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Pybus AF, Bitarafan S, Brothers RO, Rohrer A, Khaitan A, Moctezuma FR, Udeshi K, Davies B, Triplett S, Griffin MN, Dammer EB, Rangaraju S, Buckley EM, Wood LB. Profiling the neuroimmune cascade in 3xTg-AD mice exposed to successive mild traumatic brain injuries. J Neuroinflammation 2024; 21:156. [PMID: 38872143 PMCID: PMC11177462 DOI: 10.1186/s12974-024-03128-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/12/2024] [Indexed: 06/15/2024] Open
Abstract
Repetitive mild traumatic brain injuries (rmTBI) sustained within a window of vulnerability can result in long term cognitive deficits, depression, and eventual neurodegeneration associated with tau pathology, amyloid beta (Aβ) plaques, gliosis, and neuronal and functional loss. However, a comprehensive study relating acute changes in immune signaling and glial reactivity to neuronal changes and pathological markers after single and repetitive mTBIs is currently lacking. In the current study, we addressed the question of how repeated injuries affect the brain neuroimmune response in the acute phase of injury (< 24 h) by exposing the 3xTg-AD mouse model of tau and Aβ pathology to successive (1x-5x) once-daily weight drop closed-head injuries and quantifying immune markers, pathological markers, and transcriptional profiles at 30 min, 4 h, and 24 h after each injury. We used young adult 2-4 month old 3xTg-AD mice to model the effects of rmTBI in the absence of significant tau and Aβ pathology. We identified pronounced sexual dimorphism in this model, with females eliciting more diverse changes after injury compared to males. Specifically, females showed: (1) a single injury caused a decrease in neuron-enriched genes inversely correlated with inflammatory protein expression and an increase in AD-related genes within 24 h, (2) each injury significantly increased a group of cortical cytokines (IL-1α, IL-1β, IL-2, IL-9, IL-13, IL-17, KC) and MAPK phospho-proteins (phospho-Atf2, phospho-Mek1), several of which co-labeled with neurons and correlated with phospho-tau, and (3) repetitive injury caused increased expression of genes associated with astrocyte reactivity and macrophage-associated immune function. Collectively our data suggest that neurons respond to a single injury within 24 h, while other cell types, including astrocytes, transition to inflammatory phenotypes within days of repetitive injury.
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Affiliation(s)
- Alyssa F Pybus
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Sara Bitarafan
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Rowan O Brothers
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Alivia Rohrer
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Arushi Khaitan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Felix Rivera Moctezuma
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Kareena Udeshi
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Brae Davies
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Sydney Triplett
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Martin N Griffin
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Eric B Dammer
- Center for Neurodegenerative Diseases, School of Medicine, Emory University, Atlanta, GA, USA
| | - Srikant Rangaraju
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, USA
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA.
- Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Levi B Wood
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA.
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2
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Meier TB. The search for blood-biomarkers of persistent post-concussion symptoms. J Neurol Sci 2024; 460:123015. [PMID: 38627180 DOI: 10.1016/j.jns.2024.123015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA; Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI 53226, USA; Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Fry L, Logemann A, Waldron E, Holker E, Porter J, Eskridge C, Naini S, Basso MR, Taylor SE, Melnik T, Whiteside DM. Emotional functioning in long COVID: Comparison to post-concussion syndrome using the Personality Assessment Inventory. Clin Neuropsychol 2024; 38:963-983. [PMID: 37838973 DOI: 10.1080/13854046.2023.2264546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/22/2023] [Indexed: 10/17/2023]
Abstract
Objective: Recent studies on Long COVID found that patients report prominent emotional distress and significant correlations between distress and cognitive performance have been identified, raising the question of how to manage or treat these issues. To understand psychological functioning in Long COVID further, this study examined personality responses on the Personality Assessment Inventory (PAI) to compare psychological functioning in a Long COVID group with a post-concussion syndrome (PCS) group, a syndrome with a significant psychological component. Participants and methods: Participants included 201 consecutive Long COVID outpatients (Mean age = 48.87 years, mean education = 14.82, 71.6% Female, 82.6% White) and a comparison group of 102 consecutively referred PCS outpatients (Mean age = 46.08, mean education = 14.17, 63.7% Female, 88.2% White). Effect sizes and t-tests were calculated using the PAI validity, clinical, interpersonal, and treatment consideration scales as well as clinical subscales. Results: The results replicated earlier findings on the PAI in Long COVID by demonstrating that both Long COVID and PCS groups had the highest mean elevations on SOM and DEP scales but no statistically significant between group differences in mean scale elevations. Results support similarities in psychological functioning between Long COVID and PCS patients emphasizing the importance of evaluating psychological functioning in neuropsychological evaluations for these populations. Further, results suggest that psychological treatment strategies for PCS patients may be helpful for Long COVID patients, but more research is needed.
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Affiliation(s)
- Laura Fry
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Allison Logemann
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Eric Waldron
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Erin Holker
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jim Porter
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Courtney Eskridge
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Savana Naini
- Graduate School of Professional Psychology, University of St Thomas, Saint Paul, MN, USA
| | - Michael R Basso
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, NY, USA
| | - Sarah E Taylor
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Tanya Melnik
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Douglas M Whiteside
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
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Clarke GJB, Skandsen T, Zetterberg H, Follestad T, Einarsen CE, Vik A, Mollnes TE, Pischke SE, Blennow K, Håberg AK. Longitudinal Associations Between Persistent Post-Concussion Symptoms and Blood Biomarkers of Inflammation and CNS-Injury After Mild Traumatic Brain Injury. J Neurotrauma 2024; 41:862-878. [PMID: 38117157 DOI: 10.1089/neu.2023.0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
The aim of our study was to investigate the biological underpinnings of persistent post-concussion symptoms (PPCS) at 3 months following mild traumatic brain injury (mTBI). Patients (n = 192, age 16-60 years) with mTBI, defined as Glasgow Coma Scale (GCS) score between 13 and 15, loss of consciousness (LOC) <30 min, and post-traumatic amnesia (PTA) <24 h were included. Blood samples were collected at admission (within 72 h), 2 weeks, and 3 months. Concentrations of blood biomarkers associated with central nervous system (CNS) damage (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], and tau) and inflammation (interferon gamma [IFNγ], interleukin [IL]-8, eotaxin, macrophage inflammatory protein-1-beta [MIP]-1β, monocyte chemoattractant protein [MCP]-1, interferon-gamma-inducible protein [IP]-10, IL-17A, IL-9, tumor necrosis factor [TNF], basic fibroblast growth factor [FGF]-basic platelet-derived growth factor [PDGF], and IL-1 receptor antagonist [IL-1ra]) were obtained. Demographic and injury-related factors investigated were age, sex, GCS score, LOC, PTA duration, traumatic intracranial finding on magnetic resonance imaging (MRI; within 72 h), and extracranial injuries. Delta values, that is, time-point differences in biomarker concentrations between 2 weeks minus admission and 3 months minus admission, were also calculated. PPCS was assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI). In single variable analyses, longer PTA duration and a higher proportion of intracranial findings on MRI were found in the PPCS group, but no single biomarker differentiated those with PPCS from those without. In multi-variable models, female sex, longer PTA duration, MRI findings, and lower GCS scores were associated with increased risk of PPCS. Inflammation markers, but not GFAP, NFL, or tau, were associated with PPCS. At admission, higher concentrations of IL-8 and IL-9 and lower concentrations of TNF, IL-17a, and MCP-1 were associated with greater likelihood of PPCS; at 2 weeks, higher IL-8 and lower IFNγ were associated with PPCS; at 3 months, higher PDGF was associated with PPCS. Higher delta values of PDGF, IL-17A, and FGF-basic at 2 weeks compared with admission, MCP-1 at 3 months compared with admission, and TNF at 2 weeks and 3 months compared with admission were associated with greater likelihood of PPCS. Higher IL-9 delta values at both time-point comparisons were negatively associated with PPCS. Discriminability of individual CNS-injury and inflammation biomarkers for PPCS was around chance level, whereas the optimal combination of biomarkers yielded areas under the curve (AUCs) between 0.62 and 0.73. We demonstrate a role of biological factors on PPCS, including both positive and negative effects of inflammation biomarkers that differed based on sampling time-point after mTBI. PPCS was associated more with acute inflammatory processes, rather than ongoing inflammation or CNS-injury biomarkers. However, the modest discriminative ability of the models suggests other factors are more important in the development of PPCS.
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Affiliation(s)
- Gerard Janez Brett Clarke
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- UK Dementia Research Institute at UCL, University College London, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Turid Follestad
- Department of Clinical and Molecular Medicine, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinical Research Unit Central Norway, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cathrine Elisabeth Einarsen
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tom Eirik Mollnes
- Department of Immunology, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
- Center of Molecular Inflammation Research, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Søren Erik Pischke
- Department of Immunology, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
- Clinic for Emergencies and Critical Care, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Asta Kristine Håberg
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Di Battista AP, Rhind SG, Shiu M, Hutchison MG. Whole blood stimulation provides preliminary evidence of altered immune function following SRC. BMC Immunol 2024; 25:6. [PMID: 38218771 PMCID: PMC10788016 DOI: 10.1186/s12865-023-00595-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/26/2023] [Indexed: 01/15/2024] Open
Abstract
PURPOSE To implement an approach combining whole blood immune stimulation and causal modelling to estimate the impact of sport-related concussion (SRC) on immune function. METHODS A prospective, observational cohort study was conducted on athletes participating across 13 university sports at a single academic institute; blood was drawn from 52 athletes, comprised of 22 athletes (n = 11 male, n = 11 female) within seven days of a physician-diagnosed SRC, and 30 healthy athletes (n = 18 female, n = 12 male) at the beginning of their competitive season. Blood samples were stimulated for 24 h under two conditions: (1) lipopolysaccharide (lps, 100ng/mL) or (2) resiquimod (R848, 1uM) using the TruCulture® system. The concentration of 45 cytokines and chemokines were quantitated in stimulated samples by immunoassay using the highly sensitive targeted Proximity Extension Assays (PEA) on the Olink® biomarker platform. A directed acyclic graph (DAG) was used as a heuristic model to make explicit scientific assumptions regarding the effect of SRC on immune function. A latent factor analysis was used to derive two latent cytokine variables representing immune function in response to LPS and R848 stimulation, respectively. The latent variables were then modelled using student-t regressions to estimate the total causal effect of SRC on immune function. RESULTS There was an effect of SRC on immune function in males following SRC, and it varied according to prior concussion history. In males with no history of concussion, those with an acute SRC had lower LPS reactivity compared to healthy athletes with 93% posterior probability (pprob), and lower R848 reactivity with 77% pprob. Conversely, in males with a history of SRC, those with an acute SRC had higher LPS reactivity compared to healthy athletes with 85% pprob and higher R848 reactivity with 82%. In females, irrespective of concussion history, SRC had no effect on LPS reactivity. However, in females with no concussion history, those with an acute SRC had higher R848 reactivity compared to healthy athletes with 86% pprob. CONCLUSION Whole blood stimulation can be used within a causal framework to estimate the effect of SRC on immune function. Preliminary evidence suggests that SRC affects LPS and R848 immunoreactivity, that the effect is stronger in male athletes, and differs based on concussion history. Replication of this study in a larger cohort with a more sophisticated causal model is necessary.
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Affiliation(s)
- Alex P Di Battista
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada.
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Maria Shiu
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Michael G Hutchison
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, Toronto, ON, Canada
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6
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Guha L, Agnihotri TG, Jain A, Kumar H. Gut microbiota and traumatic central nervous system injuries: Insights into pathophysiology and therapeutic approaches. Life Sci 2023; 334:122193. [PMID: 37865177 DOI: 10.1016/j.lfs.2023.122193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023]
Abstract
Traumatic brain injury and spinal cord injury are two distinct but fundamentally similar types of acute insults to the central nervous system (CNS) that often culminate in death or cognitive and motor impairment. Over the past decade, researchers have tapped into research to discover the potential role being played by gut bacteria in CNS. After an acute CNS injury, the altered composition of the gut microbiota disturbs the balance of the bidirectional gut-brain axis, aggravating secondary CNS injury, motor dysfunctions, and cognitive deficits, which worsens the patient's prognosis. Some of the well-known therapeutic interventions which can also be used as adjuvant therapy for alleviating CNS injuries include, the use of pro and prebiotics, fecal microbiota transplantation, and microbial engineering. In this review, we aim to discuss the importance of gut microbes in our nervous system, anatomy, and signaling pathways involved in regulating the gut-brain axis, the alteration of the gut microbiome in CNS injuries, and the therapeutic strategies to target gut microbiomes in traumatic CNS injuries.
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Affiliation(s)
- Lahanya Guha
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Tejas Girish Agnihotri
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Aakanchha Jain
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Hemant Kumar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar, Gujarat 382355, India.
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Clark IA, Vissel B. Autocrine positive feedback of tumor necrosis factor from activated microglia proposed to be of widespread relevance in chronic neurological disease. Pharmacol Res Perspect 2023; 11:e01136. [PMID: 37750203 PMCID: PMC10520644 DOI: 10.1002/prp2.1136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023] Open
Abstract
Over a decade's experience of post-stroke rehabilitation by administering the specific anti-TNF biological, etanercept, by the novel perispinal route, is consistent with a wide range of chronically diminished neurological function having been caused by persistent excessive cerebral levels of TNF. We propose that this TNF persistence, and cerebral disease chronicity, largely arises from a positive autocrine feedback loop of this cytokine, allowing the persistence of microglial activation caused by the excess TNF that these cells produce. It appears that many of these observations have never been exploited to construct a broad understanding and treatment of certain chronic, yet reversible, neurological illnesses. We propose that this treatment allows these chronically activated microglia to revert to their normal quiescent state, rather than simply neutralizing the direct harmful effects of this cytokine after its release from microglia. Logically, this also applies to the chronic cerebral aspects of various other neurological conditions characterized by activated microglia. These include long COVID, Lyme disease, post-stroke syndromes, traumatic brain injury, chronic traumatic encephalopathy, post-chemotherapy, post-irradiation cerebral dysfunction, cerebral palsy, fetal alcohol syndrome, hepatic encephalopathy, the antinociceptive state of morphine tolerance, and neurogenic pain. In addition, certain psychiatric states, in isolation or as sequelae of infectious diseases such as Lyme disease and long COVID, are candidates for being understood through this approach and treated accordingly. Perispinal etanercept provides the prospect of being able to treat various chronic central nervous system illnesses, whether they are of infectious or non-infectious origin, through reversing excess TNF generation by microglia.
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Affiliation(s)
- Ian A. Clark
- Research School of Biology, Australian National UniversityCanberraAustralian Capital TerritoryAustralia
| | - Bryce Vissel
- St Vincent's Hospital Centre for Applied Medical ResearchSt Vincent's HospitalDarlinghurstAustralia
- UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and HealthSchool of Clinical Medicine, UNSW SydneySydneyNew South WalesAustralia
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Bødker RL, Marcussen M. Pilot study protocol of a randomized controlled trial for the potential effects of creatine monohydrate on persistent post-concussive symptoms. Front Neurol 2023; 14:1209548. [PMID: 37475743 PMCID: PMC10354866 DOI: 10.3389/fneur.2023.1209548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Background Mild traumatic brain injury or concussion is a global public concern, with an estimated annual incidence between 48 million and 96 million worldwide. It is a socioeconomical problem, and almost one-third of individuals with concussion suffer from severe persistent post-concussive symptoms (PPCS), with an increased risk of unemployment or terminating their studies. To date, no single treatment is available with guaranteed success. Creatine monohydrate (CrM) has shown potential as a treatment for post-concussive symptoms, having a positive impact on cognitive function, chronic fatigue, depression, and anxiety. The aim of this study is to examine the effect of CrM on PPCS assessed using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). Methods The study is designed as a double-blinded randomised controlled trial. Study participants are found through neurological outpatient clinics in Denmark or through social media. They will be between 25 and 35 years of age, will have suffered from PPCS for 6-12 months prior to inclusion, and will have no comorbidities. The participants will be randomly allocated to either an intervention group (INT), placebo group (PLA), or control group (CG). Baseline data will be collected immediately after inclusion, and the study period will be 7 weeks. Follow-up data will be collected 1 week after the end of the study period. The primary outcome of the study is changes in RPQ score. Changes in weight and training status will be adjusted for as potential confounders. Ethics and dissemination This protocol is approved by the National Committee on Health Research (97508) and by the Danish Data Protection Agency 11.651. The investigators intend to submit their study findings for publication in peer-reviewed journals and disseminate the findings via presentation at academic meetings/conferences.Clinical Trial registration: NCT05562232, registered September 30, 2022.
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Affiliation(s)
- Ronni Lykke Bødker
- Commotio Denmark, Køge, Denmark
- Department of Public Health, University of Southern, Odense, Denmark
| | - Michael Marcussen
- Department of Public Health, University of Southern, Odense, Denmark
- Research unit of Psychiatry, Region Zealand, Slagelse, Denmark
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Naumenko Y, Yuryshinetz I, Zabenko Y, Pivneva T. Mild traumatic brain injury as a pathological process. Heliyon 2023; 9:e18342. [PMID: 37519712 PMCID: PMC10372741 DOI: 10.1016/j.heliyon.2023.e18342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023] Open
Abstract
Traumatic brain injury (TBI) is defined as dysfunction or other evidence of brain pathology caused by external physical force. More than 69 million new cases of TBI are registered worldwide each year, 80% of them - mild TBI. Based on the physical mechanism of induced trauma, we can separate its pathophysiology into primary and secondary injuries. Many literature sources have confirmed that mechanically induced brain injury initiates ionic, metabolic, inflammatory, and neurovascular changes in the CNS, which can lead to acute, subacute, and chronic neurological consequences. Despite the global nature of the disease, its high heterogeneity, lack of a unified classification system, rapid fluctuation of epidemiological trends, and variability of long-term consequences significantly complicate research and the development of new therapeutic strategies. In this review paper, we systematize current knowledge of biomechanical and molecular mechanisms of mild TBI and provide general information on the classification and epidemiology of this complex disorder.
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Affiliation(s)
- Yana Naumenko
- Bogomoletz Institute of Physiology, Department of Sensory Signalization, Kyiv, Ukraine
| | - Irada Yuryshinetz
- Bogomoletz Institute of Physiology, Department of Sensory Signalization, Kyiv, Ukraine
| | - Yelyzaveta Zabenko
- Bogomoletz Institute of Physiology, Department of Sensory Signalization, Kyiv, Ukraine
| | - Tetyana Pivneva
- Bogomoletz Institute of Physiology, Department of Sensory Signalization, Kyiv, Ukraine
- Kyiv Academic University, Kyiv, Ukraine
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Pybus AF, Bitarafan S, Brothers RO, Rohrer A, Khaitan A, Moctezuma FR, Udeshi K, Davies B, Triplett S, Dammer E, Rangaraju S, Buckley EM, Wood LB. Profiling the neuroimmune cascade in 3xTg mice exposed to successive mild traumatic brain injuries. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.13.544838. [PMID: 37397993 PMCID: PMC10312742 DOI: 10.1101/2023.06.13.544838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Repetitive mild traumatic brain injuries (rmTBI) sustained within a window of vulnerability can result in long term cognitive deficits, depression, and eventual neurodegeneration associated with tau pathology, amyloid beta (Aβ) plaques, gliosis, and neuronal and functional loss. However, we have limited understanding of how successive injuries acutely affect the brain to result in these devastating long-term consequences. In the current study, we addressed the question of how repeated injuries affect the brain in the acute phase of injury (<24hr) by exposing the 3xTg-AD mouse model of tau and Aβ pathology to successive (1x, 3x, 5x) once-daily weight drop closed-head injuries and quantifying immune markers, pathological markers, and transcriptional profiles at 30min, 4hr, and 24hr after each injury. We used young adult mice (2-4 months old) to model the effects of rmTBI relevant to young adult athletes, and in the absence of significant tau and Aβ pathology. Importantly, we identified pronounced sexual dimorphism, with females eliciting more differentially expressed proteins after injury compared to males. Specifically, females showed: 1) a single injury caused a decrease in neuron-enriched genes inversely correlated with inflammatory protein expression as well as an increase in AD-related genes within 24hr, 2) each injury significantly increased expression of a group of cortical cytokines (IL-1α, IL-1β, IL-2, IL-9, IL-13, IL-17, KC) and MAPK phospho-proteins (phospho-Atf2, phospho-Mek1), several of which were co-labeled with neurons and correlated with phospho-tau, and 3) repetitive injury caused increased expression of genes associated with astrocyte reactivity and immune function. Collectively our data suggest that neurons respond to a single injury within 24h, while other cell types including astrocytes transition to inflammatory phenotypes within days of repetitive injury.
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11
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Malik S, Alnaji O, Malik M, Gambale T, Farrokhyar F, Rathbone MP. Inflammatory cytokines associated with mild traumatic brain injury and clinical outcomes: a systematic review and meta-analysis. Front Neurol 2023; 14:1123407. [PMID: 37251220 PMCID: PMC10213278 DOI: 10.3389/fneur.2023.1123407] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Mild traumatic brain injuries (mTBIs) trigger a neuroinflammatory response, which leads to perturbations in the levels of inflammatory cytokines, resulting in a distinctive profile. A systematic review and meta-analysis were conducted to synthesize data related to levels of inflammatory cytokines in patients with mTBI. The electronic databases EMBASE, MEDLINE, and PUBMED were searched from January 2014 to December 12, 2021. A total of 5,138 articles were screened using a systematic approach based on the PRISMA and R-AMSTAR guidelines. Of these articles, 174 were selected for full-text review and 26 were included in the final analysis. The results of this study demonstrate that within 24 hours, patients with mTBI have significantly higher levels of Interleukin-6 (IL-6), Interleukin-1 Receptor Antagonist (IL-1RA), and Interferon-γ (IFN-γ) in blood, compared to healthy controls in majority of the included studies. Similarly one week following the injury, patients with mTBI have higher circulatory levels of Monocyte Chemoattractant Protein-1/C-C Motif Chemokine Ligand 2 (MCP-1/CCL2), compared to healthy controls in majority of the included studies. The results of the meta-analysis also confirmed these findings by demonstrating significantly elevated blood levels of IL-6, MCP-1/CCL2, and Interleukin-1 beta (IL-1β) in the mTBI population compared to healthy controls (p < 0.0001), particularly in the acute stages (<7 days). Furthermore, it was found that IL-6, Tumor Necrosis Factor-alpha (TNF-α), IL-1RA, IL-10, and MCP-1/CCL2 were associated with poor clinical outcomes following the mTBI. Finally, this research highlights the lack of consensus in the methodology of mTBI studies that measure inflammatory cytokines in the blood, and also provides direction for future mTBI research.
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Affiliation(s)
- Shazia Malik
- Neurosciences Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Omar Alnaji
- Faculty of Life Sciences, McMaster University, Hamilton, ON, Canada
| | - Mahnoor Malik
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON, Canada
| | - Teresa Gambale
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Michel P. Rathbone
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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12
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Chakraborty R, Tabassum H, Parvez S. NLRP3 inflammasome in traumatic brain injury: Its implication in the disease pathophysiology and potential as a therapeutic target. Life Sci 2023; 314:121352. [PMID: 36592789 DOI: 10.1016/j.lfs.2022.121352] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/18/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Abstract
Traumatic brain injury (TBI), an acquired brain injury imparted by a mechanical trauma to the head, has significant ramifications in terms of long-term disability and cost of healthcare. TBI is characterized by an initial phase of cell death owing to direct mechanical injury, followed by a secondary phase in which neuroinflammation plays a pivotal role. Activation of inflammasome complexes triggers a cascade that leads to activation of inflammatory mediators such as caspase-1, Interleukin (IL)-18, and IL-1β, eventually causing pyroptosis. NLRP3 inflammasome, a component of the innate immune response, has been implicated in a number of neurodegenerative diseases, including TBI. Recent findings indicate that NLRP3 inhibitors can potentially ameliorate neuroinflammation and improve cognition and motor function in TBI. The NLRP3 inflammasome also holds potential as a predictive biomarker for the long-term sequelae following TBI. Although several therapeutic agents have shown promising results in pre-clinical studies, none of them have been effective in human trials for TBI, to date. Thus, it is imperative that such promising therapeutic candidates are evaluated in clinical trials to assess their efficacy in alleviating neurological impairments in TBI. This review offers an insight into the pathophysiology of TBI, with an emphasis on neuroinflammation in the aftermath of TBI. We highlight the NLRP3 inflammasome and explore its role in the neuroinflammatory cascade in TBI. We also shed light on its potential as a prospective biomarker and therapeutic target for TBI management.
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Affiliation(s)
- Rohan Chakraborty
- Department of Toxicology, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi 110062, India
| | - Heena Tabassum
- Division of Basic Medical Sciences, Indian Council of Medical Research, Ministry of Health and Family Welfare, Govt. of India, V. Ramalingaswami Bhawan, P.O. Box No. 4911, New Delhi 110029, India
| | - Suhel Parvez
- Department of Toxicology, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi 110062, India.
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13
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Tabor J, La P, Kline G, Wang M, Bonfield S, Machan M, Wynne-Edwards K, Emery C, Debert C. Saliva Cortisol as a Biomarker of Injury in Youth Sport-Related Concussion. J Neurotrauma 2023; 40:296-308. [PMID: 35906800 DOI: 10.1089/neu.2022.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Increasing rates of sport-related concussion (SRC) in youth impose a significant burden on public health systems and the lives of young athletes. Accurate prediction for those likely to develop persistent post-concussion symptomology (PPCS) using a fluid biomarker, reflecting both acute injury and recovery processes, would provide the opportunity for early intervention. Cortisol, a stress hormone released through the hypothalamic-pituitary-adrenal (HPA) axis following injury, may provide a missing physiological link to clinical recovery. This cohort study investigated the change in saliva cortisol following SRC and the association between cortisol and symptom burden in pediatric ice hockey players. Further, the association between cortisol levels and medical clearance to return to play was explored. In total, cortisol samples from 233 players were included; 165 athletes (23.6% female) provided pre-injury saliva and 68 athletes (19.1% female) provided post-SRC saliva samples for cortisol analysis. Quantile (median) regressions were used to compare cortisol between pre-injury and post-SRC groups, and the association between total symptoms (/22) and symptom severity scores (/132) reported on the Sport Concussion Assessment Tool (SCAT)3/SCAT5 and post-SRC cortisol (adjusting for age, sex, history of concussion, and time from injury to sample collection). Results demonstrated significantly lower saliva cortisol in post-SRC athletes compared with the pre-injury group (β = -0.62, 95% confidence interval [CI; -1.08, -0.16], p = 0.009). Post-SRC cortisol was not significantly associated with the SCAT3/SCAT5 symptom totals or symptom severity scores; however, females were found to report more symptoms (β = 6.95, 95% CI [0.35, 13.55], p = 0.040) and greater symptom severity (β = 23.87, 95% CI [9.58, 38.15], p = 0.002) compared with males. Exploratory time-to-event analysis revealed a point estimate suggesting a potential association between low cortisol levels and days to medical clearance to return to play. Although preliminary, these findings suggest that the HPA axis may be dysregulated post-SRC. Further, our exploratory analysis and case presentation of post-injury outliers highlight the need to further research cortisol as a prognostic biomarker to inform individualized sex-specific care after SRC.
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Affiliation(s)
- Jason Tabor
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Parker La
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Kline
- Division of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meng Wang
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephan Bonfield
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Machan
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Wynne-Edwards
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carolyn Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chantel Debert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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14
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Toman E, Hodgson S, Riley M, Welbury R, Di Pietro V, Belli A. Concussion in the UK: a contemporary narrative review. Trauma Surg Acute Care Open 2022; 7:e000929. [PMID: 36274785 PMCID: PMC9582316 DOI: 10.1136/tsaco-2022-000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/03/2022] [Indexed: 11/18/2022] Open
Abstract
Concussion has been receiving an increasing amount of media exposure following several high-profile professional sports controversies and multimillion-dollar lawsuits. The potential life-changing sequalae of concussion and the rare, but devasting, second impact syndrome have also gained much attention. Despite this, our knowledge of the pathological processes involved is limited and often extrapolated from research into more severe brain injuries. As there is no objective diagnostic test for concussion. Relying on history and examination only, the diagnosis of concussion has become the rate-limiting step in widening research into the disease. Clinical study protocols therefore frequently exclude the most vulnerable groups of patients such as those with existing cognitive impairment, concurrent intoxication, mental health issues or learning difficulties. This up-to-date narrative review aims to summarize our current concussion knowledge and provides an insight into promising avenues for future research.
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Affiliation(s)
- Emma Toman
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK,Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sam Hodgson
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Max Riley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Richard Welbury
- School of Dentistry, University of Central Lancashire, Preston, UK
| | - Valentina Di Pietro
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Antonio Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK,Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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15
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Tabor JB, McCrea MA, Meier TB, Emery CA, Debert CT. Hiding in Plain Sight: Factors Influencing the Neuroinflammatory Response to Sport-Related Concussion. Neurotrauma Rep 2022; 3:200-206. [PMID: 35734393 PMCID: PMC9153987 DOI: 10.1089/neur.2021.0081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Sport-related concussion (SRC) is a major concern among athletes and clinicians around the world. Research into fluid biomarkers of SRC has made significant progress in understanding the complex underlying pathophysiology of concussion. However, little headway has been made toward clinically validating any biomarkers to improve the clinical management of SRC. A major obstacle toward clinical translation of any fluid biomarker is the heterogeneity of SRC overlapping with multiple physiological systems involved in pathology and recovery. Neuroinflammation post-SRC is one such system that may confound fluid biomarker data on many fronts. Neuroinflammatory processes consist of cell mediators, both within the central nervous system and the periphery, that play vital roles in regulating the response to brain injury. Further, neuroinflammation is influenced by many biopsychosocial variables present in most athletic populations. In this commentary, we propose that future fluid biomarker research should take a systems biology approach in the context of the neuroinflammatory response to SRC. We highlight how biological variables, such as age, sex, immune challenges, and hypothalamic-pituitary-adrenal (HPA)-axis responses to stress, may alter neuroinflammation. Further, we underscore the importance of accounting for health and lifestyle variables, such as diet, exercise, sleep, and pre-morbid medical factors, when measuring inflammatory markers of SRC. To successfully move toward clinical translation, fluid biomarker research should take a more holistic approach in study design and data interpretation, collecting information on hidden variables that may be influencing the neuroinflammatory response to SRC.
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Affiliation(s)
- Jason B. Tabor
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Carolyn A. Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Chantel T. Debert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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16
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Forstenpointner J, Elman I, Freeman R, Borsook D. The Omnipresence of Autonomic Modulation in Health and Disease. Prog Neurobiol 2022; 210:102218. [PMID: 35033599 DOI: 10.1016/j.pneurobio.2022.102218] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/13/2021] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Abstract
The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.
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Affiliation(s)
- Julia Forstenpointner
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, SH, Germany.
| | - Igor Elman
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Borsook
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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17
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Malik S, Alnaji O, Malik M, Gambale T, Rathbone MP. Correlation between Mild Traumatic Brain Injury-Induced Inflammatory Cytokines and Emotional Symptom Traits: A Systematic Review. Brain Sci 2022; 12:brainsci12010102. [PMID: 35053845 PMCID: PMC8773760 DOI: 10.3390/brainsci12010102] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 01/09/2023] Open
Abstract
Both mild traumatic brain injuries (mTBI) and systemic injuries trigger a transient neuroinflammatory response that result in similar clinical outcome. The ensuing physical, cognitive, and emotional symptoms fail to subside in approximately 15–20% of the concussed population. Emotional impairments, particularly depression, anxiety, and post-traumatic stress disorder (PTSD), are commonly associated with poor recovery following mTBI. These emotional impairments also have a significant neuroinflammatory component. We hypothesized that the inflammatory cytokines seen in mTBI patients with emotional symptoms would coincide with those commonly seen in patients with emotional symptoms without mTBI. A systematic review was conducted to identify the most common neuroinflammatory cytokines in the mTBI population with psychological symptoms (depression, anxiety, PTSD). The electronic databases EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, and PSYCINFO were searched from data inception to 31 August 2021. A systematic screening approach was employed from screening to data analysis. A total of 994 articles were screened, 108 were selected for full article review, and 8 were selected for data analysis. The included studies consisted of 875 patients of which 81.3% were male. The mean sample size of patients with at least one mTBI was 73.8 ± 70.3 (range, 9–213), with a mean age of 33.9 ± 4.8 years. The most common cytokines associated with poor psychological outcomes involving PTSD and/or depression in the chronic mTBI population were IL-6, TNFα, IL-10, and CRP.
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Affiliation(s)
- Shazia Malik
- Neurosciences Graduate Program, McMaster University, Hamilton, ON L8S 4L8, Canada
- Correspondence:
| | - Omar Alnaji
- Faculty of Life Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Mahnoor Malik
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Teresa Gambale
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (T.G.); (M.P.R.)
| | - Michel Piers Rathbone
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (T.G.); (M.P.R.)
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18
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Aghakhani N. Relationship between mild traumatic brain injury and the gut microbiome: A scoping review. J Neurosci Res 2021; 100:827-834. [PMID: 34964504 DOI: 10.1002/jnr.25004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 10/07/2021] [Accepted: 12/10/2021] [Indexed: 12/14/2022]
Abstract
There is increasing evidence for the important role of gut microbiota (GMB) in the development and progression of neurologic pathologies. Some studies have shown that modifying the microbiome profile can confer benefits to patients. Mild traumatic brain injury (mTBI) is a common occurrence in the general population. Although most patients recover, in a minority, disabling symptoms can persist for several months. We carried out a review of the literature to assess the effect of mTBI on GMB and to determine whether alleviating dysbiosis can improve clinical outcomes in mTBI patients. We performed searches in Medline/PubMed and Embase using the keywords "MTBI" AND "microbiome" OR "microbiota". Additional articles were identified by manual searches and using the Google search engine. In animal models, a clear perturbation of GMB was reported following TBI and probiotic supplementation (Lactobacillus acidophilus or Clostridium butyricum) improved neurologic function. There were no studies on changes in GMB after mTBI in humans; however, pre- or probiotic supplementation reduced the infection rate in patients with severe TBI and shortened the time spent in the intensive care unit without conferring any neurologic benefits. Thus, although the findings from animal models are promising, clinical studies are needed to determine whether therapeutic strategies that restore gut microbiome profile can improve long-term outcomes of patients with mTBI.
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Affiliation(s)
- Nozar Aghakhani
- Department of Neurosurgery, Center for Evaluation and Multidisciplinary Care of the Mild Traumatic Brain Injury, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
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19
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Zhang Y, Huang Z, Xia H, Xiong J, Ma X, Liu C. The benefits of exercise for outcome improvement following traumatic brain injury: Evidence, pitfalls and future perspectives. Exp Neurol 2021; 349:113958. [PMID: 34951984 DOI: 10.1016/j.expneurol.2021.113958] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/04/2021] [Accepted: 12/15/2021] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury (TBI), also known as a silent epidemic, is currently a substantial public health problem worldwide. Given the increased energy demands following brain injury, relevant guidelines tend to recommend absolute physical and cognitive rest for patients post-TBI. Nevertheless, recent evidence suggests that strict rest does not provide additional benefits to patients' recovery. By contrast, as a cost-effective non-pharmacological therapy, exercise has shown promise for enhancing functional outcomes after injury. This article summarizes the most recent evidence supporting the beneficial effects of exercise on TBI outcomes, focusing on the efficacy of exercise for cognitive recovery after injury and its potential mechanisms. Available evidence demonstrates the potential of exercise in improving cognitive impairment, mood disorders, and post-concussion syndrome following TBI. However, the clinical application for exercise rehabilitation in TBI remains challenging, particularly due to the inadequacy of the existing clinical evaluation system. Also, a better understanding of the underlying mechanisms whereby exercise promotes its most beneficial effects post-TBI will aid in the development of new clinical strategies to best benefit of these patients.
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Affiliation(s)
- Yulan Zhang
- Cognitive & Sports Neuroscience Laboratory, National Demonstration Center for Experimental Sports Science Education, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China; Laboratory of Laser Sports Medicine, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China
| | - Zhihai Huang
- Cognitive & Sports Neuroscience Laboratory, National Demonstration Center for Experimental Sports Science Education, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China
| | - Honglin Xia
- Laboratory of Regenerative Medicine in Sports Science, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China
| | - Jing Xiong
- Cognitive & Sports Neuroscience Laboratory, National Demonstration Center for Experimental Sports Science Education, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China; Laboratory of Laser Sports Medicine, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China
| | - Xu Ma
- Cognitive & Sports Neuroscience Laboratory, National Demonstration Center for Experimental Sports Science Education, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China; Laboratory of Laser Sports Medicine, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China
| | - Chengyi Liu
- Laboratory of Laser Sports Medicine, College of Physical Education and Sports Science, South China Normal University, Guangzhou, Guangdong 510006, China.
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20
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O'Brien WT, Symons GF, Bain J, Major BP, Costello DM, Sun M, Kimpton JS, Chen Z, Brady RD, Mychasiuk R, O'Brien TJ, Monif M, Shultz SR, McDonald SJ. Elevated Serum Interleukin-1β Levels in Male, but not Female, Collision Sport Athletes with a Concussion History. J Neurotrauma 2021; 38:1350-1357. [PMID: 33308001 DOI: 10.1089/neu.2020.7479] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
It is increasingly reported that a history of concussion may be associated with chronic deleterious consequences. While the pathophysiology that contributes to these consequences is not well understood, neuroinflammation is postulated to be critical. Activation of multi-protein complexes termed inflammasomes, a key component of this inflammatory response, has been reported in more severe TBIs; however, it has not been investigated in milder TBIs, such as concussion. This study investigated serum levels of interleukin (IL)-1β and IL-18 (key proteins activated downstream of these inflammasomes) at acute, sub-acute, and chronic time-points post-concussion. We recruited 105 Australian footballers (65 male, 40 female) during the pre-season, then prospectively followed these players for the occurrence of concussion during the season. At baseline, 58 footballers reported a previous concussion history, and 47 reported no previous concussion history. Additionally, 25 players sustained a mid-season concussion and were sampled at 2, 6, and 13 days post-concussion. Serum levels of IL-1β and IL-18 were quantified using highly sensitive Simoa HD-X Analyzer assays. At baseline, IL-1β levels were higher in male, but not female, footballers with a previous concussion history compared with footballers with no concussion history. There was also a positive correlation between years of collision sport participation and IL-18 levels in males. No evidence was found in males or females to indicate that IL-1β or IL-18 levels differed at 2, 6, or 13 days post-concussion. These findings provide novel insights into potential sex-specific physiological consequences of concussion, and suggest that neuroinflammation may be persistent chronically following concussion in male athletes.
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Affiliation(s)
- William T O'Brien
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Georgia F Symons
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Jesse Bain
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Brendan P Major
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Daniel M Costello
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Mujun Sun
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Joshua S Kimpton
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Zhibin Chen
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Epidemiology, Monash University, Melbourne, Victoria, Australia
| | - Rhys D Brady
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Melbourne Health, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Melbourne Health, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Physiology, University of Melbourne, Parkville, Victoria, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Physiology, Anatomy, and Microbiology, La Trobe University, Melbourne, Victoria, Australia
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21
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McIntyre M, Amiri M, Kumbhare D. Postconcussion Syndrome: A Diagnosis of Past Diagnostic and Statistical Manual of Mental Disorders. Am J Phys Med Rehabil 2021; 100:193-195. [PMID: 32889864 DOI: 10.1097/phm.0000000000001586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT After concussion, a subset of patients have persistent symptoms that are functionally limiting and may be difficult to treat. These symptoms were previously captured in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) under the diagnosis of "Post-Concussion Syndrome." However, in the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, postconcussion syndrome has been eliminated. The elimination of "Post-Concussion Syndrome" moves the Diagnostic and Statistical Manual of Mental Disorders further away from congruence with the International Classification of Diseases (ICD-10) with respect to the classification of postconcussion symptomology. Although this change likely had the positive effect of reducing misdiagnoses of symptoms due to other causes, the authors highlight the potential issues surrounding the elimination of postconcussion syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. This opinion piece also emphasizes the multiple diagnostic and therapeutic challenges that may result for those involved in the treatment of, or research regarding, concussion patients with persistent symptoms. Future revisions that provide clear clinical diagnostic criteria may be beneficial.
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Affiliation(s)
- McKyla McIntyre
- From the Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (MM, MA, DK); and University of Toronto, Department of Medicine, Division of Physical Medicine and Rehabilitation, Toronto, Ontario, Canada (DK)
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22
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Niu X, Bai L, Sun Y, Wang Y, Bai G, Yin B, Wang S, Gan S, Jia X, Liu H. Mild traumatic brain injury is associated with effect of inflammation on structural changes of default mode network in those developing chronic pain. J Headache Pain 2020; 21:135. [PMID: 33228537 PMCID: PMC7684719 DOI: 10.1186/s10194-020-01201-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/10/2020] [Indexed: 02/09/2023] Open
Abstract
Background Mild traumatic brain injury (mTBI) has a higher prevalence (more than 50%) of developing chronic posttraumatic headache (CPTH) compared with moderate or severe TBI. However, the underlying neural mechanism for CPTH remains unclear. This study aimed to investigate the inflammation level and cortical volume changes in patients with acute PTH (APTH) and further examine their potential in identifying patients who finally developed CPTH at follow-up. Methods Seventy-seven mTBI patients initially underwent neuropsychological measurements, 9-plex panel of serum cytokines and MRI scans within 7 days post-injury (T-1) and 54 (70.1%) of patients completed the same protocol at a 3-month follow-up (T-2). Forty-two matched healthy controls completed the same protocol at T-1 once. Results At baseline, mTBI patients with APTH presented significantly increased GM volume mainly in the right dorsal anterior cingulate cortex (dACC) and dorsal posterior cingulate cortex (dPCC), of which the dPCC volume can predict much worse impact of headache on patients’ lives by HIT-6 (β = 0.389, P = 0.007) in acute stage. Serum levels of C-C motif chemokine ligand 2 (CCL2) were also elevated in these patients, and its effect on the impact of headache on quality of life was partially mediated by the dPCC volume (mean [SE] indirect effect, 0.088 [0.0462], 95% CI, 0.01–0.164). Longitudinal analysis showed that the dACC and dPCC volumes as well as CCL2 levels had persistently increased in patients developing CPTH 3 months postinjury. Conclusion The findings suggested that structural remodelling of DMN brain regions were involved in the progression from acute to chronic PTH following mTBI, which also mediated the effect of inflammation processes on pain modulation. Trial registration ClinicalTrial.gov ID: NCT02868684; registered 16 August 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-020-01201-7.
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Affiliation(s)
- Xuan Niu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Radiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Lijun Bai
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China.
| | - Yingxiang Sun
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yuan Wang
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guanghui Bai
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shan Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Shuoqiu Gan
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Xiaoyan Jia
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Hongjuan Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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23
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Guan Y, Cheng CH, Chen W, Zhang Y, Koo S, Krengel M, Janulewicz P, Toomey R, Yang E, Bhadelia R, Steele L, Kim JH, Sullivan K, Koo BB. Neuroimaging Markers for Studying Gulf-War Illness: Single-Subject Level Analytical Method Based on Machine Learning. Brain Sci 2020; 10:brainsci10110884. [PMID: 33233672 PMCID: PMC7699718 DOI: 10.3390/brainsci10110884] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
Gulf War illness (GWI) refers to the multitude of chronic health symptoms, spanning from fatigue, musculoskeletal pain, and neurological complaints to respiratory, gastrointestinal, and dermatologic symptoms experienced by about 250,000 GW veterans who served in the 1991 Gulf War (GW). Longitudinal studies showed that the severity of these symptoms often remain unchanged even years after the GW, and these veterans with GWI continue to have poorer general health and increased chronic medical conditions than their non-deployed counterparts. For better management and treatment of this condition, there is an urgent need for developing objective biomarkers that can help with simple and accurate diagnosis of GWI. In this study, we applied multiple neuroimaging techniques, including T1-weighted magnetic resonance imaging (T1W-MRI), diffusion tensor imaging (DTI), and novel neurite density imaging (NDI) to perform both a group-level statistical comparison and a single-subject level machine learning (ML) analysis to identify diagnostic imaging features of GWI. Our results supported NDI as the most sensitive in defining GWI characteristics. In particular, our classifier trained with white matter NDI features achieved an accuracy of 90% and F-score of 0.941 for classifying GWI cases from controls after the cross-validation. These results are consistent with our previous study which suggests that NDI measures are sensitive to the microstructural and macrostructural changes in the brain of veterans with GWI, which can be valuable for designing better diagnosis method and treatment efficacy studies.
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Affiliation(s)
- Yi Guan
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | - Chia-Hsin Cheng
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | - Weifan Chen
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | - Yingqi Zhang
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | - Sophia Koo
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | - Maxine Krengel
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | | | - Rosemary Toomey
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
| | - Ehwa Yang
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (E.Y.); (J.-H.K.)
| | - Rafeeque Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA;
| | - Lea Steele
- Neuropsychiatry Division, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Jae-Hun Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (E.Y.); (J.-H.K.)
| | - Kimberly Sullivan
- School of Public Health, Boston University, Boston, MA 02118, USA;
- Correspondence: (K.S.); (B.-B.K.)
| | - Bang-Bon Koo
- School of Medicine, Boston University, Boston, MA 02118, USA; (Y.G.); (C.-H.C.); (W.C.); (Y.Z.); (S.K.); (M.K.); (R.T.)
- Correspondence: (K.S.); (B.-B.K.)
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24
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Quinn DK, Upston J, Jones T, Brandt E, Story-Remer J, Fratzke V, Wilson JK, Rieger R, Hunter MA, Gill D, Richardson JD, Campbell R, Clark VP, Yeo RA, Shuttleworth CW, Mayer AR. Cerebral Perfusion Effects of Cognitive Training and Transcranial Direct Current Stimulation in Mild-Moderate TBI. Front Neurol 2020; 11:545174. [PMID: 33117255 PMCID: PMC7575722 DOI: 10.3389/fneur.2020.545174] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Persistent post-traumatic symptoms (PPS) after traumatic brain injury (TBI) can lead to significant chronic functional impairment. Pseudocontinuous arterial spin labeling (pCASL) has been used in multiple studies to explore changes in cerebral blood flow (CBF) that may result in acute and chronic TBI, and is a promising neuroimaging modality for assessing response to therapies. Methods: Twenty-four subjects with chronic mild-moderate TBI (mmTBI) were enrolled in a pilot study of 10 days of computerized executive function training combined with active or sham anodal transcranial direct current stimulation (tDCS) for treatment of cognitive PPS. Behavioral surveys, neuropsychological testing, and magnetic resonance imaging (MRI) with pCASL sequences to assess global and regional CBF were obtained before and after the training protocol. Results: Robust improvements in depression, anxiety, complex attention, and executive function were seen in both active and sham groups between the baseline and post-treatment visits. Global CBF decreased over time, with differences in regional CBF noted in the right inferior frontal gyrus (IFG). Active stimulation was associated with static or increased CBF in the right IFG, whereas sham was associated with reduced CBF. Neuropsychological performance and behavioral symptoms were not associated with changes in CBF. Discussion: The current study suggests a complex picture between mmTBI, cerebral perfusion, and recovery. Changes in CBF may result from physiologic effect of the intervention, compensatory neural mechanisms, or confounding factors. Limitations include a small sample size and heterogenous injury sample, but these findings suggest promising directions for future studies of cognitive training paradigms in mmTBI.
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Affiliation(s)
- Davin K Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Joel Upston
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Thomas Jones
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Emma Brandt
- Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States
| | | | - Violet Fratzke
- Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States.,Chicago Medical School, Chicago, IL, United States
| | - J Kevin Wilson
- Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States
| | - Rebecca Rieger
- Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States
| | | | - Darbi Gill
- Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States
| | - Jessica D Richardson
- Department of Speech and Hearing Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Richard Campbell
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, United States.,Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States
| | - Vincent P Clark
- Department of Psychology, University of New Mexico, Albuquerque, NM, United States.,Mind Research Network, Albuquerque, NM, United States
| | - Ronald A Yeo
- Department of Neuroscience, University of New Mexico, Albuquerque, NM, United States.,Department of Psychology, University of New Mexico, Albuquerque, NM, United States
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25
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Cheng CH, Koo BB, Calderazzo S, Quinn E, Aenlle K, Steele L, Klimas N, Krengel M, Janulewicz P, Toomey R, Michalovicz LT, Kelly KA, Heeren T, Little D, O’Callaghan JP, Sullivan K. Alterations in high-order diffusion imaging in veterans with Gulf War Illness is associated with chemical weapons exposure and mild traumatic brain injury. Brain Behav Immun 2020; 89:281-290. [PMID: 32745586 PMCID: PMC7755296 DOI: 10.1016/j.bbi.2020.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/11/2020] [Accepted: 07/08/2020] [Indexed: 01/02/2023] Open
Abstract
The complex etiology behind Gulf War Illness (GWI) has been attributed to the combined exposure to neurotoxicant chemicals, brain injuries, and some combat experiences. Chronic GWI symptoms have been shown to be associated with intensified neuroinflammatory responses in animal and human studies. To investigate the neuroinflammatory responses and potential causes in Gulf War (GW) veterans, we focused on the effects of chemical/biological weapons (CBW) exposure and mild traumatic brain injury (mTBI) during the war. We applied a novel MRI diffusion processing method, Neurite density imaging (NDI), on high-order diffusion imaging to estimate microstructural alterations of brain imaging in Gulf War veterans with and without GWI, and collected plasma proinflammatory cytokine samples as well as self-reported health symptom scores. Our study identified microstructural changes specific to GWI in the frontal and limbic regions due to CBW and mTBI, and further showed distinctive microstructural patterns such that widespread changes were associated with CBW and more focal changes on diffusion imaging were observed in GW veterans with an mTBI during the war. In addition, microstructural alterations on brain imaging correlated with upregulated blood proinflammatory cytokine markers TNFRI and TNFRII and with worse outcomes on self-reported symptom measures for fatigue and sleep functioning. Taken together, these results suggest TNF signaling mediated inflammation affects frontal and limbic regions of the brain, which may contribute to the fatigue and sleep symptoms of the disease and suggest a strong neuroinflammatory component to GWI. These results also suggest exposures to chemical weapons and mTBI during the war are associated with different patterns of peripheral and central inflammation and highlight the brain regions vulnerable to further subtle microscale morphological changes and chronic signaling to nearby glia.
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Affiliation(s)
| | - Bang-Bon Koo
- School of Medicine, Boston University, Boston, MA, US
| | | | - Emily Quinn
- School of Public Health, Boston University, Boston MA USA
| | - Kristina Aenlle
- Nova Southeastern University, Fort Lauderdale, FL, USA
- Department of Veterans Affairs, Miami VA Healthcare System, Research Service, Miami, FL, USA
| | - Lea Steele
- Baylor College of Medicine, Houston, TX, USA
| | - Nancy Klimas
- Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Maxine Krengel
- School of Public Health, Boston University, Boston MA USA
| | | | | | - Lindsay T. Michalovicz
- Health Effects Laboratory Division, Center for Disease Control and Prevention – National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Kimberly A Kelly
- Health Effects Laboratory Division, Center for Disease Control and Prevention – National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Timothy Heeren
- School of Public Health, Boston University, Boston MA USA
| | | | - James P. O’Callaghan
- Health Effects Laboratory Division, Center for Disease Control and Prevention – National Institute for Occupational Safety and Health, Morgantown, WV, USA
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26
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Altered motor system function in post-concussion syndrome as assessed via transcranial magnetic stimulation. Clin Neurophysiol Pract 2020; 5:157-164. [PMID: 32939420 PMCID: PMC7479250 DOI: 10.1016/j.cnp.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 11/22/2022] Open
Abstract
Study examining corticospinal and cortical activity in post-concussion. Reduction in GABAB-mediated inhibition observed. These changes were associated with depression-related symptoms.
Objective It is unclear why specific individuals incur chronic symptoms following a concussion. This exploratory research aims to identify and characterize any neurophysiological differences that may exist in motor cortex function in post-concussion syndrome (PCS). Methods Fifteen adults with PCS and 13 healthy, non-injured adults were tested. All participants completed symptom questionnaires, and transcranial magnetic stimulation (TMS) was used to measure intracortical and transcallosal excitability and inhibition in the dominant motor cortex. Results Cortical silent period (p = 0.02, g = 0.96) and ipsilateral silent period (p = 0.04, g = 0.78) were shorter in the PCS group compared to the control group which may reflect reduced GABA-mediated inhibition in PCS. Furthermore, increased corticomotor excitability was observed in the left hemisphere but not the right hemisphere. Conclusions These data suggest that persistent neurophysiological differences are present in those with PCS. The exact contributing factors to such changes remain to be investigated by future studies. Significance This study provides novel evidence of lasting neurophysiological changes in PCS.
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27
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Padilla-Zambrano HS, Deora H, Arnout M, Mendoza-Florez R, Cardenas-Chavez WE, Herrera-Martinez MP, Ortega-Sierra MG, Agrawal A, Moscote-Salazar LR. The Role of Microglia in Cerebral Traumatic Injury and its Therapeutic Implications. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractMicroglia have a variety of functions in the brain such as synaptic remodeling, damage repair of the central nervous system (CNS), and CNS’ inflammatory response to peripheral infections. The response depends on the type of insult and infection and includes a range of variety of activation states, the duration of which will decide the outcome. In response to traumatic brain injury (TBI), early activation can lead to early restoration of function, while prolonged and continuous activation can cause neurodegeneration states. Current evidence, however, states that this may not be the case. In this article, we discuss this seldom understood topic of microglia response to TBI, and analyze their distribution, function and possible sites of manipulation. Animal studies have allowed genetic and pharmacological manipulations of microglia activation, in order to define their role. Microglia activation can be remote to the site of injury, and thus their manipulation may play a significant role in the response to any trauma.
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Affiliation(s)
- Huber S. Padilla-Zambrano
- Biomedical Research Center (CIB), Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | | | - Romario Mendoza-Florez
- Biomedical Research Center (CIB), Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Wiston Eduardo Cardenas-Chavez
- Biomedical Research Center (CIB), Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Monica Patricia Herrera-Martinez
- Biomedical Research Center (CIB), Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | | | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Luis Rafael Moscote-Salazar
- Biomedical Research Center (CIB), Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
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28
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Quinones MM, Gallegos AM, Lin FV, Heffner K. Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review. COGNITIVE, AFFECTIVE & BEHAVIORAL NEUROSCIENCE 2020; 20:455-480. [PMID: 32170605 PMCID: PMC7682894 DOI: 10.3758/s13415-020-00782-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Compelling evidence from animal and human research suggest a strong link between inflammation and posttraumatic stress disorder (PTSD). Furthermore, recent findings support compromised neurocognitive function as a key feature of PTSD, particularly with deficits in attention and processing speed, executive function, and memory. These cognitive domains are supported by brain structures and neural pathways that are disrupted in PTSD and which are implicated in fear learning and extinction processes. The disruption of these supporting structures potentially results from their interaction with inflammation. Thus, the converging evidence supports a model of inflammatory dysregulation and cognitive dysfunction as combined mechanisms underpinning PTSD symptomatology. In this review, we summarize evidence of dysregulated inflammation in PTSD and further explore how the neurobiological underpinnings of PTSD, in the context of fear learning and extinction acquisition and recall, may interact with inflammation. We then present evidence for cognitive dysfunction in PTSD, highlighting findings from human work. Potential therapeutic approaches utilizing novel pharmacological and behavioral interventions that target inflammation and cognition also are discussed.
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Affiliation(s)
- Maria M Quinones
- Elaine C. Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester Medical Center, Rochester, NY, 14642, USA.
| | - Autumn M Gallegos
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Feng Vankee Lin
- Elaine C. Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester Medical Center, Rochester, NY, 14642, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, USA
| | - Kathi Heffner
- Elaine C. Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester Medical Center, Rochester, NY, 14642, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
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29
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Di Battista AP, Rhind SG, Richards D, Hutchison MG. An investigation of plasma interleukin-6 in sport-related concussion. PLoS One 2020; 15:e0232053. [PMID: 32343752 PMCID: PMC7188239 DOI: 10.1371/journal.pone.0232053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/06/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Increasing evidence suggests inflammation is an important component of concussion pathophysiology. However, its etiology, restitution, and potential clinical repercussions remain unknown. The purpose of the current study was to compare the blood concentrations of interleukin (IL) -6, a prominent inflammatory cytokine, between healthy athletes and athletes with a sport-related concussion (SRC), while addressing the potential confounds of sex, recent physical activity, and the interacting effect of concussion history. METHOD A prospective, observational cohort study was conducted on athletes at a single academic institute participating across 13 interuniversity sports. Follow-up of 96 athletes who agreed to provide a blood sample was completed: 41 athletes with a physician diagnosed SRC, and 55 healthy athletes. Ella™, the high sensitivity immunoassay system by ProteinSimple was used to measure peripheral plasma concentrations of IL-6 within the first week (median = 4 days, range = 2-7) following injury. A resampled ordinary least squares regression was used to evaluate the relationship between IL-6 concentrations and concussion status, while partial least squares regression was used to evaluate the relationship between IL-6 and both symptom burden and time to clinical recovery. RESULTS Regression analysis identified a negative relationship between plasma IL-6 concentrations and the interaction between an acute SRC and a history of concussion (β = -0.29, p = 0.029). IL-6 did not differ between healthy athletes and those with an acute SRC independent of concussion history, and was not correlated with either recovery time or symptom burden in athletes with SRC. CONCLUSION Perturbations to circulating IL-6 concentrations, a key inflammatory cytokine, may be more pronounced following SRC in athletes who have a history of concussion. These results add to a growing body of evidence supporting the involvement of inflammation at all phases of recovery following SRC, and potentially support a concomitant effect of prior concussion on acute SRC pathophysiology.
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Affiliation(s)
- Alex P. Di Battista
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Shawn G. Rhind
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Doug Richards
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
| | - Michael G. Hutchison
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
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30
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Baker JG, Willer BS, Dwyer MG, Leddy JJ. A preliminary investigation of cognitive intolerance and neuroimaging among adolescents returning to school after concussion. Brain Inj 2020; 34:818-827. [PMID: 32324445 DOI: 10.1080/02699052.2020.1749932] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PRIMARY OBJECTIVE To introduce the concept of cognitive intolerance. A test is proposed to measure this concept and pilot data are presented to support this measure and future research to develop this concept into a construct. Research design: Three-group comparison to protect larger study blinding. Methods and procedures: Two groups of student athletes (n = 13, n = 13) between 13 and 17 (mean 15.1 ± 1.1 years; 58% male) who sustained a sport-related concussion within 10 days and one group (n = 13) of age-matched healthy controls were recruited for a comparison of correlations between self and observer ratings of cognitive difficulties and DTI fractional anisotropy (FA) using tract-based spatial statistics (TBSS) analysis at two time points. Main outcomes and results: Significant negative only associations (higher cognitive difficulty and lower FA) with DTI FA were found in white matter tracts. These included the anterior corpus callosum, frontal-parietal longitudinal fasciculi, and cortical-subcortical pathways at only the second time point. Several working memory networks would likely involve connections using the above-identified white matter tracts. Conclusions: Cognitive intolerance can be defined as symptom exacerbation from prolonged cognitive activity. Cognitive intolerance could be measured by the n-back working memory task and time to symptom exacerbation.
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Affiliation(s)
- John G Baker
- Departments of UBMD Orthopedics and Sports Medicine and Nuclear Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, New York, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, New York, USA
| | - Michael G Dwyer
- Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, New York, USA
| | - John J Leddy
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, New York, USA
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31
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O'Brien WT, Pham L, Symons GF, Monif M, Shultz SR, McDonald SJ. The NLRP3 inflammasome in traumatic brain injury: potential as a biomarker and therapeutic target. J Neuroinflammation 2020; 17:104. [PMID: 32252777 PMCID: PMC7137518 DOI: 10.1186/s12974-020-01778-5] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/17/2020] [Indexed: 01/14/2023] Open
Abstract
There is a great clinical need to identify the underlying mechanisms, as well as related biomarkers, and treatment targets, for traumatic brain injury (TBI). Neuroinflammation is a central pathophysiological feature of TBI. NLRP3 inflammasome activity is a necessary component of the innate immune response to tissue damage, and dysregulated inflammasome activity has been implicated in a number of neurological conditions. This paper introduces the NLRP3 inflammasome and its implication in the pathogenesis of neuroinflammatory-related conditions, with a particular focus on TBI. Although its role in TBI has only recently been identified, findings suggest that priming and activation of the NLRP3 inflammasome are upregulated following TBI. Moreover, recent studies utilizing specific NLRP3 inhibitors have provided further evidence that this inflammasome is a major driver of neuroinflammation and neurobehavioral disturbances following TBI. In addition, there is emerging evidence that circulating inflammasome-associated proteins may have utility as diagnostic biomarkers of neuroinflammatory conditions, including TBI. Finally, novel and promising areas of research will be highlighted, including the potential involvement of the NLRP3 inflammasome in mild TBI, how factors such as biological sex may affect NLRP3 activity in TBI, and the use of emerging biomarker platforms. Taken together, this review highlights the exciting potential of the NLRP3 inflammasome as a target for treatments and biomarkers that may ultimately be used to improve TBI management.
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Affiliation(s)
- William T O'Brien
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Louise Pham
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Georgia F Symons
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Mastura Monif
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia.,Department of Neurology, Alfred Health, Melbourne, VIC, 3004, Australia.,Department of Neurology, Melbourne Health, Melbourne, VIC, 3004, Australia.,Department of Physiology, The University of Melbourne, Melbourne, VIC, 3052, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, 3052, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia. .,Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, 3086, Australia.
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32
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Traumatic brain injury and methamphetamine: A double-hit neurological insult. J Neurol Sci 2020; 411:116711. [DOI: 10.1016/j.jns.2020.116711] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/27/2019] [Accepted: 01/29/2020] [Indexed: 11/17/2022]
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33
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Di Battista AP, Churchill N, Rhind SG, Richards D, Hutchison MG. The relationship between symptom burden and systemic inflammation differs between male and female athletes following concussion. BMC Immunol 2020; 21:11. [PMID: 32164571 PMCID: PMC7068899 DOI: 10.1186/s12865-020-0339-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Inflammation appears to be an important component of concussion pathophysiology. However, its relationship to symptom burden is unclear. Therefore, the purpose of this study was to evaluate the relationship between symptoms and inflammatory biomarkers measured in the blood of male and female athletes following a sport-related concussion (SRC). RESULTS Forty athletes (n = 20 male, n = 20 female) from nine interuniversity sport teams at a single institution provided blood samples within one week of an SRC. Twenty inflammatory biomarkers were quantitated by immunoassay. The Sport Concussion Assessment Tool version 5 (SCAT-5) was used to evaluate symptoms. Partial least squares (PLS) analyses were used to evaluate the relationship(s) between biomarkers and symptoms. In males, a positive correlation between interferon (IFN)-γ and symptom severity was observed following SRC. The relationship between IFN-γ and symptoms was significant among all symptom clusters, with cognitive symptoms displaying the largest effect. In females, a significant negative relationship was observed between symptom severity and cytokines IFN-γ, tumor necrosis factor (TNF)-α, and myeloperoxidase (MPO); a positive relationship was observed between symptom severity and MCP-4. Inflammatory mediators were significantly associated with all symptom clusters in females; the somatic symptom cluster displayed the largest effect. CONCLUSION These results provide supportive evidence of a divergent relationship between inflammation and symptom burden in male and female athletes following SRC. Future investigations should be cognizant of the potentially sex-specific pathophysiology underlying symptom presentation.
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Affiliation(s)
- Alex P Di Battista
- Faculty of Kinesiology & Physical Education, University of Toronto, 55 Harbord St., Toronto, ON, M5S 2W6, Canada.
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada.
| | - Nathan Churchill
- Neuroscience Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada
| | - Shawn G Rhind
- Faculty of Kinesiology & Physical Education, University of Toronto, 55 Harbord St., Toronto, ON, M5S 2W6, Canada
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Doug Richards
- Faculty of Kinesiology & Physical Education, University of Toronto, 55 Harbord St., Toronto, ON, M5S 2W6, Canada
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
| | - Michael G Hutchison
- Faculty of Kinesiology & Physical Education, University of Toronto, 55 Harbord St., Toronto, ON, M5S 2W6, Canada
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada
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34
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Sun Y, Bai L, Niu X, Wang Z, Yin B, Bai G, Zhang D, Gan S, Sun C, Wang S, Zhu F, Zhang M. Elevated Serum Levels of Inflammation-Related Cytokines in Mild Traumatic Brain Injury Are Associated With Cognitive Performance. Front Neurol 2019; 10:1120. [PMID: 31708858 PMCID: PMC6819507 DOI: 10.3389/fneur.2019.01120] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/08/2019] [Indexed: 11/13/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is the most common neurological insult and leads to long-lasting cognitive impairments. The immune system modulates brain functions and plays a key role in cognitive deficits, however, the relationship between TBI-induced changes in inflammation-related cytokine levels and cognitive consequences is unclear. This was investigated in the present study in two cohorts of individuals within 1 week of mTBI (n = 52, n = 43) and 54 matched healthy control subjects. Patients with mTBI were also followed up at 1 and 3 months post-injury. Measures included cognitive assessments and a 9-plex panel of serum cytokines including interleukin (IL)-1β, IL-4, IL-6, IL-8, IL-10, IL-12, chemokine ligand 2 (CCL2), interferon-γ (IFN-γ), and tumor necrosis factor-α (TNF-α). The contribution of cytokine levels to cognitive function was evaluated by multivariate linear regression analysis. The results showed that serum levels of IL-1β, IL-6, and CCL2 were acutely elevated in mTBI patients relative to controls; CCL2 level was remained high over 3 months whereas IL-1β and IL-6 levels were declined by 3 months post-injury. A high level of CCL2 was associated with greater severity of post-concussion symptoms (which survived in the multiple testing correction); elevated IL-1β was associated with worse working memory in acute phase (which failed in correction); and acute high CCL2 level predicted higher information processing speed at 3 months post-injury (which failed in correction). Thus, acute serum cytokine levels are useful for evaluating post-concussion symptoms and predicting cognitive outcome in participants with mTBI.
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Affiliation(s)
- Yingxiang Sun
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lijun Bai
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Xuan Niu
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhuonan Wang
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guanghui Bai
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Danbin Zhang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shuoqiu Gan
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Chuanzhu Sun
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Shan Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Feng Zhu
- Center for Translational Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ming Zhang
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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35
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Pham L, Shultz SR, Kim HA, Brady RD, Wortman RC, Genders SG, Hale MW, O'Shea RD, Djouma E, van den Buuse M, Church JE, Christie BR, Drummond GR, Sobey CG, McDonald SJ. Mild Closed-Head Injury in Conscious Rats Causes Transient Neurobehavioral and Glial Disturbances: A Novel Experimental Model of Concussion. J Neurotrauma 2019; 36:2260-2271. [DOI: 10.1089/neu.2018.6169] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Louise Pham
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Sandy R. Shultz
- Department Neuroscience, Monash University, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Hyun Ah Kim
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Rhys D. Brady
- Department Neuroscience, Monash University, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ryan C. Wortman
- Department Neuroscience, Monash University, Melbourne, Australia
| | - Shannyn G. Genders
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Matthew W. Hale
- Department of Psychology and Counseling, La Trobe University, Bundoora, Australia
| | - Ross D. O'Shea
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Elvan Djouma
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Maarten van den Buuse
- Department of Psychology and Counseling, La Trobe University, Bundoora, Australia
- Department of Pharmacology, University of Melbourne, Melbourne, Australia
- The College of Public Health, Medical, and Veterinary Sciences, James Cook University, Queensland, Australia
| | - Jarrod E. Church
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Brian R. Christie
- Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada
| | - Grant R. Drummond
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Christopher G. Sobey
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
| | - Stuart J. McDonald
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, Australia
- Department Neuroscience, Monash University, Melbourne, Australia
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36
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Abstract
PURPOSE OF REVIEW The concussion public health burden has increased alongside our knowledge of the pathophysiology of mild traumatic brain injury (mTBI). The purpose of this review is to summarize our current understanding of mTBI pathophysiology and biomechanics and how these underlying principles correlate with clinical manifestations of mTBI. RECENT FINDINGS Changes in post-mTBI glutamate and GABA concentrations seem to be region-specific and time-dependent. Genetic variability may predict recovery and symptom severity while gender differences appear to be associated with the neuroinflammatory response and neuroplasticity. Ongoing biomechanical research has shown a growing body of evidence in support of an "individual-specific threshold" for mTBI that varies based on individual intrinsic factors. The literature demonstrates a well-characterized timeframe for mTBI pathophysiologic changes in animal models while work in this area continues to grow in humans. Current human research shows that these underlying post-mTBI effects are multifactorial and may correlate with symptomatology and recovery. While wearable sensor technology has advanced biomechanical impact research, a definitive concussion threshold remains elusive.
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Affiliation(s)
- Rafael Romeu-Mejia
- Department of Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA
- UCLA Brain Injury Research Center, Los Angeles, CA, USA
| | - Christopher C Giza
- Department of Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA
- UCLA Brain Injury Research Center, Los Angeles, CA, USA
- Department of Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Joshua T Goldman
- Department of Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA.
- Department of Family Medicine, Division of Sports Medicine, UCLA, Los Angeles, CA, USA.
- Department of Orthopedic Surgery, UCLA, Los Angeles, CA, USA.
- Department of Intercollegiate Athletics, UCLA, Los Angeles, CA, USA.
- Center for Sports Medicine, Orthopedic Institute for Children, Los Angeles, CA, USA.
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37
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Ebert SE, Jensen P, Ozenne B, Armand S, Svarer C, Stenbaek DS, Moeller K, Dyssegaard A, Thomsen G, Steinmetz J, Forchhammer BH, Knudsen GM, Pinborg LH. Molecular imaging of neuroinflammation in patients after mild traumatic brain injury: a longitudinal 123 I-CLINDE single photon emission computed tomography study. Eur J Neurol 2019; 26:1426-1432. [PMID: 31002206 DOI: 10.1111/ene.13971] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/15/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Neuroinflammation has been proposed as part of the pathogenesis of post-concussion symptoms (PCS), but the inflammatory response of the human brain to mild traumatic brain injury (mTBI) remains unknown. We hypothesized that a neuroinflammatory response is present in mTBI at 1-2 weeks post-injury and persists in patients with PCS. METHODS We scanned 14 patients with mTBI without signs of structural damage at 1-2 weeks and 3-4 months post-injury and 22 healthy controls once using the single photon emission computed tomography tracer 123 I-CLINDE, which visualizes translocator protein (TSPO), a protein upregulated in active immune cells. PCS was defined as three or more persisting symptoms from the Rivermead Post Concussion Symptoms Questionnaire at 3 months post-injury. RESULTS Across brain regions, patients had significantly higher 123 I-CLINDE binding to TSPO than healthy controls, both at 1-2 weeks after the injury in all patients (P = 0.011) and at 3-4 months in the seven patients with PCS (P = 0.006) and in the six patients with good recovery (P = 0.018). When the nine brain regions were tested separately and results were corrected for multiple comparisons, no individual region differed significantly, but all estimated parameters indicated increased 123 I-CLINDE binding to TSPO, ranging from 2% to 19% in all patients at 1-2 weeks, 13% to 27% in patients with PCS at 3-4 months and -9% to 17% in patients with good recovery at 3-4 months. CONCLUSIONS Neuroinflammation was present in mTBI at 1-2 weeks post-injury and persisted at 3-4 months post-injury with a tendency to be most pronounced in patients with PCS.
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Affiliation(s)
- S E Ebert
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - P Jensen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - B Ozenne
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S Armand
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - C Svarer
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - D S Stenbaek
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - K Moeller
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, Copenhagen, Denmark
| | - A Dyssegaard
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - G Thomsen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - J Steinmetz
- Trauma Center, Rigshospitalet, Copenhagen, Denmark
| | - B H Forchhammer
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - G M Knudsen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - L H Pinborg
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neurology, Rigshospitalet, Copenhagen, Denmark
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38
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An integrated perspective linking physiological and psychological consequences of mild traumatic brain injury. J Neurol 2019; 267:2497-2506. [PMID: 31030257 PMCID: PMC7420827 DOI: 10.1007/s00415-019-09335-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 01/13/2023]
Abstract
Despite the often seemingly innocuous nature of a mild traumatic brain injury (mTBI), its consequences can be devastating, comprising debilitating symptoms that interfere with daily functioning. Currently, it is still difficult to pinpoint the exact cause of adverse outcome after mTBI. In fact, extensive research suggests that the underlying etiology is multifactorial. In the acute and early sub-acute stages, the pathophysiology of mTBI is likely to be dominated by complex physiological alterations including cellular injury, inflammation, and the acute stress response, which could lead to neural network dysfunction. In this stage, patients often report symptoms such as fatigue, headache, unstable mood and poor concentration. When time passes, psychological processes, such as coping styles, personality and emotion regulation, become increasingly influential. Disadvantageous, maladaptive, psychological mechanisms likely result in chronic stress which facilitates the development of long-lasting symptoms, possibly via persistent neural network dysfunction. So far, a systemic understanding of the coupling between these physiological and psychological factors that in concert define outcome after mTBI is lacking. The purpose of this narrative review article is to address how psychophysiological interactions may lead to poor outcome after mTBI. In addition, a framework is presented that may serve as a template for future studies on this subject.
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39
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Di Battista AP, Churchill N, Rhind SG, Richards D, Hutchison MG. Evidence of a distinct peripheral inflammatory profile in sport-related concussion. J Neuroinflammation 2019; 16:17. [PMID: 30684956 PMCID: PMC6347801 DOI: 10.1186/s12974-019-1402-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/08/2019] [Indexed: 12/28/2022] Open
Abstract
Background Inflammation is considered a hallmark of concussion pathophysiology in experimental models, yet is understudied in human injury. Despite the growing use of blood biomarkers in concussion, inflammatory biomarkers have not been well characterized. Furthermore, it is unclear if the systemic inflammatory response to concussion differs from that of musculoskeletal injury. The purpose of this paper was to characterize systemic inflammation after injury in athletes with sport-related concussion or musculoskeletal injury. Methods A prospective, observational cohort study was conducted employing 175 interuniversity athletes (sport-related concussion, n = 43; musculoskeletal injury, n = 30; healthy, n = 102) from 12 sports at a sports medicine clinic at an academic institution. High-sensitivity immunoassay was used to evaluate 20 inflammatory biomarkers in the peripheral blood of athletes within 7 days of injury (subacute) and at medical clearance. Healthy athletes were sampled prior to the start of their competitive season. Partial least squares regression analyses were used to identify salient biomarker contributions to class separation between injured and healthy athletes, as well as to evaluate the relationship between biomarkers and days to recovery in injured athletes. Results In the subacute period after injury, compared to healthy athletes, athletes with sport-related concussion had higher levels of the chemokines’ monocyte chemoattractant protein-4 (p < 0.001) and macrophage inflammatory protein-1β (p = 0.001); athletes with musculoskeletal injury had higher levels of thymus and activation-regulated chemokine (p = 0.001). No significant differences in biomarker profiles were observed at medical clearance. Furthermore, concentrations of monocyte chemoattractant protein-1 (p = 0.007) and monocyte chemoattractant protein-4 (p < 0.001) at the subacute time point were positively correlated with days to recovery in athletes with sport-related concussion, while thymus and activation-regulated chemokine was (p = 0.001) positively correlated with days to recovery in athletes with musculoskeletal injury. Conclusion Sport-related concussion is associated with perturbations to systemic inflammatory chemokines that differ from those observed in athletes with a musculoskeletal injury. These results support inflammation as an important facet of secondary injury after sport-related concussion that can be measured systemically in a human model of injury. Electronic supplementary material The online version of this article (10.1186/s12974-019-1402-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex P Di Battista
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada. .,Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada.
| | - Nathan Churchill
- Neuroscience Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada
| | - Shawn G Rhind
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada.,Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Doug Richards
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada.,David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
| | - Michael G Hutchison
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada.,David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
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40
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Maruta J, Lumba-Brown A, Ghajar J. Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire. Front Neurol 2018; 9:1034. [PMID: 30559709 PMCID: PMC6287109 DOI: 10.3389/fneur.2018.01034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/16/2018] [Indexed: 11/21/2022] Open
Abstract
Classifying concussion in key subtypes according to presenting symptomatology at an early post-injury stage is an emerging approach that may allow prediction of clinical trajectories and delivery of targeted treatments. The Rivermead Post-concussion Symptoms Questionnaire (RPQ) is a simple, freely available, and widely used tool for assessment of the presence and severity of various post-concussion symptoms. We aimed to probe the prevalence among athletes of symptom classes associated with identified concussion phenotypes using the RPQ at baseline and acutely after a concussion. Participants of organized sports aged 12–30 years were baseline-assessed with the expectation that some would experience a concussion during the study period. Concussed athletes were re-assessed within 2 weeks of their injuries. The RPQ was supplemented with three specific questions and reworded for baseline assessment. A binomial test was used to contrast the prevalence of an attribute in the concussed cohort against the probability established by the baseline observation. Three thousand and eighty-eight athletes were baseline-assessed and eighty-nine were re-assessed post-concussion. All concussed athletes endorsed having some elevated symptoms in the RPQ, and such endorsements were more prevalent than those among normal athletes. Moderate-to-severe post-concussion symptoms of specific classes tended to be endorsed with few additional symptoms of other classes of similar intensities. Elevated symptoms detected with the RPQ within as short as 2 weeks after a concussion may help delineate patients' clinical subtypes and guide their treatment. Further refinement of symptom questionnaires and use of objective measures will be needed to properly populate the concussion subtype classification.
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Affiliation(s)
- Jun Maruta
- Brain Trauma Foundation, New York, NY, United States.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Rehabilitation and Human Performance, New York, NY, United States
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Jamshid Ghajar
- Brain Trauma Foundation, New York, NY, United States.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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41
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The Multiple Hit Hypothesis for Gulf War Illness: Self-Reported Chemical/Biological Weapons Exposure and Mild Traumatic Brain Injury. Brain Sci 2018; 8:brainsci8110198. [PMID: 30428552 PMCID: PMC6266762 DOI: 10.3390/brainsci8110198] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 12/22/2022] Open
Abstract
The Gulf War Illness Consortium (GWIC) was designed to identify objective biomarkers of Gulf War Illness (GWI) in 1991 Gulf War veterans. The symptoms of GWI include fatigue, pain, cognitive problems, gastrointestinal, respiratory, and skin problems. Neurotoxicant exposures during deployment, such as pesticides, sarin, and pyridostigmine bromide pills have been identified as contributors to GWI. We have also found an association between mild traumatic brain injury (mTBI) and increased rates of GWI. However, the combined impact of these physical and chemical exposures has not yet been explored in GWI. The objective of this study was to examine both self-reported mTBI and exposure to chemical/biological weapons (CBW) as a multiple or two hit model for increased risk of GWI and other chronic health conditions. The study population included 125 Gulf War (GW) veterans from the Boston GWIC. Exposure to CBW was reported in 47.2% of the study population, and 35.2% reported sustaining a mTBI during the war. Results confirmed that those with both exposures (mTBI and CBW) had higher rates of comorbid chronic health conditions while rates of GWI were equivalent for mTBI and CBW or mTBI alone. The timing of exposure to mTBI was found to be strikingly different between those with GWI and those without it. Correspondingly, 42.3% of GWI cases reported experiencing a mTBI during military service while none of the controls did (p = 0.0002). Rates of mTBI before and after the war did not differ between the cases and controls. In addition, 54% of cases compared to 14.3% of controls (p = <0.001) reported being exposed to CBW during military service. The current study examined the relation of the separate and combined effects of exposure to mTBI and CBW in 1991 GW veterans. The findings from this study suggest that both exposure to mTBI and CBW are associated with the development of GWI and multiple chronic health conditions and that combined exposure appears to lead to higher risk of chronic health effects.
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42
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Munsterhjelm C, Nordgreen J, Aae F, Heinonen M, Valros A, Janczak AM. Sick and grumpy: Changes in social behaviour after a controlled immune stimulation in group-housed gilts. Physiol Behav 2018; 198:76-83. [PMID: 30290182 DOI: 10.1016/j.physbeh.2018.09.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022]
Abstract
Poor health is associated with an increased risk of tail biting outbreaks in pigs. We propose that this is because illness changes social dynamics either by changing the behaviour of the sick pig towards its penmates, the behaviour of the healthy penmates towards the sick pig, or both. We tested the effect of immune stimulation (lipopolysaccharide (LPS) injection: O111:B4; 1.5 μg kg-1 IV) on social behaviour in gilts housed in triplets in a cross-over experiment. Each pen was subjected to the control treatment (all three pigs injected with saline) and then LPS treatment (one pig injected with LPS, two injected with saline), or vice versa. LPS injected pigs had a shift in social motivation and performed more tail- and ear- directed behaviour than saline pigs two days after injection. They seemed to fit the description of 'sick and grumpy'. This change was seen about 40 h after the signs of acute illness dissipated and was not accompanied by a similar increase in activity. We discuss possible mechanisms for this behavioural change in light of changes in neurotransmitter levels at three days after LPS injection described in a previous experiment.
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Affiliation(s)
- Camilla Munsterhjelm
- Research Centre for Animal Welfare, Department of Production Animal Medicine, University of Helsinki, Finland.
| | - Janicke Nordgreen
- Department of Food Safety and Infection Biology, Faculty of Veterinary Medicine, Norwegian University of Life Sciences (NMBU), Oslo, Norway
| | - Frida Aae
- Animal Welfare Research Group, Department of Production Animal Clinical Science, Faculty of Veterinary Medicine, Norwegian University of Life Sciences (NMBU), Oslo, Norway
| | - Mari Heinonen
- Research Centre for Animal Welfare, Department of Production Animal Medicine, University of Helsinki, Finland
| | - Anna Valros
- Research Centre for Animal Welfare, Department of Production Animal Medicine, University of Helsinki, Finland
| | - Andrew M Janczak
- Animal Welfare Research Group, Department of Production Animal Clinical Science, Faculty of Veterinary Medicine, Norwegian University of Life Sciences (NMBU), Oslo, Norway
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Devoto C, Arcurio L, Fetta J, Ley M, Rodney T, Kanefsky R, Gill J. Inflammation Relates to Chronic Behavioral and Neurological Symptoms in Military Personnel with Traumatic Brain Injuries. Cell Transplant 2018; 26:1169-1177. [PMID: 28933225 PMCID: PMC5657728 DOI: 10.1177/0963689717714098] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Studies have shown that the presence of acute inflammation during recovery is indicative of poor outcomes after a traumatic brain injury (TBI); however, the role of chronic inflammation in predicting post-TBI-related symptoms remains poorly understood. The purpose of this study was to compare inflammatory biomarkers (tumor necrosis factor [TNF]-α, interleukin [IL]-6, and IL-10) in active duty personnel who either sustained or did not sustain a TBI. Service members were also assessed for post-traumatic stress disorder (PTSD), depression, and quality of life through self-reported measures. IL-6 and TNF-α concentrations were greater in the TBI group than in the control group. Of those with a TBI, IL-6 and TNF-α concentrations were greater in the high-PTSD group than the low-PTSD group. No significant differences were found in IL-10 or the IL-6/IL-10 ratios between those with low and high PTSD. Exploratory factor analysis was conducted to describe the latent structure of variables relating to emotional and physical health (i.e., Short Form 36 subcomponents, etc.) and their relationships within the TBI group with inflammatory cytokines. Four symptom profiles were found, with the third component most relating to PTSD and depression symptoms and high inflammation. This study indicates that the comorbidity of TBI and PTSD is associated with inflammation in a military sample, emphasizing the necessity for intervention in order to mitigate the risks associated with inflammation.
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Affiliation(s)
- Christina Devoto
- 1 National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, USA
| | - Lindsay Arcurio
- 1 National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, USA
| | - Joseph Fetta
- 1 National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, USA
| | - Mary Ley
- 1 National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, USA
| | - Tamar Rodney
- 2 Johns Hopkins University, School of Nursing, Baltimore, MD, USA
| | - Rebekah Kanefsky
- 1 National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, USA
| | - Jessica Gill
- 1 National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, USA
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Kenzie ES, Parks EL, Bigler ED, Wright DW, Lim MM, Chesnutt JC, Hawryluk GWJ, Gordon W, Wakeland W. The Dynamics of Concussion: Mapping Pathophysiology, Persistence, and Recovery With Causal-Loop Diagramming. Front Neurol 2018; 9:203. [PMID: 29670568 PMCID: PMC5893805 DOI: 10.3389/fneur.2018.00203] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/14/2018] [Indexed: 12/21/2022] Open
Abstract
Despite increasing public awareness and a growing body of literature on the subject of concussion, or mild traumatic brain injury, an urgent need still exists for reliable diagnostic measures, clinical care guidelines, and effective treatments for the condition. Complexity and heterogeneity complicate research efforts and indicate the need for innovative approaches to synthesize current knowledge in order to improve clinical outcomes. Methods from the interdisciplinary field of systems science, including models of complex systems, have been increasingly applied to biomedical applications and show promise for generating insight for traumatic brain injury. The current study uses causal-loop diagramming to visualize relationships between factors influencing the pathophysiology and recovery trajectories of concussive injury, including persistence of symptoms and deficits. The primary output is a series of preliminary systems maps detailing feedback loops, intrinsic dynamics, exogenous drivers, and hubs across several scales, from micro-level cellular processes to social influences. Key system features, such as the role of specific restorative feedback processes and cross-scale connections, are examined and discussed in the context of recovery trajectories. This systems approach integrates research findings across disciplines and allows components to be considered in relation to larger system influences, which enables the identification of research gaps, supports classification efforts, and provides a framework for interdisciplinary collaboration and communication-all strides that would benefit diagnosis, prognosis, and treatment in the clinic.
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Affiliation(s)
- Erin S. Kenzie
- Systems Science Program, Portland State University, Portland, OR, United States
| | - Elle L. Parks
- Systems Science Program, Portland State University, Portland, OR, United States
| | - Erin D. Bigler
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT, United States
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Miranda M. Lim
- Sleep Disorders Clinic, Division of Hospital and Specialty Medicine, Research Service, VA Portland Health Care System, Portland, OR, United States
- Departments of Neurology, Medicine, and Behavioral Neuroscience, Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, United States
| | - James C. Chesnutt
- TBI/Concussion Program, Orthopedics & Rehabilitation, Neurology and Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | | | - Wayne Gordon
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Wayne Wakeland
- Systems Science Program, Portland State University, Portland, OR, United States
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Mc Fie S, Abrahams S, Patricios J, Suter J, Posthumus M, September AV. Inflammatory and apoptotic signalling pathways and concussion severity: a genetic association study. J Sports Sci 2018; 36:2226-2234. [PMID: 29509495 DOI: 10.1080/02640414.2018.1448570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The objective was to investigate the relationship between IL-1B rs16944, IL-6 rs1800795, and CASP8 rs3834129 genetic polymorphisms and concussion severity. Rugby players from high school, senior amateur, and professional teams completed a concussion severity questionnaire and donated a DNA sample. Participants (n = 163) were split into symptom severity groups around the median number and duration of symptoms. The frequency of participants with high symptom counts (more than five symptoms) increased across the IL-1B (C/C: 35%; C/T: 51%; T/T: 56%; P = 0.047) and the IL-6 (C/C: 31%; C/G: 44%; G/G: 58%; P = 0.027) genotypes. The C-C inferred interleukin allele construct frequency, created from combining the IL-1B and IL-6 genotype data, was lower in participants reporting a high symptom count (18%), compared to those with a low symptom count (fewer than six symptoms, 36%, P = 0.002). Similarly, the C-C inferred interleukin allele construct frequency was lower in those reporting prolonged symptom duration (more than one week, 16%), as opposed to short symptom duration (less than one week, 34%, P = 0.015). This study provides evidence of novel inflammatory pathway genetic associations with concussion severity, which supports the hypothesis implicating neuroinflammation in the development of concussion symptoms.
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Affiliation(s)
- Sarah Mc Fie
- a Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Science , University of Cape Town , Cape Town , South Africa
| | - Shameemah Abrahams
- a Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Science , University of Cape Town , Cape Town , South Africa
| | - Jon Patricios
- b Morningside Sports Medicine Clinic , Johannesburg , South Africa.,c Section of Sports Medicine , University of Pretoria , Pretoria , South Africa.,d Department of Emergency Medicine , University of the Witwatersrand , Johannesburg , South Africa
| | - Jason Suter
- e Sports Science Sports and Exercise Medicine Clinic , Cape Town , South Africa
| | - Michael Posthumus
- a Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Science , University of Cape Town , Cape Town , South Africa
| | - Alison V September
- a Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Science , University of Cape Town , Cape Town , South Africa
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Truettner JS, Bramlett HM, Dietrich WD. Hyperthermia and Mild Traumatic Brain Injury: Effects on Inflammation and the Cerebral Vasculature. J Neurotrauma 2018; 35:940-952. [PMID: 29108477 DOI: 10.1089/neu.2017.5303] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Mild traumatic brain injury (mTBI) or concussion represents the majority of brain trauma in the United States. The pathophysiology of mTBI is complex and may include both focal and diffuse injury patterns. In addition to altered circuit dysfunction and traumatic axonal injury (TAI), chronic neuroinflammation has also been implicated in the pathophysiology of mTBI. Recently, our laboratory has reported the detrimental effects of mild hyperthermic mTBI in terms of worsening histopathological and behavioral outcomes. To clarify the role of temperature-sensitive neuroinflammatory processes on these consequences, we evaluated the effects of elevated brain temperature (39°C) on altered microglia/macrophage phenotype patterns after mTBI, changes in leukocyte recruitment, and TAI. Sprague-Dawley male rats underwent mild parasagittal fluid-percussion injury under normothermic (37°C) or hyperthermic (39°C) conditions. Cortical and hippocampal regions were analyzed using several cellular and molecular outcome measures. At 24 h, the ratio of iNOS-positive (M1 type phenotype) to arginase-positive (M2 type phenotype) cells after hyperthermic mTBI showed an increase compared with normothermia by flow cytometry. Inflammatory response gene arrays also demonstrated a significant increase in several classes of pro-inflammatory genes with hyperthermia treatment over normothermia. The injury-induced expression of chemokine ligand 2 (Ccl2) and alpha-2-macroglobulin were also increased with hyperthermic mTBI. With western blot analysis, an increase in CD18 and intercellular cell adhesion molecule-1 (ICAM-1) with hyperthermia and a significant increase in Iba1 reactive microglia are reported in the cerebral cortex. Together, these results demonstrate significant differences in the cellular and molecular consequences of raised brain temperature at the time of mTBI. The observed polarization toward a M1-phenotype with mild hyperthermia would be expected to augment chronic inflammatory cascades, sustained functional deficits, and increased vulnerability to secondary insults. Mild elevations in brain temperature may contribute to the more severe and longer lasting consequences of mTBI or concussion reported in some patients.
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Affiliation(s)
- Jessie S Truettner
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - W Dalton Dietrich
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
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The effect of an acute systemic inflammatory insult on the chronic effects of a single mild traumatic brain injury. Behav Brain Res 2018; 336:22-31. [DOI: 10.1016/j.bbr.2017.08.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/18/2017] [Accepted: 08/23/2017] [Indexed: 12/19/2022]
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Sundman MH, Chen NK, Subbian V, Chou YH. The bidirectional gut-brain-microbiota axis as a potential nexus between traumatic brain injury, inflammation, and disease. Brain Behav Immun 2017; 66:31-44. [PMID: 28526435 DOI: 10.1016/j.bbi.2017.05.009] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/25/2017] [Accepted: 05/10/2017] [Indexed: 02/06/2023] Open
Abstract
As head injuries and their sequelae have become an increasingly salient matter of public health, experts in the field have made great progress elucidating the biological processes occurring within the brain at the moment of injury and throughout the recovery thereafter. Given the extraordinary rate at which our collective knowledge of neurotrauma has grown, new insights may be revealed by examining the existing literature across disciplines with a new perspective. This article will aim to expand the scope of this rapidly evolving field of research beyond the confines of the central nervous system (CNS). Specifically, we will examine the extent to which the bidirectional influence of the gut-brain axis modulates the complex biological processes occurring at the time of traumatic brain injury (TBI) and over the days, months, and years that follow. In addition to local enteric signals originating in the gut, it is well accepted that gastrointestinal (GI) physiology is highly regulated by innervation from the CNS. Conversely, emerging data suggests that the function and health of the CNS is modulated by the interaction between 1) neurotransmitters, immune signaling, hormones, and neuropeptides produced in the gut, 2) the composition of the gut microbiota, and 3) integrity of the intestinal wall serving as a barrier to the external environment. Specific to TBI, existing pre-clinical data indicates that head injuries can cause structural and functional damage to the GI tract, but research directly investigating the neuronal consequences of this intestinal damage is lacking. Despite this void, the proposed mechanisms emanating from a damaged gut are closely implicated in the inflammatory processes known to promote neuropathology in the brain following TBI, which suggests the gut-brain axis may be a therapeutic target to reduce the risk of Chronic Traumatic Encephalopathy and other neurodegenerative diseases following TBI. To better appreciate how various peripheral influences are implicated in the health of the CNS following TBI, this paper will also review the secondary biological injury mechanisms and the dynamic pathophysiological response to neurotrauma. Together, this review article will attempt to connect the dots to reveal novel insights into the bidirectional influence of the gut-brain axis and propose a conceptual model relevant to the recovery from TBI and subsequent risk for future neurological conditions.
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Affiliation(s)
- Mark H Sundman
- Department of Psychology, University of Arizona, Tucson, AZ, USA.
| | - Nan-Kuei Chen
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA
| | - Vignesh Subbian
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA; Department of Systems and Industrial Engineering, University of Arizona, Tucson, AZ, USA
| | - Ying-Hui Chou
- Department of Psychology, University of Arizona, Tucson, AZ, USA; Cognitive Science Program, University of Arizona, Tucson, AZ, USA; Arizona Center on Aging, University of Arizona, Tucson, AZ, USA
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49
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Brenner LA, Stearns-Yoder KA, Hoffberg AS, Penzenik ME, Starosta AJ, Hernández TD, Hadidi DA, Lowry CA. Growing literature but limited evidence: A systematic review regarding prebiotic and probiotic interventions for those with traumatic brain injury and/or posttraumatic stress disorder. Brain Behav Immun 2017; 65:57-67. [PMID: 28606462 DOI: 10.1016/j.bbi.2017.06.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/18/2017] [Accepted: 06/07/2017] [Indexed: 01/10/2023] Open
Abstract
Traumatic brain injury (TBI) is highly prevalent among a wide range of populations, including civilians, military personnel, and Veterans. TBI sequelae may be further exacerbated by symptoms associated with frequently occurring comorbid psychiatric conditions, including posttraumatic stress disorder (PTSD). This is particularly true among the population of military personnel from recent conflicts in Iraq and Afghanistan, with a history of mild TBI (mTBI) and PTSD. The need for efficacious treatments for TBI and comorbid PTSD is significant, and evidence-based interventions for these frequently co-occurring conditions are limited. Based on findings suggesting that inflammation may be an underlying mechanism of both conditions, anti-inflammatory/immunoregulatory agents, including probiotics, may represent a novel strategy to treat TBI and/or PTSD-related symptoms. The focus of this systematic review was to identify and evaluate existing research regarding prebiotic and probiotic interventions for the populations of individuals with a history of TBI and/or PTSD. Only 4 studies were identified (3 severe TBI, 1 PTSD, 0 co-occurring TBI and PTSD). Although findings suggested some promise, work in this area is nascent and results to date do not support some claims within the extensive coverage of probiotics in the popular press.
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Affiliation(s)
- Lisa A Brenner
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States; Departments of Physical Medicine and Rehabilitation, Psychiatry and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Denver, CO, United States.
| | - Kelly A Stearns-Yoder
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States; Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Denver, CO, United States
| | - Adam S Hoffberg
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States
| | - Molly E Penzenik
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States
| | - Amy J Starosta
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States
| | - Theresa D Hernández
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States; Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, United States; Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Daniel A Hadidi
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States; Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Christopher A Lowry
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, United States; Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Denver, CO, United States; Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, CO, United States
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50
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Montgomery S, Hiyoshi A, Burkill S, Alfredsson L, Bahmanyar S, Olsson T. Concussion in adolescence and risk of multiple sclerosis. Ann Neurol 2017; 82:554-561. [DOI: 10.1002/ana.25036] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences; Örebro University; Örebro Sweden
- Clinical Epidemiology Unit, Department of Medicine; Karolinska Institute; Solna Sweden
- Department of Epidemiology and Public Health; University College London; London United Kingdom
| | - Ayako Hiyoshi
- Clinical Epidemiology and Biostatistics, School of Medical Sciences; Örebro University; Örebro Sweden
| | - Sarah Burkill
- Clinical Epidemiology Unit, Department of Medicine; Karolinska Institute; Solna Sweden
- Center for Pharmacoepidemiology, Department of Medicine; Karolinska Institute; Solna Sweden
| | - Lars Alfredsson
- Institute of Environmental Medicine; Karolinska Institute; Stockholm Sweden
- Center for Occupational and Environmental Medicine, Stockholm County Council; Stockholm Sweden
| | - Shahram Bahmanyar
- Clinical Epidemiology Unit, Department of Medicine; Karolinska Institute; Solna Sweden
- Center for Pharmacoepidemiology, Department of Medicine; Karolinska Institute; Solna Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Center for Molecular Medicine; Karolinska Institute; Stockholm Sweden
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