LA JOLLA, CALIF— At first glance it looks like any other board game: Four people are sitting around a table, rolling dice, moving game pieces, and collecting or losing play money. But the questions that the players are answering reveal that this game is not just a trivial pursuit.

“If one is shot and the bullet lodges in the left temporal insula, what deficits of smell would one have?” reads one game card. “What pontine nucleus contains tracts that directly connect to the thalamus, basal ganglia, and hypothalamus, and control both motor and mood?” asks another.

Welcome to Critical Endeavors, the first board game designed to teach neuroanatomy.

The game is the brainchild of Robin Hurley, MD, Assistant Professor in the Departments of Psychiatry and Behavioral Science and Radiology at Baylor College of Medicine in Houston, and Medical Director of the Integrated Mental Health Program at the Houston Veterans Affairs Medical Center. After several years of using conventional methods to teach functional neuroanatomy to psychiatry residents and faculty, Dr. Hurley had the idea of presenting the lecture material in game form. “The first version of the game was taped and pasted onto an old board game,” she recalls. “That year I gave the residents the reading assignment two weeks before the scheduled classes, then had them play the game during what previously was lecture time. It was a great hit.”

For several years, Baylor had a monopoly on the game. Then Dr. Hurley found herself on the American Neuropsychiatric Association (ANPA) Education Committee, where she was encouraged (or “forced,” as she puts it) to unveil the game to a wider audience, “over my protests that it was far too crude to be shown to anyone.” Spurred by the enthusiastic response, Dr. Hurley worked with Katherine Taber, PhD, Assistant Professor of Psychiatry and Behavioral Science and Radiology at Baylor, to create a more polished version of the game, which was presented at a poster session at ANPA’s recent annual meeting. Once again the reaction was extremely positive: The game table that was set up near the poster display was surrounded by players for the entire session.

The game questions are written at five different levels of difficulty, ranging from high school/college to advanced questions suitable for practicing neuropsychiatrists. The game comes in “cortical” and “subcortical” versions. In the Baylor program, 70 minutes are allotted for a game; for added motivation, the top two players each year receive gift certificates to a medical bookstore.

One key aspect of the game is that its format is easily adaptable to other medical and scientific disciplines; thus, if the opportunity arose, the questions could be rewritten to teach the anatomy of, say, the gastrointestinal tract. Indeed, Drs. Hurley and Taber are currently collaborating on a version designed for use in an undergraduate physiological psychology course. They are also launching, together with faculty at other residency programs, a formal validation study to see whether psychiatry residents who play the game learn the material as well as they would have if they had attended traditional lectures. “Once validation studies are completed—and, hopefully, successful—we will make the game and card sets available,” Dr. Hurley says.

IS ALCHOL A NEUROPROTECTANT?

Medical science has no shortage of seemingly paradoxical findings, and here’s another. Although drinking alcohol increases one’s risk of traumatic brain injury (TBI) by impairing judgment and fostering risk-taking, TBI patients who had been using alcohol shortly before their injury may actually have better outcomes than those who had been alcohol-free.

That conclusion, courtesy of investigators at Walter Reed Army Medical Center in Washington, DC, is based on findings from the latest study to examine whether alcohol has neuroprotective effects. The results of prior research have been somewhat mixed: Although most animal studies have found that low doses of alcohol protect against neuronal injury, human studies have not consistently seen such a relationship, in part because it is difficult to determine what the patient’s alcohol level had been at the time of injury.

In the new study, presented at the ANPA meeting, Molly B. Sparling, a National Research Manager in Walter Reed’s Defense and Veterans Head Injury Program, and colleagues evaluated 138 military service members who had sustained a moderate to severe TBI. Thirty-nine participants had been drinking alcohol at the time of injury; 99 had not. Most demographic and medical characteristics—including duration of consciousness loss—were statistically identical in users and nonusers, although there were trends for users to have a shorter duration of posttraumatic amnesia and, a week after the injury, to have better Glasgow Outcome Scale scores. Nonetheless, both groups performed similarly at baseline on various neuropsychological measures.

But by the time of long-term follow-ups, functional outcomes had diverged. A year after injury, subjects who had been using alcohol at the time of injury were significantly more likely to be considered fit for duty compared with those who had not been drinking (85% vs 64%); the same pattern was apparent at a two-year follow-up (76% vs 54%). Although some studies have found a history of alcohol abuse (irrespective of alcohol use at the time of injury) to be a risk factor for poor outcome, history did not predict return to duty in the present study.

Why would alcohol protect against neuronal damage? Evidence from animal studies indicates that alcohol inhibits the N-methyl-D-aspartate receptors and voltage-gated calcium channels that contribute to posttraumatic excitotoxicity, the researchers noted. Other mechanisms may also come into play. The reason that some studies have failed to show neuroprotective effects, Ms. Sparling said, probably has to do with dose: Low levels of alcohol are probably neuroprotective, but at high doses the respiratory and hemodynamic effects of alcohol may outweigh the neuroprotective processes.

Though the findings need to be replicated, “based on this and some of the animal studies, there is certainly a case for low-dose alcohol being neuroprotective,” Ms. Sparling stated. “That being said, alcohol use leads to more brain injuries. We’re certainly not endorsing the use of alcohol.”

FRONTAL DAMAGE IMPAIRS SOCIAL FUNCTION

Patients with frontal lobe damage not only have impaired social cognition but are often strikingly unaware of their deficits, according to data presented by Linda Mah, MD, a Clinical Fellow at the National Institute of Neurological Disorders and Stroke.

Case reports have described social impairments in patients with frontal lobe damage—even in the absence of memory or perceptual deficits—but there has been little systematic study of the phenomenon, noted Dr. Mah. In the new study, 33 patients with frontal lobe injury (most from penetrating head wounds) and 32 normal controls completed the Interpersonal Perception Task (IPT), in which subjects answer questions about the interpersonal behavior and relationships of characters in various video segments. For example, subjects might have to judge whether a man and women had recently gotten together or had long been married.

Consistent with case reports, participants with frontal lobe injuries had a lower mean score (14.2) on the IPT than did normal controls (16.6). More striking, perhaps, was how unaware patients were of their deficits; they overestimated their performance by 8.5 points, more than double the 3.4-point overestimate seen in the control group. Patients with damage to the ventromedial prefrontal cortex had particular trouble detecting lies and kinship, whereas those without damage to this region showed deficits in interpreting aspects of competition, Dr. Mah and colleagues reported. IPT scores correlated with measures of general and working memory, but only in patients with left-sided lesions.

THE EYES HAVE IT

If a movie scene depicts two people in conversation, most viewers tend to watch the actors’ eyes—the better to pick up clues to the characters’ emotions. But autistic individuals are more likely to watch the actors’ mouths, according to findings presented by Robert T. Schultz, PhD, of the Yale University Child Study Center in New Haven, Connecticut.

Using sophisticated eye-tracking technology, researchers were able to monitor the gaze of viewers watching clips from the movie “Who’s Afraid of Virginia Woolf?” and to determine precisely which part of the screen they were looking at. Matched control subjects spent 65% of the viewing session looking at the eyes of the characters; they paid far less attention to the actors’ mouths (21%) or body (10%) or to nonhuman objects (4%). In contrast, subjects with autism were most likely to focus on the actors’ mouths (41%) and were less inclined to direct their gaze toward eyes (25%), body (25%), or objects (10%). The results illustrate the extent to which autistic individuals miss social information, Dr. Schultz noted.

—Peter Doskoch

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