Versão portuguesa do CANE (Camberwell Assessment of Need for the Elderly) : desenvolvimento e dados preliminares

RESUMO - A avaliação de necessidades de cuidados é crucial no planeamento, monitorização e avaliação de serviços de psiquiatria e saúde mental, bem como na investigação e na clínica. Este princípio é obviamente aplicável aos serviços responsáveis por populações de pessoas mais velhas. O instrumento CANE — Camberwell Assessment of Need for the Elderly possibilita uma avaliação consistente das necessidades de utentes idosos, nomeadamente em situações de patologia neuropsiquiátrica. Procede-se a uma avaliação cruzada, entrevistando a pessoa em questão, o seu cuidador informal e o técnico responsável. Esta avaliação multidimensional abrange domínios da esfera biológica, psicológica e social, sendo aplicável na comunidade ou em internamento (regime parcial ou completo). A utilidade do CANE tem sido evidenciada em contextos clínicos, de investigação e de avaliação de serviços. Existem múltiplas traduções a nível internacional, a maioria das quais validada. Na área da epidemiologia psiquiátrica nem sempre estão disponíveis os dados relativos à qualidade das adaptações de instrumentos, pelo que se apresenta o processo de desenvolvimento da versão portuguesa (de acordo com as regras para validação transcultural, no processo de tradução-retroversão). A aplicabilidade da versão portuguesa foi satisfatória neste estudo-piloto, representando a primeira fase de um trabalho multicêntrico nacional. Nesta fase inicial, foram considerados casos de idosos com patologia neuropsiquiátrica (maioritariamente demência — 71,4%), em dois centros (Lisboa e Porto) (n = 21). A média de idades foi 73,9 (± 6,3) anos, sendo 76,2% do sexo feminino. A maioria vivia em casa, apresentava co-morbilidade somática e estava em contacto com um cuidador informal (em geral, familiares do sexo feminino). Os avaliadores identificaram necessidades, nem sempre cobertas, nas seguintes dimensões: cuidados com a casa, alimentação, actividades diárias, memória, saúde física, sofrimento psicológico, companhia e dinheiro/economias. Nem sempre a perspectiva de doentes, cuidadores, técnicos e avaliadores foi inteiramente coincidente. Estes resultados preliminares da aplicação da versão portuguesa do CANE são consistentes quanto à sua validade ecológica, facial e de conteúdo, estando em curso contributos adicionais para a validação efectiva numa amostra de maior dimensão.

An episode mimicking a versive seizure in acute bilateral pontine stroke.

Pontine ischemia usually results in focal deficits such as hemiparesis, facial palsy, dysarthria, disorders of eye movements or vertigo. Although rarely described, involuntary abnormal movements and "convulsions" due to pontine lesions can also occur. Here we describe a 67-year-old woman with hypertension who presented with a tonic movement mimicking a versive seizure in the acute phase of bilateral pontine ischemia. Post-stroke movement disorders are well known. They are usually associated with supratentorial lesions and rarely occur in the acute phase, but "seizure-like" episodes can be seen in pontine ischemia. Awareness of this rare phenomenon is useful for the management of acute stroke patients.

An atypical 7q11.23 deletion in a normal IQ Williams-Beuren syndrome patient.

Williams-Beuren syndrome (WBS; OMIM no. 194050) is a multisystemic neurodevelopmental disorder caused by a hemizygous deletion of 1.55 Mb on chromosome 7q11.23 spanning 28 genes. Haploinsufficiency of the ELN gene was shown to be responsible for supravalvular aortic stenosis and generalized arteriopathy, whereas LIMK1, CLIP2, GTF2IRD1 and GTF2I genes were suggested to be linked to the specific cognitive profile and craniofacial features. These insights for genotype-phenotype correlations came from the molecular and clinical analysis of patients with atypical deletions and mice models. Here we report a patient showing mild WBS physical phenotype and normal IQ, who carries a shorter 1 Mb atypical deletion. This rearrangement does not include the GTF2IRD1 and GTF2I genes and only partially the BAZ1B gene. Our results are consistent with the hypothesis that hemizygosity of the GTF2IRD1 and GTF2I genes might be involved in the facial dysmorphisms and in the specific motor and cognitive deficits observed in WBS patients.

Sclérodermie et risques oncologiques [Systemic sclerosis and cancer]

The combination of skin induration with clinical features such as dyspnea, facial telangiectasia, digital infarctions and/or dysphagia supports the diagnosis of systemic sclerosis. The oesophageal dysmotility is associated with symptoms which may delay the diagnosis of gastro-oesophageal cancer. Herein we report a case of long standing systemic sclerosis with heartburn and dysphagia symptoms which were monitored closely. Unfortunately, these symptoms delayed the diagnosis of gastric adenocarcinoma. This case prompted us to review the evidence of the association of cancer and systemic sclerosis and if any oncologic evaluation is required during the follow-up of patients affected with systemic sclerosis.

Tracking the source of cerebellar epilepsy: hemifacial seizures associated with cerebellar cortical dysplasia.

Traditionally, subcortical structures such as the cerebellum are supposed to exert a modulatory effect on epileptic seizures, rather than being the primary seizure generator. We report a 14-month old girl presenting, since birth, with seizures symptomatic of a right cerebellar dysplasia, manifested as paroxystic contralateral hemifacial spasm and ipsilateral facial weakness. Multimodal imaging was used to investigate both anatomical landmarks related to the cerebellar lesion and mechanisms underlying seizure generation. Electric source imaging (ESI) supported the hypothesis of a right cerebellar epileptogenic generator in concordance with nuclear imaging findings; subsequently validated by intra-operative intralesional recordings. Diffusion spectrum imaging-related tractography (DSI) showed severe cerebellar structural abnormalities confirmed by histological examination. We suggest that hemispheric cerebellar lesions in cases like this are likely to cause epilepsy via an effect on the facial nuclei through ipsilateral and contralateral aberrant connections.

A t(7;12) balanced translocation with breakpoints overlapping those of the Williams-Beuren and 12q14 microdeletion syndromes.

The molecular characterization of balanced chromosomal rearrangements have always been of advantage in identifying disease-causing genes. Here, we describe the breakpoint mapping of a de novo balanced translocation t(7;12)(q11.22;q14.2) in a patient presenting with a failure to thrive associated with moderate mental retardation, facial anomalies, and chronic constipation. The localization of the breakpoints and the co-occurrence of Williams-Beuren syndrome and 12q14 microdeletion syndrome phenotypes suggested that the expression of some of the dosage-sensitive genes of these two segmental aneuploidies were modified in cells of the proposita. However, we were unable to identify chromosomes 7 and/or 12-mapping genes that showed disturbed expression in the lymphoblastoids of the proposita. This case showed that position-effect might operate in some tissues, but not in others. It also illustrates the overlap of phenotypes presented by patients with the recently described 12q14 structural rearrangements.

Molecular screening of ADAMTSL2 gene in 33 patients reveals the genetic heterogeneity of geleophysic dysplasia.

Background Geleophysic dysplasia (GD, OMIM 231050) is an autosomal recessive disorder characterised by short stature, small hands and feet, stiff joints, and thick skin. Patients often present with a progressive cardiac valvular disease which can lead to an early death. In a previous study including six GD families, we have mapped the disease gene on chromosome 9q34.2 and identified mutations in the A Disintegrin And Metalloproteinase with Thrombospondin repeats-like 2 gene (ADAMTSL2). Methods Following this study, we have collected the samples of 30 additional GD families, including 33 patients and identified ADAMTSL2 mutations in 14/33 patients, comprising 13 novel mutations. The absence of mutation in 19 patients prompted us to compare the two groups of GD patients, namely group 1, patients with ADAMTSL2 mutations (n=20, also including the 6 patients from our previous study), and group 2, patients without ADAMTSL2 mutations (n=19). Results The main discriminating features were facial dysmorphism and tip-toe walking, which were almost constantly observed in group 1. No differences were found concerning heart involvement, skin thickness, recurrent respiratory and ear infections, bronchopulmonary insufficiency, laryngo-tracheal stenosis, deafness, and radiographic features. Conclusions It is concluded that GD is a genetically heterogeneous condition. Ongoing studies will hopefully lead to the identification of another disease gene.

Artificial muscle: the human chimera is the future.

Severe heart failure and cerebral stroke are broadly associated with the impairment of muscular function that conventional treatments struggle to restore. New technologies enable the construction of "smart" materials that could be of great help in treating diseases where the main problem is muscle weakness. These materials "behave" similarly to biological systems, because the material directly converts energy, for example electrical energy into movement. The extension and contraction occur silently like in natural muscles. The real challenge is to transfer this amazing technology into devices that restore or replace the mechanical function of failing muscle. Cardiac assist devices based on artificial muscle technology could envelope a weak heart and temporarily improve its systolic function, or, if placed on top of the atrium, restore the atrial kick in chronic atrial fibrillation. Artificial sphincters could be used to treat urinary incontinence after prostatectomy or faecal incontinence associated with stomas. Artificial muscles can restore the ability of patients with facial paralysis due to stroke or nerve injury to blink. Smart materials could be used to construct an artificial oesophagus including peristaltic movement and lower oesophageal sphincter function to replace the diseased oesophagus thereby avoiding the need for laparotomy to mobilise stomach or intestine. In conclusion, in the near future, smart devices will integrate with the human body to fill functional gaps due to organ failure, and so create a human chimera.

Resultate und ausser- gewöhnliche Komplikationen der Chirurgie der Gehörgangexostosen [Results and extraordinary complications of surgery for exostoses of the external auditory canal].

We present a retrospective study on 22 operations of exostosis of the external auditory canal in 20 patients. 8 patients were passionated by water sports. The most frequent indication for surgery (13 operations) was recurrent external otitis or ceruminal obstruction. In 7 cases the need for a wider access to the middle ear indicated surgery. Surgery was usually performed as an outpatient procedure, maximum hospitalization was 3 days. The mean healing period was 6 (3-10) weeks. Mean follow up was 43 (3-110) months. There were no severe intraoperative complications such as facial paresis, lesions of the ossicles or of the inner ear. As intraoperative complications we found 2 perforations of the tympanic membrane, 2 expositions of the capsule of the mandibular joint, one of which was followed by chronic pain. As postoperative complications we found an early soft tissue stenosis of the external auditory canal and one late soft tissue stenosis which recurred after revision surgery. No recurrence of exostosis was seen. We describe an up to now unknown complication: the appearance of bilateral petrositis caused by staphylococcus epidermidis after bilateral surgery in an otherwise healthy patient. This study confirms that severe complications are rare, minor ones however relatively common. And that also minor complications may have a troublesome follow. Therefore and because of the potential of severe complications indication for surgery must be made cautiously and risks of the operation must not be underestimated.

Physiological reactivity and the perception of emotional stimuli as they relate to social adaptive functioning after traumatic brain injury / y Melonie Jane Hopkins.

Traumatic brain injury (TBI) often affects social adaptive functioning and these changes in social adaptability are usually associated with general damage to the frontal cortex. Recent evidence suggests that certain neurons within the orbitofrontal cortex appear to be specialized for the processing of faces and facial expressions. The orbitofrontal cortex also appears to be involved in self-initiated somatic activation to emotionally-charged stimuli. According to Somatic Marker Theory (Damasio, 1994), the reduced physiological activation fails to provide an individual with appropriate somatic cues to personally-relevant stimuli and this, in turn, may result in maladaptive behaviour. Given the susceptibility of the orbitofrontal cortex in TBI, it was hypothesized that impaired perception and reactivity to socially-relevant information might be responsible for some of the social difficulties encountered after TBL Fifteen persons who sustained a moderate to severe brain injury were compared to age and education matched Control participants. In the first study, both groups were presented with photographs of models displaying the major emotions and either asked to identify the emotions or simply view the faces passively. In a second study, participants were asked to select cards from decks that varied in terms of how much money could be won or lost. Those decks with higher losses were considered to be high-risk decks. Electrodermal activity was measured concurrently in both situations. Relative to Controls, TBI participants were found to have difficulty identifying expressions of surprise, sadness, anger, and fear. TBI persons were also found to be under-reactive, as measured by electrodermal activity, while passively viewing slides of negative expressions. No group difference,in reactivity to high-risk card decks was observed. The ability to identify emotions in the face and electrodermal reactivity to faces and to high-risk decks in the card game were examined in relationship to social monitoring and empathy as described by family members or friends on the Brock Adaptive Functioning Questionnaire (BAFQ). Difficulties identifying negative expressions (i.e., sadness, anger, fear, and disgust) predicted problems in monitoring social situations. As well, a modest relationship was observed between hypo-arousal to negative faces and problems with social monitoring. Finally, hypo-arousal in the anticipation of risk during the card game related to problems in empathy. In summary, these data are consistent with the view that alterations in the ability to perceive emotional expressions in the face and the disruption in arousal to personally-relevant information may be accounting for some of the difficulties in social adaptation often observed in persons who have sustained a TBI. Furthermore, these data provide modest support for Damasio's Somatic Marker Theory in that physiological reactivity to socially-relevant information has some value in predicting social function. Therefore, the assessment of TBI persons, particularly those with adaptive behavioural problems, should be expanded to determine whether alterations in perception and reactivity to socially-relevant stimuli have occurred. When this is the case, rehabilitative strategies aimed more specifically at these difficulties should be considered.

Non-invasive measurement of trigeminal nerve somatosensory evoked potentials

Whiplash injuries are common yet enigmatic to substantiate clinically. Trigeminal somatosensory evoked potentials (TSEPs) were posited as an indicator of trigeminal nerve conduction damage resulting from whiplash. Alternating polarity square-wave current stimuli were applied transcutaneously in the facial region. 379 recorded pilot trials from 27 participants (8 male and 19 female) were utilized to develop a non-invasive recording capability for TSEPs. Stimulus intensity and artifact, cortical recording sites, stimulation electrode design and placement were explored. Statistically significant differences in amplitude of TSEP waveform components at 13, 19 and 27 ms between uninjured and whiplashed participants were noted. Increased stimulus intensity in whiplashed participants was observed to increase TSEP amplitude. The present methodology and hardware are discussed and directions for future advancement of the current process are outlined.

Investigating opposing aftereffects in 8-year-olds and adults

Previous studies have shown that adults and 8-year-olds process faces using norm-based coding and that prolonged exposure to one kind of facial distortion (e.g., compressed features) temporarily shifts the prototype, a process called adaptation, making similarly distorted faces appear more attractive (Anzures et aI., 2009; Valentine, 1999; Webster & MacLin, 1999). Aftereffects provide evidence that our prototype is continually updated by experience. When adults are adapted to two face categories (e.g., Caucasian and Chinese; male and female) distorted in opposing directions (e.g., expanded vs. compressed), their attractiveness ratings shift in opposite directions (Bestelmeyer et aI., 2008; Jaquet et aI., 2007), indicating that adults have dissociable prototypes for some face categories. I created a novel meth04 to investigate whether children show opposing aftereffects. Children and adults were adapted to Caucasian and Chinese faces distorted in opposite directions in the context of a computerized storybook. When testing adults to validate my method, I discovered that opposing aftereffects are contingent on how participants categorize faces and that this categorization is dependent on the context in which adapting stimuli are presented. Opposing aftereffects for Caucasian and Chinese faces were evident when the salience of race was exaggerated by presenting faces in the context of racially segregated birthday parties; expanded faces selected as most normal more often for the race of face that was expanded during adaptation than for the race of face that was compressed. However, opposing aftereffects were not evident when members of the two groups were presented engaging in cooperative social interactions at a racially integrated birthday party. Using the storybook that emphasized face race I 11 provide the first evidence that 8-year-olds demonstrate opposing aftereffects for two face categories defined by race, both when judging face normality and when rating attractiveness.

Supporting fathering through infant massage

Developing a strong relationship is essential for optimal child development and it is possible for fathers to fully participate in developing this close bond. Men often develop this relationship through interactive play which usually occurs later in their child's development. As a result, fathers often feel dissatisfied with their ability to form a close attachment in the early post-partum period, which in turn may increase their stress level. However, men can be prepared for the transition to fatherhood if they develop the knowledge and skill necessary to create positive relationships with their infants. Infant massage appears to be a viable option for teaching fathers care-giving sensitivity. To build on the notion of teaching fathers attachment system behaviour in early infancy, a quasi-experimental, mixed methods study was employed. Twenty-four infant-father dyads were recruited for the study. The fathers were asked to fill out the Parent Stress Index and a facial cues rating scale at two times, one month apart. The experimental group also participated in an infant massage intervention taught by a Certified Infant Massage Instructor of the International Association of Infant Massage. A repeated measures MANOVA revealed infant massage decreased paternal stress. Qualitatively, the fathers provided rich descriptions of their experience in the baby massage class which provided useful insight into the efficacy of the intervention. Overall, the fathers enjoyed the experience but did not necessarily see the direct benefit of the intervention on their relationship. Recommendations for pre and postnatal education for fathers are made.

Behavioural and neural correlates of emotion recognition as a function of psychopathic personality traits

Psychopathy is associated with well-known characteristics such as a lack of empathy and impulsive behaviour, but it has also been associated with impaired recognition of emotional facial expressions. The use of event-related potentials (ERPs) to examine this phenomenon could shed light on the specific time course and neural activation associated with emotion recognition processes as they relate to psychopathic traits. In the current study we examined the PI , N170, and vertex positive potential (VPP) ERP components and behavioural performance with respect to scores on the Self-Report Psychopathy (SRP-III) questionnaire. Thirty undergraduates completed two tasks, the first of which required the recognition and categorization of affective face stimuli under varying presentation conditions. Happy, angry or fearful faces were presented under with attention directed to the mouth, nose or eye region and varied stimulus exposure duration (30, 75, or 150 ms). We found that behavioural performance to be unrelated to psychopathic personality traits in all conditions, but there was a trend for the Nl70 to peak later in response to fearful and happy facial expressions for individuals high in psychopathic traits. However, the amplitude of the VPP was significantly negatively associated with psychopathic traits, but only in response to stimuli presented under a nose-level fixation. Finally, psychopathic traits were found to be associated with longer N170 latencies in response to stimuli presented under the 30 ms exposure duration. In the second task, participants were required to inhibit processing of irrelevant affective and scrambled face distractors while categorizing unrelated word stimuli as living or nonliving. Psychopathic traits were hypothesized to be positively associated with behavioural performance, as it was proposed that individuals high in psychopathic traits would be less likely to automatically attend to task-irrelevant affective distractors, facilitating word categorization. Thus, decreased interference would be reflected in smaller N170 components, indicating less neural activity associated with processing of distractor faces. We found that overall performance decreased in the presence of angry and fearful distractor faces as psychopathic traits increased. In addition, the amplitude of the N170 decreased and the latency increased in response to affective distractor faces for individuals with higher levels of psychopathic traits. Although we failed to find the predicted behavioural deficit in emotion recognition in Task 1 and facilitation effect in Task 2, the findings of increased N170 and VPP latencies in response to emotional faces are consistent wi th the proposition that abnormal emotion recognition processes may in fact be inherent to psychopathy as a continuous personality trait.

The Effects of Body Posture on Emotion Perception: A Developmental and Theoretical Analysis

Previously, studies investigating emotional face perception - regardless of whether they involved adults or children - presented participants with static photos of faces in isolation. In the natural world, faces are rarely encountered in isolation. In the few studies that have presented faces in context, the perception of emotional facial expressions is altered when paired with an incongruent context. For both adults and 8- year-old children, reaction times increase and accuracy decreases when facial expressions are presented in an incongruent context depicting a similar emotion (e.g., sad face on a fear body) compared to when presented in a congruent context (e.g., sad face on a sad body; Meeren, van Heijnsbergen, & de Gelder, 2005; Mondloch, 2012). This effect is called a congruency effect and does not exist for dissimilar emotions (e.g., happy and sad; Mondloch, 2012). Two models characterize similarity between emotional expressions differently; the emotional seed model bases similarity on physical features, whereas the dimensional model bases similarity on underlying dimensions of valence an . arousal. Study 1 investigated the emergence of an adult-like pattern of congruency effects in pre-school aged children. Using a child-friendly sorting task, we identified the youngest age at which children could accurately sort isolated facial expressions and body postures and then measured whether an incongruent context disrupted the perception of emotional facial expressions. Six-year-old children showed congruency effects for sad/fear but 4-year-old children did not for sad/happy. This pattern of congruency effects is consistent with both models and indicates that an adult-like pattern exists at the youngest age children can reliably sort emotional expressions in isolation. In Study 2, we compared the two models to determine their predictive abilities. The two models make different predictions about the size of congruency effects for three emotions: sad, anger, and fear. The emotional seed model predicts larger congruency effects when sad is paired with either anger or fear compared to when anger and fear are paired with each other. The dimensional model predicts larger congruency effects when anger and fear are paired together compared to when either is paired with sad. In both a speeded and unspeeded task the results failed to support either model, but the pattern of results indicated fearful bodies have a special effect. Fearful bodies reduced accuracy, increased reaction times more than any other posture, and shifted the pattern of errors. To determine whether the results were specific to bodies, we ran the reverse task to determine if faces could disrupt the perception of body postures. This experiment did not produce congruency effects, meaning faces do not influence the perception of body postures. In the final experiment, participants performed a flanker task to determine whether the effect of fearful bodies was specific to faces or whether fearful bodies would also produce a larger effect in an unrelated task in which faces were absent. Reaction times did not differ across trials, meaning fearful bodies' large effect is specific to situations with faces. Collectively, these studies provide novel insights, both developmentally and theoretically, into how emotional faces are perceived in context.