summary (MCS) and physical component summary (PCS) of the SF-36 to assess health-related quality of life. RESULTS: The United States had the highest prevalence of DNR orders (7.5%) and rate of withdrawal from hemodialysis (3.5 per 100 patient-years). Significant and independent associations with higher odds ratio (OR) of DNR were observed for older age (OR 1.16 per 10 years higher, P = 0.03) and nursing home residence (OR 2.34, P = 0.003), and with higher relative risk (RR) of withdrawal from dialysis (RR 2.38, P < 0.001). Patients who withdrew from hemodialysis died within a mean of 7.8 days and a median of 6.0 days. CONCLUSION: The higher prevalence of DNR and rate of withdrawal from hemodialysis in the United States are consistent with its greater legal and cultural emphasis on patient autonomy. By showing characteristics associated with these outcomes, this study contributes to our understanding of why hemodialysis patients request DNR or withdraw from treatment.

Anemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

BACKGROUND: Anemia is common in hemodialysis (HD) patients. METHODS: Data collected from nationally representative samples of HD patients (n = 11,041) in 2002 to 2003 were used to describe current anemia management for long-term HD patients at 309 dialysis units in 12 countries. Analyses of associations and outcomes were adjusted for demographics, 15 comorbid classes, laboratory values, country, and facility clustering. RESULTS: For patients on dialysis therapy for longer than 180 days, 23% to 77% had a hemoglobin (Hgb) concentration less than 11 g/dL (<110 g/L), depending on country; 83% to 94% were administered erythropoietin (EPO). Mean Hgb levels were 12 g/dL (120 g/L) in Sweden; 11.6 to 11.7 g/dL (116 to 117 g/L) in the United States, Spain, Belgium, and Canada; 11.1 to 11.5 g/dL (111 to 115 g/L) in Australia/New Zealand, Germany, Italy, the United Kingdom, and France; and 10.1 g/dL (101 g/L) in Japan. Hgb levels were substantially lower for new patients with end-stage renal disease, and EPO use before ESRD ranged from 27% (United States) to 65% (Sweden). By patient, EPO use significantly declined with greater Hgb concentration (adjusted odds ratio, 0.61 per 1-g/dL [10-g/L] greater Hgb level; P < 0.0001), as did EPO dosage. Case-mix-adjusted mortality and hospitalization risk declined by 5% and 6% per 1-g/dL greater patient baseline Hgb level (P < or = 0.003 each), respectively. Furthermore, patient mortality and hospitalization risks were 10% to 12% lower for every 1-g/dL greater facility mean Hgb level. Patients were significantly more likely to have Hgb levels of 11 g/dL or greater (> or =110 g/L) if they were older; were men; had polycystic kidney disease; had greater albumin, transferrin saturation, or calcium levels; were not dialyzing with a catheter; or had lower ferritin levels. Facilities with greater intravenous iron use showed significantly greater facility mean Hgb concentrations. Mean EPO dose varied from 5,297 (Japan) to 17,360 U/wk (United States). Greater country mean EPO doses were significantly associated with greater country mean Hgb concentrations. Several patient characteristics were associated with greater EPO doses. Even in some countries with high intravenous iron use, 35% to 40% of patients had a transferrin saturation less than 20% (below guidelines). CONCLUSION: These findings indicate large international variations in anemia management, with significant improvements during the last 5 years, although many patients remain below current anemia guidelines, suggesting large and specific opportunities for improvement.

La victimización por violencia urbana: niveles y factores asociados en ciudades de América Latina y España / Being a victim of urban violence: its likelihood and its associated variables in cities of Latin America and Spain

En este artículo se comparan los niveles de victimización por diversas causas y se identifican los factores asociados con ella en ocho ciudades de América Latina y España. Con este propósito se utilizaron los datos del estudio multicéntrico ACTIVA, que se realizó en 1996 bajo la coordinación de la Organización Panamericana de la Salud. La muestra estudiada estuvo constituida por 10.821 personas, repartidas entre las ciudades de Salvador de Bahia y Rio de Janeiro, Brasil; Cali, Colombia; Caracas, Venezuela; Madrid, España; San José, Costa Rica; San Salvador, El Salvador y Santiago, Chile, que representan a la población de cada ciudad entre los 18 y 70 años de edad. Los resultados revelan que los niveles de victimización por diversos tipos de violencia son diferentes en cada ciudad y que las variables asociadas con la victimización con más frecuencia en las ciudades, aunque no en todas, son el sexo, la edad y el consumo de alcohol

El impacto psicosocial de la violencia en San Salvador / The psychosocial impact of violence in San Salvador

En este estudio se busca lograr dos objetivos: primero, describir los niveles de victimización de la población salvadoreña a causa de la violencia delictiva y el tipo de población más afectada por ella; segundo, averiguar si estos niveles de victimización están relacionados con la presencia de normas, actitudes y comportamientos que favorecen la aparición de la violencia. Para ello se utilizaron los datos del proyecto ACTIVA de El Salvador, que fue realizado por el Instituto Universitario de Opinión Pública entre los meses de octubre y noviembre de 1996 con una muestra de 1.290 entrevistas personales, presuntamente representativa de las personas entre los 18 y 70 años de edad que residen en el Area Metropolitana de San Salvador. La muestra se obtuvo mediante un muestreo probabilístico y multietápico. Los resultados revelan que el nivel de victimización por la violencia es bastante alto en San Salvador y que afecta sobre todo a los hombres y a los jóvenes, y sugieren que las personas que han sido víctimas de agresiones graves suelen mostrar con más frecuencia que el resto normas de justificación y aprobación del uso de la violencia, inclinación por el uso de armas, y conductas de agresión hacia otras personas

La victimización por violencia urbana : niveles y factores asociados en ciudades de América Latina y España / Being a victim of urban violence : its likelihood and its associated variables in cities of Latin America and Spain

En este artículo se comparan los niveles de victimización por diversas causas y se identifican los factores asociados con ella en ocho ciudades de América Latina y España. Con este propósito se utilizaron los datos del estudio multicéntrico ACTIVA, que se realizó en 1996 bajo la coordinación de la Organización Panamericana de la Salud. La muestra estudiada estuvo constituida por 10.821 personas, repartidas entre las ciudades de Salvador de Bahia y Rio de Janeiro, Brasil; Cali, Colombia; Caracas, Venezuela; Madrid, España; San José, Costa Rica; San Salvador, El Salvador y Santiago, Chile, que representan a la población de cada ciudad entre los 18 y 70 años de edad. Los resultados revelan que los niveles de victimización por diversos tipos de violencia son diferentes en cada ciudad y que las variables asociadas con la victimización con más frecuencia en las ciudades, aunque no en todas, son el sexo, la edad y el consumo de alcohol

El impacto psicosocial de la violencia en San Salvador / The psychosocial impact of violence in San Salvador

En este estudio se busca lograr dos objetivos: primero, describir los niveles de victimización de la población salvadoreña a causa de la violencia delictiva y el tipo de población más afectada por ella; segundo, averiguar si estos niveles de victimización están relacionados con la presencia de normas, actitudes y comportamientos que favorecen la aparición de la violencia. Para ello se utilizaron los datos del proyecto ACTIVA de El Salvador, que fue realizado por el Instituto Universitario de Opinión Pública entre los meses de octubre y noviembre de 1996 con una muestra de 1.290 entrevistas personales, presuntamente representativa de las personas entre los 18 y 70 años de edad que residen en el Area Metropolitana de San Salvador. La muestra se obtuvo mediante un muestreo probabilístico y multietápico. Los resultados revelan que el nivel de victimización por la violencia es bastante alto en San Salvador y que afecta sobre todo a los hombres y a los jóvenes, y sugieren que las personas que han sido víctimas de agresiones graves suelen mostrar con más frecuencia que el resto normas de justificación y aprobación del uso de la violencia, inclinación por el uso de armas, y conductas de agresión hacia otras personas