Relative to Typical Antipsychotic Drugs, Aripiprazole Is a Safer Alternative for Alleviating Behavioral Disturbances After Experimental Brain Trauma.

BACKGROUND: Antipsychotic drugs (APDs) are used to manage traumatic brain injury (TBI)-induced behavioral disturbances, such as agitation and aggression. However, APDs exhibiting D2 receptor antagonism impede cognitive recovery after experimental TBI. Hence, empirical evaluation of APDs with different mechanistic actions is warranted. Aripiprazole (ARIP) is a D2 and 5-hydroxytryptamine1A (5-HT1A) receptor agonist; pharmacotherapies with these properties enhance cognition after TBI. OBJECTIVE: To test the hypothesis that ARIP would increase behavioral performance and decrease histopathology after TBI. METHODS: Adult male rats were subjected to either a controlled cortical impact (CCI) or sham injury and then randomly assigned to ARIP (0.1 or 1.0 mg/kg) or VEH (1.0 mL/kg, saline vehicle) groups. Treatments began 24 hours after surgery and were administered once daily for 19 days. Motor (beam-balance/beam-walk) and cognitive (Morris water maze) performance was assessed on postoperative days 1 to 5 and 14 to 19, respectively, followed by quantification of hippocampal CA1,3 neuron survival and cortical lesion volume. RESULTS: Beam-balance was significantly improved in the CCI + ARIP (1.0 mg/kg) group versus CCI + ARIP (0.1 mg/kg) and CCI + VEH (P < .05). Spatial learning and memory retention were significantly improved in the CCI + ARIP (0.1 mg/kg) group versus the CCI + ARIP (1.0 mg/kg) and CCI + VEH groups (P < .05). Both doses of ARIP reduced lesion size and CA3 cell loss versus VEH (P < .05). Importantly, neither dose of ARIP impeded functional recovery as previously reported with other APDs. CONCLUSION: These findings support the hypothesis and endorse ARIP as a safer APD for alleviating behavioral disturbances after TBI.

Divergent long-term consequences of chronic treatment with haloperidol, risperidone, and bromocriptine on traumatic brain injury-induced cognitive deficits.

Antipsychotic drugs (APDs) are provided in the clinic to manage traumatic brain injury (TBI)-induced agitation and aggression. Experimental TBI studies consistently show that daily administration of the APDs, haloperidol (HAL) and risperidone (RISP), hinder recovery. However, it is unknown how long the adverse effects remain after cessation of treatment. To elucidate this clinically relevant issue, anesthetized male rats were randomly assigned to four TBI (controlled cortical impact) and four sham groups administered HAL (0.5 mg/kg), RISP (0.45 mg/kg), bromocriptine (BRO; 5.0 mg/kg, included as a control for D2 receptor action), or vehicle (VEH; 1 mL/kg) 24 h after surgery and once-daily for 19 days. Motor and cognitive recovery was assessed on days 1-5 and 14-19, respectively, and again at 1 and 3 months after drug withdrawal. No overall group differences were observed for motor function among the TBI groups, although the HAL group showed a greater beam-walk deficit on day 5 versus the VEH and BRO groups. Cognitive recovery was significantly impaired in the HAL and RISP groups during the treatment phase versus VEH and BRO. Further, BRO was superior to VEH (p=0.0042). At 1 month, both groups that received APDs continued to exhibit significant cognitive impairment versus VEH and BRO; at 3 months, only the HAL group was impaired. Moreover, the HAL, RISP, and VEH groups continued to be cognitively deficient versus BRO, which also reduced cortical damage. These data replicate previous reports that HAL and RISP impede cognitive recovery after TBI and expand the literature by revealing that the deleterious effects persist for 3 months after drug discontinuation. BRO conferred cognitive benefits when administered concomitantly with behavioral testing, thus replicating previous findings, and also after cessation demonstrating enduring efficacy.

Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures.

OBJECTIVES: The purpose of this study is to assess the initial results of percutaneously reducing and fixing calcaneus fractures compared with a concurrent control group that was openly reduced and internally fixed through an extensile lateral approach. DESIGN: Retrospective cohort study, consecutive series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred twenty patients with 125 intra-articular calcaneus fractures were selected as a consecutive series with treatment method randomized by surgeon and time of presentation. INTERVENTION: Patients treated with open reduction and internal fixation (OR group) had an extended lateral approach and fractures were fixed with plates and screws. Patients treated with percutaneous reduction (PR group) had small incisions with indirect fragment manipulation, and the reduction achieved was secured with screws alone. MAIN OUTCOME MEASUREMENT: Clinical and radiographic assessment. RESULTS: There were 41 patients with 42 fractures in the OR group and 79 patients with 83 fractures in the PR group. There were no significant differences in sex, age, open fractures, fracture classification, or initial Bohler's angle between the two groups. Bohler's angle was improved after surgery by an average of 22.4 degrees in the OR group and 25.3 degrees in the PR group (P = 0.31). The average loss of reduction at healing (minimum 4 months postoperatively) was not significantly different between the two groups. Deep infection occurred in six of 42 of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 in the OR group and five of 83 in the PR group (P = 0.03). The need for late subtalar fusions (two of 26 and three of 41 with full 2-year follow-up) and implant removal (five of 42 and 10 of 83) was not significantly different. CONCLUSIONS: The results of this study suggest that in comparison to open reduction, this method of percutaneously reducing and fixing calcaneus fractures minimizes complications and achieves and maintains extra-articular reductions as well as the standard extensile open reduction and internal fixation. Further study of this technique is warranted. This should include assessment of articular reduction and longer follow-up of a larger number of patients.

No technological innovation is a panacea: a case series in quality improvement for primary care mental health services.

Evaluations of quality improvement efforts targeted at mental health services in primary care pediatrics are rare. We evaluated a short-targeted educational session, a Web-based system, the Child Health and Development Interactive System, and a local area mental health services resource guide. Most physicians believed the information in the educational session was at least somewhat likely to change their practice. However, only 9.2% of the families invited to complete the Web-based system did so. Physicians found access to the Web-based system time consuming and, because the billing code for the screening activity was carved out of most of Ohio's privately-insured contract, physicians received no reimbursement for the screenings. Physicians were unenthusiastic about the local resource guide because the resources were not rated for quality. This quality improvement effort demonstrates that there are not easy solutions to practice change and highlights the need for implementation support when introducing new technology.