Immediate plate fixation of open tibial plafond fractures does not elevate risk of infection.

OBJECTIVE: To determine if immediate plate fixation of open tibial plafond fractures has a negative effect on soft tissue complications and increases the risk of deep infection. DESIGN: This was a single-institution retrospective cohort study performed at level-1 trauma center. All patients with open OTA/AO 43C plafond fractures treated over 20-year period with follow-up until fracture union or development of deep infection. Ninety-nine of 333 identified patents met the inclusion criteria. The intervention was operative treatment of open tibial plafond fractures. The main outcome measurements were return to operating room for deep infection, nonunion, and below knee amputation. RESULTS: The overall rate of complications was 52%. Gender, body mass index, tobacco use, diabetes, ASA classification, time to OR from injury, wound location, and associated fibula fracture were not associated with deep infection. There was a significant difference in Gustilo-Anderson fracture grade among infected versus non-infected (P = 0.04). There was no significant difference in postoperative infection rates between patients treated with external fixation, external fixation and limited plate fixation, and plate fixation alone during initial surgery (P = 0.64). CONCLUSION: It is well established that open pilon fractures have a high incidence for postoperative infection and development of complications such as nonunion. As these injuries have poor clinical outcomes, any additional measures to prevent infection and soft tissue complications should be utilized. In appropriately selected cases, both immediate plate fixation and immediate limited plate fixation with external fixation at the time of I&D do not appear to elevate risk of deep infection. LEVEL OF EVIDENCE: Therapeutic Level III.

Human sweat contains oxytocin.

BACKGROUND: Oxytocin (OT) has been detected in various body fluids, including blood, urine, saliva, breastmilk, and spinal fluid. Consistent with models that regard skin as a social organ and in line with studies demonstrating that skin cells express both OT and its receptor, our study sought to examine the presence of OT in human sweat. METHODS: Overall, 553 individuals participated in a pilot study and three experiments. Firstly, 50 participants provided sweat after engaging in various sports for different durations. Secondly, 26 participants provided sweat from forehead, upper-chest, forearm, and underarm, including 11 in natural setting and 15 following OT administration and a 30-minute exercise. Thirdly, of 435 volunteers, 97 provided sufficient axillary sweat for assaying. Of these, 84 participated in a naturalistic experiment that involved saliva and sweat collection in response to physical activity in either solitary or social settings. OT and testosterone (TS) were assayed in sweat and saliva. RESULTS: Intense activity for at least 25 min was required to produce sufficient sweat for OT analysis. Highest OT levels were found in axillary sweat compared to sweat from the forehead, upper-chest, and forearm. Salivary OT and TS increased after both solitary and social physical activity; however, higher sweat OT was found after solitary sports. Post-hoc preliminary findings indicate that highly extroverted individuals exercising in solitary environments showed the highest sweat OT levels. CONCLUSIONS: Findings demonstrate, for the first time, the presence of OT in human sweat and show the feasibility of its measurement. Much further research is required to illuminate how sweat OT is impacted by personality and social context and to uncover the role of the skin in OT production.

Comparable Outcomes Between Native and Periprosthetic Fractures of the Distal Femur.

Despite the rising prevalence of arthroplasty and aging population, limited data exist regarding differences in periprosthetic fracture clinical outcomes compared with native counterparts. This study compares differences in hospital treatment, morbidity, and mortality associated with periprosthetic distal femur fractures at an urban level 1 trauma center. We retrospectively reviewed all adult AO/OTA type 33 fractures (526) that presented to our institution between 2009 and 2018. In total, 54 native and 54 periprosthetic fractures were matched by age and gender. We recorded demographics, operative measures, length of stay (LOS), discharge disposition, and mortality. We used McNemar's and paired t-tests for analysis where appropriate (p < 0.05) (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY; IBM Corp.). The average age at injury was 74 years ± 12 (native) compared with 73 years ± 12 (periprosthetic). After 1:1 matching, the groups had similar body mass index (31.01 vs. 32.98, p = 0.966 for native and periprosthetic, respectively) and mechanisms of injury with 38 native and 44 periprosthetic (p = 0.198) fractures from low-energy falls. Both groups had 51/54 fractures managed with open reduction internal fixation with a locking plate. The remaining were managed via amputation or intramedullary nail fixation. Mean operative time (144 minutes (±64) vs. 132 minutes (±62), p = 0.96) and estimated blood loss (319 mL (±362) vs. 289 mL (±231), p = 0.44) were comparable between the native and periprosthetic groups, respectively. LOS: 9 days ± 7 (native) versus 7 days ± 5 (periprosthetic, p = 0.31); discharge disposition (to skilled nursing facility/rehab): n = 47 (native) versus n = 43 (periprosthetic, p = 0.61); and mortality: n = 6 (native) versus n = 8 (periprosthetic, p = 0.55). No significant differences were observed. We found no statistical differences in morbidity and mortality in periprosthetic distal femur fractures treated over 10 years at a level 1 trauma center. Native and periprosthetic AO/OTA type 33 distal femur fractures are serious injuries with similar outcomes at a level 1 trauma center.

An anatomical study defining the safe range of angles in percutaneous iliosacral and transsacral screw fixation.

Percutaneous iliosacral screw fixation and transsacral fixation are challenging procedures requiring extensive knowledge of sacral anatomy to avoid damaging nearby neurovascular structures. Greater knowledge of anatomical screw trajectory and size allowances would be helpful to guide surgical placement. An anatomical study of 40 cadaveric sacra in specimens ages 18-65 was performed. Three-dimensional surface scans were obtained, and computer modeling software was used to simulate a 7.3 mm diameter screw with 1 mm buffer inserted orthogonal to the sacroiliac joint in the pelvic inlet and outlet views. Transsacral screws were also inserted into S1 and S2 vertebrae. For screws orthogonal to the sacroiliac joint, the overall mean screw insertion angle was 4.1° ± 7.5° (range, -18.3° to 22.0°) in the inlet view in the posterior to anterior direction, and 21.7° ± 5.1° (range, 8.2°-36.3°) in the outlet view in the caudal to cranial direction. Before breaching the sacrum, the range of sacral tunnel lengths was between 31.1 and 70.1 mm with a range of diameters between 9.3 and 13.3 mm. Transsacral screws inserted into either the S1 or S2 vertebrae did not breach the sacrum in 40% (16/40) at each level. 30% (12/40) of sacra could not safely accommodate both S1 and S2 transsacral screws. There is an initial screw insertion angle range of -4° to 12° in the inlet view and 16°-27° in the outlet view. There was always adequate size to accept a 7.3 mm or larger screw.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

OBJECTIVE: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN: Retrospective cohort study. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Virtual Reality Tools for Assessing Unilateral Spatial Neglect: A Novel Opportunity for Data Collection.

Unilateral spatial neglect (USN) is a syndrome characterized by inattention to or inaction in one side of space and affects between 23-46% of acute stroke survivors. The diagnosis and characterization of these symptoms in individual patients can be challenging and often requires skilled clinical staff. Virtual reality (VR) presents an opportunity to develop novel assessment tools for patients with USN. We aimed to design and build a VR tool to detect and characterize subtle USN symptoms, and to test the tool on subjects treated with inhibitory repetitive transcranial magnetic stimulation (TMS) of cortical regions associated with USN. We created three experimental conditions by applying TMS to two distinct regions of cortex associated with visuospatial processing- the superior temporal gyrus (STG) and the supramarginal gyrus (SMG) - and applied sham TMS as a control. We then placed subjects in a virtual reality environment in which they were asked to identify the flowers with lateral asymmetries of flowers distributed across bushes in both hemispaces, with dynamic difficulty adjustment based on each subject's performance. We found significant differences in average head yaw between subjects stimulated at the STG and those stimulated at the SMG and marginally significant effects in the average visual axis. VR technology is becoming more accessible, affordable, and robust, presenting an exciting opportunity to create useful and novel game-like tools. In conjunction with TMS, these tools could be used to study specific, isolated, artificial neurological deficits in healthy subjects, informing the creation of VR-based diagnostic tools for patients with deficits due to acquired brain injury. This study is the first to our knowledge in which artificially generated USN symptoms have been evaluated with a VR task.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Rupture of Achilles Tendon in an Adolescent with a History of Ponseti Casting and Achilles Tenotomy: A Case Report.

CASE: We present the case of a 15-year-old girl who has a history of Ponseti casting followed by Achilles tenotomies for congenital clubfeet as an infant and subsequently suffered an acute traumatic midsubstance Achilles tendon rupture on the left and midsubstance Achilles tendinosis on the right. CONCLUSIONS: Traumatic pediatric Achilles ruptures are rare. There are no prior reported cases in patients with a history of Achilles tenotomy, despite it being a described potential complication. This case highlights the potential for an Achilles rupture years after tenotomy and presents surgical repair as a satisfactory treatment option for Achilles ruptures in adolescents.

An anatomic study of the distal femoral epiphysis.

BACKGROUND: The anatomy of the undulating distal femoral physis may be relevant to growth disturbance after physeal fractures and screw fixation about the physis. The surface anatomy of this physis has not been well described. METHODS: We performed an anatomic study on 26 cadaveric distal femoral epiphyses in specimens 3 to 18 years of age. High-resolution 3-dimensional surface scans were obtained and analyzed to determine the heights, approximate surface areas, and locations of the major undulations. RESULTS: Gross examination revealed lateral and anteromedial peripheral notches at the metaphyseal-epiphyseal junction, which deepen with advancing skeletal maturity. Within the epiphysis, there are 3 major undulations: a central ridge, lateral ridge, and medial peak, with mean heights of 5.5 mm (range, 2.9 to 9.8 mm), 2.5 mm (1.0 to 5.7 mm), and 2.9 mm (0.9 to 4.7 mm), respectively. The normalized height and surface area of each undulation decreased with increasing age, most dramatically in the central ridge. With respect to a line connecting the medial and lateral aspects of the physis, we found that the central peak passes more superior with younger age, and tends to be more posteriorly located. The lowest point of the physis is located either anteromedial or posterolateral. CONCLUSIONS: The central ridge, lateral ridge, and medial peak are the 3 major undulations in the distal femoral physis. The central ridge has the greatest height and most dramatic decrease in relative size with increasing age, suggesting structural importance. This anatomic data can guide metaphyseal and epiphyseal screw fixation. CLINICAL RELEVANCE: This study provides quantitative data on the topographic anatomy of the distal femoral physis, which can guide screw placement about the physis. These data may help identify fractures patterns with a greater risk of growth disturbance and key radiographic landmarks for guiding fracture reduction.

An anatomic study of the epiphyseal tubercle and its importance in the pathogenesis of slipped capital femoral epiphysis.

BACKGROUND: It has been proposed that the epiphyseal tubercle on the inferior surface of the capital femoral epiphysis may be responsible for the clinical distinction between a stable and an unstable slipped capital femoral epiphysis (SCFE). The anatomy of the tubercle and its relationship to the lateral epiphyseal vessels have not previously been rigorously defined. METHODS: Twenty-two cadaveric capital femoral epiphyses from donors who had been three to seventeen years of age were analyzed and then digitized with use of a high-resolution laser scanner. The height, location, and approximate surface area of the epiphyseal tubercle were measured and were normalized to the size of the entire capital femoral epiphysis. RESULTS: In all specimens except that from the youngest donor, the foramina for the lateral epiphyseal vessels were visible and were located directly superior to the epiphyseal tubercle. The height of the epiphyseal tubercle was 4.4 ± 1.1 mm. When normalized to the overall size of the capital femoral epiphysis, the relative height (r = 0.71) and relative area (r = 0.56) of the epiphyseal tubercle decreased with increasing age. The epiphyseal tubercle was consistently located in the posterosuperior quadrant, with its position being more posterior and less superior in specimens from younger donors. CONCLUSIONS: The epiphyseal tubercle appears to be a major stabilizer, or keystone, of the capital femoral epiphysis and the lateral epiphyseal vessels. Its relative decrease in height and surface area with increasing age may help explain the susceptibility of individuals to SCFE in adolescence: in a stable SCFE, the physis rotates on the tubercle; however, in an unstable SCFE, the tubercle dislodges, leading to more substantial displacement of the capital femoral epiphysis and the lateral epiphyseal vessels, risking osteonecrosis.

The shape of the proximal femur influences acetabular wear patterns over time.

BACKGROUND: Femoroacetabular impingement has been proposed as a cause of early osteoarthritis, but it is not known how this develops over time or whether the shape of the proximal femur influences this risk. QUESTIONS/PURPOSES: (1) Which areas of the acetabulum are worn more frequently by individuals with a cam deformity of the proximal femur? (2) Do observed acetabular wear patterns differ based on the etiology of the cam deformity? (3) Do wear patterns of individuals with a cam deformity differ based on an individual's age? METHODS: We examined 645 corresponding femora and acetabuli from the Hamann-Todd Osteological Collection and determined the offset and alpha angle using photographs; 370 specimens met inclusion criteria and were examined for signs of wear and the locations of wear were recorded. Specimens were separated into eight subgroups based on age either younger than 40 years or older than 60 years, alpha angle greater or less than 55°, and degree of anterior head-neck offset. We compared the prevalence of wear between groups in each location. RESULTS: Individuals with abnormal geometry of the proximal femur demonstrated different wear patterns from individuals with normal geometry. There were few differences in wear patterns identified based on the etiology of the femoral deformity. Abnormal femoral geometry was associated with more frequent wear primarily at the anterosuperior acetabulum for individuals younger than 40 years of age and globally for individuals older than 60 years of age. CONCLUSION: Femoral geometry appears to influence the pattern of acetabular wear occurring over time.

Effects of acute sprint interval cycling and energy replacement on postprandial lipemia.

High postprandial blood triglyceride (TG) levels increase cardiovascular disease risk. Exercise interventions may be effective in reducing postprandial blood TG. The purpose of this study was to determine the effects of sprint interval cycling (SIC), with and without replacement of the energy deficit, on postprandial lipemia. In a repeated-measures crossover design, six men and six women participated in three trials, each taking place over 2 days. On the evening of the first day of each trial, the participants either did SIC without replacing the energy deficit (Ex-Def), did SIC and replaced the energy deficit (Ex-Bal), or did not exercise (control). SIC was performed on a cycle ergometer and involved four 30-s all-out sprints with 4-min active recovery. In the morning of day 2, responses to a high-fat meal were measured. Venous blood samples were collected in the fasted state and at 0, 30, 60, 120, and 180 min postprandial. There was a trend toward a reduction with treatment in fasting TG (P = 0.068), but no significant treatment effect for fasting insulin, glucose, nonesterified fatty acids, or betahydroxybutryrate (P > 0.05). The postprandial area under the curve (mmol·l(-1)·3 h(-1)) TG response was significantly lower in Ex-Def (21%, P = 0.006) and Ex-Bal (10%, P = 0.044) than in control, and significantly lower in Ex-Def (12%, P = 0.032) than in Ex-Bal. There was no treatment effect (P > 0.05) observed for area under the curve responses of insulin, glucose, nonesterified fatty acids, or betahydroxybutryrate. SIC reduces postprandial lipemia, but the energy deficit alone does not fully explain the decrease observed.

Evidence for a neuroendocrinological foundation of human affiliation: plasma oxytocin levels across pregnancy and the postpartum period predict mother-infant bonding.

Although research on the neurobiological foundation of social affiliation has implicated the neuropeptide oxytocin in processes of maternal bonding in mammals, there is little evidence to support such links in humans. Plasma oxytocin and cortisol of 62 pregnant women were sampled during the first trimester, last trimester, and first postpartum month. Oxytocin was assayed using enzyme immunoassay, and free cortisol was calculated. After the infants were born, their interactions with their mothers were observed, and the mothers were interviewed regarding their infant-related thoughts and behaviors. Oxytocin was stable across time, and oxytocin levels at early pregnancy and the postpartum period were related to a clearly defined set of maternal bonding behaviors, including gaze, vocalizations, positive affect, and affectionate touch; to attachment-related thoughts; and to frequent checking of the infant. Across pregnancy and the postpartum period, oxytocin may play a role in the emergence of behaviors and mental representations typical of bonding in the human mother.

Oxytocin during pregnancy and early postpartum: individual patterns and maternal-fetal attachment.

Oxytocin (OT), a nanopeptide hormone, plays a role in the emergence of maternal behavior, yet few studies examined OT in humans across pregnancy and the postpartum. We followed healthy women at three points: first trimester of pregnancy, third trimester, and first postpartum month. Plasma OT levels showed high individual stability. A third of the sample showed consistent OT levels, whereas others showed increasing or decreasing trends or peak in late pregnancy. The increase in OT from early to late pregnancy correlated with higher maternal-fetal bonding. These data may help set standards for OT levels and underscore links with maternal-infant attachment.

Voxel-based study of structural changes in first-episode patients with bipolar disorder.

BACKGROUND: Although morphometric studies of bipolar disorder (BD) suggest that neurofunctional abnormalities reflect underlying structural changes, it remains unclear whether abnormalities are present at illness onset or reflect disease progression. Previous voxel-based morphometry (VBM) findings suggest that ventrolateral prefrontal cortex (VLPFC) changes develop over time, whereas morphologic abnormalities elsewhere in the anterior limbic network (ALN) are present early in BD. In this study, we used VBM to explore structural brain changes in first-episode bipolar patients. METHODS: First-episode bipolar (n = 33) and healthy (n = 33) subjects underwent magnetic resonance imaging. Images were normalized and compared on a voxel-by-voxel basis. RESULTS: Bipolar subjects showed no change in VLPFC density or volume. We observed increased volume in left thalamus and fusiform and cerebellum bilaterally; increased gray matter density in anterior cingulate and posterior parietal structures; and increased gray matter volume and density in middle/superior temporal and posterior cingulate gyri. No areas of decreased volume or density were observed. CONCLUSIONS: These data indicate that structural changes are absent from VLPFC early in the course of BD. Morphologic abnormalities are present in other portions of the ALN and in structures previously observed to mediate neurofunctional changes in BD, suggesting that dysfunctional neuronal proliferation or pruning may occur in bipolar patients.

Measuring cortisol in human psychobiological studies.

The steroid cortisol is an extensively studied and important variable in developmental and other behavioral studies. Cortisol has been assayed by various methods using a range of substrates including blood, saliva, and urine. Cortisol in blood exists in two forms. While most is bound to carrier proteins, a small portion exists in a soluble free form. The informed choice of cortisol fraction and measurement method is critical for research. Such choices should be influenced by understanding the characteristics of the various cortisol fractions, along with their binding proteins' biological functions and relationship to the hypothalamic-pituitary-adrenal (HPA) axis. The goal of this paper is to familiarize researchers with key points for evaluating the choice of total and free cortisol in research as well reviewing various options for measuring free cortisol. These points are raised with special emphasis on their significance during pregnancy and the post-partum. Such information may prove useful in informing researcher's cortisol-related protocols and in the interpretation of cortisol data.

Evidence of white matter pathology in bipolar disorder adolescents experiencing their first episode of mania: a diffusion tensor imaging study.

OBJECTIVE: Previous diffusion tensor imaging findings have supported suggestions that bipolar disorder is characterized by subtle white matter changes. The chronic nature of the study population, however, has limited interpretation of these findings. In this study the authors utilized diffusion tensor imaging to study white matter tracts of adolescents in their first episode of mania to address whether abnormalities are present in early bipolar disorder. METHOD: Eleven medication-naive adolescents in their first episode of mania and 17 healthy subjects underwent diffusion tensor imaging scans. Fractional anisotropy and trace apparent diffusion coefficients of prefrontal and posterior regions of interest were compared between groups. RESULTS: Bipolar adolescents showed significantly decreased fractional anisotropy only in superior-frontal white matter tracts. Trace apparent diffusion coefficients did not significantly differ in any regions examined. CONCLUSIONS: These findings suggest that prefrontal white matter abnormalities are present early in bipolar disorder and may consist largely of axonal disorganization. The presence of changes in young first-episode patients also suggests that white matter pathology may represent an early marker of bipolar disorder.

Changes in gray matter volume in patients with bipolar disorder.

BACKGROUND: Several lines of evidence suggest the presence of neurofunctional abnormalities in patients with bipolar disorder. These functional abnormalities may stem from structural pathology in these or connected brain regions. Previous studies have generally used a region of interest (ROI) approach to study morphologic changes in bipolar disorder with inconsistent findings among research groups, which may reflect differences in how ROIs are defined. Voxel based morphometry (VBM) allows a more exploratory analysis without the necessity for predefined anatomic boundaries. In this study we utilized VBM to compare gray matter volume between groups of bipolar and healthy subjects. METHODS: Thirty-two patients with bipolar disorder and 27 healthy subjects participated in structural magnetic resonance imaging (MRI) scans. MRI images were segmented, normalized to a standard stereotactic space, and compared on a voxel-by-voxel basis using statistical parametric mapping. RESULTS: Bipolar subjects showed increased gray matter in several regions including portions of anterior cingulate, ventral prefrontal cortex, fusiform gyrus and parts of the primary and supplementary motor cortex. Bipolar subjects showed decreased gray matter volume in superior parietal lobule. CONCLUSIONS: These data support suggestions that neurofunctional deficits are related to structural brain abnormalities in patients with bipolar disorder. The increased gray matter observed in several regions suggests that some affected areas may demonstrate volumetric expansion, at least in some patient populations.