Resumo Este estudo teve como objetivo caracterizar as associações de pessoas com doenças raras, como uma importante fonte de apoio psicossocial. Foram realizadas entrevistas a 38 participantes de 23 associações e delegações de pessoas com doenças raras, vinculadas ao Centro de Genética Preditiva e Preventiva. Das análises emergiram três categorias conceptuais: (1) missão das associações; (2) contexto do trabalho associativo; e (3) estratégias e oportunidades. Os principais obstáculos ao papel das associações como fonte de apoio às pessoas doentes e suas famílias foram: (1) dificuldade em encontrar voluntários; (2) baixo nível de literacia sobre doenças raras; (3) pouco envolvimento dos profissionais de saúde e população; e (4) dificuldade em obter financiamento. Os resultados mostraram que as associações têm um papel fundamental na defesa dos direitos das pessoas com doenças raras, sendo possível potenciar o seu trabalho, maximizando a integração com os serviços de saúde e a sua visibilidade.

Abstract Rare disease associations in Portugal: An important source of psychosocial support: This study aimed at characterizing the rare disease patients’ associations, as a relevant source of psychosocial support. Thirty-eight participants were interviewed, from 23 patients’ associations (or its regional sections), connected to Centro de Genética Preditiva e Preventiva. Three conceptual categories have emerged in their discourses: (1) mission of their associations; (2) current context of associative work; and (3) strategies used and existing opportunities. The most common limitations were (1) the difficulty in finding volunteers; (2) the low literacy about rare diseases; (3) the limited involvement of professionals and of the general population; and (4) difficulties with funding. Our results showed that associations do play a key role in the advocacy for patients with rare diseases; and that it is possible to reinforce their articulation with existing resources, facilitating their integration with healthcare services and, thus, maximizing their visibility.

A instabilidade crónica da articulação trapeziometacárpica é uma entidade rara que ocorre sobretudo em contexto de laxidez articular sistémica. Os principais sintomas são a dor nos movimentos de pinça e sensação de instabilidade. A doença pode ser diagnosticada pela radiografia em stress. O tratamento cirúrgico está indicado quando os sintomas persistem apesar de tratamento conservador com fisioterapia e imobilização. Os autores apresentam um caso clínico de instabilidade crónica isolada e não traumática da articulação trapeziometacárpica numa criança de 12 anos. Após falência de tratamento conservador com fisioterapia e imobilização gessada, a doente foi tratada cirurgicamente com ligamentoplastia pela técnica de Eaton-Littler modificada, com bons resultados aos 3 anos de seguimento.

Chronic instability of the trapeziometacarpal joint is a rare entity that occurs mainly in the context of systemic joint laxity. The main symptoms are pain in pincer movements and feeling of instability. The disease can be diagnosed by stress radiography. Surgical treatment is indicated when symptoms persist despite conservative treatment with physical therapy and immobilization. The authors present a clinical case of isolated and non-traumatic chronic instability of the trapeziometacarpal joint in a 12-year-old child. After failure of conservative treatment with physical therapy and plaster immobilization, the patient was surgically treated with ligamentplasty using the modified Eaton-Littler technique, with good results at 3 years follow-up.

RESUMO A doença de Machado-Joseph, também conhecida como ataxia espinocerebelar tipo 3 (SCA3), representa a forma mais comum de ataxia hereditária autossômica dominante no mundo. Paula Coutinho, neurologista portuguesa de reputação mundial, teve participação fundamental na definição desta doença há mais de 40 anos.

ABSTRACT Machado-Joseph disease, also known as spinocerebellar ataxia type 3, is the most common form of autosomal dominant ataxia in the world. Paula Coutinho, a highly-regarded Portuguese neurologist worldwide, had a seminal participation in the definition of this disease, more than 40 years ago.

Resumen Los objetivos de este estudio son saber si los sujetos en riesgo eran conscientes de su riesgo del 50% para la polineuropatía amiloide familiar (PAF); conocer el valor del riesgo subjetivo; y comprender la asociación entre las características sociodemográficas y la percepción del riesgo y entre el riesgo real y la percepción subjetiva del riesgo. Se examinaron 174 sujetos con riesgo de PAF del 50%. 52,9% de los sujetos en riesgo eran conscientes de su condición de riesgo del 50%. El valor medio del riesgo subjetivo fue mayor y más cercano al 50% cuando los sujetos eran conscientes de su condición de riesgo del 50%. La educación se asoció a una mayor conciencia de estar al 50% de riesgo. Parece que la información sobre los conocimientos previos antes de realizar el asesoramiento genético aumenta el riesgo subjetivo.

Abstract The aims of this study are to know if subjects at-risk were aware of their 50% risk for Familial Amyloidotic Polyneuropathy (FAP); to know the value of the subjective risk; to understand the association between sociodemographic characteristics and risk perception, and between the risk status and the subjective perception of risk. 174 subjects 50% at-risk for FAP were tested. 52.9% subjects at-risk were aware of their 50% risk condition. The mean value of the subjective risk was higher and closer to 50% when the subjects were aware of their 50% risk condition. Education was associated to a higher awareness of being at 50% risk. It seems that information on previous knowledge before performing the genetic counselling increases the subjective risk.

The role of the clinical psychologist in the context of genetic counseling includes support for the process of decision-making for subjects at-risk, regardless of the decision that was made. For this, it is important to know the motivations behind these decisions. What may be considered advant-ageous and justifiable reasons to perform the PST for genetic diseases from the medical and public point of view, i.e., planning for the future, helping in the choice of a profession, family planning, improving quality of life and contributing to health, may not be recognized as such by the individual seeking the PST. This study addresses the motivation to perform the presymptomatic testing (PST) of subjects at-risk for three diseases, Familial Amyloid Polyneuro pathy (FAP), Huntington's disease (HD), and Machado-Joseph disease (MJD), compared with the motivation to perform the PST for Hemochromatosis (HH). FAP, HD and MJD are three genetic (monogenic) autosomal dominant late-onset diseases (LON-Ds) with no cure. FAP is a progressive sensorimotor and autonomic neuropathy of adult hood. HD is characterized by a triad of clinical symptoms of chorea (motor, cognitive and psychiatric symptoms), emotional distress and cognitive decline. MJD is characterized by slowly progressive clumsiness in the arms and legs, a staggering lurching gait, sometimes mistaken for drunkenness, difficulty with speech and swallowing, involuntary eye movements, and may be accompanied by double vision or bulging eyes, and lower limb spasticity. HH is a disease in which too much iron accumulates in parenchymal organs, leading to iron overload and subsequent organ toxicity and failure. The study participants consisted in 213 subjects at genetic risk for FAP, HD, and MJD and 31 subjects at genetic risk for HH, that were assessed through an interview to obtain sociodemographic data and the answer to one question about motivation to perform PST: "Which were the reasons that led you to perform the predictive test? "This study was carried out in Center for Predictive and Preventive Genetics (CGPP), Institute for Molecular and Cell Biology (IBMC), Porto (Portugal). This research used a mixed-method, since qualitative and quantitative techniques of data analysis were used. Before deciding to seek genetic counseling and to know their genetic status, subjects at-risk have naturally considered their motives and it was probably the pro-counseling reasons the ones dictating the motivation to perform the PST. This may suggest that in fact there is a prior self-selection to the test, i.e. only those considering to have emotional skills to go through the process, performing the test. Seven major categories were obtained. The most significant ones for FAP, HD and MJD were reasons related to the future, reasons related to others and reasons related to curiosity and to the need to know. For HH, the most important ones were reasons related to others and reasons related to the characteristics of the disease. The motivation of subjects at-risk to perform the PST for FAP, HD and MJD is external and unrelated to the disease, while the motivation of subjects at-risk to perform the PST for HH is related to the disease. Reasons related to others area common motivation: as subjects at-risk for FAP, HD and MJD, subjects at-risk for HH also chose reasons related to others as one of the most important motivations to carry out the PST. These subjects also care about the fact that they can transmit the disease to their children and care about other family members which are already ill. The category reasons related to others includes sub-categories that identify the person and the situation that led to the decision to perform a PST. Subjects at-risk are also concerned about the fact that they have to decide whether or not to have children and its economic implications.

El papel del psicólogo clínico en el contexto del consejo genético incluye brindar apoyo a los sujetos en riesgo en el proceso de toma de decisiones, independientemente de la decisión adoptada por el sujeto (conociendo o no el resultado de las pruebas genéticas). El estudio que se informa aborda la motivación para realizar las pruebas pre-sintomáticas (PPS) de sujetos en situación de riesgo para tres enfermedades: polineuropatía amiloide familiar (PAF), la enfermedad de Huntington (EH) y la enfermedad de Machado-Joseph (EMJ) y comparar con la motivación para realizar las PPS para hemocromatosis (HH). La muestra consistió en 213 sujetos portugueses que tenían riesgo genético para contraer las tres enfermedades y 31 sujetos en situación de riesgo genético para contraer hemocromatosis. Ellos fueron evaluados con una entrevista para obtener datos sociodemográficos y debían responder a una pregunta sobre la motivación para llevar a cabo las pruebas pre-sintomáticas. Se obtuvieron siete categorías principales y las siguientes son las más significativas para PAF, EH y EMJ: razones relacionadas con el futuro, razones relacionadas con los demás y razones relacionadas con la curiosidad y la necesidad de conocer. Para hemocromatosis, las más importantes resultaron ser razones relacionadas con los demás y las relacionadas con las características de la enfermedad. La motivación para realizar el test pre-sintomático (PST) de la PAF, EH y EMJ es externa y sin relación con la enfermedad, mientras que la motivación de los sujetos en situación de riesgo para la HH está relacionada con la enfermedad. Las razones relacionadas con los demás es una motivación común en ambos grupos. A los sujetos también les preocupa la posibilidad de transmitir la enfermedad a sus hijos.

Objective: To study anxiety as a variable of the mid- and long-term psychological impact of pre-symptomatic testing for three autosomal dominant late-onset disorders – Huntington’s disease (HD), Machado-Joseph disease (MJD) and familial amyloid polyneuropathy (FAP) TTR V30M – in a Portuguese sample. Methods: This cross-sectional study included 203 participants: 170 (83.7%) underwent pre-symptomatic testing for FAP, 29 (14.3%) for HD, and 4 (2%) for MJD. Of the 203 participants, 73 (36.0%) were asymptomatic carriers, 29 (14.5%) were symptomatic carriers, 9 (4.5%) were diagnosed with FAP and had a liver transplant, and 89 (44.5%) were non-carriers. Most were women (58.1%) and married (66.5%). The anxiety variable was assessed using the Zung Self-Rating Anxiety Scale (SAS). Results: The anxiety scores were higher for symptomatic carriers and for those who underwent psychological support consultations over the years. For symptomatic carriers, the mean scores were superior to 40 points, which reflects clinical anxiety. Conclusion: Although it was not possible to differentiate between the mid- and long-term psychological impacts, this study supports the conclusion that the proximity to the age of symptoms onset might be a trigger for anxiety.

Machado-Joseph disease (MJD) is an autosomal dominant, late-onset neurological disorder and the most common form of spinocerebellar ataxia (SCA) worldwide. Diagnostic genetic testing is available to detect the disease-causing mutation by direct sizing of the CAG repeat tract in the ataxin 3 gene. Presymptomatic testing (PST) can be used to identify persons at risk of developing the disease. Genetic counseling provides patients with information about the disease, genetic risks, PST, and the decision-making process. In this study, we present the protocol used in PST for MJD and the relevant observations from two centers: Brazil (Porto Alegre) and Portugal (Porto). We provide a case report that illustrates the significant ethical and psychological issues related to PST in late-onset neurological disorders. In both centers, counseling and PST are performed by a multidisciplinary team, and genetic testing is conducted at the same institutions. From 1999 to 2012, 343 individuals sought PST in Porto Alegre; 263 (77%) of these individuals were from families with MJD. In Porto, 1,530 individuals sought PST between 1996 and 2013, but only 66 (4%) individuals were from families with MJD. In Brazil, approximately 50% of the people seeking PST eventually took the test and received their results, whereas 77% took the test in Portugal. In this case report, we highlight several issues that might be raised by the consultand and how the team can extract significant information. Literature about PST testing for MJD and other SCAs is scarce, and we hope this report will encourage similar studies and enable the implementation of PST protocols in other populations, mainly in Latin America.

No âmbito do protocolo do teste preditivo para doenças neurogenéticas de aparecimento tardio (Doença de Huntington, Doença de Machdo-Joseph e Polineuropatia Amiloidótica Familiar) aplicado a sujeitos em risco para estas doenças, investigamos o bem estar psicológico destes sujeitos. Averiguar se o bem estar psicológico dos sujeitos em risco, comparativamente com a população geral, é mais ou menos elevado. The Psychological General Well Being (PGWB) Index ( Escala de Bem Estar Psicológico Geral) foi desenvolvida com o objectivo de oferecer um índice que medisse as auto representações dos estados emocionais ou afectivos intrapessoais que reflectisse a noção subjectiva de bem estar ou distress. Comparamos os resultados do grupo de sujeitos em risco com o grupo de controlo: Existem diferenças significativas em relação aos factores ansiedade e bem estar positivo. O grupo em risco apresenta menos ansiedade e maior bem estar positivo. O grupo de risco tem indicadores de bem estar psicológico mais elevados do que o grupo de controlo. Seria de esperar que os sujeitos em risco de doença neurogenética de aparecimento tardio apresentassem valores mais baixos no que diz respeito ao bem estar psicológico geral, uma vez que estão relativamente conscientes do risco que correm de serem portadores duma doença desse tipo. Contudo, não é isso que verificamos, pelo contrário, o grupo de risco apresenta um maior bem estar psicológico em relação ao grupo de controlo. Concluímos que o grupo em risco de ser portador de gene de doença neurogenética de aparecimento tardio apresenta globalmente um maior bem estar psicológico do que o grupo de controlo. Os dados obtidos apontam para duas hipóteses: a) a de estarmos perante uma atitude defensiva e de negação por parte dos indivíduos de risco; b) a de estarmos perante indivíduos mais resistentes do ponto de vista psicológico, o que poderá ter motivado a auto-selecção para aderirem ao Teste Preditivo.

Psychological issues are important for counselling and intervention in late-onset diseases (Huntington Disease, Machado Joseph Disease and), namely in the process of adjustment to the results of genetic testing. Our aim was to evaluate psychological wellbeing in persons coming for pre-symptomatic testing comparing with normal population. The Psychological General Well Being (PGWB) Schedule was developed for the purpose of providing na index that could be used to measure self-representations of intrapersonal affective or emotional states reflecting a sense of subjective wellbeing or distress. We compared the results between the group of individuals at-risk and the control group: there are significative differences regarding the anxiety and positive wellbeing factors. The group at-risk presents less anxiety and more positive wellbeing. The group at-risk shows higher psychologycal wellbeing indicators than the control group. One may have expected that individuals at-risk who came for pre-symptomatic testing were more concerned about their health and showed more adverse indicators regarding their psychological wellbeing, since they are more aware of the risk of being or not a carrier of one of those diseases. Our results, however, proved to be different: the group at-risk presents less anxiety and more positive wellbeing and shows higher psychologycal wellbeing indicators than the control group. Facing those results we may suggest two possible explanations(a) a defensive and denial attitude from the group of individuals at-risk, and/or that (b) these are psychologically more resilient, what may have motivated adhesion to pre-symptomatic testing, through their own auto-selection.