Editorial Commentary: Anterior Cruciate Ligament Repair or Reconstruction With Internal Bracing, for Properly Indicated Patients, Is Safe, Biocompatible, and Biomimetic

Anterior cruciate ligament (ACL) reconstruction with internal bracing (IB)-and ACL repair with IB when indicated-reduces graft or repair failure. IB is safe and protects ligament reconstructions and repairs. The IB construct should not be misunderstood as a synthetic ligament. To be effective, suture tape must be independently secured with the knee in full extension, reflecting the terminal length of the ACL. Regardless of graft type, the graft must be cyclically tensioned independent of the IB to allow for creep, and when properly performed, this significantly increases the ultimate tensile strength of the construct and reduces graft elongation, without stress shielding. Thus, the generic term "suture augmentation" may be misleading because the successful results reported apply to the IB technique. In our experience, the failure rate after ACL reconstruction with IB is 1% at the 5-year follow-up period. Notably, these results were achieved without an additional lateral extra-articular procedure.

Deficits in muscle strength are not seen following recovery from augmented primary repair of anterior cruciate ligament tears

OBJECTIVES

Anterior cruciate ligament (ACL) repair for proximal tears, where the ligament is re-attached and augmented with suture tape, can negate the need for graft harvest, thereby maintaining native anatomy. Autograft harvest has been associated with persistent deficits in lower limb muscle strength after recovery from ACL reconstruction. The aim of this study is to compare lower limb muscle strength following ACL repair and reconstruction.

METHODS

Nineteen ACL repair patients augmented with suture tape and nineteen ipsilateral semitendinosus-gracilis autograft ACL reconstruction patients (both mean 4 years postoperatively) were recruited, along with twenty healthy volunteers. Patient-reported outcome measures (PROMs) were obtained using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner scores. Maximal isometric quadriceps and hamstring strength at 90° knee flexion were measured using a fixed Myometer after a warm-up and three maximal-effort contractions.

RESULTS

Mean hamstring strength of the reconstructed legs was lower than that of healthy volunteers by 0.29 Nm/kg. The hamstring strength ratio of the operated side to the uninjured side was greater in the repair (95% ​± ​13) than in the reconstruction (81% ​± ​18) group. There were no statistically significant differences between sides for quadriceps peak torque or for hamstrings in the volunteer or repair group. PROMs scores for the reconstruction group were significantly lower than volunteers across all domains and lower than repair for KOOS activities of daily living and Lysholm scores.

CONCLUSION

Hamstring weakness seen following ACL reconstruction is not evident following ACL repair with suture tape augmentation. Strength asymmetry could contribute to re-injury risk and influence functional performance, while altered loads affect knee biomechanics and may lead to osteoarthritis progression. The absence of these deficits in the repair group demonstrates a potential benefit of this technique when used in appropriate patients.

LEVEL OF EVIDENCE

II.

Outcomes of Anterior Cruciate Ligament Reconstruction With Independently Tensioned Suture Tape Augmentation at 5-Year Follow-up

BACKGROUND

Reconstruction using autograft remains the gold standard surgical treatment for anterior cruciate ligament (ACL) injuries. However, up to 10% to 15% of patients will suffer a graft failure in the future. Cadaveric studies have demonstrated that the addition of suture tape augmentation to ACL autograft constructs can increase graft strength and reduce elongation under cyclical loading.

PURPOSE/HYPOTHESIS

This study aimed to investigate the clinical outcomes and rerupture rates after ACL reconstruction (ACLR) with suture tape augmentation. We hypothesized that augmentation with suture tape would lead to lower rerupture rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients undergoing primary ACLR using hamstring or patellar tendon autografts augmented with suture tape between 2015 and 2019 were recruited prospectively. Patients with multiligament injuries or a concomitant lateral extra-articular procedure were excluded. Patients were observed in person for 6 months, and patient-reported outcome measures (PROMs) were collected at 2 and 5 years postoperatively. All patients were contacted, and records were reviewed to determine the incidence of graft failure. PROMs collected were as follows: Knee injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12), Tegner and Marx activity scores, and visual analog scale for pain (VAS).

RESULTS

A total of 97 patients, with a mean age of 34.7 (±13.4) years, were included (76% men; 52 hamstring and 45 patellar tendon grafts). The mean graft diameter was 8 (±1) mm. There was 1 rerupture (1.1%) out of the 90 patients who were contactable at a mean of 5 years postoperatively. Median KOOS scores at 2 years were as follows: Pain, 94; Symptoms, 86; Activities of Daily Living, 99; Sport and Recreation, 82; and Quality of Life, 81. The postoperative scores were significantly higher than the preoperative scores (P < .001). The VR-12 Physical score improved from 43 preoperatively to 55 at 2 years and remained at 56 at 5 years. The VAS pain, Tegner, and Marx scores were 0, 6, and 9, respectively, at 2 years postoperatively. There was no difference in PROMs between graft types.

CONCLUSION

This study demonstrates encouraging results of suture tape augmentation of autograft ACLR for both hamstring and patellar tendon grafts. The failure rate of 1.1% at a mean follow-up of 5 years is lower than published rates for reconstruction, and PROMs results are satisfactory. The technique is safe to use and may permit a return to the preinjury sporting level with a lower chance of reinjury.

Anterior Cruciate Ligament Reconstruction and Accelerated Rehabilitation with InternalBrace™ Augmentation in a Professional Footballer

INTRODUCTION

Interest in anterior cruciate ligament (ACL) repair has been increasing as an alternative to traditional reconstructive techniques and encouraging results have been demonstrated using internal bracing with suture tape augmentation (FiberTape®, Arthrex, Naples, Florida). ACL repair is challenging if the rupture is mid-substance or distal. We describe the case of a hybrid ACL reconstruction with internal brace augmentation.

MATERIALS AND METHODS

This retrospective case report documents the rehabilitation process of a 31-year-old professional footballer who had an isolated ACL rupture. The patient underwent a hybrid ACL reconstruction with bone-patellar tendon-bone autograft and suture tape augmentation 10 days after his injury. A task-based rehabilitation programme defined by six progressive phases relevant to performance-based outcome measures was undertaken. Each phase had clear, functional, progressive goals incorporating exercises to improve mobility, neuromuscular control, strength, and a progressive return to running and sport-specific movements.

RESULTS

Using the rehabilitation framework outlined, this player produced excellent results in all objective criteria postoperatively and was able to return to unrestricted full team training in under five months (146 days) following surgery.

CONCLUSIONS

This case presentation demonstrates the safe and accelerated return to professional football following ACL reconstruction augmented with internal bracing. The player was able to meet all criteria-based aspects of return to play.

Effects of social influence and implementation climate and leadership on nurse-led early mobility behaviours in critical care

Introduction

Early mobility (EM), initiating and advancing physical activity in the earliest days of critical illness, has been described as the most difficult component of the ABCDEF bundle to implement and coordinate. Successful implementation of EM in clinical practice requires multiple targeted implementation strategies.

Objective

Describe the associations of nurses’ EM attitudes, subjective norms, perceived behavioural control, intention, and implementation climate and leadership with self-reported and documented EM behaviour in the intensive care unit (ICU).

Design

This was a two-site, descriptive, cross-sectional study to explore nurses’ perception of the factors influencing EM adherence.

Setting

Three ICUs (medical, surgical and cardiovascular) in an academic medical centre and two ICUs (medical/surgical and cardiovascular) in a regional medical centre in middle Tennessee.

Patients

Critically ill adults.

Interventions

None.

Main outcome measures

A 34-item investigator-developed survey, Implementation Leadership Scale, and Implementation Climate Scale were administered to ICU nurses. Survey development was informed by a Theory of Planned Behavior based elicitation study and implementation science frameworks.

Results

The academic medical centre had markedly lower EM documentation. We found no difference in nurses’ EM attitudinal beliefs, social influence, facilitators, and barriers at both sites. Nurses perceived moderate social influence to perform EM similarly across sites and considerable control over their ability to perform EM. We did note site differences for implementation climate and leadership and objective EM adherence with the regional community medical centre demonstrating statistically significant relationships of implementation climate and leadership with self-report and documented EM behaviours.

Conclusions

We identified contextual differences in implementation climate and leadership influence when comparing nurse EM behaviours. Streamlined documentation, leadership advocacy for interprofessional coordination and manpower support, and multicomponent context-based implementation strategies could contribute to better EM adherence.

Medial Patellofemoral Ligament Repair with Suture Tape Augmentation: A Case Series With Five-Year Follow Up

INTRODUCTION

The medial patellofemoral ligament (MPFL) is the main restraining force against lateral patellar displacement in the first 20 degrees of knee flexion and is often disrupted following patellar subluxation or dislocation. MPFL reconstruction is commonly performed to restore patellar stability but requires autograft harvest with associated donor site morbidity. The aim of this study was to assess the five-year outcomes of MPFL repair performed with suture tape augmentation.

MATERIALS AND METHODS

All patients who underwent isolated MPFL repair for recurrent patellar instability between 2011 and 2017 were included. Patients requiring any additional surgery, such as osteotomy, were excluded. Patient-reported outcomes were measured at two-year follow up using the Knee Injury and Osteoarthritis Outcome (KOOS) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12), Marx Activity Scale, and an overall satisfaction questionnaire. At the end of the study period, any complications or secondary surgeries were determined.

RESULTS

Eighteen patients underwent MPFL repair with one lost to follow up. There was a significant improvement in all subscales of the KOOS scoring systems, the WOMAC functional score, and the VR-12 physical score. A significant decrease was seen in the VAS-pain score. A non-significant decrease was seen in the Marx activity scale from pre-injury. The majority of patients reported satisfaction with reduction in pain and return to sporting activities. There were no complications with no further instability episodes.

CONCLUSION

This is the first study that describes the five-year follow-up results of patients treated with MPFL repair and suture tape augmentation. Our results show that this technique is an alternative treatment to traditional MPFL reconstruction with comparable outcomes and avoidance of autograft harvest.

Anterior cruciate ligament repair with internal brace augmentation: A systematic review

BACKGROUND

Primary repair of anterior cruciate ligament (ACL) ruptures has re-emerged as a treatment option for proximal tears, with internal brace augmentation often utilised. The aim of this study is to provide an overview of the current evidence presenting outcomes of ACL repair with internal bracing to assess the safety and efficacy of this technique.

METHODS

All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears, augmented with internal bracing from 2014-2021 were included. Primary outcome was failure rate and secondary outcomes were subjective patient reported outcome measures (PROMs) and objective assessment of anteroposterior knee laxity.

RESULTS

Nine studies were included, consisting of 347 patients, mean age 32.5 years, mean minimum follow up 2 years. There were 36 failures (10.4%, CI 7.4% - 14.1%). PROMs reporting was variable across studies. KOOS, Lysholm and IKDC scores were most frequently used with mean scores > 87%. The mean Tegner and Marx scores at follow-up were 6.1 and 7.8 respectively. The mean side to side difference measured for anteroposterior knee laxity was 1.2mm.

CONCLUSIONS

This systematic review with meta-analysis shows that ACL repair with internal bracing is a safe technique for treatment of proximal ruptures, with a failure rate of 10.4%. Subjective scores and clinical laxity testing also revealed satisfactory results. This suggests that ACL repair with internal bracing should be considered as an alternative to ACL reconstruction for acute proximal tears, with the potential benefits of retained native tissue and proprioception, as well as negating the need for graft harvest.

Quantifying graft impingement in anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament reconstructions (ACLR) fail at a rate of 10-15%, with graft impingement often a cause. In this study we investigate the prevalence and causes of impingement seen during ACLR surgery.

METHODS

We reviewed consecutive primary ACLR from 2012-2018. Graft impingement was estimated intraoperatively by placing the arthroscope through the tibial tunnel and passively extending the knee, observing how much was obscured by the lateral femoral condyle from an anterior and lateral direction. Preoperative MRI scans were used to measure the intercondylar notch; Notch Width Index (NWI) and Notch Depth Index (NDI). Positioning of the tunnels was determined on postoperative radiographs.

RESULTS

There were 283 ACLRs performed with 33 failures diagnosed on MRI (11.7%). 257 patients had complete imaging and follow up (91%). The mean age was 28 (±9) years and mean follow-up 5.3 (±1.8) years. The mean NWI was 0.26(±0.03), and NDI was 0.49(±0.06). The tibial tunnel aperture was located 42(±6) % of the way from anterior-posterior and 39(±6) % from medial-lateral. Impingement requiring a notchplasty was observed in 80% of cases, with lateral impingement more prominent.

CONCLUSIONS

The amount of impingement did not correlate with tunnel position, which was located within the recommended area. There was a weak negative correlation between NWI and lateral impingement (r_s = -0.16, p = 0.01), and NDI and anterior impingement (r_s = -0.12, p = 0.04), therefore a smaller notch is associated with greater impingement. Despite optimal tunnel positioning, impingement still occurs in a significant number of cases therefore notchplasty should always be considered to keep revision rates low.

Organizational Characteristics and Readiness for Tobacco-Free Workplace Program Implementation Moderates Changes in Clinician's Delivery of Smoking Interventions within Behavioral Health Treatment Clinics

BACKGROUND

Smoking is elevated amongst individuals with behavioral health disorders, but not commonly addressed. Taking Texas Tobacco Free is an evidence-based, tobacco-free workplace program that addresses this, in-part, by providing clinician training to treat tobacco use in local mental health authorities (LMHAs). This study examined organizational moderators of change in intervention delivery from pre- to post-program implementation.

METHODS

LMHA leaders completed the Organizational Readiness for Implementing Change (ORIC) and provided organization demographics pre-implementation. Clinicians (N = 1237) were anonymously surveyed about their consistent use of the 5As (Asking about smoking; Advising clientele to quit; Assessing willingness to quit; Assisting them to quit; Arranging follow-up) pre- and post-program implementation. Adjusted generalized linear mixed models were used for analyses (responses nested within LMHAs), with interaction terms used to assess moderation effects.

RESULTS

Clinician delivery of 5As increased pre- to post-implementation (p < .001). LMHAs with fewer employees (ref = ≤300) demonstrated greater increases in Asking, Assessing, and Assisting over time. LMHAs with fewer patients (ref = ≤10 000) evinced greater changes in Asking over time. Less initial ORIC Change Efficacy, Change Commitment, and Task Knowledge were each associated with greater pre- to post-implementation changes in Asking. Less initial Task Knowledge was associated with greater increases in Advising, Assessing, and Assisting. Finally, less initial Resource Availability was associated with greater increases in Assisting (all moderation term ps < .025).

CONCLUSION

The smallest and least ready LMHAs showed the largest gains in tobacco cessation intervention delivery; thus, low initial readiness was not a barrier for program implementation, particularly when efficacy-building training and resources are provided.

IMPLICATIONS

This study examined organizational moderators of increases in tobacco cessation treatment delivery over time following the implementation of a comprehensive tobacco-free workplace program within 20 of 39 LMHAs across Texas (hundreds of clinics; servicing >50% of the state) from 2013 to 2018. Overall, LMHAs with fewer employees and patients, and that demonstrated the least initial readiness for change, evinced greater gains in intervention delivery. Findings add to dissemination and implementation science by supporting that low initial readiness was not a barrier for this aspect of tobacco-free workplace program implementation when resources and clinician training sessions were provided.

Stabilisation of pathological humerus fractures using cement augmented plating: A case series

The humerus is the second most common long bone for metastatic tumours. These lesions result in weakened bone architecture and increased fracture risk with patients suffering pain, loss of function and diminished quality of life, often when life expectancy is short. Fractures or impending fractures require surgical stabilisation to relieve pain and restore function for the remainder of the patient's life without the need for further surgery. Conventional management of these lesions in the humerus is intramedullary nailing, however there are issues with this technique, particularly regarding rigidity of fixation. Advances in contoured locking plates have led to the development of different stabilisation techniques. The preferred technique in our regional oncology unit is curettage of the tumour and plating, augmented with cement to fill the defect and restore the structural morphology. In this case series we evaluate the survivorship of the construct and the clinical outcomes in patients who had an established or prospective pathological humeral fracture treated with curettage and cement augmented plating, since 2010. We identified 19 patients; 17 had metastasis and 2 myeloma of whom 15 had established fractures and four impending. The mean age at surgery was 69 years (51-86), and mean time since surgery 3.2 years. Overall mean follow up time was 20 months with 14 patients deceased and 5 surviving. There was 100% survivorship of the construct with no mechanical failures and no re-operations. There were no post-operative wound complications. Excellent early pain control was achieved in 18 patients with one experiencing pain controlled by analgesia. Function was assessed using Toronto Extremity Salvage Score (TESS) and was satisfactory; mean 79/100 (range 72-85). Cement augmented plating for pathological humerus fractures is a suitable alternative to intramedullary nailing and addresses several of the concerns with that technique. It provides immediate rigidity and allows early unrestricted function.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Suture Tape Augmentation

The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee, with injury usually occurring as a result of multidirectional sports. The incidence of ACL injury has continued to increase, with most patients opting for surgery to improve stability as well as permit a return to sport. Traditional methods of ACL reconstruction can achieve this but are not without their problems, including graft rupture, residual laxity, and donor-site morbidity. There is therefore a requirement for further research into newer, innovative surgical techniques to help improve complication rates. This article describes, with video illustration, ACL reconstruction using a reduced-size bone-patellar tendon-bone autograft with suture tape augmentation. The augmentation acts as a stabilizer during the early stages of graft incorporation while resisting against reinjury during an accelerated recovery. The ability to use a reduced-size graft decreases the donor-site burden, and retention of residual native ACL tissue, when possible, may help with proprioception.

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Internal Brace Augmentation: Minimum 2-Year Patient-Reported Outcome Measures

Background

The anterolateral ligament (ALL) contributes to anterolateral rotational stability of the knee. Internal bracing of the anterior cruciate ligament (ACL) and ALL reinforces the ligaments and encourages natural healing by protecting both during the healing phase and supporting early mobilization.

Purpose/Hypothesis

To assess the 2-year patient-reported outcomes of combined ACL repair and ALL internal brace augmentation. We hypothesized that significant improvements in outcomes would be seen.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 43 consecutive patients with acute proximal ACL ruptures were prospectively evaluated for a minimum of 2 years. The mean age at the time of surgery was 25.7 years (range, 13-56 years). Indications for the combined ACL/ALL procedure were associated Segond fractures, grade 3 pivot shift, or high levels of sporting activity. Patients with chronic ruptures or with multiligament injuries were excluded. The Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12), and Marx activity scale were collected preoperatively and at 12 and 24 months postoperatively. Patients with any postoperative complications were identified at the time of this analysis.

Results

The mean follow-up period was 44.8 months. Five patients were lost to follow-up, leaving 38 patients (88.4%) in the final analysis. The mean KOOS for Pain, Symptoms, Activities of Daily Living, Sport/Recreation, and Quality of Life improved from a respective 64.9, 58.6, 75.0, 33.7, and 28.9 preoperatively to 91.1, 81.8, 96.1, 82.8, and 74.3 at the 2-year follow-up (P < .0001). The mean WOMAC scores for pain, stiffness, and function improved from 77.5, 65.3, and 75.0 preoperatively to 94.6, 88.6, and 96.0 at the 2-year follow-up (P < .0001). The VAS pain score improved from 3.4 preoperatively to 0.7 at the 2-year follow-up, and the VR-12 physical score improved from 34.4 preoperatively to 52.7 at the 2-year follow-up (P < .0001 for both ). However, the Marx activity score decreased from 13.3 preinjury to 10.6 at the 2-year follow-up (P = .01). Two patients (5.3%) sustained a rerupture.

Conclusion

Combined ACL repair and ALL internal brace augmentation demonstrated excellent outcomes in 94.7% of the study patients. Based on our experience with this cohort as well as our isolated ACL repair data, we suggest that high-risk patients with ACL ruptures have an additional ALL procedure to provide rotational stability.

Adapting and Evaluating Implementation of a Tobacco-Free Workplace Program in Behavioral Health Centers

Objectives: State-administered community behavioral health centers (CBHCs) rarely treat tobacco dependence, despite high client tobacco use. Using a mixed-methods approach we examine the adaptation and implementation of an evidence-based tobacco-free workplace (TFW) program in 2 CBHCs (17 individual clinics). Methods: Varied data collection included pre- and post-implementation leader, clinician, and staff surveys; pre-, mid-, and post-implementation staff and client focus groups; and monthly implementation logs. The RE-AIM framework guided translation of behavioral interventions into sustainable practice. Results: Pre- to post-implementation increases were seen in training receipt among clinicians and employees. Both CBHCs adopted a 100% TFW policy, integrated tobacco screenings into routine practice, and delivered evidence-based practices (EBPs). Qualitative methods enlisted key stakeholders contributing towards adapting program strategies to local contexts, addressing barriers, adjusting tobacco screening administration, and understanding reasons for success or failure to implement specific components. Conclusions: Program implementation at both CBHCs increased organizational capacity in the provision of EBPs to treat tobacco dependence through successfully meeting the majority of our RE-AIM targets. Findings contribute to the development of flexible strategies and interventions responsive to variable implementation contexts and barriers; enhancing the effectiveness and sustainability of a TFW program.

Tobacco-related knowledge following a comprehensive tobacco-free workplace program within behavioral health facilities: Identifying organizational moderators

OBJECTIVE

Although smoking prevalence rates among behavioral health consumers is nearly five times that of the general population, evidence-based policies and practices to address tobacco use are uncommon within behavioral health settings. This study assessed changes in non-clinical, general staff and clinician tobacco-related knowledge following brief education provided as part of a comprehensive tobacco-free workplace program implementation and explored organizational moderators of pre- to post-education knowledge change.

METHODS

Fifteen behavioral health facilities, comprising hundreds of individual clinics in Texas, participated in a one (for general staff) or two (for clinicians) hour educational session.

RESULTS

There were large effect sizes in general staff knowledge gain within each consortium, and large effect sizes in clinician knowledge gain in all but one consortium. Knowledge of the requirements for change, perceived availability of resources, and total number of client contacts moderated general staff knowledge gain. Value in the change and total number of client contacts moderated training effectiveness among clinicians.

CONCLUSIONS

We conclude that a brief tobacco-related education for behavioral health employees was effective in increase attendee knowledge.

PRACTICE IMPLICATIONS

Attention to organization-level factors moderating knowledge gain has the potential to guide and improve program implementation.

Evaluation of the Taking Texas Tobacco Free Workplace Program within behavioral health centers

Despite the health benefits of tobacco control and cessation initiatives, tobacco users with behavioral health disorders (BHDs) have less access to evidence-based tobacco dependence treatment. Academic-community partnerships can help guide the translation of tobacco-related research findings and evidence-based guidelines into real-world applications. Through a comprehensive, evidence-based, multilevel, and multicomponent program, Taking Texas Tobacco Free (TTTF) facilitated the implementation of tobacco-free workplaces at 18 local mental health authorities in Texas, comprising over 250 individual community behavioral health centers. Compared with preprogram implementation, key accomplishments postimplementation include: (1) educated over 5,000 employees (nonclinical staff and providers) on the hazards of tobacco use and benefits of quitting, particularly among people with BHD; providers were additionally trained on the use of evidence based practices (EBPs; i.e. 5A's model, use of pharmacotherapy) to identify and treat tobacco use among people with BHD; (2) providers' significant increase in conducting tobacco-use assessments and using EBPs; (3) significant decrease in nonclinical staff tobacco use; (4) increase in quit attempts among consumers as evidenced by the demand for nicotine replacement therapy; and (5) reach to over 115,000 community members through outreach and education about the benefits of quitting tobacco use and maintaining a healthy lifestyle. TTTF demonstrated that the implementation of a comprehensive tobacco-free workplace program in behavioral health settings is feasible and beneficial, facilitating the capacity building of healthcare professionals and enhancing their resulting engagement in EBPs, and promoting healthier lifestyles among employees, consumers, and community members as a whole.

Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up

The ulnar collateral ligament (UCL) is the primary restraint to valgus angulation at the elbow. Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing. Conventional treatment is reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation. Modern surgical techniques have led to renewed interest in repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. Here we present the first patient treated with this technique who achieved excellent recovery with return to college level American Football after 4 months. Five years later he has good elbow function and plays at the same level.

Acromioclavicular Joint Stabilisation Using the Internal Brace Principle

Injury of the acromioclavicular joint (AC joint) is one of the most common conditions affecting the shoulder girdle in athletes, particularly in contact sports. It is generally agreed that surgical management provides superior outcomes in high-grade injuries (Rockwell Grades IV-VI), with nonoperative management preferred in low-grade injuries (Grades I-II). Controversy still exists regarding the optimal treatment for Grade III injuries, with various sources reporting quicker return to activity and reduced complications with nonoperative management, but superior long-term function and satisfaction in cases managed surgically. Mean predicted return to sporting action in surgical cases varies in the literature from four months to 9.5 months.

Effects of a Tobacco-Free Work Site Policy on Employee Tobacco Attitudes and Behaviors, Travis County, Texas, 2010-2012

Background

The adoption of tobacco-free policies in behavioral health settings is an important step in reducing staff tobacco use as well as the high rates of tobacco use among people with mental illness and behavioral disorders. Studies have demonstrated the importance of staff support when implementing tobacco-free workplace policies, but there is limited research examining tobacco use prevalence among staff and staff attitude before and after policy adoption.

Community Context

Integral Care, a local authority for behavioral health and developmental disabilities in Austin, Texas, and Austin Public Health embarked on a comprehensive planning process before implementing a 100% tobacco-free campus policy. The objectives were 1) assess staff tobacco use and attitudes toward a tobacco-free policy, 2) communicate policy to staff, 3) provide staff education and training, and 4) provide cessation resources.

Methods

Integral Care and Austin Public Health conducted a web-based employee survey 6 months before and 6 and 12 months after implementation of the policy to measure tobacco use prevalence and attitudes among employees.

Outcome

Employees had significant improvements in tobacco use prevalence and attitudes toward the tobacco-free policy from pre-implementation to post-implementation. Tobacco use prevalence among staff decreased from 27.6% to 13.8%, and support for the policy increased from 60.6% to 80.3% at 12 months post-implementation.

Interpretation

Adoption of 100% tobacco-free campus policies in behavioral health settings can result in significant reductions in staff tobacco use. Leadership should provide staff with education, training, and cessation support before adoption of tobacco-free work site policies to ensure success.

Addressing Tobacco Use Among Consumers and Staff at Behavioral Health Treatment Facilities Through Comprehensive Workplace Programming

Tobacco use is the leading cause of death and disability in the United States; cigarette smoking is the most common form of tobacco use. Smoking has become increasingly concentrated among individuals with behavioral health needs (e.g., persistent mental illness) and has led to increased morbidity and mortality in this group relative to the general population. Comprehensive tobacco-free workplace programs are effective in reducing tobacco use and cigarette smoke exposure among behavioral health consumers and the individuals who serve them. Taking Texas Tobacco-Free (TTTF) represents an academic-community partnership formed to address tobacco use among consumers and employees at behavioral health clinics across Texas via the dissemination of an evidence-based, multicomponent tobacco-free workplace program. Program components of TTTF include tobacco-free campus policy implementation and enforcement, staff education about tobacco use hazards, provider training to regularly screen for and address tobacco dependence via intervention, and community outreach. These components, the nature of the academic-community partnership, the process of behavioral health facility involvement and engagement, and the benefits and challenges of implementation from the perspectives of the project team and participating clinic leaders are described. This information can guide similar academic and community partnerships and inform the implementation of other statewide tobacco-free workplace programming.

Minimising costs in spinal surgery: is group & save testing justified in lumbar decompression surgery?

BACKGROUND

Lumbar microdiscectomy and laminectomy are two of the most common neurosurgical procedures performed worldwide. Current practice still sees pre-operative group and save testing prior to this surgery. The aim of this study was to determine the need for pre-operative group and save and post-operative blood checks.

METHODS

Patient archives were reviewed to identify those undergoing primary elective lumbar decompression surgery at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Hematology results before and after surgery, whether group and save was carried out, and blood transfusion requirements, if any, were collected.

RESULTS

A total of 200 patients in total were included. Ninety-one percent of microdiscectomy patients and 95% of laminectomy patients underwent group and save testing prior to surgery. No patients received a transfusion as a result of their procedure. The mean hemoglobin drop after surgery was 11 g/L for the microdiscectomy group and 17 g/L for the laminectomy group.

CONCLUSIONS

Our findings strongly suggest that pre-operative group and save is unnecessary in lumbar microdiscectomy and laminectomy. As such, we support the abandonment of routine pre-operative group and save and post-operative blood checks, with significant cost saving effects. However, O negative blood should always be available in case of major peri-operative bleeding.

Anterior Cruciate Ligament Repair with Internal Brace Ligament Augmentation

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction using tendon or ligament autograft is the gold standard surgical treatment for acute ruptures; however, this is still associated with subsequent problems and variable outcomes. Renewed interest in healing of injured ACL tissue has led to new surgical repair techniques.

CASE DESCRIPTION

We report the case of one of the first patients to undergo this novel procedure of ACL repair with internal bracing. An internal brace is a bridging concept using braided suture tape and knotless bone anchors to reinforce ligament strength. We followed the case of one of the first patients to undergo this technique over two years post-operatively.

OUTCOMES

In this case, we present a good functional outcome along with radiographic and arthroscopic evidence of a healed ACL with normal appearance. The successful application of this technique has been demonstrated.

DISCUSSION

ACL repair techniques are re-emerging as a promising treatment option for acute proximal ruptures. Repair of the ACL can be performed successfully and has the advantage of retaining the natural proprioceptive fibres of the ligament. The internal brace acts as a secondary stabiliser after repair, which may allow accelerated rehabilitation and return to sports, whilst resisting injury recurrence when this is possible.

CONCLUSIONS

Repair with internal bracing of the ACL provides an unobtrusive support which allows accelerated recovery. In this case, we demonstrate with radiographic and arthroscopic evidence, a robustly healed ACL after repair with internal bracing. Functional outcomes are excellent over two years following surgery and long term; retained proprioception may prevent re-injury and development of post-traumatic osteoarthritis.

Increased trends in the use of treatment-limiting decisions in a regional neurosurgical unit

INTRODUCTION

Treatment-limiting decisions (TLDs) are employed to actively withhold treatment from patients whom clinicians feel would derive no benefit or suffer detrimental effects from further intervention. The use of such decisions has been heavily discussed in the media and clinicians in the past have been reluctant to institute them, even though it is in the best interests of the patients. Their use is influenced by several ethical, religious and social factors all of which have changed significantly over time. This study reports the trends in use of TLDs in a regional neurosurgical unit over 23 years.

METHODS

Patient archives were reviewed to identify the number of admissions and procedures performed at the Institute of Neurological Sciences, Glasgow, in the years 1988, 1997 and 2011. Death certificate records were used to identify mortality in the unit in the year 2011. Patient records were used to obtain details of diagnosis, time from admission to death, and the presence and timing of a TLD.

RESULTS

The results show an increase in the use of TLDs, with decisions made for 89% of those who died in 2011, compared to 68% in 1997 and 51% in 1988. The number of admissions has increased substantially since 1988 as has the percentage of patients undergoing surgery (46, 67 and 72% in 1988, 1997 and 2011, respectively).

CONCLUSION

There is a trending increase in the number of patients who have a TLD in our regional neurosurgical unit. This demonstrates an increased willingness of clinicians to recognise poor prognosis and to withdraw or withhold treatment in these cases. Continued appropriate use of the TLD is recommended but it is to only ever reflect the best interests of the patient.

Knotless Repair of Achilles Tendon Rupture in an Elite Athlete: Return to Competition in 18 Weeks

Rupture of the Achilles tendon is an increasingly common injury, particularly in physically active males, and current evidence favors minimally invasive surgical repair. We describe the case of a 36-year-old male elite bobsled athlete with complete rupture of the Achilles tendon. He was treated with surgical repair of the ruptured tendon using an innovative, minimally invasive procedure based on an internal bracing concept and was able to undergo early mobilization and aggressive physiotherapy rehabilitation. His recovery was such that he returned to training at 13 weeks postoperatively and participated in an international competition at 18 weeks, winning a World Cup silver medal. He subsequently raced at the 2014 Winter Olympic Games at 29 weeks after surgery. At >2 years since his injury, he has experienced no complications or reinjury. This represents an exceptional recovery that far exceeds the standard expected for such injuries. The use of this technique for athletes could enable accelerated return to sporting activity and attainment of their preinjury activity levels.

Computer-assisted measurements of coronal knee joint laxity in vitro are related to low-stress behavior rather than structural properties of the collateral ligaments

The relationship between coronal knee laxity and the restraining properties of the collateral ligaments remains unknown. This study investigated correlations between the structural properties of the collateral ligaments and stress angles used in computer-assisted total knee arthroplasty (TKA), measured with an optically based navigation system. Ten fresh-frozen cadaveric knees (mean age: 81 ± 11 years) were dissected to leave the menisci, cruciate ligaments, posterior joint capsule and collateral ligaments. The resected femur and tibia were rigidly secured within a test system which permitted kinematic registration of the knee using a commercially available image-free navigation system. Frontal plane knee alignment and varus-valgus stress angles were acquired. The force applied during varus-valgus testing was quantified. Medial and lateral bone-collateral ligament-bone specimens were then prepared, mounted within a uni-axial materials testing machine, and extended to failure. Force and displacement data were used to calculate the principal structural properties of the ligaments. The mean varus laxity was 4 ± 1° and the mean valgus laxity was 4 ± 2°. The corresponding mean manual force applied was 10 ± 3 N and 11 ± 4 N, respectively. While measures of knee laxity were independent of the ultimate tensile strength and stiffness of the collateral ligaments, there was a significant correlation between the force applied during stress testing and the instantaneous stiffness of the medial (r = 0.91, p = 0.001) and lateral (r = 0.68, p = 0.04) collateral ligaments. These findings suggest that clinicians may perceive a rate of change of ligament stiffness as the end-point during assessment of collateral knee laxity.

Standardising the clinical assessment of coronal knee laxity

Clinical laxity tests are used for assessing knee ligament injuries and for soft tissue balancing in total knee arthroplasty. This study reports the development and validation of a quantitative technique of assessing collateral knee laxity through accurate measurement of potential variables during routine clinical examination. The hypothesis was that standardisation of a clinical stress test would result in a repeatable range of laxity measurements.

Non-invasive infrared tracking technology with kinematic registration of joint centres gave real-time measurement of both coronal and sagittal mechanical tibiofemoral alignment. Knee flexion, moment arm and magnitude of the applied force were all measured and standardised. Three clinicians then performed six knee laxity examinations on a single volunteer using a target moment of 18 Nm.

Standardised laxity measurements had small standard deviations (within 1.1°) for each clinician and similar mean values between clinicians, with the valgus laxity assessment (mean of 3°) being slightly more consistent than varus (means of 4° or 5°).

The manual technique of coronal knee laxity assessment was successfully quantified and standardised, leading to a narrow range of measurements (within the accuracy of the measurement system). Minimising the subjective variables of clinical examination could improve current knowledge of soft tissue knee behaviour.

A comparison of the bioeffects of four different modes of stone therapy on renal function and morphology

A variety of therapeutic options exists for removal of symptomatic renal calculi, including extracorporeal shock wave lithotripsy, percutaneous nephrostolithotomy and open pyelolithotomy or nephrolithotomy. Although lithotripsy offers the advantage of reduced patient morbidity, the relative alterations in renal function and morphology for each of the respective treatment modalities have not been completely assessed. We evaluated 17 pigs (40 to 50 lb.) for evidence of histologic and functional renal changes after a pyelotomy (N = 3) or nephrotomy (N = 4), piezoelectric lithotripsy (N = 5), or placement of a percutaneous nephrostomy tube with balloon dilation (N = 5). Pathologic evaluation one month after treatment revealed no renal scarring in the animals that underwent a pyelotomy and minimal parenchymal fibrosis in the nephrotomy and lithotripsy groups (0.014 +/- 0.001% and 0.015 +/- 0.002%, respectively). In contrast, the percutaneous nephrostomy group demonstrated 1.53 +/- 0.4% of the treated kidney to be involved by scarring (p < 0.001). Despite the statistically significant increase in renal scarring after percutaneous nephrostomy, neither creatinine and PAH clearances nor renal plasma flows changed significantly among the four treatment groups. Moreover, no change in renal function after treatment was observed when compared with baseline evaluations. All four therapeutic options for renal stone removal appear to result in small amounts of renal parenchymal damage but are not associated with significant alterations in renal function.

Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone

The management of partial transection of the anterior urethra following penetrating penile injuries is controversial. Optional therapeutic techniques range from a primary sutured reapproximation to urinary diversion alone. We recently managed 17 low velocity gunshot wounds to the external genitalia in which the missile traversed the penile corpus cavernosum, and was associated with less than 40% transection of the corpus spongiosum and anterior urethra. Nine patients were managed with suprapubic diversion, skin débridement and corporeal closure along with placement of a urethral catheter. Eight patients were managed by suprapubic diversion, débridement, closure of the corporeal bodies and a primary sutured reapproximation of the anterior urethra. Urethral strictures developed in 7 patients (78%) managed by a suprapubic tube and urethral stenting during an average followup of 20 months (range 18 to 24). In contrast, 1 patient (12%) managed by a sutured urethral approximation had a urethral stricture during an average followup of 20 months (range 18 to 30, p < 0.01). Our data support a significantly better prognosis for partial transection of the anterior urethra secondary to low velocity gunshot wounds if managed by aggressive wound débridement, corporeal repair, placement of a suprapubic catheter and primary repair of the urethra.

Treatment philosophy and retreatment rates following piezoelectric lithotripsy

Second generation lithotriptors offer the advantage of anesthesia-free fragmentation of renal and ureteral calculi but they frequently require multiple treatments to attain a stone-free status. However, excessive single lithotripsy sessions or multiple treatments may be associated with significant damage to the kidney. For some clinicians a common treatment philosophy involves evaluation of serial plain abdominal films every 24 hours after lithotripsy and immediate retreatment of all patients with incomplete fragmentation. To avoid unnecessary retreatments and, thus, minimize potential renal damage, we prospectively evaluated 100 patients undergoing lithotripsy on a Wolf Piezolith 2300 device. Patients were routinely treated with 4,000 shocks at 1,100 bar. Serial plain abdominal films were obtained at 1 day and 2 weeks after lithotripsy. The need for retreatment was determined by the plain abdominal film results. Additional therapy was considered necessary if there was no stone fragmentation or if residual fragments measured greater than 4 mm. Of the patients whose plain abdominal film at 24 hours indicated the need for a repeat treatment 43% were stone-free on the 2-week film. Thus, these patients were spared an unnecessary treatment by allowing adequate time for the stone fragments to pass spontaneously. Our data suggest that repeat treatments on second generation lithotriptors should not be performed within 24 hours. Rather, the patient should be reevaluated at least 1 to 2 weeks later to avoid unnecessary retreatment with the attendant potential for renal injury. In addition, when comparing the retreatment rates of various lithotriptors, one should also consider the treatment philosophy used at the particular institution and the timing of the radiographic studies used to determine the stone-free status.

Postpubertal genitourinary function following posterior urethral disruptions in children

A total of 24 boys sustaining a simultaneous pelvic fracture and posterior urethral disruption was observed from the time of injury through puberty. Average length of followup was 6 years. In contrast to the adult, in whom the urethra is invariably injured at the prostatomembranous junction, the posterior urethral disruptions in the prepubertal patient were at 3 distinct locations: 1) supraprostatic in 4 patients, 2) transprostatic in 4 and 3) prostatomembranous in 16. Prolonged followup through puberty in these children revealed that the frequency of complications was significantly higher for urethral injuries proximal to the prostatomembranous region compared to those at this latter site: impotence 75% versus 31%, intractable strictures following repairs 75% versus 12% and urinary incontinence 25% versus 0%. In summary, the prognosis of children who sustain a posterior urethral disruption should be based on the location of the injury and must remain guarded until the individual attains a postpubertal status.

Testicular tumors in men with human immunodeficiency virus

During a 2-year period 5 men positive for the human immunodeficiency virus (HIV) presented with 6 testis tumors among a total of 3,015 men seen at our hospital acquired immunodeficiency syndrome (AIDS) clinic. This testis tumor incidence of 0.2% is 57 times that of the United States average of 3.5 cases per 100,000 men. Two patients were only HIV positive and 3 others already had AIDS-related complex for 2 to 15 months at the time of tumor diagnosis. Tumor histology was mixed germ cell tumor in 4 patients, pure seminoma in 1 and Burkitt's lymphoma in 1. Patients underwent routine staging evaluations. Three patients had low stage mixed germ cell tumor (clinical stage 1 or 2A) and underwent retroperitoneal lymphadenectomy, which revealed pathological stage 1 or 2A disease in 1 and 2, respectively. These patients did not receive adjuvant chemotherapy. Two patients had advanced mixed germ cell tumor (clinical stage 2C) or Burkitt's lymphoma (clinical stage 4) and received combination chemotherapy from the onset. Outcome was evaluated with regard to progression of HIV disease and tumor status. The 2 patients who were only HIV positive remained so for 9 and 48 months. The 3 patients with AIDS-related complex had progression to AIDS within 1 to 9 months and 2 of these patients died 1 1/2 and 7 months after tumor diagnosis. All 3 patients with resected low stage disease had tumor recurrence within 1 to 9 months and were begun on platinum-based combination chemotherapy. The risk of false low clinical staging and early tumor progression may be higher in HIV positive men than in other testis tumor patients. Patient ability to tolerate chemotherapy and to obtain a satisfactory tumor response appeared to be primarily related to lack of progression of HIV disease to frank AIDS.

Temporal effects of shock wave lithotripsy

Previous studies have demonstrated that renal parenchymal injury following extracorporeal shock wave lithotripsy is dependent upon shock wave power as well as the total number of shock waves administered. In order to determine the deleterious effects of temporal versus cumulative doses of shock wave administration, adult female rabbits were divided into five groups receiving either: 1000 shock waves in one session; 2000 shock waves in one session; 2000 shock waves in two sessions, one week apart; unilateral nephrectomy without lithotripsy; or anesthesia only as control population. One month following lithotripsy, renal functional studies for gamma glutamyl transferase and N-acetyl-beta-glucosaminidase revealed persistent enzymuria in the animals treated with 2000 shocks in one session. Pathologic studies in these animals confirmed an increased area of periglomerular and intratubular fibrosis when compared to animals managed by either 1000 shocks or 2000 shocks in divided doses (p less than 0.01). These findings suggest the importance of avoiding single treatments with large doses of shock waves and favor the administration of multiple small-doses of shock waves to minimize renal damage during the treatment of patients with hard or large calculi.

A comparison of renal damage induced by varying modes of shock wave generation

To evaluate for the possible differences in the extent of pathologic injury occurring following treatment with various lithotripsy modalities, we subjected rabbits to treatment on either an electrohydraulic, electromechanical, or piezoelectric lithotripter. Functional evaluations by enzymuria failed to reveal any difference in the extent of damage between the lithotripters. Pathologic evaluation of the kidneys revealed that both electrohydraulic and electromechanical lithotripsy resulted in an increased instance of acute subcapsular hematoma and fibrosis when compared to piezoelectric treated kidneys (p less than 0.001). Despite the definitive differences noted in the acute animals, there was no significant variation in the area of permanent renal damage that occurred between the various lithotripters.

Prostatomembranous urethral disruptions: management by suprapubic cystostomy and delayed urethroplasty

Management of prostatomembranous urethral disruptions associated with pelvic fractures remains a major controversy in urology. A group of 64 patients who suffered a prostatomembranous urethral disruption in association with a pelvic fracture and who were managed initially by suprapubic cystostomy with delayed urethroplasty was compared to 17 patients managed initially by primary realignment. No statistically significant difference in the incidence of impotence or urinary incontinence was found between the 2 groups (p greater than 0.5) Secondary reconstructions for impassable strictures developed in 95% of the patients treated by a suprapubic tube alone compared to 53% of those treated by primary realignment. Indeed, only 1 patient in the latter group achieved urethral continuity that did not require further intervention. We conclude that while primary realignment is associated with no increase in the instance of impotence and urinary incontinence, it subjects the patient to a major operation at a critical time and provides little in the way of long-term positive gains for the effort expended. In the final analysis the outcome is more dependent upon the nature of the injury and the quality of the repair than upon the order in which the repair is effected.

Extracorporeal shock wave lithotripsy. An update

Extracorporeal shock wave lithotripsy has revolutionized the treatment of urinary calculi. It should be considered the treatment of choice for renal stones smaller than 2 cm and for the majority of ureteral calculi, under which circumstances success rates approaching 80 to 90 per cent may be anticipated. Larger renal calculi or impacted ureteral stones probably should be managed by endoscopic techniques with or without adjunctive intracorporeal (ultrasonic or electrohydraulic) lithotripsy or laser fragmentation. Recent modifications in lithotripter design have been focused on the development of pain-free lithotripsy. Concomitant with a decrease in power, however, is an attendant decrease in the efficiency with which stones can be fragmented, resulting in an increase in the number of lithotripsy treatments required for adequate stone fragmentation. Additionally, sonography is assuming an increasing role in stone localization, and its use will require sonographic training on the part of the urologist. Biliary lithotripsy has been promising in preliminary European studies, with success rates approaching 90 per cent. It must be noted, however, that the U.S. experience has not been as impressive. Moreover, only 20 to 30 per cent of patients referred for biliary lithotripsy appear to be optimal candidates for this new technique. Adjunctive dissolution of gallstones with chronic oral medical therapy may be required after biliary lithotripsy, and long-term follow-up studies still need to be performed. Finally, the potential deleterious effects of extracorporeal shock wave lithotripsy must always be kept in mind. Although the majority of clinical and animal investigations have documented no significant long-term alterations in renal function, care must still be exercised when performing lithotripsy with the knowledge of the potential for long-term injurious effects on the functioning renal parenchyma.

Effects of faking instructions on the psychological screening inventory

Effects of two faking instructions on Psychological Screening Inventory scores were investigated. With both faking instructions, scores on all five scales were significantly different from those obtained under regular instructions. The defensiveness scale shows promise in being able to detect faking.

Need associations to acquisition modes, education, and adjustment

3 primary modes of acquisition were defined as the achievement, aggression, and succorance needs of the Murray need system. Picture Identification Test need associations of these acquisition modes were analyzed for 12 male groups differing in education and/or adjustment. Application of t tests to discriminate the 12 groups with 57 need-association variables produced a 5:1 ratio of obtained to chance expected ts (p < .05). Of the 57 variables 51 had significant F ratios (p = .05) for between-within groups variance from a discriminant analysis of the same data. These results indicated that acquisition need association indices are related to personal adjustment and educational achievement.

Flagellar bundles of the honeybee pathogen, Bacillus larvae; their occurrence, size, and development in vivo and in vitro

Flagellar bundles of the honeybee pathogen, Bacillus larvae, occurred in vivo and in vitro. Bundles as large as 47.5 × 0.6 μ developed in the gut contents of young honeybee larvae from 48 to 72 h after ingestion of spores. In vitro, they were produced in two types of media, and were seen as early as 24 h after the initiation of vegetative growth. Flagellar bundle formation was not related to sporulation.In stained sections of honeybee larvae infected with B. larvae, vegetative cells had a peritrichous coat of flagella which was apparently shed at a specific stage in the growth of the pathogen. It is probable that the release of a single flagellum or a coat of flagella is biochemically initiated both in vivo and in vitro.

Perception of apparent motion and degree of mental pathology

Measures of apparent motion discrimination ability, memory, and intertrial variability were obtained for groups of 54 normal, 32 neurotic, 54 alcoholic, 54 admission schizophrenic, 108 chronic schizophrenic, and 103 geriatric Ss. The groups differed on all three apparent motion measures, with the greatest impairment manifested by groups with the most severe mental pathology. Low intercorrelations of the apparent motion tasks, differences in correlations with IMPS items, and differences among the groups supported the hypothesis that apparent motion perception and memory processes are independent functions which are impaired to different degrees by different types of mental pathology.