The spin move to facilitate antegrade coronoid fixation in terrible triad injuries.

BACKGROUND: The role of the coronoid process in elbow instability has been established. When necessary, coronoid fixation can be challenging. Placing fixation perpendicular to the fracture requires achieving a trajectory as close as possible to the midline axis of the proximal ulna, either from anterior to posterior or vice versa. The aim of this study was to determine whether coronoid exposure-and the ability to place fixation from anterior to posterior-is improved via a lateral extensor-splitting approach with forearm supination, that is, the "spin move," with progressive stages of lateral elbow instability. METHODS: The lateral extensor-splitting approach was performed on 9 cadaveric upper extremities. A 0.157-mm (0.062-inch) wire was drilled perpendicularly into the lateral aspect of the humerus just proximal to the lateral epicondyle. A second wire was drilled into the tip of the coronoid, aiming for a drill trajectory as close as possible to the midline axis. The angle between the 2 wires was measured as the initial angle. Three stages of progressive lateral elbow instability were produced by sequential release of the lateral ulnar collateral ligament (LUCL), common extensor origin (CEO), and posterior capsule. At each stage, the spin move was performed and the angle between the 2 wires was measured. The difference between this angle and the initial angle was calculated, with the average value reported as the Δ angle for each stage. The average difference between each stage and the next stage was reported. RESULTS: The spin move resulted in Δ angles of 10.3° with the LUCL released, 20° with the CEO released, and 29.1° with the posterior capsule released. Progressing from LUCL release to CEO release to posterior capsule release, the Δ angle between the K-wires increased an average of 9.6° from the LUCL stage to the CEO stage and 9.1° from the CEO stage to the posterior capsule stage. CONCLUSION: The spin move is a simple maneuver that can improve exposure of the coronoid process regardless of the degree of elbow instability. This may facilitate a more perpendicular screw, bone tunnel, or suture anchor trajectory via the lateral approach, reducing the need for posterior-to-anterior fixation. The improved exposure is inferred from the differences in the K-wire angles with and without the spin move. This study has also quantified the change in coronoid exposure using the angles of the wires with progressive release of the LUCL, CEO, and posterior capsule. If necessary, releasing the CEO or posterior capsule with eventual repair may allow improved coronoid fixation from the lateral approach.

Transition of historial tube flaps to free flap for 2-stage total knee arthroplasty in a patient with a history of Gustilo grade IIIB tibia fracture.

We report the case of a 56-year-old patient who had posttraumatic bilateral knee arthritis and underwent sequential bilateral total knee arthroplasty (TKA). The left knee joint required 2-stage reconstruction: a free flap for enhanced soft-tissue coverage and then left knee TKA. Uniquely, at age 16 years this patient sustained a left tibia grade IIIB high-energy crush injury in a car crash and underwent reconstruction with multiple pedicle tube flaps and transfer of soft tissues. Most of that reconstruction was done between the ages of 16 and 19. At age 56 years, staged TKA was performed. To our knowledge, this is the first report of a knee reconstructed with pedicle tube flaps for a grade IIIB tibial fracture, followed years later by free-flap coverage before TKA. This report offers insights and treatment recommendations through long-term follow-up of a unique case and a historical perspective on how reconstructive options have evolved.

Premorbid and current neuropsychological function in opiate abusers receiving treatment.

BACKGROUND: There is an established corpus of evidence linking substance abuse with neuropsychological impairment, particularly implicating frontal lobe functions. These could potentially be premorbid to, rather than consequences of, direct effects of substance abuse. METHODS: A matched pairs design was employed in which currently abstinent opiate abusers in treatment were matched to 22 healthy control individuals. These were compared for premorbid and current neurobehavioral abnormalities with the self-report Frontal Systems Behavior Scale (FrSBe). Estimated premorbid and current IQ scores were also ascertained. RESULTS: There was no difference between the groups regarding socioeconomic background. There was no evidence for an alteration in cognitive function as measured by current IQ associated with opiate abuse, nor evidence of premorbidly lower IQ. However, with the FrSBe, the opiate abusers reported overall higher levels of apathy. They also had raised FrSBe total scores, indicating the presence of neurobehavioral features associated with frontal lobe impairment. Furthermore, the opiate abusers reported higher levels of these neurobehavioral abnormalities compared to their matched controls, even in the period preceding substance abuse. CONCLUSIONS: The results suggest that some substance abusing individuals in treatment demonstrate raised levels of neurobehavioral abnormalities, independently of general intellectual functioning. Furthermore, the results imply that these abnormalities may have already been present prior to the effects on the nervous system of substance abuse.

Higher or lower? The functional anatomy of perceived allocentric social hierarchies.

The perception and judgement of social hierarchies forms an integral part of social cognition. Hierarchical judgements can be either self-referential or allocentric (pertaining to two or more external agents). In psychiatric conditions such as dissocial personality disorder and schizophrenia, the impact of hierarchies may be problematic. We sought to elucidate the brain regions involved in judging allocentric social hierarchies. Twenty-two healthy male subjects underwent three fMRI scans. During scanning, subjects answered questions concerning visually-presented target pairs of human individual's relative superiority within a specific social hierarchy or their perceived degree of social alliance (i.e., whether they were "friends or enemies"). Subjects also made judgements relating to target pairs' age, gender and fame to control for confounding factors and performed a baseline numerical task. Response times increased in line with hypothesized ascending executive load. Both social hierarchy and social alliance judgements activated left ventrolateral prefrontal cortex (VLPFC), left dorsal inferior frontal gyrus (IFG) and bilateral fusiform gyri. In addition, social alliance judgements activated right dorsal IFG and medial prefrontal cortex. When compared directly with social alliance, social hierarchy judgements activated left orbitofrontal cortex. Detecting the presence of social hierarchies and judging other's relative standing within them implicates the cognitive executive, in particular the VLPFC. Our finding informs accounts of 'normal' social cognition but our method also provides a means of probing the dissocial brain in personality disorder and schizophrenia where executive function may be dysfunctional.

Neurobehavioural and cognitive function is linked to childhood trauma in homeless adults.

OBJECTIVES: To describe levels of traumatic childhood events in a sample of homeless individuals and to assess the contribution of traumatic events to neurobehavioural traits (measured with the Frontal Systems Behaviour Scale, FrSBe) and general cognitive function (IQ). DESIGN: A sample of 55 homeless adults was recruited from homeless services in the city of Sheffield, UK. All were interviewed to acquire substance misuse information, record experiences of childhood trauma, and assess cognitive and neurobehavioural traits. METHODS: Experiences of abuse and neglect were assessed with the Childhood Trauma Questionnaire. Participants also completed the Wechsler Abbreviated Scale of Intelligence and the FrSBe, which was completed with respect to current behaviour and conduct prior to homelessness. RESULTS: Around three-quarters of the sample scored in the clinically significant range for current neurobehavioural impairment. They also reported high levels of impairment when rating retrospectively for the period before they were homeless. The mean group IQ was below average at 88. Abuse or neglect during their upbringing was reported by 89% of the sample. Emotional abuse, emotional neglect, and physical neglect were all positively correlated with total FrSBe scores. Sexual abuse, emotional neglect, and physical neglect were all negatively correlated with IQ. The associations between trauma and IQ and neurobehavioural traits appear generally unrelated to the presence of substance misuse in the sample. CONCLUSION: Our homeless sample displayed relatively low IQ with high levels of neurobehavioural impairment. Our evidence suggests that these neuropsychological factors may, in part, constitute a long-term consequence of childhood trauma.

The functional anatomical distinction between truth telling and deception is preserved among people with schizophrenia.

BACKGROUND: A recently emergent functional neuroimaging literature has described the functional anatomical correlates of deception among healthy volunteers, most often implicating the ventrolateral prefrontal and anterior cingulate cortices. To date, there have been no such imaging studies of people with severe mental illness. AIMS: To discover whether the brains of people with schizophrenia would manifest a similar functional anatomical distinction between the states of truthfulness and deceit. It is hypothesised that, as with healthy people, persons with schizophrenia will show activation in the ventrolateral prefrontal and anterior cingulate cortices when lying. METHOD: Fifty-two people satisfying Diagnostic and Statistical Manual of Mental Disorder-IV criteria for schizophrenia or schizoaffective disorder underwent functional magnetic resonance imaging at 3 T while responding truthfully or with lies to questions concerning their recent actions. Half the sample was concurrently experiencing delusions. RESULTS: As hypothesised, patients exhibited greater activity in ventrolateral prefrontal cortices while lying. Truthful responses were not associated with any areas of relatively increased activation. The presence or absence of delusions did not substantially affect these findings, although subtle laterality effects were discernible upon post hoc analyses. CONCLUSIONS: As in healthy cohorts, the brains of people with schizophrenia exhibit a functional anatomical distinction between the states of truthfulness and deceit. Furthermore, this distinction pertains even in the presence of delusions.

If brain scans really detected deception, who would volunteer to be scanned?

Recent neuroimaging studies investigating the neural correlates of deception among healthy people, have raised the possibility that such methods may eventually be applied during legal proceedings. Were this so, who would volunteer to be scanned? We report a "natural experiment" casting some light upon this question. Following broadcast of a television series describing our team's investigative neuroimaging of deception in 2007, we received unsolicited (public) correspondence for 12 months. Using a customized template to examine this material, three independent assessors unanimously rated 30 of an initial 56 communications as unequivocally constituting requests for a "scan" (to demonstrate their author's "innocence"). Compared with the rest, these index communications were more likely to originate from incarcerated males, who were also more likely to engage in further correspondence. Hence, in conclusion, if neuroimaging were to become an acceptable means of demonstrating innocence then incarcerated males may well constitute those volunteering for such investigation.

Evidence of mnemonic ability selectively affecting truthful and deceptive response dynamics.

In the executive model of deception, the telling of a lie necessitates the inhibition of a veridical prepotent response (the truth), and such inhibition incurs a temporal penalty, manifest as a longer response time. If memory processes are engaged in generating such truths, then memory function should affect truthful and deceptive response times. To investigate this we examined the relationship between performance on a semantic knowledge deception task and a test of verbal memory in 40 college students. We found that verbal memory performance differentially affects the temporal parameters of truth and deception.

A neuroanatomical basis for the frequency of discrete spontaneous activities in schizophrenia.

Limited behavioural repertoire impacts quality of life in chronic schizophrenia. We have previously shown that the amount of movement exhibited by patients with schizophrenia is positively correlated with the volume of left anterior cingulate cortex and that this quantity of movement can be increased by modafinil. However, increased movement in itself may be of limited clinical significance. Hence, we sought to analyse the 'structure' of spontaneous movement in patients with schizophrenia and to examine whether the chunking of spontaneous activity has a neuroanatomical basis. 'Actiwatches' were used to record spontaneous motor activity over a 20 hour period in sixteen male patients with schizophrenia. Time-series data were analysed for the number of discrete spontaneous activities, which might indicate a degree of structure to ongoing activity. Subjects underwent a whole-brain structural MRI scan. The 'number of discrete movement epochs' correlated with volumes of regions within bilateral rostro-ventral putamen and temporal poles. These data suggest that in people with schizophrenia the volume of bilateral putamen may influence the complexity of their behaviours, as distinct from the overall amount of behaviour. The results are presented in the context of a large body of previous research examining the role of the basal ganglia in motor and cognitive pattern generation.

Can pharmacology help enhance human morality?

A responsible person, a moral agent, takes account of their future behaviour and its likely impact upon others. Such an agent may choose to influence their future by exogenous means. If so, might pharmacology help them to do this? Is it doing so already? I argue that it is.

Looking for truth and finding lies: the prospects for a nascent neuroimaging of deception.

Lying is ubiquitous and has acquired many names. In 'natural experiments', both pathological lying and truthfulness implicate prefrontal cortices. Recently, the advent of functional neuroimaging has allowed investigators to study deception in the non-pathological state. Prefrontal cortices are again implicated, although the regions identified vary across experiments. Forensic application of such technology (to the detection of deceit) requires the solution of tractable technical problems. Whether we 'should' detect deception remains an ethical problem: one for societies to resolve. However, such a procedure would only appear to be ethical when subjects volunteer to participate, as might occur during the investigation of alleged miscarriages of justice. We demonstrate how this might be approached.

Time perspective, depression, and substance misuse among the homeless.

Using the Zimbardo Time Perspective Inventory (ZTPI; P. G. Zimbardo & J. N. Boyd, 1999), the authors found that homeless people, in comparison with a control group, had a significantly more negative outlook concerning their past and present as evinced by high Past-Negative and Present-Fatalistic scores and low Past-Positive scores on the ZTPI. However, the homeless individuals were almost indistinguishable from control participants on measures of Present-Hedonism and Future thinking. The homeless individuals had significantly higher levels of depression, with 31 out of 50 (62%) reaching criteria for probable depression. However, this finding was unrelated to their atypical time perspective. There was no significant relation between substance misuse and time perspective. Despite their current difficulties, including depression and drug abuse, the homeless individuals maintained a propensity toward future thinking characterized by striving to achieve their goals.

Speaking of secrets and lies: the contribution of ventrolateral prefrontal cortex to vocal deception.

Behavioural and functional anatomical responses exhibited by humans support the hypothesis that deception involves the prefrontal executive. Functional neuroimaging studies have demonstrated that ventrolateral prefrontal cortex (among other areas) is activated during lying, compared with telling the truth. However, despite some consistencies discernible across studies, problems remain concerning experimental validity, e.g., the expediencies of experimenter-sanctioned cued-deception (i.e., subjects being told when to lie); such 'lies' may not have comprised adequate proxies for 'real-life' deception. In this experiment, we attempted to address such confounding issues by designing an fMRI paradigm in which subjects chose when to lie (thereby minimising cue-dependency), using spoken words, concerning intimate material, which they regarded as 'embarrassing'; and where further control conditions required them to 'comply' with their examiners or to 'defy' them (by withholding pre-specified responses). The main effect of lying revealed significant activation of ventrolateral prefrontal cortices. These results replicate and extend our previous findings to those circumstances under which subjects are allowed to choose when to deceive.

'Munchausen's syndrome by proxy' or a 'miscarriage of justice'? An initial application of functional neuroimaging to the question of guilt versus innocence.

'Munchausen's syndrome by proxy' characteristically describes women alleged to have fabricated or induced illnesses in children under their care, purportedly to attract attention. Where conclusive evidence exists the condition's aetiology remains speculative, where such evidence is lacking diagnosis hinges upon denial of wrong-doing (conduct also compatible with innocence). How might investigators obtain objective evidence of guilt or innocence? Here, we examine the case of a woman convicted of poisoning a child. She served a prison sentence but continues to profess her innocence. Using a modified fMRI protocol (previously published in 2001) we scanned the subject while she affirmed her account of events and that of her accusers. We hypothesized that she would exhibit longer response times in association with greater activation of ventrolateral prefrontal and anterior cingulate cortices when endorsing those statements she believed to be false (i.e., when she 'lied'). The subject was scanned 4 times at 3 Tesla. Results revealed significantly longer response times and relatively greater activation of ventrolateral prefrontal and anterior cingulate cortices when she endorsed her accusers' version of events. Hence, while we have not 'proven' that this subject is innocent, we demonstrate that her behavioural and functional anatomical parameters behave as if she were.

A systematic review of cognition in homeless children and adolescents.

Objectives The cognitive function of homeless children and adolescents may be overlooked, albeit understandably, when societal interventions focus on their immediate housing needs. Nevertheless, homelessness might be hypothesized to carry many risks for the developing mind and brain. We wanted to discover whether this hypothesis had been tested previously. Design A systematic review to examine whether cognitive impairments were reported in homeless children and adolescents. Setting Objective, systematic review of standard databases, examined by key word searches. Participants Children and adolescents. Main outcome measures Formal assessments of cognition. Results We found that in spite of there being many homeless children in the world, fewer than 2000 have been assessed cognitively and reported in the literature. Yet when compared with those who are domiciled, these children tend to have lower intellectual functioning and decreased academic achievement. Furthermore, adolescents evince cognitive impairments in the contexts of drug, physical, and sexual abuse. Conclusions We suggest that cognitive and mental health screening be incorporated into those intervention programs deployed to facilitate societal reintegration of homeless children and adolescents.

Impact of modafinil on prefrontal executive function in schizophrenia.

OBJECTIVE: The purpose of this study was to investigate the acute effects of modafinil on prefrontal activation and cognitive control of motor activity in people with schizophrenia and prominent negative symptoms. METHOD: In a crossover design, 12 subjects with schizophrenia were studied twice, receiving either modafinil or placebo prior to functional magnetic resonance imaging (fMRI). Inside the scanner, they performed a task probing cognitive control that required deliberate variation of motor activity in time. RESULTS: Modafinil administration was associated with significantly greater activation of the dorsolateral prefrontal cortex during fMRI. Its physiological and behavioral effects were correlated. This was most evident in individuals with worse baseline executive function. Focal response to modafinil in the left dorsolateral prefrontal cortex and baseline letter fluency scores predicted most of the variance in the drug's effect on cognitive control. CONCLUSIONS: Modafinil did not improve cognitive control in all schizophrenia patients. Increased activation in the dorsolateral prefrontal cortex and in neuropsychological performance were observed in patients with suboptimal baseline function.

A functional magnetic resonance imaging study of social cognition in schizophrenia during an acute episode and after recovery.

OBJECTIVE: Difficulty with social interactions is a characteristic of schizophrenia. The authors used functional magnetic resonance imaging (fMRI) to investigate brain activation changes during a social cognition paradigm in patients with schizophrenia during and after an acute episode and their association with social and executive function. METHOD: In a longitudinal study design, 14 patients with schizophrenia experiencing an acute episode had an fMRI scan. They returned for a follow-up scan after clinical improvement. Fourteen healthy comparison subjects were also scanned twice with approximately the same time interval between scans as in the patient group. The authors employed a social cognition fMRI paradigm involving empathic and forgivability judgments. Schizophrenia symptoms, social functioning and illness insight scales, and the Wisconsin Card Sorting Test were used to examine whether improvement on these measures was associated with recovery of brain activation in response to the social cognition paradigm. RESULTS: After recovery from the acute episode, patients exhibited increased activation in the left medial prefrontal cortex, which was, in turn, significantly correlated with improved insight and social functioning. Decreased symptom severity and improved performance on the Wisconsin Card Sorting Test were not significantly associated with increased left medial prefrontal cortex activation. CONCLUSIONS: This is the first study to the authors' knowledge to use a social cognition paradigm to reveal improved left medial prefrontal cortex activation in schizophrenia after recovery from an acute episode. These results suggest that restored left medial prefrontal cortex activation may mediate improvement of insight and social functioning in patients with schizophrenia.

Modafinil and unconstrained motor activity in schizophrenia: double-blind crossover placebo-controlled trial.

Avolition affects quality of life in chronic schizophrenia. We investigated the effect of modafinil upon unconstrained motor activity in 18 male patients. In a randomised crossover design study, wrist-worn actigraphic monitors were used to objectively record motor activity over a 20 h period. Patients' total activity was significantly greater when given the drug. These data suggest that modafinil increases quantifiable motor behaviour in schizophrenia and may have an impact on avolition.