The neurobehavioral sequelae of TBI consist of a spectrum of somatic, neurologic, and psychiatric symptoms. The challenge for clinicians lies in understanding the interface of the various symptoms ...and how they interrelate with other entities. Specifically, the challenge is differentiating post-TBI-related symptoms from preexisting or de novo psychiatric, neurologic, and/or systemic disorders. A comprehensive evaluation and a multidisciplinary approach to evaluating patients are essential to be able to develop the differential diagnosis needed to design a management plan that maximizes recovery.
The neurobehavioral sequelae (NBS) of traumatic brain injury (TBI) consist of a spectrum of somatic, neurological, and psychiatric symptoms. The challenge for clinicians lies in understanding the ...interface of the various symptoms and how they interrelate with other entities. Specifically, the challenge is differentiating post-TBI-related symptoms from pre-existing or de novo psychiatric, neurological, and/or systemic disorders. A comprehensive evaluation and a multidisciplinary approach to evaluating patients are essential to be able to develop the differential diagnosis needed to design a management plan that maximizes recovery.
This clinical policy provides evidence-based recommendations on select issues in the management of adult patients with mild traumatic brain injury (TBI) in the acute setting. It is the result of ...joint efforts between the American College of Emergency Physicians and the Centers for Disease Control and Prevention and was developed by a multidisciplinary panel. The critical questions addressed in this clinical policy are: (1) Which patients with mild TBI should have a noncontrast head computed tomography (CT) scan in the emergency department (ED)? (2) Is there a role for head magnetic resonance imaging over noncontrast CT in the ED evaluation of a patient with acute mild TBI? (3) In patients with mild TBI, are brain specific serum biomarkers predictive of an acute traumatic intracranial injury? (4) Can a patient with an isolated mild TBI and a normal neurologic evaluation result be safely discharged from the ED if a noncontrast head CT scan shows no evidence of intracranial injury? Inclusion criteria for application of this clinical policy's recommendations are nonpenetrating trauma to the head, presentation to the ED within 24 hours of injury, a Glasgow Coma Scale score of 14 or 15 on initial evaluation in the ED, and aged 16 years or greater. The primary outcome measure for questions 1, 2, and 3 is the presence of an acute intracranial injury on noncontrast head CT scan; the primary outcome measure for question 4 is the occurrence of neurologic deterioration.
Schizophrenia is associated with abnormalities in glucose metabolism that may lead to insulin resistance and a 3 fold higher incidence of type II diabetes mellitus. The goal of the present studies ...was to assess the role of insulin-dependent Akt signaling in schizophrenia and in animal and cellular models of insulin resistance. Our studies revealed a functional decrease in insulin receptor (IR)-mediated signal transduction in the dorsolateral prefrontal cortex (BA46) of medicated schizophrenics relative to control patients using post-mortem brain material. We found ∼
50% decreases in the content and autophosphorylation levels of IRβ and ∼
76–78% decreases in Akt content and activity (pSer
473-Akt). The inhibition of IRβ signaling was accompanied by an elevated content of glycogen synthase kinase (GSK)-3α and GSK-3β without significant changes in phospho-Ser
21/9 GSK-3α/β levels. A cellular model of insulin resistance was induced by IRβ knockdown (siRNA). As in schizophrenia, the IRβ knockdown cells demonstrated a reduction in the Akt content and activity. Total GSK-3α/β content remained unaltered, but phospho-Ser
21/9 GSK-3α/β levels were reduced indicating a net increase in the overall enzyme activity similar to that in schizophrenia. Insulin resistance phenotype was induced in mice by treatment with antipsychotic drug, clozapine. Behavioral testing showed decreases in startle response magnitude in animals treated with clozapine for 68
days. The treatment resulted in a functional inhibition of IRβ but the Akt activation status remained unaltered. Changes in GSK-3α/β were consistent with a net decrease in the enzyme activity, as opposed to that in schizophrenia. The results suggest that alterations in insulin-dependent Akt signaling in schizophrenia are similar to those observed in our cellular but not animal models of insulin resistance. In animal model, clozapine ameliorates IRβ deficits at the GSK-3α/β level, which may justify its role in treatment of schizophrenia. Our studies suggest that aberrant IR function may be important in the pathophysiology of schizophrenia.
A concussion results from a force to the brain that results in a transient loss of connectivity within the brain. Sport psychiatrists are increasingly called to be part of the concussion team and ...need to be prepared to manage issues related to concussion and its behavioural sequelae. Objectively, the best evidence available suggests that deficits in attention and/or in balance are the most reliable objective findings that a concussion has occurred. Prognosis after a concussion is generally very good, although a sub-set of patients that are yet well defined seem pre-disposed to delayed recovery. Neither head CT nor MRI are sufficiently sensitive to diagnose the type of injuries that pre-dispose patients to the neurobehavioural sequelae that have been associated with a concussion; confounding this is the finding that many of these signs and symptoms associated with concussion occur in other types of non-head injuries. Brain biomarkers and functional MRI (fMRI) hold promise in both diagnosis and prognosis of concussion, but are still research tools without validated clinical utility at this time. Finally, neurocognitive testing holds promise as a diagnostic criterion to demonstrate injury but, unfortunately, these tests are also limited in their prognostic utility and are of limited value.
BACKGROUND:Currently, there is no evidence-based definition for concussion that is being uniformly applied in clinical and research settings.
OBJECTIVE:To conduct a systematic review of the ...highest-quality literature about concussion and to assemble evidence about the prevalence and associations of key indicators of concussion. The goal was to establish an evidence-based foundation from which to derive, in future work, a definition, diagnostic criteria, and prognostic indicators for concussion.
METHODS:Key questions were developed, and an electronic literature search from 1980 to 2012 was conducted to acquire evidence about the prevalence of and associations among signs, symptoms, and neurologic and cognitive deficits in samples of individuals exposed to potential concussive events. Included studies were assessed for potential for bias and confound and rated as high, medium, or low potential for bias and confound. Those rated as high were excluded from the analysis. Studies were further triaged on the basis of whether the definition of a case of concussion was exclusive or inclusive; only those with wide, inclusive case definitions were used in the analysis. Finally, only studies reporting data collected at fixed time points were used. For a study to be included in the conclusions, it was required that the presence of any particular sign, symptom, or deficit be reported in at least 2 independent samples.
RESULTS:From 5437 abstracts, 1362 full-text publications were reviewed, of which 231 studies were included in the final library. Twenty-six met all criteria required to be used in the analysis, and of those, 11 independent samples from 8 publications directly contributed data to conclusions. Prevalent and consistent indicators of concussion are (1) observed and documented disorientation or confusion immediately after the event, (2) impaired balance within 1 day after injury, (3) slower reaction time within 2 days after injury, and/or (4) impaired verbal learning and memory within 2 days after injury.
CONCLUSION:The results of this systematic review identify the consistent and prevalent indicators of concussion and their associations, derived from the strongest evidence in the published literature. The product is an evidence-based foundation from which to develop diagnostic criteria and prognostic indicators.
ABBREVIATIONS:GCS, Glasgow Coma ScaleLOC, loss of consciousnessPCE, potential concussive eventPTA, posttraumatic amnesiaSOT, Sensory Organization TestSSD, signs, symptoms, neurologic deficits, and cognitive deficits
BackgroundThere are claims that second-generation antipsychotics produce fewerextrapyramidal side-effects (EPS) compared with first-generationdrugs.AimsTo compare the incidence of treatment-emergent ...EPS betweensecond-generation antipsychotics and perphenazine in people withschizophrenia.MethodIncidence analyses integrated data from standardised rating scales anddocumented use of concomitant medication or treatment discontinuation forEPS events. Mixed model analyses of change in rating scales from baselinewere also conducted.ResultsThere were no significant differences in incidence or change in ratingscales for parkinsonism, dystonia, akathisia or tardive dyskinesia whencomparing second-generation antipsychotics with perphenazine or comparingbetween second-generation antipsychotics. Secondary analyses revealedgreater rates of concomitant antiparkinsonism medication amongindividuals on risperidone and lower rates among individuals onquetiapine, and lower rates of discontinuation because of parkinsonismamong people on quetiapine and ziprasidone. There was a trend for agreater likelihood of concomitant medication for akathisia amongindividuals on risperidone and perphenazine.ConclusionsThe incidence of treatment-emergent EPS and change in EPS ratingsindicated that there are no significant differences betweensecond-generation antipsychotics and perphenazine or betweensecond-generation antipsychotics in people with schizophrenia.
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