Selecting a free flap for soft tissue coverage in lower extremity reconstruction.

BACKGROUND: Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. METHODS: Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. CONCLUSIONS: The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Continuous performance tests are sensitive to ADHD in adults but lack specificity. A review and critique for differential diagnosis.

Historically, the focus for Attention Deficit Hyperactivity Disorder (ADHD) has been on children, with considerable research and many opinions available in this area. More recently, the focus has been expanded to include ADHD in adults. Assessment of ADHD in adults is complicated by the high rate of co-occurring disorders as well as symptom overlap with a number of disorders. One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review.

Validity of DSM-IV ADHD predominantly inattentive and combined types: relationship to previous DSM diagnoses/subtype differences.

UNLABELLED: Since 1980, three different diagnostic nomenclatures have been published regarding attention-deficit hyperactivity disorder (ADHD). These changing conceptualizations and diagnostic criteria have generated considerable confusion. OBJECTIVE: To examine the multidimensional DSM-IV ADHD criteria in relation to how children and adolescents with a previous DSM-III ADD diagnosis or a DSM-III-R ADHD diagnosis are diagnosed according to DSM-IV criteria. METHOD: Children whose original diagnoses were according to DSM-III and DSM-III-R criteria received retrospective diagnoses according to DSM-IV criteria. RESULTS: Predominantly inattentive (n = 30) and combined types (n = 26) were compared on their previous DSM-III and DSM-III-R diagnoses and on demographic, behavioral, cognitive, and comorbidity variables. Predominantly inattentive and combined type diagnoses corresponded with DSM-III ADD/WO and ADD/H diagnoses, respectively. The DSM-III-R ADHD diagnosis did not correspond with either DSM-IV subtype. Children with the combined type diagnosis had more externalizing codiagnoses, and their parents reported more externalizing, delinquent, and aggressive behaviors. Children with the predominantly inattentive type had more math learning disability codiagnoses. CONCLUSION: Results support a multidimensional conceptualization of ADHD. There exists close correspondence between the DSM-III ADD/WO type and the DSM-IV predominantly inattentive type and between the DSM-III ADD/H type and the DSM-IV combined type.

Comorbidity of central auditory processing disorder and attention-deficit hyperactivity disorder.

UNLABELLED: Research has indicated that children with attention-deficit hyperactivity disorder (ADHD) demonstrate significant difficulty on tasks used to assess central auditory processing skills. These findings have raised the question of whether ADHD and central auditory processing disorder (CAPD) represent a singular disorder. OBJECTIVE: The current study explored the incidence of ADHD in a group of 30 children who met diagnostic criteria for CAPD. METHOD: Consecutive referrals specifically for this project were assessed on a variety of measures. In addition, rating scales were completed by teachers and structured interviews were completed with parents. RESULTS: Results indicate that although the incidence rate of ADHD (50%) in this sample significantly exceeds that found in the normative population (p < .001), not all children with CAPD demonstrated behaviors consistent with diagnostic criteria for ADHD. Furthermore, there was a low incidence of any other behavioral disorder in this sample. In contrast, it was found that the sample as a whole demonstrated impaired language abilities. No significant differences emerged across cognitive, auditory, or language measures. CONCLUSION: This study further supports the need for increased collaboration of those professionals who work with these children given the extent of overlap of language and behavioral difficulties in this sample.

Neuropsychological profiles of children diagnosed as specific language impaired with and without hyperlexia.

This study compared the neuropsychological profiles of 46 children with Specific Language Impairment (SLI) and 16 children with SLI and Hyperlexia (SLI + H). The results indicated that the essential feature of Hyperlexia is Specific Language Impairment and not reading disability. Thus, Hyperlexia would be best conceptualized as a subgroup of Developmental Language Disorder rather than as a subgroup of Developmental Dyslexia. Further, the SLI + H group exhibited significantly better developed visual/spatial memory which, along with average visual perceptual skills, appears to be the major contributing factor to their elevated word recognition and spelling ability. Finally, it should be noted that both groups of children exhibited decreasing performance on tasks of immediate auditory/verbal memory as the language/semantic demands of the memory task increased. This finding appears to be the result of a limited capacity for immediate verbal processing and not the result of a deficit in verbal learning and recall.

Verbal fluency in children: developmental issues and differential validity in distinguishing children with attention-deficit hyperactivity disorder and two subtypes of dyslexia.

Previous research studies have shown that in adults, verbal fluency is impaired after lesion to the frontal lobes and left temporal lobe. More recently, there have been a few studies reported which indicated that in children, like adults, left hemisphere and frontal lesions result in pronounced effects on verbal fluency. The present study examined developmental differences in verbal fluency within a sample of 130 normal children, aged 6 to 12 years. Additionally, the same verbal fluency test was administered to two subgroups of children with developmental dyslexia and a group of children with attention-deficit/hyperactivity disorder (ADHD). Analysis of variance (ANOVA) revealed significant between-group differences by age in the normal children. Further, ANOVA demonstrated that the verbal fluency measure was clinically useful in differentiating the Language Disorder/Dysphonetic Dyslexic subgroup from the Visual-Spatial/Dyseidetic Dyslexic subgroup and the ADHD group, with the latter two groups performing within the average range.

Validity of the Auditory Continuous Performance Test in differentiating central processing auditory disorders with and without ADHD.

The use of continuous performance tasks has been examined as a potential measure for clinical/laboratory identification of Attention-deficit/hyperactivity disorder. The present study compared the performance of 30 children, 26 boys and 4 girls ranging in age from 9-0 to 12-11, with central auditory processing disorders (CAPD) who did not meet criteria for coexisting ADHD with the performance of children with CAPD coexisting with ADHD (CAPD/ADHD) on the Auditory Continuous Performance Test (ACPT). In interpreting the results, the variability as well as the actual counts for correct responses and total errors were considered. Results indicated limited potential for the use of the ACPT in the differential diagnosis of ADHD. Implications of the results as well as considerations for future research are discussed.

Effects of stimulants on the continuous performance test (CPT): implications for CPT use and interpretation.

An increasing number of treatment plans for individuals with attention-deficit/hyperactivity disorder (ADHD), as well as other disorders, include stimulant medication. The purpose of this study was to investigate the effects of stimulant medications on attention and impulsivity as measured by continuous performance tests (CPTs). The effect of other stimulants (e.g., caffeine, nicotine) on CPT performance was examined as well. Although various versions of the CPT were used in the studies reviewed, the research supports improvements in CPT performance with stimulant treatment. Implications for the use of CPTs in evaluating the effects of medications on attention are discussed. Also presented are implications for control of common substances like nicotine or caffeine when CPT is used and interpreted as a measure of attention.

Diagnosing ADHD (predominantly inattentive and combined type subtypes): discriminant validity of the behavior assessment system for children and the achenbach parent and teacher rating scales.

Compared the effectiveness of discriminating attention deficit/hyperactivity disorder (ADHD) subtypes using the Parent Rating Scale (PRS) and Teacher Rating Scale (TRS) of the Behavior Assessment System for Children (BASC) and the Parent Report Form and Teacher Report Form (TRF) of the Achenbach Child Behavior Checklist (CBCL). To determine the extent to which these scales measured similar behaviors, Pearson Product-Moment Correlations were computed for the parent scales (PRS and CBCL) and for the teacher scales (TRS and TRF). Results indicated that correlations were significant for a number of scales. Discriminant analysis does not suggest a strong advantage of either measure in differentiating children with ADHD from those who do not meet criteria for ADHD, except for the BASC TRS which has better predictive ability for children who do not meet ADHD criteria. For subtypes of ADHD, and specifically the ADHD: Predominantly Inattentive subtype, however, results would favor the use of the BASC PRS and TRS.