Mes: junio 2015

Deficits in social cognition are an evident clinical feature of the Asperger syndrome (AS). Although many daily life problems of adults with AS are related to social cognition impairments, few studies have conducted comprehensive research in this area. The current study examined multiple domains of social cognition in adults with AS assessing the executive functions (EF) and exploring the intra and inter-individual variability. Fifteen adults diagnosed with AS and 15 matched healthy controls completed a battery of social cognition tasks. This battery included measures of emotion recognition, theory of mind, empathy, moral judgment, social norms knowledge and self-monitoring behavior in social settings. We controlled for the effect of EF and explored the individual variability. The results indicated that adults with AS had a fundamental deficit in several domains of social cognition. We also found high variability in the social cognition tasks. In these tasks, AS participants obtained mostly subnormal performance. Executive functions did not seem to play a major role in the social cognition impairments. Our results suggest that adults with AS present a pattern of social cognition deficits characterized by the decreased ability to implicitly encode and integrate contextual information in order to access to the social meaning. Nevertheless, when social information is explicitly presented or the situation can be navigated with abstract rules, performance is improved. Our findings have implications for the diagnosis and treatment of individuals with AS as well as for the neurocognitive models of this syndrome.

La interocepción como censado del estado homeostático y visceral, ha sido recientemente postulada como requisito para la conciencia de estados emocionales corporales (Craig, 2009). Vías parasimpáticas y espinotalámicas que codifican esta información corporal tienen relevo en la corteza insular. Simultáneamente, han sido descriptas otras funciones insulares implicadas en procesos conscientes, como la intencionalidad, la toma de decisiones, la conciencia sensorio-motora, la percepción temporal, reconocer la imagen visual de uno mismo o percibir confiables a otros individuos (Craig, 2009; Ibanez, Gleichgerrcht, & Manes, 2010). Esta evidencia, sumada a resultados de estudios de lesión y neuroimágenes funcionales, sugiere que la corteza insular anterior (IA) sería la encargada de integrar señales multimodales cognitivas, emocionales y sociales para dirigir las conductas motivacionales que entrañan la supervivencia del individuo. En esta revisión analizamos el cúmulo de evidencia que involucran a la interocepción y al procesamiento insular integrativo en el surgimiento de estados emocionales conscientes, a través de estudios de lesiones y de técnicas de conectividad funcional en resonancia magnética funcional (RMF).

La escala de impulsividad de Barratt es un instrumento diseñado para evaluar el constructo impulsividad en tres dimensiones: atencional, motora y no planeada. La escala ha sido aplicada en pacientes con diferentes diagnósticos, en los cuales la sintomatología de impulsividad es característica. En Argentina no existen estudios que evalúen las propiedades psicométricas del instrumento en población clínica. El objetivo del trabajo fue evaluar las propiedades psicométricas de la escala en una muestra de la Ciudad de Buenos Aires. Se seleccionaron 150 sujetos adultos: 67 no presentaban diagnóstico psiquiátrico relevante, 56 cumplían criterios de trastorno bipolar y 27 presentaban diagnóstico de trastorno por déficit de atención. Se evaluaron la consistencia interna, la validez de constructo, la validez discriminativa y la estructura factorial. El alfa de Cronbach fue de 0,84 para la escala total. Asimismo, el instrumento ha demostrado indicadores aceptables de validez de constructo y validez discriminativa. Se encontraron diferencias al comparar la estructura factorial original con los resultados del presente estudio. Los resultados apoyan la utilidad de la escala en el contexto psiquiátrico, científico y clínico para evaluar el constructo de impulsividad. El puntaje total de la escala ha obtenido los indicadores más robustos de confiabilidad y validez.

INTRODUCTION: The processing of the emotion of disgust is attributed to the insular cortex (IC), which is also responsible for social emotions and higher-cognitive functions. We distinguish the role of the IC from its connections in regard to these functions through the assessment of emotions and social cognition in a double case report. These subjects were very rare cases that included a focal IC lesion and a subcortical focal stroke affecting the connections of the IC with frontotemporal areas. MATERIALS & METHODS: Both patients and a sample of 10 matched controls underwent neuropsychological and affective screening questionnaires, a battery of multimodal basic emotion recognition tests, an emotional inference disambiguation task using social contextual clues, an empathy task and a theory of mind task. RESULTS: The insular lesion (IL) patient showed no impairments in emotion recognition and social emotions and presented with a pattern of delayed reaction times (RTs) in a subset of both groups of tasks. The subcortical lesion (SL) patient was impaired in multimodal aversive emotion recognition, including disgust, and exhibited delayed RTs and a heterogeneous pattern of impairments in subtasks of empathy and in the contextual inference of emotions. CONCLUSIONS: Our results suggest that IC related networks, and not the IC itself, are related to negative emotional processing and social emotions. We discuss these results with respect to theoretical approaches of insular involvement in emotional and social processing and propose that IC connectivity with frontotemporal and subcortical regions might be relevant for contextual emotional processing and social cognition.

Introduction: The development of screening tools for the assessment of cognitive status in patients with dementia must be brief yet both highly sensitive and specific in order to ensure its clinical utility. In this sense, it is important to adapt tools widely used around the world to particular populations, allowing for a more proper validity of its use in everyday clinical practice. One of the most popular general cognitive screening tools is the Addenbrooke´s Cognitive Examination (ACE), which has been adapted and validated in multiple languages and populations. Objective: To assess the usefulness of the Peruvian version of the ACE in patients with dementia. Materials and methods: Healthy controls, patients with Alzheimer disease (AD) and patients with Frontotemporal Dementia (FTD) were assessed with the Peruvian version of the ACE, the ADAScog to determine dementia severity, and a complete neuropsychological battery. Results: The Peruvian version of the ACE showed very good internal con- sistency, strong concurrent validity as revealed by significant correlations between the ACE total score and both the MMSE and ADAScog. The ACE was able to differentiate healthy controls from patients with dementia with high discriminatory accuracy. Using a cut-off score of 86 (out of 100), the ACE was exhibited a sensitivity of 100% and a specificity of 100%.

INTRODUCCIÓN: La simulación de enfermedad mental ha sido un recurso utilizado por losimputados en causas penales con el fin de obtener beneficios ligados a la exención de la pena porun delito cometido, elección del lugar de alojamiento, trato o tratamiento recibido durante lareclusión. OBJETIVO: El presente trabajo intenta desarrollar un instrumento objetivo deevaluación que permita discriminar a los simuladores de enfermedad mental de los pacientespsiquiátricos dentro del ámbito penal. PACIENTES Y MÉTODO: Se evaluaron 92 derivaciones ala Unidad Psiquiátrica de Varones U.20 del Servicio Penitenciario Federal. Las evaluaciones serealizaron en la Sala de Observación y Evaluación Psiquiátrica (SOEP) por psiquiatras,neuropsicológos y trabajadores sociales. Se utilizaron criterios estandarizados de detección deSimulación, pruebas de diagnóstico clínico (MINI) y el Protocolo de Evaluación de Simulación(PES). RESULTADOS: El PES presentó, utilizando como punto de corte 17,5 puntos, un gradode sensibilidad de 92% y de especificidad de 95%. Los resultados obtenidos no han sidoinfluenciados por el nivel educativo, diagnóstico o causa penal del evaluado, tampoco por la edad o los antecedentes tóxicos del mismo. El protocolo no ha discriminado el resultado desimuladores vs. retrasos mentales moderados/grave. CONCLUSIONES: El PES resulta unaherramienta útil para el diagnóstico clínico de simulación dentro del ámbito penal. La correctadiferenciación de patologías psiquiátricas u otros problemas que requieran de atención(problemas institucionales, familiares, legales) resulta en un beneficio para el pacientepsiquiátrico prisionizado y el cuidado del espacio de tratamiento para los mismos.

In this work, we explored convergent evidence supporting the fronto-striatal model of obsessive-compulsive disorder (FSMOCD) and the contribution of event-related potential (ERP) studies to this model. First, we considered minor modifications to the FSMOCD model based on neuroimaging and neuropsychological data. We noted the brain areas most affected in this disorder -anterior cingulate cortex (ACC), basal ganglia (BG) and orbito-frontal cortex (OFC)- and their related cognitive functions, such as monitoring and inhibition. Then, we assessed the ERPs that are directly related to the FSMOCD, including the error-related negativity (ERN), N200 and P600. Several OCD studies present enhanced ERN and N2 responses during conflict tasks as well as an enhanced P600 during working memory tasks. Evidence from ERP studies (especially regarding ERN and N200 amplitude enhancement), neuroimaging and neuropsychological findings suggests abnormal activity in the OFC, ACC and BG in OCD patients. Moreover, additional findings from these analyses suggest dorsolateral prefrontal and parietal cortex involvement, which might be related to executive function deficits. Thus, these convergent results suggest the existence of a self-monitoring imbalance involving inhibitory deficits and executive dysfunctions. OCD patients present an impaired ability to monitor, control, and inhibit intrusive thoughts, urges, feelings and behaviors. In the current model, this imbalance is triggered by an excitatory role of the BG (associated with cognitive or motor actions without volitional control) and inhibitory activity of the OFC as well as excessive monitoring of the ACC to block excitatory impulses. This imbalance would interact with the reduced activation of the parietal-DLPC network, leading to executive dysfunction. ERP research may provide further insight regarding the temporal dynamics of action monitoring and executive functioning in OCD.

In the ARISTOTLE trial, the rate of stroke or systemic embolism was reduced by apixaban compared with warfarin in patients with atrial fibrillation (AF). Patients with AF and previous stroke or transient ischaemic attack (TIA) have a high risk of stroke. We therefore aimed to assess the efficacy and safety of apixaban compared with warfarin in prespecified subgroups of patients with and without previous stroke or TIA. METHODS: Between Dec 19, 2006, and April 2, 2010, patients were enrolled in the ARISTOTLE trial at 1034 clinical sites in 39 countries. 18,201 patients with AF or atrial flutter were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalised ratio 2·0-3·0). The median duration of follow-up was 1·8 years (IQR 1·4-2·3). The primary efficacy outcome was stroke or systemic embolism, analysed by intention to treat. The primary safety outcome was major bleeding in the on-treatment population. All participants, investigators, and sponsors were masked to treatment assignments. In this subgroup analysis, we estimated event rates and used Cox models to compare outcomes in patients with and without previous stroke or TIA. The ARISTOTLE trial is registered with ClinicalTrials.gov, number NTC00412984. FINDINGS: Of the trial population, 3436 (19%) had a previous stroke or TIA. In the subgroup of patients with previous stroke or TIA, the rate of stroke or systemic embolism was 2·46 per 100 patient-years of follow-up in the apixaban group and 3·24 in the warfarin group (hazard ratio [HR] 0·76, 95% CI 0·56 to 1·03); in the subgroup of patients without previous stroke or TIA, the rate of stroke or systemic embolism was 1·01 per 100 patient-years of follow-up with apixaban and 1·23 with warfarin (HR 0·82, 95% CI 0·65 to 1·03; p for interaction=0·71). The absolute reduction in the rate of stroke and systemic embolism with apixaban versus warfarin was 0·77 per 100 patient-years of follow-up (95% CI -0·08 to 1·63) in patients with and 0·22 (-0·03 to 0·47) in those without previous stroke or TIA. The difference in major bleeding with apixaban compared with warfarin was 1·07 per 100 patient-years (95% CI 0·09-2·04) in patients with and 0·93 (0·54-1·32) in those without previous stroke or TIA. INTERPRETATION: The effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA. Owing to the higher risk of these outcomes in patients with previous stroke or TIA, the absolute benefits of apixaban might be greater in this population. FUNDING: Bristol-Myers Squibb and Pfizer.

Faced with a moral dilemma, conflict arises between a cognitive controlled response aimed at maximizing welfare, i.e. the utilitarian judgment, and an emotional aversion to harm, i.e. the deontological judgment. In the present study, we investigated moral judgment in adult individuals with high functioning autism/Asperger syndrome (HFA/AS), a clinical population characterized by impairments in prosocial emotions and social cognition. In Experiment 1, we compared the response patterns of HFA/AS participants and neurotypical controls to moral dilemmas with low and high emotional saliency. We found that HFA/AS participants more frequently delivered the utilitarian judgment. Their perception of appropriateness of moral transgression was similar to that of controls, but HFA/AS participants reported decreased levels of emotional reaction to the dilemma. In Experiment 2, we explored the way in which demographic, clinical and social cognition variables including emotional and cognitive aspects of empathy and theory of mind influenced moral judgment. We found that utilitarian HFA/AS participants showed a decreased ability to infer other people’s thoughts and to understand their intentions, as measured both by performance on neuropsychological tests and through dispositional measures. We conclude that greater prevalence of utilitarianism in HFA/AS is associated with difficulties in specific aspects of social cognition.

El síndrome inflamatorio de reconstitución inmune (SIRI) es una complicación poco frecuente pero grave que aumenta la morbimortalidad de algunos pacientes en los que su sistema inmune comienza a recuperarse tras la disminución del tratamiento inmunosupresor y reacciona contra una infección oportunista adquirida previamente. Dicha respuesta inflamatoria es excesiva y produce un deterioro paradójico del estado clínico del paciente, a pesar de estar recibiendo adecuado tratamiento infeccioso.
Presentamos el caso de una mujer de 67 años, inmunosuprimida por un trasplante hepatorrenal, que consulta por cuadro de deterioro general con disminución de la ingesta, tendencia al sueño y cefalea. Se diagnostica criptococosis meníngea e inicia tratamiento antifúngico adecuado con una respuesta inicial favorable. Tras dos meses experimenta una recaída de sus síntomas, agregando mayor compromiso neurológico. El caso clínico plantea las posibles causas de dicho empeoramiento, remarcando la importancia de considerar al SIRI.