Características clínico-epidemiológicas de COVID-19 en pacientes de la comunidad y del Hospital Regional Lambayeque, Perú

Introducción: Desde el inicio del brote de COVID-19 se han descrito diferencias entre las características clínicas, la evolución y el pronóstico de los pacientes de distintas localidades del Perú y del mundo. Objetivo: Determinar las características clínicas y epidemiológicas de la COVID-19 en pacientes de la comunidad y del Hospital Regional Lambayeque. Métodos: Se realizó un estudio de enfoque cuantitativo, nivel relacional y diseño observacional con datos secundarios. Se empleó la técnica de la documentación, se verificaron los datos recolectados en la ficha estandarizada de investigación clínica epidemiológica de COVID-19 del Ministerio de Salud del Perú. Resultados: De 4 463 pacientes analizados en el 36,4 % se detectó la presencia de SARS-CoV-2 y de éstos la mediana de edad fue de 40 años, siendo el sexo femenino el más frecuente (53,4 %). Del total de participantes, 23,7 % no registraron síntomas, sin embargo, los pacientes que declararon tos, dolor de garganta, malestar, fiebre/escalofrío, disnea, anosmia, ageusia y exudado faríngeo tenían más probabilidades de resultar infectados. De los positivos a la COVID-19, 40,2 % presentaban alguna comorbilidad. Las ocupaciones de policía/militar, ama de casa, estudiante y obrero de construcción civil tenían más probabilidades de dar positivo, mientras que, el personal sanitario tuvo 33 % menos probabilidad de infección. Conclusiones: Casi cuatro de cada 10 participantes tuvieron infección por SARS-CoV-2, existió predominio en los varones y personas en edad económicamente activa. La cuarta parte fueron asintomáticos. La tos, dolor de garganta, malestar y fiebre fueron los síntomas más frecuentes; menos frecuentes fueron la dificultad respiratoria, la anosmia, ageusia y exudado faríngeo, pero representaron mayor probabilidad de infección. Casi dos de cada 10 pacientes presentaron comorbilidad como problemas cardiovasculares, diabetes, asma y obesidad. En cuanto a las ocupaciones, el personal sanitario, policial y ama de casa fueron los grupos más afectados.

Introduction: Since the beginning of the outbreak, differences have been described between the clinical characteristics, evolution and prognosis of patients from different locations in Peru and the world. Objective: To determine the clinical and epidemiological characteristics of COVID-19 in patients from the community and the Lambayeque Regional Hospital. Methods: A study of quantitative approach, relational level and observational design with secondary data was carried out. The documentation technique was used, the data collected in the standardized COVID-19 clinical epidemiological investigation form of the Ministry of Health of Peru was verified. Results: Of 4,463 patients analyzed, 36.4 % had the presence of SARS-CoV-2, and of these the average age was 40 years, with the female sex being the most frequent (53.4 %). Of the total participants, 23.7 % had no symptoms, however, patients who reported cough, sore throat, malaise, fever/chills, dyspnea, anosmia, ageusia, and pharyngeal exudate were more likely to be infected with SARS- CoV-2. Of the positive patients for COVID-19, 40.2 % had some comorbidity. Likewise, the occupations of police/military, housewife, student and civil construction worker were more likely to test positive for COVID-19, while health personnel had a 33 % lower probability of SARS-CoV-2 infection. Conclusions: It is concluded that almost four out of 10 participants had SARS-CoV-2 infection, of which there was a predominance in men and people of economically active age. A quarter were asymptomatic. Cough, sore throat, malaise, and fever were the most frequent symptoms; likewise, respiratory distress, anosmia, ageusia, and pharyngeal exudate were less frequent, but represented a higher probability of infection. Almost two out of 10 patients had comorbidities such as cardiovascular problems, diabetes, asthma, and obesity. Regarding occupations, health personnel, police and housewives were the most affected groups.

Factores asociados a mortalidad en pacientes con Covid-19 en un hospital público / Factors associated with mortality in patients with Covid-19 in a public hospital

El objetivo del estudio fue determinar los factores asociados a mortalidad hospitalaria en pacientes con enfermedad por coronavirus 2019 (COVID-19). Se realizó un estudio observacional, analítico, de casos y controles. Se incluyeron pacientes hospitalizados con diagnóstico de la COVID-19 por prueba serológica y/o prueba molecular entre el marzo y agosto del 2020. Para el análisis estadístico se empleó la prueba de Mann Whitney y para el análisis de los factores asociados se utilizó regresión logística. La significancia de p-valor fue < 0,05. Se incluyó 814 pacientes, 556 (68,3%) fueron varones y 246 (30,2%) mayores de 60 años. La presencia de alguna comorbilidad se evidenció en 29,6 % (241 pacientes); 35,8% (292) fallecieron. La mediana de la edad de los fallecidos fue mayor en comparación a los sobrevivientes (59 vs 49; p>0,01). Las comorbilidades asociadas a la COVID-19 fueron: la obesidad (OR= 2,14; IC 95%: 1,38 ­ 3,32) y la hipertensión arterial (OR=1,86; IC 95%: 1,06-3,24). Asimismo, niveles de saturación de oxígeno menor al 85% al ingreso al hospital (OR= 3,58; IC 95%: 2,82- 4,53); la edad mayor a 60 años (OR=1,96; IC 95%: 1,54- 2,50) y el sexo masculino (OR= 1,64; IC95; 1,12-2,39) fueron asociados a mayor mortalidad. Finalmente, los factores asociados a mortalidad hospitalaria fueron saturación de oxígeno menor al 85% al ingreso al hospital, mayor de 60 años de edad, obesidad e hipertensión arterial(AU)

The objective of the study was to determine the factors associated with hospital mortality in patients with coronavirus disease 2019 (COVID-19). An observational, analytical, case-control study was conducted. Hospitalized patients diagnosed with COVID-19 by serological test and/or molecular test between March and August 2020 were included. The Mann Whitney test was used for statistical analysis and logistic regression was used for the analysis of associated factors. The significance of p-value was <0.05. A total of 814 patients were included, 556 (68.3%) were men and 246 (30.2%) were older than 60 years. The presence of some comorbidity was evidenced in 29.6% (241 patients); 35.8% (292) died. The median age of the deceased was higher compared to the survivors (59 vs. 49; p>0.01). The comorbidities associated with COVID-19 were: obesity (OR= 2.14; 95% CI: 1.38-3.32) and arterial hypertension (OR=1.86; 95% CI: 1.06- 3.24). Likewise, oxygen saturation levels less than 85% at hospital admission (OR= 3.58; 95% CI: 2.82-4.53); age over 60 years (OR=1.96; 95% CI: 1.54-2.50) and male gender (OR= 1.64; 95% CI: 1.12-2.39) were associated with greater mortality. Finally, the factors associated with hospital mortality were oxygen saturation less than 85% at hospital admission, older than 60 years of age, obesity, and arterial hypertension(AU)

Perfiles de jugadores con trastorno de juego en función de la impulsividad y regulación emocional / Profiles of players with gaming disorder based on impulsivity and emotional regulation

Este estudio tiene como objetivos examinar la relación entre la edad, la conducta de juego, los síntomas psicológicos disfuncionales y otras conductas adictivas comórbidas, así como evaluar las diferencias entre dichas variables en función de los distintos perfiles de jugadores con base en la impulsividad y la regulación emocional. Participaron 95 personas pertenecientes a muestra clínica (93,5% hombres y 6,5% mujeres). Los resultados muestran que las dificultades de regulación emocional y la impulsividad estarían asociadas al trastorno de juego, abuso de videojuegos y sintomatología psicológica disfuncional. Asimismo, se han observado dos grupos, de los cuales el primero estaría formado por personas con menores dificultades de regulación emocional, menor gravedad psicopatológica y ligera mayor impulsividad; mientras que el segundo estaría compuesto por personas con mayores dificultades de regulación emocional, mayor gravedad psicopatológica y un problema de juego de mayor gravedad. Estos resultados arrojan luz sobre la importancia de conocer las características diferenciales de cada tipología de jugador, para ofrecer estrategias de prevención y tratamiento lo más adaptadas posibles a cada persona (AU)

This study aims to examine relationship between age, gambling behaviour, dysfunctional psychological symptoms, and other comorbid addictive behaviours. Secondly, it aims to study the differences between the aforementioned variables according to gambler profiles based on impulsivity and emotional regulation. A sample of 95 participants conformed the clinical sample (93.5% men and 6.5% women). Results suggest that difficulties in emotion regulation and impulsivity are associated with gambling disorder, video game abuse, and dysfunctional psychological symptomatology. Likewise, two clusters have been observed, the first one is composed of participants with fewer difficulties in emotion regulation, less psychopathological severity, and greater impulsivity. The second cluster is composed of participants with greater difficulties in emotion regulation, as well as greater psychopathological and gambling severity. These results highlight the relevance of understanding different gambler profiles in order to design prevention and treatment strategies adapted to each person (AU)

Comorbilidad en pacientes con trastornos del neurodesarrollo / Comorbility in patients with neurodevelopmental disorders

Introducción: El término trastornos del neurodesarrollo incluye diferentes combinaciones de deficiencias en las habilidades esperadas para la edad cronológica de un niño, considerando las esferas motoras, del lenguaje, la socialización, sensorial y el control de esfínter, y en los pacientes afectados pueden asociarse algunas enfermedades (comorbilidad). Objetivo: Examinar las principales comorbilidades crónicas que pueden presentarse en pacientes con trastornos del neurodesarrollo. Métodos: Las fuentes de búsquedas fueron las bases de datos computarizadas: PubMed, Ebsco, SciELO. Además, referencias identificadas en los artículos revisados y que se consideraron importantes y con validez científica. con diez años o menos de publicación, 42/59 se publicaron en los últimos cinco años. Se utilizaron para la búsqueda las palabras clave: trastornos del neurodesarrollo, desarrollo infantil, comorbilidad, trastorno autístico; en idioma español, inglés, o francés, en dependencia de la fuente Resultados: Las comorbilidades más frecuentes, o importantes por su implicación en la vida de los pacientes con trastornos del neurodesarrollo son: la epilepsia, los trastornos de la audición y la visión, las enfermedades mentales, las dificultades en la deglución y el estado nutricional deficiente. Consideraciones finales: La ocurrencia de comorbilidad en pacientes con trastornos del neurodesarrollo es frecuente, puede presentarse en el sistema nervioso o en otros sistemas del organismo y contribuye a que la calidad de vida de estos pacientes se afecte en mayor cuantía(AU)

Introduction: The term neurodevelopmental disorder includes different combinations of deficiencies in the abilities expected for the chronological age of a child, taking into account the motor, speech, socialization, sensorial and sphincter control's scopes, and in the affected patients can be related some diseases (comorbility). Objective: To examine the main chronic comorbilities that can present in patients with neurodevelopmental disorders. Methods: The search sources were computerized databases as: PubMed, Ebsco, SciELO; also references identified in the reviewed articles and that were considered as important and with scientific validity, with ten or less years of being published. 42 of 59 were published in the last five years. There were used for the search the following keywords in Spanish, English and French languages, depending on the source: neurodevelopmental disorders, children development, comorbility, autistic disorder. Results: The most frequent comorbilities or the ones which are important due to their impact in the life of patients with neurodevelopmental disorders are: epilepsy, audition and sight disorders, mental conditions, deglutition difficulty and poor nutritional state. Final considerations: The occurrence of comorbility in patients with neurodevelopmental disorders is frequent; it can be present in the nervous system or in other systems of the body, and it contributes for the life quality of these patients being less affected(AU)

Esclerosis múltiple asociada a disfunción tiroidea en pacientes de la Provincia de Pichincha / Multiple Sclerosis associated with thyroid dysfunction in patients from the Province of Pichincha

Introducción. Existe poca información disponible sobre disfunción tiroidea en pacientes con esclerosis múltiple (EM), la mayoría proviene de estudios enfocados en la influencia del interferón b-1 (IFNb) en el hipotiroidismo. Objetivo. El objetivo del presente estudio es analizar el comportamiento epidemiológico del hipotiroidismo en un grupo de pacientes con esclerosis múltiple. Material y métodos. Estudio observacional, descriptivo, transversal, en pacientes con esclerosis múltiple atendidos en consulta externa del Hospital de Especialidades Carlos Andrade Marín entre septiembre del 2013 y octubre del 2015, a quienes se les diagnosticó disfunción tiroidea. Resultados. Se incluyeron 81 pacientes con esclerosis múltiple de los cuales el 17,2% (n=14) tuvieron hipotiroidismo clínico y subclínico confirmado. De este grupo, un paciente fue de sexo masculino y 13 del femenino. El promedio de edad fue 40±13,5 años. En los pacientes con comorbilidad esclerosis múltiple-hipotiroidismo, se encontró 78,5% (n=63) la variedad Remitente Recurrente y en 21% (n=17) la variedad progresiva. Se evidenció comorbilidad diabetes mellitus tipo 2 en pacientes con hipotiroidismo y esclerosis múltiple en un 24% (n=4). Cabe mencionar que entre los pacientes con comorbilidad de esclerosis múltiple e hipotiroidismo, el 14% (n=2) presentaron una tercera enfermedad autoinmune como lupus eritematoso sistémico. Conclusiones. La prevalencia encontrada de hipotiroidismo en pacientes con esclerosis múltiple en esta serie fue similar a la reportada en estudios internacionales. Sin embargo, no podemos asegurar si es similar a la de población ecuatoriana en general, ya que no existen estudios que precisen la prevalencia de hipotiroidismo en Ecuador, aunque esta se estima alrededor del 15 a 20%.

Introduction. There is little information available regarding thyroid dysfunction in patients with Multiple Sclerosis (MS). Most information on this matter comes from studies focused on the influence of Interferon b-1 in hypothyroidism. Objective. The goal of this study was to analyze the epidemiology of hypothyroidism in a group of MS patients. Materials and methods. Observational, descriptive, cross-sectional study carried out on Multiple Sclerosis (MS) patients of the external care area of the Carlos Andrade Marín Specialties Hospital between September 2013 and October 2015, who had been diagnosed with thyroid dysfunctions. Results. Eighty-one MS patients were included in the study, and 17.2% (n=14) of them had confirmed clinical and subclinical hypothyroidism. Out of these, 7.1% (n=l) was male and 92% (n=13) were females, with an age range of M=40, SD-=13.55. In patients with MS-hypothyroidism comorbidity, 78.5% (n=63) had a relapsing-remitting variety, and 21% (n=17) a progressive variety. A Diabetes Mellitus Type 2 comorbidity was evident in hypothyroidism and MS patients; 14% (n=4) were diagnosed with a third autoimmune disease, such as systemic lupus erythematosus. Conclusions. The prevalence of hypothyroidism found in MS patients within this study was similar to the prevalence reported in international studies. However, we cannot be certain whether or not this value was similar to the overall Ecuadorian population, since there are no studies that pinpoint the exact prevalence of hypothyroidism in Ecuador, although this rate is estimated to be within a range of 15 to 20%.

El cerebro, las drogas y los genes / Brain, drugs and genes

In this second paper of the Brain, Drugs and Genes review we would like to discuss illicit drugs and the genetics that may predispose subjects to addiction. We describe the effects, action sites and pathophysiological consequences of the use of these illicit drugs. The drugs that are reviewed are marijuana, heroin, cocaine, methamphetamine and 3,4-methylenedioxymethamphetamine or MDMA, also known as ecstasy. All of them cause an effect on the brain, modifying the activity of the neuronal systems, altering the activity or availability of the neurotransmitters or emulating their actions. The risk of dependence is related to the velocity with which these drugs induce plastic changes in the brain, very much like a learning process. Such changes underlie the patient's dependence to drugs. Therefore when a long term user quits and deprives the brain abruptly of these drugs, an abstinence syndrome is precipitated and it may be quite severe. Only for marijuana it seems to be mild, misleading people to believe this drug does not cause physical dependence. Marijuana (Cannabis sativa) is a plant which has its active principle A9-tetrahydrocannabinol (THC) in almost all its parts, i. e. the flowers, stems, seeds and leaves. It actually contains over 60 cannabinoids as well as other chemical compounds. Marijuana causes euphoria followed by relaxation and several other reinforcing effects. Among the adverse effects marijuana causes: alteration of short-term memory, slowness of reflexes, depression and anxiety, bronchitis and lung infections. Marijuana effects depend on the activation of the CB1 and CB2 receptors, distributed in the entire body. The CB1 receptor is mainly present in the brain. In medicine, A9-THC has been useful in treating symptoms caused by chemotherapy, and in treating the anorexia caused by the Acquired Immune Deficiency Syndrome. Also, an antagonist of the CB1 receptor, Rimonabant, has been used to treat morbid obesity with certain degree of success. However, despite this promising application of Rimonabant, the side effects it caused led to its withdrawal from the market in Europe, Canada and Mexico. Heroin, derived from morphine, which in turn is isolated from opium, causes euphoria and analgesia, suppresses hunger, increases energy and induces sleepiness. The adverse effects are liver and kidney diseases as well as a decrease in breathing and heart rates. This drug acts on the opioid receptors: MOR, DOR and KOR. Cocaine, derived from the coca plant (Erythroxylum coca) produces immediate rewarding effects that last between 30 to 60 min, and causes anxiety once its serum concentration drops. Due to its very short half-life, it is the most addictive of all drugs. Cocaine reduces hunger, thirst and sleep. The most used forms of cocaine are powder and crack (available as rock). The mechanism of action by which cocaine and related compounds induce their effects is the blockade of the dopamine transporter at the synapsis, leaving dopamine available for a longer time at the synapses of the motivation-reward system. Cocaine and related compounds induce blood vessel constriction, muscular spasm, chest pain, and an increase in heart rate and blood pressure, thus augmenting the risk of cardiac arrest and stroke. The methamphetamine, a synthetic stimulant, is a crystalline, odorless, bitter drug which causes a pleasant feeling and euphoria. Its action mechanism is the blockade of the dopamine transporter, same as cocaine. The effects pursued by the users of crystal methamphetamine are increased alertness, increase in physical activity and decrease in hunger. Its side effects include increase in body temperature, heart rate and blood pressure, thus augmenting the risk for stroke. Methamphetamine also triggers violent behavior, anxiety, irritability, confusion, paranoia and hallucinations. This compound has been used for medical reasons, such as in the treatment of narcolepsy and obesity. 3,4-methylenedioxymethamphetamine, MDMA or ecstasy, is a synthetic compound with stimulant and hallucinatory effects. Its action is exerted mainly on the serotonin transporter, leaving serotonin available at the synapsis for a longer time. After clearance from the bloodstream this drug causes severe depression. Ecstasy is also combined with other stimulants. All the drugs discussed here induce body changes that compromise the life of the user, or his health at the very least. Despite this fact, the highly reinforcing effects the drugs produce by over activating the motivation-rewarding system compel their repetitive use. Not all users, however, are equally vulnerable to becoming addicted or respond the same way to the use of drugs. The individual response depends, in part, on genetic factors, as we discuss in the following section. It is evident that not only environmental factors account for the vulnerability to addiction. Genetic factors also have a substantial contribution. In order to facilitate the understanding of the interaction environment-gene, we define the following concepts: gene, allele, mutation, polymorphism, heritability and epigenesis. Apparently, the genetic contribution to addiction vulnerability varies depending on the drug. For example, cocaine and opiates are much more dependant on genetic factors to trigger addiction than are nicotine, alcohol or marijuana. Mutations or polymorphisms carried by several genes might make the difference between being at high or low risk for addiction. They may also underlie the degree of response to rehabilitation treatments. Addiction, then, is a result of an interaction between environment and genes. Environmental demands make the organism modify its structure and physiology in order to cope efficiently to such demands. One crucial way to do so is by changing gene expression. Changes in gene expression may be a consequence of chemical rearrangements in the chromatin structure, which lead to transcriptional modifications that affect the expression of the proteins the genes encode. Consequently, the normal functions of such proteins in different systems are also altered. These adaptive rearrangements in the chromatin structure are called epigenesis. The epigenetic changes induced by environmental stimuli have been proved to affect the expression of several neurotransmitter receptors and trophic factors, among many other molecules crucial for the proper functioning of the Central Nervous System. Hence, these chromatin's structural changes, triggered by environmental demands, are most likely to help the subject cope with such specific demands. However, this adaptation is not free of charge, and requires a toll to be paid which is: vulnerability to addiction. Finally, one question arises: Who is the person most likely to seek a drug of abuse? Statistics have shown that those patients suffering from a psychiatric illness. This hypothesis suggests that addiction is a symptom or a disease caused by a psychiatric illness such as a personality disorder, depression or schizophrenia. Hence, at the end, drug addiction would be a co-morbid entity, generating what in Spanish we call the dual-disease. On the other hand, the self-medication hypothesis also makes sense, at least for an extensive group of patients. This hypothesis suggests that patients take drugs of abuse to relief the symptoms caused by their psychiatric pathology. The present review discusses the interaction between brain circuits, drugs and genes to generate an addict patient. We do not intend to revise each field exhaustively, but rather we intend to give the reader a general scenario on the convergence of these three worlds. Thus it may be better understood how addiction develops and how it may be treated.

En este segundo artículo sobre el tema reseñamos brevemente las drogas de abuso ilícitas. Describiremos también cómo la genética contribuye en forma importante en el desarrollo de la adicción. La marihuana (Cannabis sativa) es una de las drogas más populares entre los jóvenes. Se presenta para su consumo en dos formas: hachís, como un triturado de la planta seca y como aceite. Una vez consumida, sus efectos tardan en aparecer según la vía de administración. Por ejemplo, cuando se inhala, sus efectos aparecen en unos cuantos segundos. Después de que el principio activo de la marihuana (A9-THC) llega al cerebro y se une a sus receptores (CB1), produce euforia seguida de relajación, se perciben más intensamente los olores, los sabores y los sonidos y parece que el tiempo pasa lentamente. Su consumo, al igual que todas las drogas de abuso, tiene efectos adversos. Sin embargo, la marihuana cuenta con un potencial uso en la medicina por sus propiedades antieméticas, orexigénicas y analgésicas. La heroína es derivada de la morfina (ingrediente activo del opio, Papaver somniferum). El opio se fuma o se utiliza como un extracto disuelto en alcohol (láudano), y la heroína se aspira o fuma. Sus efectos aparecen rápidamente e incluyen euforia, aumento de la energía, supresión del hambre, analgesia y somnolencia. La heroína, así como el opio y la morfina, ejercen su efecto a través de los receptores opioides. Su consumo deteriora el hígado, los riñones, los pulmones y el corazón. La cocaína (Erythroxylum coca) es una droga estimulante altamente adictiva. Al consumirla se experimenta mejoría de la autoestima y la auto-confianza, acompañada de excitación. Estos efectos son inmediatos y duran entre 30 y 60 minutos y son consecuencia de la inhibición de la recaptura de dopamina. Adicionalmente la cocaína inhibe el apetito y el sueño. Sus efectos adversos son la contracción de los vasos sanguíneos, espasmos musculares, dolor de pecho, embolias o derrames cerebrales, aumento en la frecuencia cardiaca y muerte. La metanfetamina se sintetiza fácilmente a partir de la anfetamina (derivado de la efedrina), lo que facilita su fabricación en laboratorios clandestinos. Cuando se fuma o se inyecta por vía intravenosa produce una sensación sumamente placentera (<

El cerebro y las drogas, sus mecanismos neurobiológicos / Brain, drugs, its neurobiological mechanisms

The pleasant sensation experienced when, for example eating or having sex is regulated by the motivation-rewarding system. This rewarding sensation makes the subject to repeat the behavior in order to obtain the reinforcer once more. This system can be corrupted by drugs of abuse by triggering an «intense feeling of pleasure¼ and inducing plastic changes. In normal conditions, a natural reinforcer is a stimulus generating a benefit to the organism. For example, food will provide energy and structure among many other benefits. Sex, in turn, accomplishes the function of giving new beings to the species and to create boundaries between subjects to generate groups and culture. Due to these facts, it is crucial to reinforce this kind of behaviors. They are crucial for the subject's life. In contrast, drugs do not produce any benefit to the subject or group. Although in ancient times human beings used drugs as a means to develop and practice their mysticism, such practice is no longer associated with the use of drugs. With the exception of present time aboriginal communities, none of the regular users in our countries consume drugs with ritual-mystical purposes. Hence, we have to accept that drugs are of no use for human beings. They do not help us as species to have more adapted, intelligent or developed subjects in our communities. However, their ability to stimulate the rewarding system makes them popular and dangerous to the individual's health and life. The motivation-rewarding system is regulated by numerous neurotransmitters, among them dopamine, that is released in the nucleus accumbens (NAc) and synthesized by the neurons located in the ventral tegmetal area (VTA). There are other substances that modulate the activity of the dopaminergic neurons in the VTA, such as serotonin, acetylcholine, gamma-aminobutyric acid (GABA) and glutamate. The activation of the VTA and its consequent activation of the NAc enhance the release of neuromodulators such as endorphins and endocannabinoids, thus generating the subjective sensation of pleasure. All these interactions trigger the activity of memory systems generating a memory trace encoding the characteristics of the substance or behavior causing pleasure. This occurs in the context that the brain accepts these substances or behaviors as beneficial to the organism. The punishment system is also a very important system working in tight communication with the pleasure system. Fear is one of the most critical adapting behaviors for any subject in the animal kingdom. Fear helps us to avoid dangerous stimulus and behaviors. There is also pleasure involved in escaping this kind of situations. It seems like there is an interaction between the motivation-rewarding and the punishment systems. As a result, there is a balance at times in favor of pleasure, at times in favor of punishment depending on the quality of the stimulus. This balance gives the valence to the emotion triggered by the stimulus. A stimulus with a positive valence will increase the probability of exhibiting the behavior displayed to obtain it, while a stimulus with a negative valence will increase the probability of exhibiting the behavior displayed to avoid it. In this context, the so-called non-natural reinforcers such as drugs of abuse act directly on the pleasure system. For example, nicotine acts on the nicotinic receptor of ACh, alcohol, on the receptor of GABAa and glutamate (NMDA), marihuana on the endocannabinoid receptor (CB1 R), located in the motivation-rewarding system triggering an «intense sensation of pleasure¼. However, two main shortcomings make drugs of abuse dangerous: first, their effect is short and, second, they do not convey any beneficial effect to the organism whatsoever. Brain mechanisms not very well defined detect this lack of benefit; hence, the motivation-rewarding system reduces its response by means of at least two plastic changes, reducing the availability of receptors (epigenetic changes induced by the drug) and by increasing the activity of the punishment system to maintain the balance. As a result, the subject does not experience the same pleasure with the same dose of the drug. In the clinic we call this phenomenon tolerance. If the individual insists in pursuing the same intensity of pleasure, he/she has to consume more of the drug, forcing the brain to strengthen its plastic changes. In this context, we can say that these systems are defending themselves against the action of the drug. Then, why do subjects insist in pursuing the effect of drugs? Very likely because the substrate of the subject's disorder resides anywhere in the brain but in the pleasure system. If so, this indicates that drug addiction is a disorder caused by another disease, very likely a psychiatric one. Several factors contribute to generate drug addiction, i. e. social, psychological and genetic. Genes contribute in different ways to generate the subject's vulnerability to suffer an addiction. A gene mutation (alteration in genetic information) or a given polymorphism (the existence of multiple alleles of a gene in a population) can produce a dysfunctional protein or alter its normal levels. Such changes may make some individuals vulnerable to the initial use of drugs of abuse. However, those genes facilitating adjustments in the motivation-rewarding system that occur after the repeated consumption of drugs of abuse seem to be functioning normally, as we can infer from the development of tolerance. The heritability of these genes, making subjects vulnerable to addiction, has been studied in many ways, including studies of families, adoptees, and twins (monozygotic and dizygotic). From these studies it has been possible to calculate the heritability index, a measure which indicates how much variance of a trait in a specific sample is associated to genetic factors and how much to the environment. The heritability index has a range from 1, meaning the maximum genetic influence, to 0, meaning the maximum environment influence. At present, a significant number of genes have been involved in facilitating addiction to drugs, and also very important, to the response to treatment for rehabilitation. The expression of the genes is regulated by a series of processes called epigenesis. Epigenetic changes can be a result of the interaction between genes and environment. This interaction results in chemical processes that modify chromatin structure. For example, cytosine nucleotide methylation causes chromatin condensation, which interferes with gene transcription; hence, the protein encoded by this gene will be reduced, and the function in which it participates will be altered. As an example, when the methylation of the gene encoding for the glucocorticoid receptor occurs in rats, it reduces the bioavailability of this receptor and increases the release of corticosterone when rats are stressed. At the behavioral level, rats seem to be more stressed most of the time as compared with rats without methylation of this gene. Almost every stimulus in the environment is a potential promoter of epigenesis. Epigenesis is important to occur, since it is an adaptive response of the organism to the environment. It seems like the switches of the genes are turned on or off according to environment circumstances. These genetic changes will be ultimately expressed as plastic changes pursuing the right adaptation of the subject to the environment. Parental care seems to be one crucial contributor to these epigenetic modifications. For example, when a mother-rat provides poor care (feeding, grooming, and physical contact) to its litter during the neonate period, facilitates the methylation of genes, as it has been proved for the glucocorticoid receptor. These changes generate subjects with poor stress management and less capability for learning. Likewise, it makes them susceptible to drug addiction. These results highlight the importance of parental care as provider of a healthy environment, which is modeling the expression of their genes, hence their behavior.

La definición de adicción propuesta por la Organización Mundial de la Salud, dicha de manera sucinta, indica que es una enfermedad cerebral que provoca una búsqueda compulsiva de la droga y su uso, a pesar de las consecuencias adversas que ésta provoque. La fisiopatología de la enfermedad sugiere una interacción entre mecanismos cerebrales, cambios genéticos y medio ambiente. El objetivo de este artículo es discutir la evidencia que existe sobre los sistemas cerebrales que son afectados por las drogas, qué genes participan y cómo el medio ambiente tiene una participación crucial para generar esta enfermedad. Discutiremos tres secciones: el cerebro, las drogas y los genes. La primera trata sobre cómo el cerebro responde ante estímulos reforzantes y cómo estos sistemas cerebrales promueven que el individuo repita la conducta que lo llevó a adquirir el reforzador originalmente, para obtenerlo de nuevo. A este sistema se le denomina sistema de motivación-recompensa. Este sistema responde muy activamente ante reforzadores naturales (estímulos que buscan preservar la vida del individuo), pero también a reforzadores no naturales. En este grupo de estímulos están las drogas de abuso. El sistema de motivación-recompensa está modulado por diversas estructuras subcorticales y corticales que incluyen un sistema de castigo. Estos sistemas util izan una gran diversidad de neurotransmisores y neuromoduladores que inducirán una sensación de placer ante la presencia del estímulo reforzante. Todas las drogas de abuso provocan un efecto sobre los receptores y sobre los transportadores de los neurotransmisores, al igual que sobre las enzimas que participan en la síntesis y degradación de estos mediadores químicos. El uso repetido de la droga modifica así estructural y funcionalmente al cerebro. Estos cambios plásticos desarrollados en el sistema de la motivación-recompensa y también en el de castigo, provocan un nuevo balance entre ellos que lleva al individuo a un estado de alostasis, en el cual la droga se convierte en una necesidad. En otro artículo haremos una reseña sobre drogas lícitas e ilícitas; sus efectos, sus sitios de acción y las consecuencias adversas de su uso. La última sección versará sobre la genética: definimos los conceptos de gen y alelo, de mutación y polimorfismo, heredabilidad y epigenética, a fin de entender qué hace a un individuo vulnerable a la adicción de una droga de abuso. Si bien para la adicción existe una contribución ambiental, la contribución genética es importante. Esta contribución no es igual para las diferentes drogas. La cocaína y los opiáceos, no solamente son las drogas más adictivas, sino también las que mayor contribución genética tienen en comparación con otras (v. gr. nicotina, alcohol o marihuana). Los polimorfismos en diversos genes hacen vulnerable a un cerebro para convertirse en adicto a alguna droga o, por el contrario, dificultan la eficiencia de los tratamientos en contra de la adicción. Entre los polimorfismos que se han descrito son de interés los genes que codifican para las enzimas hepáticas citocromo P450, ya que estos polimorfismos modifican la vulnerabilidad para la adicción al tabaco, al alcohol y a la heroína. Es menester considerar la influencia genética en la adicción puesto que las variaciones a este nivel harán responder diferencialmente al tratamiento a personas con el mismo tipo de adicción. Por ello, hay que enfatizar el uso individualizado de la terapia. Por último, planteamos que quienes buscarán con mayor probabilidad el uso de una droga son quienes presentan una enfermedad psiquiátrica de fondo, así que la adicción representa sólo una parte de una enfermedad dual o comorbilidad. En este contexto, la hipótesis de la automedicación sugiere que los pacientes buscan la droga con el fin de controlar su patología inicial. Esta revisión busca integrar la interacción entre el cerebro, las drogas y los genes, pero no pretende ser exhaustiva. Nuestro interés es dar un panorama al lector sobre cómo estos tres mundos convergen, para entender cómo ocurre esta enfermedad y tratarla diferencialmente entre los individuos.

Trastornos por abuso y dependencia de sustancias en población colombiana: su prevalencia y comorbilidad con otros trastornos mentales seleccionados / Substance use disorders in Colombia: prevalence and comorbidity with other mental disorders

Introducción: Poco se conoce sobre la prevalencia de los trastornos por abuso y dependencia de sustancias y su comorbilidad con otros trastornos psiquiátricos en Colombia. Objetivos: Calcular la prevalencia anual y de vida para uso y trastornos por abuso o dependencia de sustancias y su comorbilidad con trastornos del ánimo, ansiedad e impulsividad. Método: Analítico, a partir de la información de la Encuesta Nacional de Hogares, que para el diagnóstico de los trastornos psiquiátricos aplicó el CIDI-WHO a 3.896 adultos de 18 a 54 años de edad no institucionalizados y residentes en el área urbana. Resultados: La prevalencia anual para trastorno por uso de sustancias en los 12 meses anteriores fue de 0,7% y para alguna vez en la vida de 2,4%. En el grupo de trastornos de ansiedad, el estrés postraumático presentó la mayor fuerza de asociación. Entre los trastornos del estado del ánimo, el trastorno afectivo bipolar (TAB) I presentó la asociación más alta. Entre los trastornos del impulso, la asociación más fuerte se encontró con el trastorno de la conducta. Conclusión: Este estudio sugiere que existe una fuerte asociación entre los trastornos por uso de sustancias y otros trastornos psiquiátricos, como el síndrome de estrés postraumático, el TAB I y trastornos de la conducta. Estos resultados tienen gran importancia clínica y de salud pública...

Introduction: Little is known about the prevalence of drug use, abuse and dependence and its comorbility with DSM-IV mental disorders in the general population in Colombia. Objective: To estimate the lifetime and 12-month prevalence of comorbidities such as anxiety, mood, impulse control, and substance disorders in the Colombia National Comorbidity Survey. Method: Nationally representative face-to-face household survey conducted using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview with 3,896 respondents 18 to 54 years old. Results: the lifetime and 12-month prevalence of substance use disorders were 0.7% and 2.4%, respectively. An important contribution of this study is the assessment of the associations between substance use disorders and other psychiatric disorders studied. In the anxiety disorders group, posttraumatic stress had the strongest association with substance use disorders. Among mood disorders, bipolar I disorder had the highest association. Among the disorders of impulse, the strongest association found was with conduct disorder. Conclusion: There is a strong association between substance use disorders and other psychiatric disorders such as post-traumatic stress disorder, bipolar I disorder, and conduct disorder. These results have great clinical and public health relevance...

Prevalencia del Trastorno Obsesivo Compulsivo y su comorbilidad con el Trastorno Depresivo Mayor en adolescentes escolarizados / Prevalence of Obsessive Compulsive Disorder and its comorbidity with Major Depressive Disorder in adolescent students

Introducción: dos tercios de los adolescentes con Trastorno Obsesivo Compulsivo tienen otro diagnóstico psiquiátrico. El objetivo del estudio fue estimar la prevalencia del Trastorno Obsesivo Compulsivo y del Trastorno Depresivo Mayor en adolescentes escolarizados y su comorbilidad. Métodos: 390 adolescentes realizaron la entrevista clínica estructurada para los trastornos del Eje 1, módulos para Trastorno Obsesivo Compulsivo y Trastorno Depresivo Mayor. Examinamos los factores socio demográficos con análisis bivariado, estratificado y con regresión logística no condicional. Resultados: la prevalencia del Trastorno Obsesivo Compulsivo fue 7,63, la comorbilidad con depresión fue 48,27 y se encontró asociación entre los dos dos trastornos (RP 6,6 IC 3,45 - 12,61); la prevalencia de depresión fue 11,7; controlando variables confusoras en mujeres se observó que trabajar (RP 3,14), la edad (RP 1,45) Y tener trastorno depresivo mayor (RP 3,88), aumentan el riesgo de padecer de trastorno obsesivo compulsivo; en cambio en hombres solo el trastorno depresivo mayor mostró un mayor riesgo (RP 10,88). Conclusiones: la prevalencia del trastorno obsesivo compulsivo y trastorno depresivo mayor así como su comorbilidad en adolescentes escolarizados es alta; la edad de las adolescentes y el hecho de trabajar podrían ser un factor de riesgo en la presencia de Trastorno Obsesivo Compulsivo.

Introduction: at least two-thirds of the adolescents with Obsessive Compulsive Disorder have another psychiatric disorder. The objective of this study was to estimate the prevalence of Obsessive Compulsive Disorder and Major Depressive Disorder in adolescent students and its comorbidity. Methods: 390 adolescents were performed a structured clinical interview, clinical version: Obsessive Compulsive Disorder and Major Depressive Disorder modules. The inquired sociodemographic factors were analyzed with bivariate and multivariate statistical analysis and with non conditional logistic regression. Results: Obsessive Compulsive Disorder was 7.63, its comorbility with major depressive disorder was 48.27 and there was an association between both disorders (OR 6.6 IC 3.45 -12.61); Major Depressive Disorder prevalence was 1l.7; when we controlled confusing variables in women we found that work (OR 3,14), age (OR 1,45) and major depressive disorder (OR 3,88), showed higher risk of having Obsessive Compulsive Disorder; in contrast with the men just Major Depressive Disorder showed higher risk of having obsessive compulsive disorder (OR 10,88). Conclusions: the Obsessive Compulsive Disorder and Major Depressive Disorder prevalence and its association in adolescent students are high; age and work could be a risk factor of having Obsessive Compulsive Disorder.

Ansiedad y depresión: el problema de la diferenciación a través de los síntomas

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SUMMARY The differentiation between the symptoms of anxiety and depression is one of the most important problems in psychology as the dilemma profoundly affects the diagnosis and clinical intervention. According to the epidemiological data there is a strong comorbility between the two types of disorder. Nevertheless, it is not known which one of them precedes or predisposes to the other. The comorbility could be also caused by the confusion between the two. There are many common symptoms and some of them traditionally attributed to the anxiety are also present in depression and vice versa. Additionally, in some cases the symptoms themselves could constitute complete clinical charts. Taking into account the above description, one of the most important current preoccupations in psychology and psychopathology is the identification of the symptoms which would be characteristic for each disorder. Although there is clinical evidence on an overlap between the symptoms, the current manuals describe two disorders and the clinical differences are crucial. One of the possible explanations of the overlap between the symptoms of anxiety and depression has been classically attributed to comorbility which means the presence of both charts in many clinical cases. Different sources indicate that the presence of anxiety in early ages can generate certain vulnerability to develop later-age major depression. On the other hand, other studies indicate that the cases in which both, depression and anxiety are present, tend to chronify and are more resistant to treatment. In this case both disorders are present but there is no sufficient evidence to determinate which one of them would be the principal diagnosis and which one would be secondary. For this reason, the explanations are confused and neither the researchers nor clinicians are satisfied. On the other hand, the concurrence of symptoms has been attributed to the instruments utilized for the evaluation. The disorders also depend on the tools for their measure which follow a theoretical model to explain the aetiology, course, prognosis and associated symptomatology. This way, the implicit bias of the instruments is to privilege a specific aspect which depends on the definition of disorders without taking into account the other aspects. According the description above, the evaluation, especially in case of depression, is characterized by multiplicity of instruments and diversity of contents which are evaluated. Thus, it is difficult to establish the characteristic symptoms as in many cases only some of them coincide when utilizing different tools. Moreover, many symptoms which are detected by scales of depression are also present in anxiety disorders. This difficulty is one of the most important problems in clinics as it affects the validity and reliability of the tools which assess the disorders. The importance of the instructions given to the subjects should also be emphasized. In many cases they lead to the confusion of the measures of frequency and severity which is related to the classical discussion about the dimensional or categorical character of depression. Some authors state that the consideration of depression as a dimensional disorder makes possible to understand that some charts, as for example the anxiety disorders, can appear as a consequence of certain vulnerability generated by the depression. One of the alternatives to explain the presence of symptoms shared by the anxiety and depression is to consider the existence of a factor of negative affect which would be present in both types of disorder. This point of view is derived from the correspondence between some common symptoms in depression and anxiety observed in clinics. Additionally, some items included in the self-report questionnaires and scales are the same for the two disorders. The group of symptoms includes sadness, crying, psychomotor restlessness and irritability among others. The factor which includes these symptoms is called negative affect and would be common for the anxiety and depression. Although the negative affect factor is the same for anxiety and depression, some elements are characteristic for one disorder but not for the other. In case of anxiety, according to the tripartite model the characteristic factor refers to high physiological activation related to the vegetative symptoms. On the other hand, in depression, the negative affect is also accompanied by low positive affect which can be seen in the lost of interest in things which were enjoyed before (anhedony). Thus, the anxiety would be defined as high negative affect together with high physiological arousal whereas depression is characterized by high negative affect and low positive affect. For all the reasons described above, the importance of applying adequate and reliable instruments to evaluate the disorders should be emphasized. These instruments would help to clarify the features of each disorder and would support more effective interventions to decrease the rate and incidence of mental disorders in the population. In relation to this, Spielberger et al. offer an instrument which differentiates the aspects characteristic for depression utilizing two different scales: depression as a trait and as a state. The instrument allows the differentiation between the trait and the state which provides the information about the aspects which are more stable and lasting in time related to the mood which probably refer to the personality traits (the trait scale). The aspects which depend more on the punctual moments are measured by the state scale. This is possible thanks to the instructions which evaluate in a different manner the frequency and the severity which are usually confused in most of the scales. The component of negative affect (Dysthymia) which is common for the anxiety and depression is evaluated together with positive affect (Euthymia) and offers the valuation of low affectation levels which are not considered in most of the self-report questionnaires, although they are crucial for the clinical practice and investigation.

Juego patológico: comorbilidad con dependencia de sustancias, trastorno afectivo bipolar y trastorno Obsesivo-compulsivo / Pathological gambling: comorbidity with substance dependence, bipolar disorder and obsessive-compulsive disorder

Objetivos: Determinar la proporción de pacientes con juego patológico en un grupo de pacientes dependientes de sustancias contrastado con pacientes con enfermedad afectiva bipolar y TOC. Describir las características clínicas y sociodemográficas de los grupos y la aplicabilidad del Cuestionario SOGS (South Oaks Gambling Screen) en una muestra Colombiana. Diseño:Estudio Descriptivo,Serie de Casos. Participantes: 80 sujetos de los cuales 41 presentaban un Trastorno por Dependencia de Sustancias, 19 Enfermedad Afectiva Bipolar y 20 TOC, en la ciudad de Santafé de Bogotá Medida Desenlace Principal: Puntaje obtenido en la escala de SOGS. Instrumentos: Se realizaron entrevistas clínicas semiestructuradas de acuerdo con los criterios del DSMIIIR que se contrastaron posteriormente con el DSM-IV. Se utilizó el SOGS y el Y-BOCS. Resultados: En el grupo de pacientes Dependientes de Sustancias el 24.4 % reportaron niveles de 0 en el SOGS, 29.3 % niveles entre 1 y 4 para SOGS (juego social) , 46.3% reportaron puntajes mayores entre 5 y 18 compatibles con juego patológico. Dentro del grupo de TOC un 70% tuvieron puntajes de 0 en el SOGS, un 10 % entre 1 y 4 (juego social), un 20% probable juego patológico. En cuanto a los pacientes con Trastorno Afectivo Bipolar un 47.4% reportaron puntajes de 0, un 10.5% puntajes compatibles con juego social y un 42.1% entre 5 y 10 en el cuestionario SOGS. Conclusiones: El presente estudio abre un campo de investigación alrededor del juego patológico en pacientes con Dependencia de Sustancias,Trastornos Afectivos y TOC en nuestro medio...

Objective: To determine the proportion of patients with pathologic gambling in a group of substance abuse patients in contrast with a group of patients with bipolar disorder and OCD. To describe the clinical and socio-demographic characteristics of the groups and the applicability of the SOGS (South Oaks Gambling Screen) in a Colombian sample. Design: Descriptive study, Case-series study.Participants: 80 subjects from which 41 had substance abuse, 19 bipolar disorder and 20 OCD, in the city of Santafé de Bogotá. Principal Outcome Measure: The score obtained in the SOGS scale. Instruments: Semiestructural clinical interviews was done in agreement to the DSMIII-R criteria and then was contrasted with DSM-.IV. The SOGS and the Y-BOCS were used.Results: In the substance abuse group 24.4% report scores of 0in the SOGS, 29.3% scores between 1-4 for SOGS (social gambling), 46.3% report high scores between 5-18 compatible with pathologic gambling. In the OCD group 70% had 0 score in the SOGS, 10% between 1-4 (social gambling), and a 20 % a probable pathologic gambling. In regard to the patients with Bipolar Disorder 47.4% report score of 0, a 10.5% scores compatible with social gambling and 42.1 % between 5-10 in the SOGS. Conclusion: This study open the field of investigations around the pathologic gambling in substance abuse, bipolar disorder and OCD patients in our medium...