In vivo imaging of nitric oxide in the male rat brain exposed to a shock wave.

While numerous studies have suggested the involvement of cerebrovascular dysfunction in the pathobiology of blast-induced traumatic brain injury (bTBI), its exact mechanisms and how they affect the outcome of bTBI are not fully understood. Our previous study showed the occurrence of cortical spreading depolarization (CSD) and subsequent long-lasting oligemia/hypoxemia in the rat brain exposed to a laser-induced shock wave (LISW). We hypothesized that this hemodynamic abnormality is associated with shock wave-induced generation of nitric oxide (NO). In this study, to verify this hypothesis, we used an NO-sensitive fluorescence probe, diaminofluorescein-2 diacetate (DAF-2 DA), for real-time in vivo imaging of male Sprague-Dawley rats' brain exposed to a mild-impulse LISW. We observed the most intense fluorescence, indicative of NO production, along the pial arteriolar walls during the period of 10-30 min post-exposure, parallel with CSD occurrence. This post-exposure period also coincided with the early phase of hemodynamic abnormalities. While the changes in arteriolar wall fluorescence measured in rats receiving pharmacological NO synthase inhibition by nitro-L-arginine methyl ester (L-NAME) 24 h before exposure showed a temporal profile similar to that of changes observed in LISW-exposed rats with CSD, their intensity level was considerably lower; this suggests partial involvement of NOS in shock wave-induced NO production. To the best of our knowledge, this is the first real-time in vivo imaging of NO in rat brain, confirming the involvement of NO in shock-wave-induced hemodynamic impairments. Finally, we have outlined the limitations of this study and our future research directions.

Blast-Induced Neurotrauma Results in Spatially Distinct Gray Matter Alteration Alongside Hormonal Alteration: A Preliminary Investigation.

Blast-induced neurotrauma (BINT) frequently occurs during military training and deployment and has been linked to long-term neuropsychological and neurocognitive changes, and changes in brain structure. As military personnel experience frequent exposures to stress, BINT may negatively influence stress coping abilities. This study aimed to determine the effects of BINT on gray matter volume and hormonal alteration. Participants were Canadian Armed Forces personnel and veterans with a history of BINT (n = 12), and first responder controls (n = 8), recruited due to their characteristic occupational stress professions. Whole saliva was collected via passive drool on the morning of testing and analyzed for testosterone (pg/mL), cortisol (µg/dL), and testosterone/cortisol (T/C) ratio. Voxel-based morphometry was performed to compare gray matter (GM) volume, alongside measurement of cortical thickness and subcortical volumes. Saliva analyses revealed distinct alterations following BINT, with significantly elevated testosterone and T/C ratio. Widespread and largely symmetric loci of reduced GM were found specific to BINT, particularly in the temporal gyrus, precuneus, and thalamus. These findings suggest that BINT affects hypothalamic-pituitary-adrenal and -gonadal axis function, and causes anatomically-specific GM loss, which were not observed in a comparator group with similar occupational stressors. These findings support BINT as a unique injury with distinct structural and endocrine consequences.

Measuring Resilience to Operational Stress in Canadian Armed Forces Personnel.

Adaptability to stress is governed by innate resilience, comprised of complex neuroendocrine and immune mechanisms alongside inherited or learned behavioral traits. Based on their capacity to adapt, some people thrive in stressful situations, whereas others experience maladaptation. In our study, we used state-of-the-art tools to assess the resilience level in individuals, as well as their susceptibility to developing military stress-induced behavioral and cognitive deficits. To address this complex question, we tested Canadian Armed Forces (CAF) personnel in three distinct stress environments (baselines): during predeployment training, deployment in Afghanistan, and readjustment upon return to Canada. Our comprehensive outcome measures included psychometric tests, saliva biomarkers, and computerized cognitive tests that used the Cambridge Neuropsychological Automated Test Battery. Participants were categorized based on initial biomarker measurements as being at low-, moderate-, or high stress-maladaptation risk. Biomarkers showed significant changes (ds = 0.56 to 2.44) between baselines, calculated as "delta" changes. Participants at low stress-maladaptation risk demonstrated minimal changes, whereas those at high stress-maladaptation risk showed significant biomarker variations. The psychometric patterns and cognitive functions were likewise affected across baselines, suggesting that the panel of saliva stress biomarkers could be a useful tool for determining the risk of stress maladaptation that can cause psychological and cognitive decline.

Preclinical modelling of militarily relevant traumatic brain injuries: Challenges and recommendations for future directions.

As a follow-up to the 2008 state-of-the-art (SOTA) conference on traumatic brain injuries (TBIs), the 2015 event organized by the United States Department of Veterans Affairs (VA) Office of Research and Development (ORD) analysed the knowledge gained over the last 7 years as it relates to basic scientific methods, experimental findings, diagnosis, therapy, and rehabilitation of TBIs and blast-induced neurotraumas (BINTs). The current article summarizes the discussions and recommendations of the scientific panel attending the Preclinical Modeling and Therapeutic Development Workshop of the conference, with special emphasis on factors slowing research progress and recommendations for ways of addressing the most significant pitfalls.

Individualized high-resolution analysis to categorize diverse learning and memory deficits in tau rTg4510 mice exposed to low-intensity blast.

Mild traumatic brain injury (mTBI) resulting from low-intensity blast (LIB) exposure in military and civilian individuals is linked to enduring behavioral and cognitive abnormalities. These injuries can serve as confounding risk factors for the development of neurodegenerative disorders, including Alzheimer's disease-related dementias (ADRD). Recent animal studies have demonstrated LIB-induced brain damage at the molecular and nanoscale levels. Nevertheless, the mechanisms linking these damages to cognitive abnormalities are unresolved. Challenges preventing the translation of preclinical studies into meaningful findings in "real-world clinics" encompass the heterogeneity observed between different species and strains, variable time durations of the tests, quantification of dosing effects and differing approaches to data analysis. Moreover, while behavioral tests in most pre-clinical studies are conducted at the group level, clinical tests are predominantly assessed on an individual basis. In this investigation, we advanced a high-resolution and sensitive method utilizing the CognitionWall test system and applying reversal learning data to the Boltzmann fitting curves. A flow chart was developed that enable categorizing individual mouse to different levels of learning deficits and patterns. In this study, rTg4510 mice, which represent a neuropathology model due to elevated levels of tau P301L, together with the non-carrier genotype were exposed to LIB. Results revealed distinct and intricate patterns of learning deficits and patterns within each group and in relation to blast exposure. With the current findings, it is possible to establish connections between mice with specific cognitive deficits to molecular changes. This approach can enhance the translational value of preclinical findings and also allow for future development of a precision clinical treatment plan for ameliorating neurologic damage of individuals with mTBI.

Effects of chronic mild traumatic brain injury on white matter integrity in Iraq and Afghanistan war veterans.

Mild traumatic brain injury (TBI) is a common source of morbidity from the wars in Iraq and Afghanistan. With no overt lesions on structural MRI, diagnosis of chronic mild TBI in military veterans relies on obtaining an accurate history and assessment of behavioral symptoms that are also associated with frequent comorbid disorders, particularly posttraumatic stress disorder (PTSD) and depression. Military veterans from Iraq and Afghanistan with mild TBI (n = 30) with comorbid PTSD and depression and non-TBI participants from primary (n = 42) and confirmatory (n = 28) control groups were assessed with high angular resolution diffusion imaging (HARDI). White matter-specific registration followed by whole-brain voxelwise analysis of crossing fibers provided separate partial volume fractions reflecting the integrity of primary fibers and secondary (crossing) fibers. Loss of white matter integrity in primary fibers (P < 0.05; corrected) was associated with chronic mild TBI in a widely distributed pattern of major fiber bundles and smaller peripheral tracts including the corpus callosum (genu, body, and splenium), forceps minor, forceps major, superior and posterior corona radiata, internal capsule, superior longitudinal fasciculus, and others. Distributed loss of white matter integrity correlated with duration of loss of consciousness and most notably with "feeling dazed or confused," but not diagnosis of PTSD or depressive symptoms. This widespread spatial extent of white matter damage has typically been reported in moderate to severe TBI. The diffuse loss of white matter integrity appears consistent with systemic mechanisms of damage shared by blast- and impact-related mild TBI that involves a cascade of inflammatory and neurochemical events.

Low-intensity open-field blast exposure effects on neurovascular unit ultrastructure in mice.

Mild traumatic brain injury (mTBI) induced by low-intensity blast (LIB) is a serious health problem affecting military service members and veterans. Our previous reports using a single open-field LIB mouse model showed the absence of gross microscopic damage or necrosis in the brain, while transmission electron microscopy (TEM) identified ultrastructural abnormalities of myelin sheaths, mitochondria, and synapses. The neurovascular unit (NVU), an anatomical and functional system with multiple components, is vital for the regulation of cerebral blood flow and cellular interactions. In this study, we delineated ultrastructural abnormalities affecting the NVU in mice with LIB exposure quantitatively and qualitatively. Luminal constrictive irregularities were identified at 7 days post-injury (DPI) followed by dilation at 30 DPI along with degeneration of pericytes. Quantitative proteomic analysis identified significantly altered vasomotor-related proteins at 24 h post-injury. Endothelial cell, basement membrane and astrocyte end-foot swellings, as well as vacuole formations, occurred in LIB-exposed mice, indicating cellular edema. Structural abnormalities of tight junctions and astrocyte end-foot detachment from basement membranes were also noted. These ultrastructural findings demonstrate that LIB induces multiple-component NVU damage. Prevention of NVU damage may aid in identifying therapeutic targets to mitigate the effects of primary brain blast injury.

The pathobiology of blast injuries and blast-induced neurotrauma as identified using a new experimental model of injury in mice.

Current experimental models of blast injuries used to study blast-induced neurotrauma (BINT) vary widely, which makes the comparison of the experimental results extremely challenging. Most of the blast injury models replicate the ideal Friedländer type of blast wave, without the capability to generate blast signatures with multiple shock fronts and refraction waves as seen in real-life conditions; this significantly reduces their clinical and military relevance. Here, we describe the pathophysiological consequences of graded blast injuries and BINT generated by a newly developed, highly controlled, and reproducible model using a modular, multi-chamber shock tube capable of tailoring pressure wave signatures and reproducing complex shock wave signatures seen in theater. While functional deficits due to blast exposure represent the principal health problem for today's warfighters, the majority of available blast models induces tissue destruction rather than mimic functional deficits. Thus, the main goal of our model is to reliably reproduce long-term neurological impairments caused by blast. Physiological parameters, functional (motor, cognitive, and behavioral) outcomes, and underlying molecular mechanisms involved in inflammation measured in the brain over the 30 day post-blast period showed this model is capable of reproducing major neurological changes of clinical BINT.

A heat-shock protein co-inducer treatment improves behavioral performance in rats exposed to hypoxia.

We investigated the effect of a heat-shock protein co-inducer, arimoclomol (CytRx, LA, CA), on hypoxia-adaptive responses using a rat model of simulated altitude exposure (hypobaric hypoxia).Cognitive function was measured using a T-maze and an object recognition test.Motor function was measured using an inclined-screen test and an adhesion removal test. Immunohistochemical analyses were assessed in brain for heat-shock protein 70 (HSP 70), intercellular adhesion molecule 1 (ICAM- 1) and apoptosis (TUNEL staining). Results show that both cognitive and motor performances were improved in rats treated with arimoclomol during hypoxic exposure; the hypoxia-induced expression of HSP70 and ICAM-1, and TUNEL-positive cells were reduced in brain with the treatment.Our data suggest that the arimoclomol treatment reduces the hypoxia-induced stress in brain tissue, and also improves the behavioral performance in rats during hypoxic adaptation.

Perspectives on Primary Blast Injury of the Brain: Translational Insights Into Non-inertial Low-Intensity Blast Injury.

Most traumatic brain injuries (TBIs) during military deployment or training are clinically "mild" and frequently caused by non-impact blast exposures. Experimental models were developed to reproduce the biological consequences of high-intensity blasts causing moderate to severe brain injuries. However, the pathophysiological mechanisms of low-intensity blast (LIB)-induced neurological deficits have been understudied. This review provides perspectives on primary blast-induced mild TBI models and discusses translational aspects of LIB exposures as defined by standardized physical parameters including overpressure, impulse, and shock wave velocity. Our mouse LIB-exposure model, which reproduces deployment-related scenarios of open-field blast (OFB), caused neurobehavioral changes, including reduced exploratory activities, elevated anxiety-like levels, impaired nesting behavior, and compromised spatial reference learning and memory. These functional impairments associate with subcellular and ultrastructural neuropathological changes, such as myelinated axonal damage, synaptic alterations, and mitochondrial abnormalities occurring in the absence of gross- or cellular damage. Biochemically, we observed dysfunctional mitochondrial pathways that led to elevated oxidative stress, impaired fission-fusion dynamics, diminished mitophagy, decreased oxidative phosphorylation, and compensated cell respiration-relevant enzyme activity. LIB also induced increased levels of total tau, phosphorylated tau, and amyloid ß peptide, suggesting initiation of signaling cascades leading to neurodegeneration. We also compare translational aspects of OFB findings to alternative blast injury models. By scoping relevant recent research findings, we provide recommendations for future preclinical studies to better reflect military-operational and clinical realities. Overall, better alignment of preclinical models with clinical observations and experience related to military injuries will facilitate development of more precise diagnosis, clinical evaluation, treatment, and rehabilitation.

NK1 antagonists attenuate tau phosphorylation after blast and repeated concussive injury.

Exposure to repeated concussive traumatic brain injury (TBI) and to blast-induced TBI has been associated with the potential development of the neurodegenerative condition known as chronic traumatic encephalopathy (CTE). CTE is characterized by the accumulation of hyperphosphorylated tau protein, with the resultant tau tangles thought to initiate the cognitive and behavioral manifestations that appear as the condition progresses. However, the mechanisms linking concussive and blast TBI with tau hyperphosphorylation are unknown. Here we show that single moderate TBI, repeated concussive TBI and blast-induced mild TBI all result in hyperphosphorylation of tau via a substance P mediated mechanism. Post-injury administration of a substance P, NK1 receptor antagonist attenuated the injury-induced phosphorylation of tau by modulating the activity of several key kinases including Akt, ERK1/2 and JNK, and was associated with improvement in neurological outcome. We also demonstrate that inhibition of the TRPV1 mechanoreceptor, which is linked to substance P release, attenuated injury-associated tau hyperphosphorylation, but only when it was administered prior to injury. Our results demonstrate that TBI-mediated stimulation of brain mechanoreceptors is associated with substance P release and consequent tau hyperphosphorylation, with administration of an NK1 receptor antagonist attenuating tau phosphorylation and associated neurological deficits. NK1 antagonists may thus represent a pharmacological approach to attenuate the potential development of CTE following concussive and blast TBI.

Pathophysiological response to experimental diffuse brain trauma differs as a function of developmental age.

The purpose of experimental models of traumatic brain injury (TBI) is to reproduce selected aspects of human head injury such as brain edema, contusion or concussion, and functional deficits, among others. As the immature brain may be particularly vulnerable to injury during critical periods of development, and pediatric TBI may cause neurobehavioral deficits, our aim was to develop and characterize as a function of developmental age a model of diffuse TBI (DTBI) with quantifiable functional deficits. We modified a DTBI rat model initially developed by us in adult animals to study the graded response to injury as a function of developmental age - 7-, 14- and 21-day-old rats compared to young adult (3-month-old) animals. Our model caused motor deficits that persisted even after the pups reached adulthood, as well as reduced cognitive performance 2 weeks after injury. Moreover, our model induced prominent edema often seen in pediatric TBI, particularly evident in 7- and 14-day-old animals, as measured by both the wet weight/dry weight method and diffusion-weighted MRI. Blood-brain barrier permeability, as measured by the Evans blue dye technique, peaked at 20 min after trauma in all age groups, with a second peak found only in adult animals at 24 h after injury. Phosphorus MR spectroscopy showed no significant changes in the brain energy metabolism of immature rats with moderate DTBI, in contrast to significant decreases previously identified in adult animals.

Long-term neurologic outcomes after traumatic brain injury.

OBJECTIVE: To determine the relations between traumatic brain injury (TBI) and several neurologic outcomes 6 months or more after TBI. PARTICIPANTS: Not applicable. DESIGN: Systematic review of the published, peer-reviewed literature. PRIMARY MEASURES: Not applicable. RESULTS: We identified 75 studies that examined the relations between TBI and neurologic outcomes. Unprovoked seizures are causally related to penetrating TBI as well as to moderate and severe TBI. There was only limited evidence of an association between seizures and mild TBI. Dementia of the Alzheimer's type (DAT) was associated with moderate and severe TBI, but not with mild TBI unless there was loss of consciousness (LOC); the evidence for the latter was limited. Parkinsonism was associated with moderate and severe TBI, but there was only modest evidence of a link with mild TBI without LOC. Dementia pugilistica was associated with professional boxing. There was insufficient evidence to support an association between TBI and both multiple sclerosis and amyotrophic lateral sclerosis. TBI appeared to produce a host of postconcussive symptoms (eg, memory problems, dizziness, and irritability). Moderate and severe TBI were associated with endocrine problems such as hypopituitarism and growth hormone deficiency and possibly with diabetes insipidus. There was only limited evidence of an association between mild TBI and the development of ocular/visual motor deterioration. CONCLUSION: TBI is strongly associated with several neurologic disorders 6 months or more after injury. Clinicians caring for TBI patients should monitor them closely for the development of these disorders. While some of these disorders can be treated after they arise (eg, seizures), a greater public health benefit would be achieved by preventing them before they develop. Research efforts to develop therapies aimed at secondary prevention are currently underway.

Multi-Focal Neuronal Ultrastructural Abnormalities and Synaptic Alterations in Mice after Low-Intensity Blast Exposure.

Service members during military actions or combat training are exposed frequently to primary blast generated by explosive weaponry. The majority of military-related neurotrauma are classified as mild and designated as "invisible injuries" that are prevalent during current conflicts. While the previous experimental blast injury studies using moderate- to high-intensity exposures focused mainly on gross and microscopic neuropathology, our previous studies have shown that low-intensity blast (LIB) exposures resulted in nanoscale subcellular myelin and mitochondrial damages and subsequent behavioral disorders in the absence of gross or detectable cellular damage. In this study, we used transmission electron microscopy to delineate the LIB effects at the ultrastructural level specifically focusing on the neuron perikaryon, axons, and synapses in the cortex and hippocampus of mice at seven and 30 days post-injury (DPI). We found dysmorphic dark neuronal perikaryon and "cytoplasmic aeration" of dendritic processes, as well as increased microtubular fragmentation of the myelinated axons along with biochemically measured elevated tau/phosphorylated tau/Aß levels. The number of cortical excitatory synapses decreased along with a compensatory increase of the post-synaptic density (PSD) thickness both at seven and 30 DPI, while the amount of hippocampal CA1 synapses increased with the reduced PSD thickness. In addition, we observed a significant increase in protein levels of PSD95 and synaptophysin mainly at seven DPI indicating potential synaptic reorganization. These results demonstrated that a single LIB exposure can lead to ultrastructural brain injury with accompanying multi-focal neuronal organelle alterations. This pre-clinical study provides key insights into disease pathogenesis related to primary blast exposure.

Ultrastructural brain abnormalities and associated behavioral changes in mice after low-intensity blast exposure.

Explosive blast-induced mild traumatic brain injury (mTBI), a "signature wound" of recent military conflicts, commonly affects service members. While past blast injury studies have provided insights into TBI with moderate- to high-intensity explosions, the impact of primary low-intensity blast (LIB)-mediated pathobiology on neurological deficits requires further investigation. Our prior considerations of blast physics predicted ultrastructural injuries at nanoscale levels. Here, we provide quantitative data using a primary LIB injury murine model exposed to open field detonation of 350 g of high-energy explosive C4. We quantified ultrastructural and behavioral changes up to 30 days post blast injury (DPI). The use of an open-field experimental blast generated a primary blast wave with a peak overpressure of 6.76 PSI (46.6 kPa) at a 3-m distance from the center of the explosion, a positive phase duration of approximate 3.0 milliseconds (ms), a maximal impulse of 8.7 PSI × ms and a sharp rising time of 9 × 10-3 ms, with no apparent impact/acceleration in exposed animals. Neuropathologically, myelinated axonal damage was observed in blast-exposed groups at 7 DPI. Using transmission electron microscopy, we observed and quantified myelin sheath defects and mitochondrial abnormalities at 7 and 30 DPI. Inverse correlations between blast intensities and neurobehavioral outcomes including motor activities, anxiety levels, nesting behavior, spatial learning and memory occurred. These observations uncover unique ultrastructural brain abnormalities and associated behavioral changes due to primary blast injury and provide key insights into its pathogenesis and potential treatment.

Understanding blast-induced neurotrauma: how far have we come?

Blast injuries, including blast-induced neurotrauma (BINT), are caused by blast waves generated during an explosion. Accordingly, their history coincides with that of explosives. Hence, it is intriguing that, after more than 1000 years of using explosives, our understanding of the pathological consequences of blast and body/brain interactions is extremely limited. Postconflict recovery mechanisms seemingly include the suppression of painful experiences, such as explosive injuries. Unfortunately, ignoring the knowledge generated by previous generations of scientists retards research progress, leading to superfluous and repetitive studies. This article summarizes clinical and experimental findings published about blast injuries and BINT following the wars of the 20th and 21th centuries. Moreover, it offers a personal view on potential factors interfering with the progress of BINT research working toward providing better diagnosis, treatment and rehabilitation for military personnel affected by blast exposure.

Neuroprotective effects of novel small peptides in vitro and after brain injury.

Thyrotropin-releasing hormone (TRH) and TRH analogues have been reported to be neuroprotective in experimental models of spinal cord injury and head injury. We have previously shown that a diketopiperazine structurally related to the TRH metabolite cyclo-his-pro reduces neuronal cell death in vitro and in vivo. Here we report the neuroprotective activity of other cyclic dipeptides in multiple in vitro models of neuronal injury and after controlled cortical impact (CCI) in mice. Using primary neuronal cultures, three novel dipeptides were compared to the previously reported diketopiperazine as well as to vehicle controls; each of the compounds reduced cell death after direct physical trauma or trophic withdrawal. Two of these peptides also protected against glutamate toxicity and beta-amyloid-induced injury; the latter also strongly inhibited glutamate-induced increases in intracellular calcium. Treatment with each of the test compounds resulted in highly significant improvement of motor and cognitive recovery after CCI, as well as markedly reducing lesion volumes as shown by high field magnetic resonance imaging. DNA microarray studies following fluid percussion induced traumatic brain injury (TBI) in rats showed that treatment with one of these dipeptides after injury significantly down-regulated expression of mRNAs for cell cycle proteins, aquaporins, cathepsins and calpain in ipsilateral cortex and/or hippocampus, while up-regulating expression of brain-derived neurotrophic factor, hypoxia-inducible factor and several heat-shock proteins. Many of these mRNA expression changes were paralleled at the protein level. The fact that these small peptides modulate multiple mechanisms favoring neuronal cell survival, as well as their ability to improve functional outcome and reduce posttraumatic lesion size, suggests that they may have potential utility in clinical head injury.

Novel neuroprotective tripeptides and dipeptides.

It has long been recognized that thyrotropin-releasing hormone (TRH) and certain TRH analogues are neuroprotective in a variety of animal models of CNS trauma. In addition to these neuroprotective actions, TRH and most TRH analogues have other physiological actions that may not be desirable for treatment of acute injury, such as analeptic, autonomic, and endocrine effects. We have developed a series of dual-substituted TRH analogues that have strong neuroprotective actions, but are largely devoid of these other physiological actions. In addition, we have developed a family of cyclized dipeptides (diketopiperazines), structurally somewhat related to a metabolic product of TRH, that appear even more effective as neuroprotective agents in vitro and in vivo, and may have nootropic properties. Here, we review these novel tripeptide and dipeptide compounds.

Both estrogen and progesterone attenuate edema formation following diffuse traumatic brain injury in rats.

Females have reduced brain edema compared to males after experimental brain trauma, although contradictory reports exist as to whether this is due to either estrogen or progesterone. In the present study, we demonstrate in both male and ovariectomized female rats that a single physiological dose of either hormone at 30 min after diffuse traumatic brain injury reduces both blood brain barrier permeability and edema formation. We conclude that both hormones may contribute to reduce edema in females after brain injury.

Creating a Distinct Medication-Use System for Children at the Point of Care: The Time is Now.

Children need a distinct medicines-use system designed explicitly for them since their continued inclusion in a system of prescription processing developed for adults generates insoluble risk points and workarounds. The American Academy of Pediatrics (AAP), in its policy statement released by the AAP Committee on Drugs in early 2014 about off-label use in children, posits that federal legislation on increased drug testing in children has been effective, as "there have been over 500 pediatric-specific labeling changes." However, the AAP's position has not changed materially since the original 2002 policy statement. Indeed, other health professionals, their organizations, or affiliated practice-based research network (PBRNs) mechanisms continue to be excluded from consideration, collaboration, or even honorable mention. It is noteworthy that most of the 500 labeling changes made since 1997 have addressed the scientific validity of indications for medication use in pediatric population without regard to pharmacotherapy formulation or monitoring. Medication use in children continues to be associated with an unacceptably high rate of adverse events, morbidity, and death. Children should no longer be "shoehorned" into the adult medication-use system, which faces challenges in addressing even the adult population's needs. The time is now to design a multi-phasic, systematic approach to the pharmacotherapy of children. This paper will argue for the establishment of a distinct medication use system for children, a trans-disciplinary system designed thoughtfully and intentionally, not by convention, consensus, or imitation.