It. is noteworthy, however, that Hough and colleagues49 have demonstrated that the mood stabilizers lithium, valproate, carbamazepine, and lamotrigine are all weak inhibitors of calcium influx through the glutamate N-methyl-D-aspartic acid (NMDA) receptor,

further suggesting that, modulation of this major excitatory neurotransmitter system in brain through other approaches could prove clinically useful for patients with bipolar disorder. To the extent that the ostensibly opposing behaviors and symptomatology exhibited in depression versus mania are attributable to excess Inhibitors,research,lifescience,medical activity in either inhibitory or excitatory neural substrates, one could envision how dampening neural excitability could be of potential use in both phases of the illness. Among the anticonvulsants, the sodium-channel

blockers, which inhibit, glutamate release, appear to be among those best, demonstrating antimanic efficacy compared with agents which enhance GABAergic mechanisms (gabapentin, Inhibitors,research,lifescience,medical tiagabine, topiramate) which, with the exception Inhibitors,research,lifescience,medical of valproate, do not, appear to exhibit, acute antimanic efficacy. Thus, modulation of glutamate mechanisms both to dampen overexcitability in both depression and mania, and potentially enhance glutamatergic tone for new learning and deconditioning, would appear to be valuable new potential approaches to the therapeutics of bipolar disorder. Considerable Inhibitors,research,lifescience,medical evidence implicates alteration in cytokine levels and functioning in the affective disorders.50,51 Preliminary attempts at using anti-inflammatory approaches, such as with antagonists of tumor necrosis factor, have been successful, and suggest a whole new approach to therapeutics in the future. Decreases in BDNF and increases in oxidative stress have also been seen during episodes of both mania and depression.52 As noted above, N-acctyl cysteine (NAC) is an antioxidant and a glutathione Inhibitors,research,lifescience,medical precursor. Recently, Harvey et al53 have shown significant effects of NAC over placebo in preventing bipolar episodes, particularly depressive recurrences in a selleck screening library 1-year

double-blind study. As an agent with few side effects and having the major asset, of preventing depressive episodes, this compound holds click here considerable therapeutic promise, both in its own right, and as a stalking horse for a new class of therapies. Also intriguing are the effects of NAC in decreasing cocaine intake noted above,15,54 and in reducing pathological gambling,55 problems not. uncommon in patients with bipolar illness. Vitamins, fatty acids, and other augmenting agents Megavitamin therapy has not. been proven to be effective in controlled clinical trials, but specific substances remain promising. For example, augmentation with folic acid (1 mg/day) is now widely recommended in refractory depression, based on a.

17 and studied as a strategy to provide physician guidance of patient self management in the HOMEOSTASIS trial.18 An ongoing trial called LAPTOP19 is studying the same technology in NYHA-III patients (low and preserved ejection fraction) who are on optimal medical therapy; the objective is to assess if a physician-directed patient self-management system guided by left atrial pressure will reduce HF hospitalizations. The study is expected to be complete by August 2013. ICD/CRT Device Diagnostics Monitoring for Heart Failure Implantable cardioverter

Inhibitors,research,lifescience,medical defibrillators (ICD)/cardiac resynchronization therapy (CRT) is mainstay treatment for heart failure patients. Data from 234 hospitals across United States participating in the Get With the Guidelines initiative showed that approximately 25% of patients hospitalized for heart failure either had or were eligible for Inhibitors,research,lifescience,medical an ICD.20 Thoracic impedance can be measured with these implanted devices and has been considered as a surrogate marker of pulmonary congestion. When a current is Inhibitors,research,lifescience,medical passed between the intracardiac lead and the generator, the lower the impedance to the conduction of this current, the higher the fluid content of the lungs (as fluid is a better conductor than air). In a validation study, Yu et al.21 found that the impedance started to decrease 15 days prior to worsening heart failure symptoms. Also, the change in impedance had a high correlation to change in

pulmonary capillary wedge pressure in a subset of patients with Swan-Ganz monitoring. Utilizing a threshold Inhibitors,research,lifescience,medical value of 60 Ω days, the authors found 76% sensitivity and 1.5 false-positive HF decompensations per patient-year of monitoring. In a more recent study of HF patients, Abraham et al. showed that the sensitivity of intrathoracic impedance monitoring was far superior to daily weight monitoring for predicting worsening HF events.22 On the contrary,

the SENSE-HF trial failed to show utility of the same technology,23 and also revealed many practical uncertainties such as unreliability of impedance testing early after implant. The sensitivity to predict HF events was at best Inhibitors,research,lifescience,medical 42% with a positive predictive valve of 38%. The DOT-HF trial24 studied the clinical utility of the OptiVol® (Medtronic, Inc., Minneapolis, MN) implantable monitoring tool to track changes in intrathoracic impedance. The trial was halted early due to under-recruitment. All-cause mortality and rehospitalizations did not change from selleck control to impedance-monitored therapy. Phosphatidylinositol diacylglycerol-lyase Also, post-hoc analysis showed that even if recruitment was optimal, there would not have been a significant result. Current efforts are ongoing in the Optilink-HF trial,25 where an OptiVol/CareLink® system (Medtronic, Inc., Minneapolis, MN) is being used to provide physicians with wireless alerts of threshold deviations for worsening cardiac status. To increase the predictive ability of a diagnostic algorithm, Whellan et al.

5% vs. 40% p=0.005). Conclusion While resection of pancreatic cancer can be performed with low perioperative mortality, the associated perioperative morbidity can be significant. Recent advances in surgical instrumentation have made wide spread adoption of laparoscopic distal

pancreatectomy possible. Similar to experience in other cancer types, the initial oncologic outcome with laparoscopic distal pancreatectomy appear comparable to open distal pancreatectomy. The advantage of minimally invasive surgery in terms of less blood loss and shorter hospital stay was also Inhibitors,research,lifescience,medical observed. The advances in surgical techniques also allow more aggressive surgical resection to be Inhibitors,research,lifescience,medical performed with acceptable perioperative mortality and morbidity. With the advances

in systemic treatment of pancreatic cancer, the ability to achieve negative resection margin will improve the outcome of patients with this aggressive disease. Footnotes No potential conflict of interest.
Adenocarcinoma of pancreas is the fourth Inhibitors,research,lifescience,medical most common cause of cancer-related death among U.S. men and women. Due to lack of specific symptoms and effective screening modality, about 80% of pancreatic cancer cases are diagnosed at advanced stage with locally advanced or metastatic disease. Surgical resection remains the only curative therapy for pancreatic cancer patients, and 5-year survival for surgically resected patients is only 30%. Therefore, more research and novel strategies are urgently needed to understand biology better, detect the disease sooner, Inhibitors,research,lifescience,medical and develop better treatment to improve survival and quality of life. In this focused issue, we have covered see more important topics related to biology, detection and treatment of pancreatic cancer. Inhibitors,research,lifescience,medical Imaging modality is important to identify patients at risk for pancreatic cancer. With the advance of imaging modality and technique, there has been significant improvement in identifying smaller tumor in pancreas. At present time, only about 15-20%

of patients have resectable disease at the time of diagnosis. Preoperative staging to assess the extent of disease is critical to select patients for complete (R0) resection. Besides distant metastasis, lesions involving superior mesenteric artery and/or celiac axis are generally considered unresectable. Pre-operative evaluation with computed tomography and other modality Isotretinoin such as endoscopic ultrasound can better select patients for R0 resection. Tummala et al. have reviewed different imaging modalities and their utility in assessing patients with suspicious pancreatic lesion, and identifying unresectable disease in patients with pancreatic cancer (1). The improvement in perioperative care and surgical techniques has led to decrease in mortality and morbidity for patients receiving resection of pancreatic cancer.

However, this mechanism has not been explored in AP-treated patients. Furthermore, APs may affect bone health independently of their effect on prolactin. In fact, APs, particularly second-generation

APs, modulate serotoninergic and adrenergic receptors [Richelson and Souder, 2000]. A number of functional serotonin receptors [e.g. 5-hydroxytryptamine 1A (5-HT1A), 5-HT1B, 5-HT2A, Inhibitors,research,lifescience,medical 5-HT2B] along with the serotonin transporter have been identified in bone cells [Bliziotes et al. 2001; Westbroek et al. 2001; Yadav et al. 2008]. This has recently stimulated great interest in understanding the role of serotonin in bone metabolism [Warden et al. 2010]. In fact, circulating serotonin has been implicated in reduced bone formation [Yadav et al. 2008; Modder et al. 2010], by activating the 5-HT1B receptor on osteoblasts [Yadav et al. 2008]. This activation reduces the expression of the transcription factor cyclic adenosine monophosphate response element binding protein, which in Inhibitors,research,lifescience,medical turn decreases the expression of cyclin D1, reducing osteoblast proliferation [Yadav et al. 2008]. Consistent with this finding, 5-HT1B

knockout mice display increased Inhibitors,research,lifescience,medical bone formation and bone mass [Yadav et al. 2008]. While the affinity for the 5-HT1B receptor of commonly used APs is generally low, it does vary across the different compounds [Roth et al. 2004]. Therefore, it is conceivable that some APs may promote bone formation by blocking the 5-HT1B receptor. The skeletal effect of blocking the 5-HT2A receptor, which most APs have a high affinity for [Roth et al. 2004], is less clear. This receptor is expressed on osteoblasts [Bliziotes et al. 2001] but 5-HT2A receptor knockout mice display normal bone formation and resorption and no deficit Inhibitors,research,lifescience,medical in osteoblast proliferation [Yadav et al. 2008]. In contrast, 5-HT2B receptor knockout mice exhibit impaired osteoblast recruitment and proliferation resulting in deficient cortical and trabecular BMD [Locker et al. 2006; Collet et al. 2008; Baudry et al. 2010]. Inhibitors,research,lifescience,medical Thus, APs may also interfere with bone mineralization by blocking the 5-HT2B receptor [Bymaster

et al. 1999]. However, by blocking the 5-HT2C receptors in neurons of the ventromedial hypothalamus, APs may attenuate the inhibition of the sympathetic nervous system by serotoninergic buy Everolimus signaling from the raphe nuclei [Ducy, 2011]. This, in turn, activates skeletal β2-adrenergic receptors, which negatively impact bone metabolism [Karsenty and Ducy, 2006]. Of note is that most APs have a very low affinity for much β-adrenergic receptors [Leysen et al. 1992]. However, several APs have high affinity for α1A- and α1B-adrenergic receptors [Roth et al. 2004]. Human osteoblasts express α1A-adrenergic receptors and stop proliferating when treated with α1 antagonists [Huang et al. 2009]. Expression of α1B-adrenergic receptor mRNA has also been demonstrated in human osteoclasts [Togari, 2002], suggesting that these receptors may have a role in osteoclast regulation.

In a subsequent double-blind, placebo-controlled trial in healthy individuals, transcranial magnetic stimulation showed that the intake of a single dose of the serotonin reuptake inhibitor paroxetine was Tipifarnib manufacturer associated with hyperexcitability of the primary motor cortex, whereas chronic intake was associated with hypoexcitability of the brain motor cortices. Serotonin reuptake inhibitors increase interneuron-facilitating activity in the primary motor cortex. This study demonstrated that, in recovering stroke patients, Inhibitors,research,lifescience,medical a single dose of 20 mg transiently improved motor function and acted directly on overactivating motor cortices through a fluoxetine-induced change

Inhibitors,research,lifescience,medical of cortical excitability.58,59 The FLAME trial was then designed with aim at investigating whether fluoxetine would enhance motor recovery if given soon after an ischemic stroke to patients who have motor deficits.60 In a double-blind, placebo-controlled trial, patients who had ischemic stroke and hemiplegia or hemiparesis, had Fugl-Meyer motor scale (FMMS) scores of 55 or less, and were aged between 18 years and 85 years were eligible for inclusion. They were randomly assigned to fluoxetine (20 mg once per day, orally) or placebo for Inhibitors,research,lifescience,medical 3 months starting 5 to 10 days after the onset of stroke. All patients had physiotherapy. The primary outcome measure

was the change on the FMMS between day 0 and day 90 after the start of the study drug. A total of 118 patients were randomly assigned to fluoxetine (n=59) or placebo (n=59), and 113 were included in the analysis. FMMS improvement Inhibitors,research,lifescience,medical at day 90 was significantly greater in the fluoxetine group (adjusted

mean 34·0 points [95% CI 29·7-38·4]) than in the placebo group (24·3 points [19·9-28·7]; P=0·003). This study shows for the first time that in patients with ischemic stroke and moderate-to-severe motor deficit, the early prescription of fluoxetine with physiotherapy enhanced motor recovery after Inhibitors,research,lifescience,medical 3 months. Long-term effects remain unknown but other studies suggest that the benefit persists after 1 year.61 Modulation of spontaneous brain plasticity by drugs is a promising pathway for treatment of patients with ischaemic stroke and moderate to severe motor deficit. It science is now demonstrated through the model of stroke that brain plasticity can be pharmacologically modulated. The field is now wide open. The question of the influence of aging remains. The influence of aging on brain plasticity The question of the influence of aging both on spontaneous brain plasticity and on modulated brain plasticity is of major importance. It is not easy to address, as there is no objective individual measurements of brain plasticity. So conclusions are indirect and subject to the quality of clinical trials measuring the effect of intervention on clinical changes.

2007]. There is also some evidence to suggest that agomelatine improves sleep efficiency and increases the total Ruxolitinib nmr amount of slow wave sleep [Quera Salva et al. 2007]. It is also thought to improve ‘daytime alertness’ compared with venlafaxine [Lemoine et al. 2007]. Agomelatine has also been shown to prevent relapse at similar rates to other antidepressants [Goodwin et al.

2009]. It appears to be well tolerated, with less weight gain, sexual side effects, sleep problems and withdrawal syndrome compared with SSRIs [European Public Assessment Report; Inhibitors,research,lifescience,medical Montgomery et al. 2006; Rouillon, 2006]. There is evidence that agomelatine improves Hamilton Anxiety Rating Scale scores in patients with generalized

anxiety disorder [Stein et al. 2008]. In patients with seasonal affective disorder, Inhibitors,research,lifescience,medical 25 mg of agomelatine over 14 weeks was associated with significant improvements in the Structured Interview Guide for the HAM-D, with a particular improvement in sleep disturbance and daytime fatigue [Pjrek et al. 2007]. Adjunctive use in patients with bipolar type 1 disorder Inhibitors,research,lifescience,medical also showed improvement in HAM-D scores [Calabrese et al. 2007] and the risk of triggering a manic switch was similar to that seen with venlafaxine [Calabrese et al. 2007]. This small study involved 21 patients with type I bipolar disorder Inhibitors,research,lifescience,medical who were prescribed concurrent mood-stabilizing agents (either lithium or valporic acid). All the patients were followed up for 6 weeks and although the preliminary findings suggest 25 mg of agomelatine is efficacious, a RCT is planned to confirm the results. Given its apparent efficacy and favourable side-effect profile, some have regarded agomelatine as an ‘innovative treatment for major depressive disorder patients offering a new approach in the management of depressed patients’ [den Boer et al. 2006]. However, most of the evidence about the efficacy and tolerability

Inhibitors,research,lifescience,medical of agomelatine as an antidepressant is derived from RCTs which are of short duration (usually 6–12 weeks). Currently there are no published retrospective, naturalistic studies involving agomelatine in clinical others practice and there are no published studies looking at combinations of agomelatine with other antidepressants. Aims We aimed to determine the tolerability and clinical effectiveness of agomelatine in unipolar depression in clinical practice. We also aimed to discern whether being refractory to previous treatment altered outcome. Method A retrospective analysis of all psychiatric contacts in a discrete geographical area in Scotland was undertaken searching the electronic records using the keyword ‘agomelatine’.

These include acute phase reactants, inflammatory cytokines,

and components of the complement cascade.71 The inflammatory proteins observed in AD are produced by microglia and/or astrocytes. The parallel observation of an inverse relationship between learn more rheumatoid arthritis and AD led to the hypothesis that anti-inflammatory agents Inhibitors,research,lifescience,medical reduce AD risk. Recent literature suggests an association between nonsteroidal anti-inflammatory drug (NSAID) use and decreased AD risk, including prospective data from the Baltimore Longitudinal Study of Aging. This has led to the initiation of several clinical trials of anti-inflammatory agents, many of which are still ongoing. As early as 1993, it, was noted that patients with mild-tomoderate AD treated with Inhibitors,research,lifescience,medical indomethacin, exhibited stable cognitive performance relative to patients on placcbo.72 However, not all clinical trials with anti-inflammatory agents have yielded positive findings. ‘The Alzheimer’s Disease Cooperative Study (from the National Institute of Aging [NIA]),73 a multicentcr, randomized, placebo-controlled trial of low-dose steroid prednisone conducted

in a total of 138 subjects, observed no difference in cognitive decline (assessed by the ADAS-Cog) between the prednisone and placebo treatment groups in the primary intentto-treat, analysis, or in a secondary analysis which included completers only. Inhibitors,research,lifescience,medical On the basis of these findings, they concluded that prednisone did not seem to be therapeutic for AD patients. Clinical trials of new anti-inflammatory agents, such as the cyclooxygenase-2 (COX II), inhibitors are ongoing. Several investigators Inhibitors,research,lifescience,medical have suggested that COX II inhibition directly impacts neuronal function in addition to inflammatory microglia since COX II is present not only in microglia but also in neurons.74,75 Moreover, on the basis of Inhibitors,research,lifescience,medical animal and cell studies, investigators suggest that COX II activity may contribute to neurodegencration in AD by oxidative mechanisms.76

Additional anti-inflammatory drugs, including hydroxychloroquine and colchicine, are being examined in clinical trials with AD patients. Oxidation Excess brain protein oxidation mafosfamide and decreased endogenous antioxidant activity are well noted in both normal aging and AD.77 Thus, reduction of oxidative stress has become a target, for the treatment of AD. Agents that protect against oxidative damage, such as vitamin E and Ginkgo biloba extract, are thought, to reduce neuronal damage and potentially slow the onset and/or progression of AD. An extensive clinical trial of vitamin F, and selegiline, a type B or selective monoamine oxidase inhibitor, in AD patients found that both compounds delayed the progression of nursing home placement by approximately 6 months, thus precipitating the widespread use of vitamin E. However, data on the effects of such compounds on cognitive symptoms is more limited.

Controversy exists about whether the newer antidepressants are as effective as the TCAs. Some meta-analyses,119-122 but not all,123 indicate that TCAs (eg, amitriptyline, clomipramine) and venlafaxine (at a dose of 150 mg or greater) are more effective than SSRIs (citalopram, paroxetine) or moclobemide in severely depressed inpatients. Although this is not unanimously admitted, the efficacy of TCAs is related to the administered dose (a dose of 150 mg/day is more effective

than 75 mg/day in severe depression). However, owing to their anticholinergic selleck kinase inhibitor adverse effects (such as dry mouth, constipation, blurred vision, impaired concentration, and confusion) TCAs are usually prescribed below recommended Inhibitors,research,lifescience,medical doses (for review see ref 4). Thus, in order to minimize

adverse effects, TCAs have to be started at a low dose and increased gradually (every 3 to 7 days); the delayed clinical response also makes it difficult to establish Inhibitors,research,lifescience,medical the optimal dose quickly (TCAs take 2 to 4 weeks before an antidepressant effect is evident). On the other hand, SSRIs and newer antidepressants are better tolerated than TCAs and are safer in overdose. Moreover, their dose formulation Inhibitors,research,lifescience,medical tends to ensure adequate dosing, and they can be administered at the recommended dose after a few days of treatment at a lower dose. The adverse reactions associated with the SSRIs (eg, nausea, diarrhea, anxiety, agitation, sexual dysfunction, insomnia, and anorexia) may also occur with SNRIs. Some drugs have specific adverse effects, such as hypertension with venlafaxine and Inhibitors,research,lifescience,medical agranulocytosis with mianserin. It is noteworthy that mirtazapine, induce weight gain. New treatment options such as agomelatine will have to be taken into consideration, Inhibitors,research,lifescience,medical once available. Short-term outcome It is important to review patients regularly (usually weekly for the first 4 to 6 weeks) to monitor response,

compliance, side effects with treatment, and suicidal ideation. Adverse effects are often dose-dependent, and a dose reduction may Metalloexopeptidase alleviate the problem. Moreover, tolerance occurs for many of the acute adverse effects of the antidepressants, probably as a result of receptor downregulation. For this reason, the dose can be gradually re-escalated, if needed for optimal efficacy, without the adverse effect necessarily recurring. If there is no response (< 25% improvement) after 3 weeks it is possible to increase the dose, while in case of a partial response, one could wait another 2 weeks before increasing the dose.124 What are the options in ease of nonresponse? When a patient does not respond to the first-choice antidepressant at an adequate dose, three strategies exist: increasing the dose of the antidepressant, switching to another antidepressant, or combining several drugs.

Localization of melatonin receptors Since 1987, the use of [125I]MEL as a ligand with a high specific activity has permitted studies on the localization of MEL receptors (or more exactly binding sites) of the MEL-1 family (MT1, MT2, and Mel1c).The binding sites appear to be widespread in vertebrates. Comparative distribution studies reveal the presence of MEL binding sites in the brain of five vertebrate classes (fish, amphibian, reptiles, birds, and mammals). The most relevant feature is that the distribution of MEL Inhibitors,research,lifescience,medical binding sites in lower vertebrates is much larger

than in mammals, and they are consistently found in areas associated with retinorecipient and integrative structures of the visual system.43 In mammals the situation is more contrasted. Contrary to what, is generally claimed, in mammals, MEL receptors are Inhibitors,research,lifescience,medical also present in a large number of structures. They have been described in more than 110 brain structures, among them the internal granular layer and the external plexiform layer of the olfactory bulb, lateral septum, scptohippocampal nucleus, caudate putamen bed selleck nucleus of the

stria terminalis, SCN, mediobasal hypothalamic nuclei, paraventricular nuclei of the hypothalamus, paraventricular nuclei of the thalamus, intergeniculate leaflet, central and medial amygdaloid nucleus, inferior colliculus, fasciculus retroflexus, substantia nigra, and frontal, orbitofrontal, and parietal cortex.44-46 Inhibitors,research,lifescience,medical However, Inhibitors,research,lifescience,medical a great variability has been noted in the number and location of labeled structures among the species, as well as large differences in receptor den sity between structures and in the same structures between species. Few structures are common, even among species from the same family,44 and very probably this should be correlated either

to the numerous photoperiodic responses, which are different from one species to another, or to the many different, effects described for MEL (see below). Among all these structures, the pituitary PT, which shows the highest density Inhibitors,research,lifescience,medical of MEL receptors and is the only structure found consistently labeled Tryptophan synthase in all mammals so far studied, and the SCN, which contains MEL receptors in many species, are considered as two major sites for MEL action (see below). However, it. should also be pointed out that MEL receptors/binding sites have been identified in numerous peripheral organs. The role of these receptors has not yet been extensively studied, but their presence explains the reported direct action of MEL, for example, on blood vessels47-49 and on cell-mediated and humoral immune function50 on Leydig and luteal cells.51 Its also indicates that the MEL message can be read at different levels of the organism, which should be taken into account when the potential therapeutic properties of MEL or MEL analogues are considered, especially as specific binding sites have been reported in several neoplastic tissues.

As noted above, TBI patients can reconstruct aspects of the traumatic experience that were not adequately encoded during the period of impaired consciousness. This scenario raises the possibility that treating PTSD after TBI will require adaptive reconstruction of this narrative in a way that facilitates adaptation rather than retraumatization. For example, a patient who reconstructs their memory of a car

accident in which they were excessively responsible for someone’s death will have marked depressive responses relative to a patient who reconstructs the memory in a way that accepts a more reasonable level of responsibility. Alternately, a patient can Inhibitors,research,lifescience,medical be encouraged to tolerate a level of uncertainty insofar as there is permanent amnesia of some aspect of the event; inability to tolerate Inhibitors,research,lifescience,medical uncertainty is linked to enhanced anxiety and worry.120 One of the challenges for treating PTSD after TBI is the patient’s ability to either reconstruct events in a coherent and adaptive way or to accept the uncertainty of how events transpired when they suffered their

TBI. The extent to which a person with TBI needs to reconstruct the trauma narrative to recover from PTSD has yet to be empirically determined. As noted above, several large-scale studies have reported that MTBI is associated with increased risk for PTSD.59,92,78 One possibility for Inhibitors,research,lifescience,medical this observation may be that

people who sustain a MTBI do not have a coherent narrative of their traumatic experience because of the impaired consciousness secondary to the brain injury, and this may impede their capacity to contextualize the experience in their autobiographical memory base. A second implication for PTSD treatment Inhibitors,research,lifescience,medical after TBI is that the treatment of choice for PTSD involves traumafocused exposure therapy.121 This treatment is based on extinction Inhibitors,research,lifescience,medical learning, which occurs when a conditioned stimulus is repeatedly presented in the absence of an aversive outcome, thereby facilitating new learning that Oxygenase the stimulus is no longer signaling threat. In the context of therapy, presenting memories or reminders of the trauma to the patient in the safety of therapy typically leads to symptom reduction. Exposure can either be imaginai, which involves focusing on one’s memories of the traumatic event, or in vivo, in which approaches and remains with reminders that usually trigger anxiety about the event. On the premise that fear conditioning and extinction still occurs in the context of TBI, it would seem that that exposure-based therapy is the indicated intervention for PTSD Stem Cells antagonist following TBI. Supporting this conclusion is evidence in one controlled trial of patients with acute stress disorder following MTBI that CBT effectively treated PTSD symptoms to a similar extent as when applied to non -TBI samples.