Associations Between Prior Head Injury, Physical Functioning, and Frailty in the Atherosclerosis Risk in Communities Study

BACKGROUND

Older adults have the highest rates of head injury and are at the greatest risk for subsequent dysfunction, yet research on subsequent physical decline is limited. We sought to examine cross-sectional and prospective associations of head injury with physical functioning and frailty among older adults.

METHODS

A total of 5 598 Atherosclerosis Risk in Communities Study participants from Visit 5 (2011-13) underwent assessments of physical functioning (Short Physical Performance Battery [SPPB], comprised of gait speed, chair stands, and balance) and frailty (defined using established criteria) were followed through Visit 7 (2018-19). Head injury was self-reported or based on ICD-9 codes. Adjusted linear and multinomial logistic regression models were used to estimate associations. Prospective models incorporated inverse probability of attrition weights to account for death or attrition.

RESULTS

Participants were a mean age of 75 years, 58% were women, 22% were Black, and 27% had a prior head injury. Compared to individuals without head injury, individuals with head injury had worse physical functioning (SPPB total score, β-coefficient = -0.22, 95% CI: -0.35 to -0.09) and were more likely to be pre-frail (OR = 1.19, 95% CI: 1.04 to 1.35) or frail (OR = 1.40, 95% CI: 1.08 to 1.80) compared to robust. Prospectively, head injury was associated with a 0.02 m/s greater decline (95% CI: -0.04 to -0.01) in gait speed over a median of 5 years. Among baseline robust individuals (n = 1 847), head injury was associated with increased odds of becoming pre-frail (OR = 1.32, 95% CI: 1.04 to 1.67) or frail (OR = 1.92, 95% CI: 1.05 to 3.51) compared to robust.

CONCLUSIONS

Older adults with prior head injury had worse physical functioning and greater frailty at baseline and were more likely to become frail and walk slower over time, compared to individuals without head injury.

Association between structural brain MRI abnormalities and epilepsy in older adults

OBJECTIVE

To determine the association between brain MRI abnormalities and incident epilepsy in older adults.

METHODS

Men and women (ages 45-64 years) from the Atherosclerosis Risk in Communities study were followed up from 1987 to 2018 with brain MRI performed between 2011 and 2013. We identified cases of incident late-onset epilepsy (LOE) with onset of seizures occurring after the acquisition of brain MRI. We evaluated the relative pattern of cortical thickness, subcortical volume, and white matter integrity among participants with incident LOE after MRI in comparison with participants without seizures. We examined the association between MRI abnormalities and incident LOE using Cox proportional hazards regression. Models were adjusted for demographics, hypertension, diabetes, smoking, stroke, and dementia status.

RESULTS

Among 1251 participants with brain MRI data, 27 (2.2%) developed LOE after MRI over a median of 6.4 years (25-75 percentile 5.8-6.9) of follow-up. Participants with incident LOE after MRI had higher levels of cortical thinning and white matter microstructural abnormalities before seizure onset compared to those without seizures. In longitudinal analyses, greater number of abnormalities was associated with incident LOE after controlling for demographic factors, risk factors for cardiovascular disease, stroke, and dementia (gray matter: hazard ratio [HR]: 2.3, 95% confidence interval [CI]: 1.0-4.9; white matter diffusivity: HR: 3.0, 95% CI: 1.2-7.3).

INTERPRETATION

This study demonstrates considerable gray and white matter pathology among individuals with LOE, which is present prior to the onset of seizures and provides important insights into the role of neurodegeneration, both of gray and white matter, and the risk of LOE.

Head acceleration event exposure and cognitive and functional outcomes: a comparison of multiple football seasons

Athletes in contact sports are exposed to repetitive impacts as an inherent part of sport. There is concern over the accumulative effect; however, much is still unknown regarding their short-term effects. This study investigated impact accumulation and outcomes over three seasons (2015, 2017, 2019) in NCAA Football Bowl Subdivision players. Impacts were recorded using helmet accelerometers, and virtual reality testing (VR) was done across the season. Incidence rates for impacts (total; ≥25 G to <80 G; ≥80 G) all significantly differed by season (p < 0.05). VR scores changed across the seasons, specifically significant decreases in spatial memory (p < 0.05) in 2015, significant changes in balance and spatial memory (p < 0.05) in 2017, and no significant changes in 2019. Linear regressions predicting VR change score by impact incidence rate were nonsignificant. Monitoring exposure to impacts and changes in outcomes is useful; however, results are fluid, and many factors could indirectly have protective effects on athletes.

Associations Between Head Injury and Subsequent Risk of Falls: Results From the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND AND OBJECTIVES

Falls are a leading cause of head injury among older adults, but the risk of fall occurring after a head injury is less well-characterized. We sought to examine the association between head injury and subsequent risk of falls requiring hospital care among community-dwelling older adults.

METHODS

This analysis included 13,081 participants in the Atherosclerosis Risk in Communities Study enrolled in 1987-1989 and followed through 2019. The association of head injury (time-varying exposure, self-reported and/or ICD-9/10 code identified) with the risk of subsequent (occurring >1-month after head injury) falls requiring hospital care (ICD-9/10 code defined) was modeled using Cox proportional hazards regression. Secondary analyses included Fine and Gray proportional hazards regression to account for the competing risk of death, analysis of head injury frequency and severity, and formal testing for interaction by age, sex, and race. Models were adjusted for age, sex, race/center, education, military service, alcohol consumption, smoking, diabetes, hypertension, and psychotropic medication use.

RESULTS

The mean age of participants at baseline was 54 years, 58% were female, 28% were Black, and 14% had at least one head injury occurring over the study period. Over a median 23 years of follow-up, 29% of participants had a fall requiring medical care. In adjusted Cox proportional hazards models, individuals with head injury had 2.01 (95% CI 1.85-2.18) times the risk of falls compared with individuals without head injury. Accounting for the competing risk of mortality, individuals with head injury had 1.69 (95% CI 1.57-1.82) times the risk of falls compared with individuals without head injury. We observed stronger associations among men compared with women (men: hazard ratio [HR] = 2.60, 95% CI 2.25-3.00; women: HR = 1.80, 95% CI 1.63-1.99, p-interaction <0.001). We observed evidence of a dose-response association for head injury number and severity with fall risk (1 injury: HR = 1.68, 95% CI 1.53-1.84; 2+ injuries: HR = 2.37, 95% CI 1.92-2.94 and mild: HR = 1.97, 95% CI 1.78-2.18; moderate/severe/penetrating: HR = 2.50, 95% CI 2.06-3.02).

DISCUSSION

Among community-dwelling older adults followed over 30 years, head injury was associated with subsequent falls requiring medical care. We observed stronger associations among men and with increasing number and severity of head injuries. Whether older individuals with head injury might benefit from fall prevention measures should be a focus of future research.

Selective head cooling in the acute phase of concussive injury: a neuroimaging study

Introduction

Neurovascular decoupling is a common consequence after brain injuries like sports-related concussion. Failure to appropriately match cerebral blood flow (CBF) with increases in metabolic demands of the brain can lead to alterations in neurological function and symptom presentation. Therapeutic hypothermia has been used in medicine for neuroprotection and has been shown to improve outcome. This study aimed to examine the real time effect of selective head cooling on healthy controls and concussed athletes via magnetic resonance spectroscopy (MRS) and arterial spin labeling (ASL) measures.

Methods

24 participants (12 controls; 12 concussed) underwent study procedures including the Post-Concussion Symptom Severity (PCSS) Rating Form and an MRI cooling protocol (pre-cooling (T1 MPRAGE, ASL, single volume spectroscopy (SVS)); during cooling (ASL, SVS)).

Results

Results showed general decreases in brain temperature as a function of time for both groups. Repeated measures ANOVA showed a significant main effect of time (F = 7.94, p < 0.001) and group (F = 22.21, p < 0.001) on temperature, but no significant interaction of group and time (F = 1.36, p = 0.237). CBF assessed via ASL was non-significantly lower in concussed individuals at pre-cooling and generalized linear mixed model analyses demonstrated a significant main effect of time for the occipital left ROI (F = 11.29, p = 0.002) and occipital right ROI (F = 13.39, p = 0.001). There was no relationship between any MRI metric and PCSS symptom burden.

Discussion

These findings suggest the feasibility of MRS thermometry to monitor alterations of brain temperature in concussed athletes and that metabolic responses in response to cooling after concussion may differ from controls.

Spatiotemporal profile of atrophy in the first year following moderate-severe traumatic brain injury

Traumatic brain injury (TBI) triggers progressive neurodegeneration resulting in brain atrophy that continues months-to-years following injury. However, a comprehensive characterization of the spatial and temporal evolution of TBI-related brain atrophy remains incomplete. Utilizing a sensitive and unbiased morphometry analysis pipeline optimized for detecting longitudinal changes, we analyzed a sample consisting of 37 individuals with moderate-severe TBI who had primarily high-velocity and high-impact injury mechanisms. They were scanned up to three times during the first year after injury (3 months, 6 months, and 12 months post-injury) and compared with 33 demographically matched controls who were scanned once. Individuals with TBI already showed cortical thinning in frontal and temporal regions and reduced volume in the bilateral thalami at 3 months post-injury. Longitudinally, only a subset of cortical regions in the parietal and occipital lobes showed continued atrophy from 3 to 12 months post-injury. Additionally, cortical white matter volume and nearly all deep gray matter structures exhibited progressive atrophy over this period. Finally, we found that disproportionate atrophy of cortex along sulci relative to gyri, an emerging morphometric marker of chronic TBI, was present as early as 3 month post-injury. In parallel, neurocognitive functioning largely recovered during this period despite this pervasive atrophy. Our findings demonstrate msTBI results in characteristic progressive neurodegeneration patterns that are divergent across regions and scale with the severity of injury. Future clinical research using atrophy during the first year of TBI as a biomarker of neurodegeneration should consider the spatiotemporal profile of atrophy described in this study.

Longitudinal Abnormalities in White Matter Extracellular Free Water Volume Fraction and Neuropsychological Functioning in Patients with Traumatic Brain Injury

Traumatic brain injury is a global public health problem associated with chronic neurological complications and long-term disability. Biomarkers that map onto the underlying brain pathology driving these complications are urgently needed to identify individuals at risk for poor recovery and to inform design of clinical trials of neuroprotective therapies. Neuroinflammation and neurodegeneration are two endophenotypes potentially associated with increases in brain extracellular water content, but the nature of extracellular free water abnormalities after neurotrauma and its relationship to measures typically thought to reflect traumatic axonal injury are not well characterized. The objective of this study was to describe the relationship between a neuroimaging biomarker of extracellular free water content and the clinical features of a cohort with primarily complicated mild traumatic brain injury. We analyzed a cohort of 59 adult patients requiring hospitalization for non-penetrating traumatic brain injury of all severities as well as 36 healthy controls. Patients underwent brain magnetic resonance imaging (MRI) at 2 weeks (n = 59) and 6 months (n = 29) post-injury, and controls underwent a single MRI. Of the participants with TBI, 50 underwent clinical neuropsychological assessment at 2 weeks and 28 at 6 months. For each subject, we derived a summary score representing deviations in whole brain white matter extracellular free water volume fraction (VF) and free water-corrected fractional anisotropy (fw-FA). The summary specific anomaly score (SAS) for VF was significantly higher in TBI patients at 2 weeks and 6 months post-injury relative to controls. SAS for VF exhibited moderate correlation with neuropsychological functioning, particularly on measures of executive function. These findings indicate abnormalities in whole brain white matter extracellular water fraction in patients with TBI and are an important step toward identifying and validating noninvasive biomarkers that map onto the pathology driving disability after TBI.

Structural brain network deviations predict recovery after traumatic brain injury

OBJECTIVE

Traumatic brain injury results in diffuse axonal injury and the ensuing maladaptive alterations in network function are associated with incomplete recovery and persistent disability. Despite the importance of axonal injury as an endophenotype in TBI, there is no biomarker that can measure the aggregate and region-specific burden of axonal injury. Normative modeling is an emerging quantitative case-control technique that can capture region-specific and aggregate deviations in brain networks at the individual patient level. Our objective was to apply normative modeling in TBI to study deviations in brain networks after primarily complicated mild TBI and study its relationship with other validated measures of injury severity, burden of post-TBI symptoms, and functional impairment.

METHOD

We analyzed 70 T1-weighted and diffusion-weighted MRIs longitudinally collected from 35 individuals with primarily complicated mild TBI during the subacute and chronic post-injury periods. Each individual underwent longitudinal blood sampling to characterize blood protein biomarkers of axonal and glial injury and assessment of post-injury recovery in the subacute and chronic periods. By comparing the MRI data of individual TBI participants with 35 uninjured controls, we estimated the longitudinal change in structural brain network deviations. We compared network deviation with independent measures of acute intracranial injury estimated from head CT and blood protein biomarkers. Using elastic net regression models, we identified brain regions in which deviations present in the subacute period predict chronic post-TBI symptoms and functional status.

RESULTS

Post-injury structural network deviation was significantly higher than controls in both subacute and chronic periods, associated with an acute CT lesion and subacute blood levels of glial fibrillary acid protein (r = 0.5, p = 0.008) and neurofilament light (r = 0.41, p = 0.02). Longitudinal change in network deviation associated with change in functional outcome status (r = -0.51, p = 0.003) and post-concussive symptoms (BSI: r = 0.46, p = 0.03; RPQ: r = 0.46, p = 0.02). The brain regions where the node deviation index measured in the subacute period predicted chronic TBI symptoms and functional status corresponded to areas known to be susceptible to neurotrauma.

CONCLUSION

Normative modeling can capture structural network deviations, which may be useful in estimating the aggregate and region-specific burden of network changes induced by TAI. If validated in larger studies, structural network deviation scores could be useful for enrichment of clinical trials of targeted TAI-directed therapies.

Head Injury and Long-term Mortality Risk in Community-Dwelling Adults

Importance

Head injury is associated with significant short-term morbidity and mortality. Research regarding the implications of head injury for long-term survival in community-dwelling adults remains limited.

Objective

To evaluate the association of head injury with long-term all-cause mortality risk among community-dwelling adults, with consideration of head injury frequency and severity.

Design, Setting, and Participants

This cohort study included participants with and without head injury in the Atherosclerosis Risk in Communities (ARIC) study, an ongoing prospective cohort study with follow-up from 1987 through 2019 in 4 US communities in Minnesota, Maryland, North Carolina, and Mississippi. Of 15 792 ARIC participants initially enrolled, 1957 were ineligible due to self-reported head injury at baseline; 103 participants not of Black or White race and Black participants at the Minnesota and Maryland field centers were excluded due to race-site aliasing; and an additional 695 participants with missing head injury date or covariate data were excluded, resulting in 13 037 eligible participants.

Exposures

Head injury frequency and severity, as defined via self-report in response to interview questions and via hospital-based International Classification of Diseases diagnostic codes (with head injury severity defined in the subset of head injury cases identified using these codes). Head injury was analyzed as a time-varying exposure.

Main Outcomes and Measures

All-cause mortality was ascertained via linkage to the National Death Index. Data were analyzed between August 5, 2021, and October 23, 2022.

Results

More than one-half of participants were female (57.7%; 42.3% men), 27.9% were Black (72.1% White), and the median age at baseline was 54 years (IQR, 49-59 years). Median follow-up time was 27.0 years (IQR, 17.6-30.5 years). Head injuries occurred among 2402 participants (18.4%), most of which were classified as mild. The hazard ratio (HR) for all-cause mortality among individuals with head injury was 1.99 (95% CI, 1.88-2.11) compared with those with no head injury, with evidence of a dose-dependent association with head injury frequency (1 head injury: HR, 1.66 [95% CI, 1.56-1.77]; 2 or more head injuries: HR, 2.11 [95% CI, 1.89-2.37]) and severity (mild: HR, 2.16 [95% CI, 2.01-2.31]; moderate, severe, or penetrating: HR, 2.87 [95% CI, 2.55-3.22]). Estimates were similar by sex and race, with attenuated associations among individuals aged 54 years or older at baseline.

Conclusions and Relevance

In this community-based cohort with more than 3 decades of longitudinal follow-up, head injury was associated with decreased long-term survival time in a dose-dependent manner, underscoring the importance of measures aimed at prevention and clinical interventions to reduce morbidity and mortality due to head injury.

Dynamic contrast enhanced MRI for characterization of blood-brain-barrier dysfunction after traumatic brain injury

BACKGROUND AND PURPOSE

Dysfunction of the blood-brain-barrier (BBB) is a recognized pathological consequence of traumatic brain injury (TBI) which may play an important role in chronic TBI pathophysiology. We hypothesized that BBB disruption can be detected with dynamic contrast-enhanced (DCE) MRI not only in association with focal traumatic lesions but also in normal-appearing brain tissue of TBI patients, reflecting microscopic microvascular injury. We further hypothesized that BBB integrity would improve but not completely normalize months after TBI.

MATERIALS AND METHODS

DCE MRI was performed in 40 adult patients a median of 23 days after hospitalized TBI and in 21 healthy controls. DCE data was analyzed using Patlak and linear models, and derived metrics of BBB leakage including the volume transfer constant (Ktrans) and the normalized permeability index (NPI) were compared between groups. BBB metrics were compared with focal lesion distribution as well as with contemporaneous measures of symptomatology and cognitive function in TBI patients. Finally, BBB metrics were examined longitudinally among 18 TBI patients who returned for a second MRI a median of 204 days postinjury.

RESULTS

TBI patients exhibited higher mean Ktrans (p = 0.0028) and proportion of suprathreshold NPI voxels (p = 0.001) relative to controls. Tissue-based analysis confirmed greatest TBI-related BBB disruption in association with focal lesions, however elevated Ktrans was also observed in perilesional (p = 0.011) and nonlesional (p = 0.044) regions. BBB disruption showed inverse correlation with quality of life (rho = -0.51, corrected p = 0.016). Among the subset of TBI patients who underwent a second MRI several months after the initial evaluation, metrics of BBB disruption did not differ significantly at the group level, though variable longitudinal changes were observed at the individual subject level.

CONCLUSIONS

This pilot investigation suggests that TBI-related BBB disruption is detectable in the early post-injury period in association with focal and diffuse brain injury.

Effect of Player Position on Serum Biomarkers during Participation in a Season of Collegiate Football

This prospective cohort study examined the relationship between a panel of four serum proteomic biomarkers (glial fibrillary acidic protein [GFAP], ubiquitin C-terminal hydrolase-L1 [UCH-L1], total Tau, and neurofilament light chain polypeptide [NF-L]) in 52 players from two different cohorts of male collegiate student football athletes from two different competitive seasons of Division I National Collegiate Athletic Association Football Bowl Subdivision. This study evaluated changes in biomarker concentrations (as indicators of brain injury) over the course of the playing season (pre- and post-season) and also assessed biomarker concentrations by player position using two different published classification systems. Player positions were divided into: 1) speed (quarterbacks, running backs, halfbacks, fullbacks, wide receivers, tight ends, defensive backs, safety, and linebackers) versus non-speed (offensive and defensive linemen), and 2) "Profile 1" (low frequency/high strain magnitudes positions including quarterbacks, wide receivers, and defensive backs), "Profile 2" (mid-range impact frequency and strain positions including linebackers, running backs, and tight ends), and "Profile 3" (high frequency/low strains positions including defensive and offensive linemen). There were significant increases in GFAP 39.3 to 45.6 pg/mL and NF-L 3.5 to 5.4 pg/mL over the course of the season (p < 0.001) despite only five players being diagnosed with concussion. UCH-L1 decreased significantly, and Tau was not significantly different. In both the pre- and post-season blood samples Tau and NF-L concentrations were significantly higher in speed versus non-speed positions. Concentrations of GFAP, Tau, and NF-L increased incrementally from "Profile 3," to "Profile 2" to "Profile 1" in the post-season. UCH-L1 did not. GFAP increased (by Profiles 3, 2, 1) from 42.4 to 49.6 to 78.2, respectively (p = 0.051). Tau increased from 0.37 to 0.61 to 0.67, respectively (p = 0.024). NF-L increased from 3.5 to 4.9 to 8.2, respectively (p < 0.001). Although GFAP and Tau showed similar patterns of elevations by profile in the pre-season samples they were not statistically significant. Only NF-L showed significant differences between profiles 2.7 to 3.1 to 4.2 in the pre-season (p = 0.042). GFAP, Tau, and NF-L concentrations were significantly associated with different playing positions with the highest concentrations in speed and "Profile 1" positions and the lowest concentrations were in non-speed and "Profile 3" positions. Blood-based biomarkers (GFAP, Tau, NF-L) provide an additional layer of injury quantification that could contribute to a better understanding of the risks of playing different positions.

Decreases in Dorsal Cervical Spinal Cord White Matter Tract Integrity Are Associated with Elevated Levels of Serum MicroRNA Biomarkers in NCAA Division I Collegiate Football Players

This prospective, controlled, observational cohort study assessed the performance of a novel panel of serum microRNA (miRNA) biomarkers relative to findings on cervical spinal cord magnetic resonance imaging (MRI) in collegiate football players. There were 44 participants included in the study: 30 non-athlete control subjects and 14 male collegiate football athletes participating in a Division I Football Bowl Subdivision of the National Collegiate Athletic Association. Diffuse tensor MRI and blood samples were acquired within the week before the athletic season began and within the week after the last game of the season. All miRNAs were significantly higher in athletes regardless of their fractional anisotropy (FA) values (p < 0.001), even those considered to be in the “normal” range of FA for white and gray matter integrity in the cervical spinal cord. miRNA biomarkers were most significantly correlated with FA of the white matter (WM) tracts of the dorsal (posterior) spinal cord; particularly, the fasciculus gracilis, fasciculus cuneatus, lateral corticospinal tract, rubrospinal tract, lateral reticulospinal tract, spinal lemniscus, and spinothalamic and -reticular tracts. Areas under the curve for miRNA biomarkers predicting lower FA of WM dorsal (posterior) cervical spinal tracts, therefore lower white matter integrity (connectivity), were miR-505* = 0.75 (0.54–0.96), miR-30d = 0.74 (0.52–0.95), and miR-92a = 0.75 (0.53–0.98). Should these findings be replicated in a larger cohort of athletes, these markers could potentially serve as measures of neuroimaging abnormalities in athletes at risk for concussion and subconcussive injuries to the cervical spinal cord.

Reaction Time Task Performance in Concussed Athletes over a 30-Day Period: An Observational Study

OBJECTIVE

Reaction time is a common deficit following concussion, making its evaluation critical during return-to-play protocol. Without proper evaluation, an athlete may return-to-play prematurely, putting them at risk of further injury. Although often assessed, we propose that current clinical testing may not be challenging enough to detect lingering deficits. Thus, the aim of this study was to examine reaction time in concussed individuals three times over a 30-day period through the use of a novel reaction time device consisting of simple, complex, and go/no-go reaction time tasks.

METHODS

Twenty-three concussed subjects completed simple, complex, and go/no-go reaction time tests at three different timepoints: within 7-, 14-, and 30-days of injury, and 21 healthy controls completed the three reaction time tasks during a single session.

RESULTS

Independent t-tests revealed that for the simple reaction time task, concussed participants were only significantly slower at session 1 (p = .002) when compared to controls. Complex reaction time task results showed concussed participants to be significantly slower at session 1 (p = .0002), session 2 (p = .001), and session 3 (p = .002). Go/no-go results showed concussed participants to be significantly slower than controls at session 1 (p = .003), session 2 (p = .001), and session 3 (p = .001).

CONCLUSIONS

Concussed individuals display prolonged reaction time deficits beyond the acute phase of injury, illustrated using increasingly complex tasks.

The accumulation of subconcussive impacts on cognitive, imaging, and biomarker outcomes in child and college-aged athletes: a systematic review

Examine the effect of subconcussive impact accumulation on cognitive/functional, imaging, and biomarker outcomes over the course of a single season, specifically in contact sport athletes at collegiate level or younger. Systematic review following PRISMA guidelines and using Oxford Center for Evidence-Based Medicine 2011 Levels of Evidence and Newcastle Ottawa Assessment Scale. PubMed MEDLINE, PsycInfo, SPORT-Discus, Web of Science. Original research in English that addressed the influence of subconcussive impacts on outcomes of interest with minimum preseason and postseason measurement in current youth, high school, or college-aged contact sport athletes. 796 articles were initially identified, and 48 articles were included in this review. The studies mostly involved male football athletes in high school or college and demonstrated an underrepresentation of female and youth studies. Additionally, operationalization of previous concussion history and concussion among studies was very inconsistent. Major methodological differences existed across studies, with ImPACT and diffusion tensor imaging being the most commonly used modalities. Biomarker studies generally showed negative effects, cognitive/functional studies mostly revealed no effects, and advanced imaging studies showed generally negative findings over the season; however, there was variability in the findings across all types of studies. This systematic review revealed growing literature on this topic, but inconsistent methodology and operationalization across studies makes it challenging to draw concrete conclusions. Overall, cognitive measures alone do not seem to detect changes across this timeframe while imaging and biomarker measures may be more sensitive to changes following subconcussive impacts.

Symptom Factors and Neuropsychological Performance in Collegiate Athletes with Chronic Concussion Symptoms

OBJECTIVE

The present study explored the relationship between specific types of postconcussion symptoms and cognitive outcomes in student-athletes with chronic concussion symptoms.

METHOD

Forty student-athletes with chronic concussion symptoms were given a battery of neuropsychological tests and rated themselves on a variety of postconcussion symptoms, which included the following factors derived from prior work: Physical, Sleep, Cognitive, Affective, and Headache. Cognitive outcomes included performance on composites for the memory and attention/executive functioning speed tests, respectively. The following covariates were also explored: Sex, depression symptoms, number of previous concussions, and time since injury.

RESULTS

Headache was the only individual symptom factor that significantly (p < .05) predicted worse attention/executive functioning performance. None of the symptom factors were significantly related to memory performance over and above the variable of time since injury, such that longer time since injury was related to worse memory performance.

CONCLUSION

Comparable to work examining symptom predictors of cognitive outcomes in acutely concussed samples, headache predicted worse attention/executive functioning performance. Additionally, we found that the longer athletes had been symptomatic since injury, the "worse" their memory functioning. Understanding how headache and the length of time an individual is symptomatic are related to cognitive outcomes can help inform treatment and recommendations for athletes with prolonged symptom recovery.

Changes in White Matter of the Cervical Spinal Cord after a Single Season of Collegiate Football

The involvement of the central nervous system (CNS), specifically the white matter tracts in the cervical spinal cord, was examined with diffusion tensor imaging (DTI) following exposure to repetitive head acceleration events (HAEs) after a single season of collegiate football. Fifteen National Collegiate Athletic Association (NCAA) Division 1 football players underwent DTI of the cervical spinal cord (vertebral level C1–4) at pre-season (before any contact practices began) and post-season (within 1 week of the last regular season game) intervals. Helmet accelerometer data were also collected in parallel throughout the season. From pre-season to post-season, a significant decrease (p < 0.05) of axial diffusivity was seen within the right spino-olivary tract. In addition, a significant decrease (p < 0.05) in global white matter fractional anisotropy (FA) along with increases (p < 0.05) in global white matter mean diffusivity (MD) and radial diffusivity (RD) were found. These changes in FA from pre-season to post-season were significantly moderated by previous concussion history (p < 0.05) and number of HAEs over 80 g (p < 0.05). Despite the absence of sports-related concussion (SRC), we present measurable changes in the white matter integrity of the cervical spinal cord suggesting injury from repetitive HAEs, or SRC, may include the entirety of the CNS, not just the brain.

Brain Perfusion Bridges Virtual-Reality Spatial Behavior to TPH2 Genotype for Head Acceleration Events

Neuroimaging demonstrates that athletes of collision sports can suffer significant changes to their brain in the absence of concussion, attributable to head acceleration event (HAE) exposure. In a sample of 24 male Division I collegiate football players, we examine the relationships between tryptophan hydroxylase 2 (TPH2), a gene involved in neurovascular function, regional cerebral blood flow (rCBF) measured by arterial spin labeling, and virtual reality (VR) motor performance, both pre-season and across a single football season. For the pre-season, TPH2 T-carriers showed lower rCBF in two left hemisphere foci (fusiform gyrus/thalamus/hippocampus and cerebellum) in association with higher (better performance) VR Reaction Time, a dynamic measure of sensory-motor reactivity and efficiency of visual-spatial processing. For TPH2 CC homozygotes, higher pre-season rCBF in these foci was associated with better performance on VR Reaction Time. A similar relationship was observed across the season, where TPH2 T-carriers showed improved VR Reaction Time associated with decreases in rCBF in the right hippocampus/amygdala, left middle temporal lobe, and left insula/putamen/pallidum. In contrast, TPH2 CC homozygotes showed improved VR Reaction Time associated with increases in rCBF in the same three clusters. These findings show that TPH2 T-carriers have an abnormal relationship between rCBF and the efficiency of visual-spatial processing that is exacerbated after a season of high-impact sports in the absence of diagnosable concussion. Such gene-environment interactions associated with behavioral changes after exposure to repetitive HAEs have been unrecognized with current clinical analytical tools and warrant further investigation. Our results demonstrate the importance of considering neurovascular factors along with traumatic axonal injury to study long-term effects of repetitive HAEs.

Effects of sleep disturbance on functional and physiological outcomes in collegiate athletes: A scoping review

OBJECTIVE

To investigate sleep disturbances and circadian timing changes on functional and physiological correlates specifically in collegiate athletes.

DESIGN

Scoping Review.

DATA SOURCES

PubMed MEDLINE, SPORT-Discus, CINAHL, ERIC ProQuest, Web of Science.

ELIGIBILITY CRITERIA

Articles in English, studying college athletes 18-24 years old, employing a sleep measurement, and a comparison measure of cognitive, academic performance, athletic performance, injury rate, biomarkers and physiological measures, or imaging.

RESULTS

Thirty articles met inclusion criteria. There was wide range of study design, sport studied, modality used to measure sleep, frequency of sleep measurements, and functional and physiological outcomes across studies. Sleep measurements varied greatly in frequency of data collection and type of measurement tool, with the majority using a sleep questionnaire. While all variables of interest were represented within the review, most had a focus on cognitive performance, athletic performance, or injury rate as a function of sleep. Studies using biomarkers and physiological measures or imaging were largely underrepresented. Few studies used biomarkers and physiological measures, and one study used imaging measures. Most studies in this review reported negative cognitive and academic outcomes with worse sleep quality and quantity.

CONCLUSIONS

Sleep is critical to maintaining optimal health and collegiate athletes represent a unique population given their unique time constraints, stresses, and sleep behaviors. Findings on athletic performance and injury rate as a function of sleep were mixed. Employing standardized objective methodologies in future work will allow for better understanding of the influence of sleep on the overall well-being and performance of college athletes.

Brain Perfusion Mediates the Relationship Between miRNA Levels and Postural Control

Transcriptomics, regional cerebral blood flow (rCBF), and a virtual reality-based spatial motor task were integrated using mediation analysis in a novel demonstration of “imaging omics.” Data collected in National Collegiate Athletic Association (NCAA) Division I football athletes cleared for play before in-season training showed significant relationships in 1) elevated levels of miR-30d and miR-92a to elevated putamen rCBF, 2) elevated putamen rCBF to compromised Balance scores, and 3) compromised Balance scores to elevated microRNA (miRNA) levels. rCBF acted as a consistent mediator variable (Sobel’s test P < 0.05) between abnormal miRNA levels and compromised Balance scores. Given the involvement of these miRNAs in inflammation and immune function and that vascular perfusion is a component of the inflammatory response, these findings support a chronic inflammatory model in these athletes with 11 years of average football exposure. rCBF, a systems biology measure, was necessary for miRNA to affect behavior.

Thermodynamics of coaxially stacked helixes with GA and CC mismatches

The thermodynamics of RNA helix-helix interfaces with intervening single- and tandem-GA or single-CC mismatches were studied by UV melting experiments. The model system consists of a hairpin with a four- or five-nucleotide 5' overhang which is bound by a short oligomer, creating the helical interface. Single GA interfaces are found to have favorable free energy increments of about 2 kcal/mol. This is similar to those reported for coaxially stacked flush interfaces of AU base pairs [Walter A. E., & Turner, D. H. (1994) Biochemistry 33, 12715-12719]. The free energy increment of the GA mismatches depends little on the sequence of the closing base pairs of the helixes, whether the break in the phosphate backbone is 5' or 3' with respect to the mismatch or whether the chains are extended beyond the helix-helix interface. Surprisingly, interfaces with single-CC mismatches have favorable free energy increments similar to those of GA interfaces, even though CC mismatches in coaxial stacks occur much less frequently in known RNA secondary structures. The results provide experimental support for the assumption that a bonus free energy is required for coaxially stacked helixes with intervening GA mismatches when free energy minimization is used to predict RNA secondary structures.

Sequence dependence of stability for coaxial stacking of RNA helixes with Watson-Crick base paired interfaces

Thermodynamic parameters from UV melting studies are reported for the helix-helix interfaces of coaxially stacked helixes in RNA. The model system consists of a short oligomer binding to a four-nucleotide overhang at the end of a hairpin stem, creating the helix-helix interface. Interfaces containing Watson-Crick base pairs are approximately 1 kcal/mol more stable than the corresponding nearest neighbor interaction in an uninterrupted helix. Thus the sequence dependence of stability for coaxially stacked interfaces is similar to that for regular helixes. This provides experimental evidence for an assumption that has been shown to improve predictions of RNA secondary structure [Walter, A. E., Turner, D. H., Kim, J., Lyttle, M. H., Muller, P., Mathews, D. H., & Zuker, M. (1994) Proc. Natl. Acad. Sci. U.S.A. (in press)]. The results should also be useful for modeling three-dimensional structures of RNA.

Coaxial stacking of helixes enhances binding of oligoribonucleotides and improves predictions of RNA folding

An RNA model system consisting of an oligomer binding to a 4-nt overhang at the 5' end of a hairpin stem provides thermodynamic parameters for helix-helix interfaces. In a sequence-dependent manner, oligomers bind up to 1000-fold more tightly adjacent to the hairpin stem than predicted for binding to a free tetramer at 37 degrees C. For the interface (/) in [formula: see text] additional free energy change, delta delta G 37 degrees, for binding is roughly the nearest-neighbor delta G 37 degrees for propagation of an uninterrupted helix of equivalent sequence, CGGC. When X and Z are omitted, the delta delta 37 degrees is even more favorable by approximately 1 kcal/mol (1 cal = 4.184J). On average, predictions of 11 RNA secondary structures improve from 67 to 74% accuracy by inclusion of similar stacking contributions.

The stability and structure of tandem GA mismatches in RNA depend on closing base pairs

UV melting and imino proton NMR studies show that the stabilities and structures of tandem GA mismatches in RNA are dependent upon the closing base pairs around these mismatches. Internal loops of sequence 5'XGAY3'3'YAGXS' and 5'XAGY3'3'YGAX5' in the middle of octanucleotides have a range of stabilities over 5 kcal/mol when XY is a Watson-Crick or GU pair. The order of stabilities for these internal loops is 5'-GGAC-3' > UGAG, CGAG > AGAU > UGAA > GGAU. The motifs GGAC, UGAG, and CGAG are stabilizing, while the other GA motifs are destabilizing. The GAGC motif is more stable than CAGG and CGAG, but less stable than GGAC. Chemical shifts for imino protons suggest that the G imino proton of each GA mismatch in 5'-GGAC-3', 5'-GAGC-3', and 5'-CAGG-3' [SantaLucia, J., Jr., Kierzek, R., & Turner, D. H. (1990) Biochemistry 29, 8813-8819] is involved in a hydrogen bond to the base A, whereas in other 5'-XGAY-3' sequences, it is not involved in a hydrogen bond to the base A.

Effect of a 5'-phosphate on the stability of triple helix

An effect of 5'-phosphorylation on the stability of triple helical DNA containing pyrimidine:purine:pyrimidine strands has been demonstrated by both gel electrophoresis and UV melting. A 5'-phosphate on the purine-rich middle strand of a triple helix lowers the stability of triple helix formation by approximately 1 kcal/mol at 25 degrees C. The middle strand is involved in both Watson-Crick and Hoogsteen base pairing. In contrast, a 5'-phosphate on the pyrimidine-rich strands, which are involved in either Watson-Crick or Hoogsteen base pairing, has a smaller effect on the stability of triple helix. The order of stability is: no phosphate on either strand > phosphate on both pyrimidine strands > phosphate on purine strand > phosphate on all three strands. Differential stability of triple helix species is postulated to stem from an increase in rigidity due to steric hindrance from the 5'-phosphate. This result indicates that labelling with 32P affect equilibrium in triplex formation.

Nearest-neighbor parameters for G.U mismatches: [formula; see text] is destabilizing in the contexts [formula; see text] and [formula; see text] but stabilizing in [formula; see text]

Thermodynamic parameters derived from optical melting studies are reported for duplex formation by a series of oligoribonucleotides containing G.U mismatches. The results are used to determine nearest-neighbor parameters for helix propagation by G.U mismatches. Surprisingly, the [formula; see text] nearest-neighbor free energy increment in unfavorable in the contexts [formula; see text], and [formula; see text] but favorable in the context [formula; see text]. This is a non-nearest-neighbor effect. In contrast, the [formula; see text] free energy increment is favorable and independent of context. Circular dichroism and imino proton NMR spectra of several sequences do not reveal an obvious structural basis for this dichotomy. For example, all the G.U mismatches have two slowly exchanging imino protons. The imino resonances for the G.U mismatches in GGAGUUCC, GUCGUGAC, and CCUGUAGG, however, broaden at lower temperature than the imino resonances for the interior Watson-Crick base pairs. In contrast, the imino resonances for the G.U mismatches in GGAUGUCC remain sharp at high temperature. The improved parameters for G.U mismatches should improve predictions of RNA structure from sequence.

Low molecular weight mRNA encodes a protein that controls serotonin 5-HT1c and acetylcholine M1 receptor sensitivity in Xenopus oocytes

Serotonin 5-HT1c and acetylcholine M1 receptors activate phosphoinositidase, resulting in an increased formation of IP3 and 1,2 diacylglycerol. In Xenopus oocytes injected with mRNA encoding either of these receptors, Ca2+ released from intracellular stores in response to IP3 then opens Ca(2+)-gated Cl-channels. In the present experiments, oocytes expressing a transcript from a cloned mouse serotonin 5-HT1c receptor were exposed to identical 15-s pulses of agonist, administered 2 min apart; the second current response was two to three times that of the first. However, in those oocytes coinjected with the 5-HT1c receptor transcript and a low molecular weight fraction (0.3-1.5 kb) of rat brain mRNA, the second current response was approximately 50% of the first. Thus, the low molecular weight RNA encodes a protein (or proteins) that causes desensitization. Experiments using fura-2 or a Ca(2+)-free superfusate indicated that desensitization of the 5-HT1c receptor response does not result from a sustained elevation of intracellular Ca2+ level or require the entry of extracellular Ca2+. Photolysis of caged IP3 demonstrated that an increase in IP3 and a subsequent rise in Ca2+ do not produce desensitization of either the IP3 or 5-HT1c peak current responses. Furthermore, in oocytes coinjected with the low molecular weight RNA and a transcript from the rat M1 acetylcholine receptor, the M1 current response was greatly attenuated. Our data suggest that the proteins involved in attenuation of the M1 current response and desensitization of the 5-HT1c current response may be the same.

Modulation of a cloned mouse brain potassium channel

The mouse brain K+ channel (MBK), previously cloned by others, has been independently cloned and shown to express in Xenopus oocytes. This K+ current (IK) inactivated over a time course of seconds and was sensitive to the K+ channel-blocking reagent tetraethylammonium. When the K+ channel was coexpressed with a cloned mouse brain serotonin receptor (5HT1c) in oocytes, activation of the 5HT1c receptor by a brief application of serotonin resulted in a suppression of the IK amplitude over the next 20 min. IK could also be suppressed by activation of G proteins. Suppression was also caused by intracellular Ca2+ injections and was blocked by intracellular injection of EGTA. Calmodulin antagonists block the IK suppression, but a known protein kinase inhibitor did not block suppression. The 5HT1c suppression was reversible; recovery from suppression was blocked by the protein kinase inhibitor H-7. These data suggest that the IK suppression occurs through a novel mechanism independent of A- or C-type protein kinases; suppression is best explained as being due to the action of a Ca2+/calmodulin-activated phosphatase; recovery from suppression is due to the action of a protein kinase.

Identification of a peanut agglutinin-binding protein from human retina

With the use of an antiserum raised to peanut agglutinin (PNA)-binding protein(s) from human retinas, we have identified a glycoprotein that has the same subunit molecular weight (135,000) as human interphotoreceptor retinol-binding protein (IRBP) on human retinal protein transblots, and, like IRBP, is localized in the interphotoreceptor matrix surrounding both rods and cones. We show that this PNA-binding protein is not IRBP by comparing the binding patterns of antiserum to the PNA-binding protein to binding patterns obtained with antisera to bovine and monkey IRBP.

Light-induced phosphorylation of proteins from the all-cone retina of the lizard, Anolis carolinensis

Proteins from the all-cone retina of the lizard Anolis carolinensis were phosphorylated using [gamma 32P] ATP, separated by SDS-PAGE and detected by autoradiography. Several proteins incorporated 32P. Exposure of the retinal homogenates to light brought about a dramatic increase in phosphorylation of the protein(s) with a molecular weight nearly identical to that of rat rhodopsin. It is likely that these proteins are the cone visual pigments, and that they incorporate phosphate when bleached by light. Increasing the time of the phosphorylation reaction from 1 to 30 min led to an increase in the amount of incorporation of labeled phosphate by the putative cone visual pigments, but changing the temperature from 4 degrees C to 20 degrees C decreased it. The amount of phosphate incorporation was substantially increased by NaF, a phosphatase inhibitor. This latter finding, along with the changes in incorporation of 32P with increased temperature, suggest that a phosphoprotein phosphatase is active in the lizard retina. The cation requirements, as well as the effects of cyclic nucleotides on light-induced phosphorylation of retinal lizard proteins, were also investigated.

Barium removes the ouabain-induced increase in the rod response to light

The mass receptor potential of the excised, superfused retina of the bullfrog was isolated with aspartate. Rods were selectively stimulated by using very dim flashes of light. In the presence of 0.1 mM ouabain, the amplitude of the receptor response was found first to increase transiently and, subsequently, to decrease progressively. The ouabain-induced transient increase in receptor response was completely eliminated by 0.4 mM barium chloride. However, barium did not affect the rate at which the response decayed in the presence of ouabain. The ability of barium to remove the ouabain-induced transient increase in the amplitude of the receptor response is discussed in terms of reducing the coupling ratio of the postulated electrogenic sodium-potassium pump of rods.

The effect of lead on photoreceptor response amplitude--influence of the light stimulus

The mass receptor potential of the excised, superfused retina of the bullfrog was studied. Photoreceptor responses were isolated by addition of sodium aspartate to the Ringer solutions. Responses of the cones were monitored independently from responses of the rods by employing a two-flash method of stimulation which took advantage of the very different rates of rapid dark adaptation of rods and of cones. Stimulation with paired flashes of white light at regular intervals caused enhancement of rod response amplitude in that the response grew larger with subsequent flashes until reaching a stable plateau. The degree of enhancement was directly proportional to the amount of light exposure and increased with either increasing stimulus intensity or decreasing stimulus interval. Only the rod response was affected; the cone response was not enhanced by continued stimulation. The effects of 12.5 microM PbCl2 on rod response amplitude were complex. There was a small (less than 10%) but consistent depression of rod response amplitude even when the rods were in the unenhanced state. However, the most striking effect of lead was on the enhanced response, where treatment with 12.5 microM PbCl2 led to a depression of about 33%. When added prior to light stimulation, lead significantly decreased the degree to which the rod response could be enhanced, but never prevented enhancement entirely. Removal of lead resulted in a very large increase in the degree to which the rod response was enhanced by light, even when compared to the first, lead-free control. The cone response was unaffected by 12.5 microM PbCl2.

The effects of lead and of cadmium on the mass photoreceptor potential: the dose-response relationship

The effects of micromolar (1.0-60.0 microM) amounts of lead and of cadmium on the light response of photoreceptors were studied using the isolated, perfused bullfrog retina. The effect of lead in depressing rod activity is readily and fully reversible. Lead is very effective in depressing the rod response at concentrations as low as 1.0 microM, but the effect of lead saturates at about 25.0 microM with about 34% depression of the rod response. At the higher concentrations some spontaneous recovery of rod response amplitude is observed shortly after exposure of the retina to lead begins. The cone response is affected by lead only rarely and then only at the higher concentrations. When affected, the cone response is enhanced rather than depressed. The effects of cadmium are generally similar to those of lead. However, saturating concentrations of cadmium depress the rod response to a greater degree than lead and the cadmium effects are not as readily reversible as the effects of lead at the higher concentrations. Cones are much more sensitive to cadmium than they are to lead and 60.0 microM cadmium always enhances cone response amplitude. The results of experiments in which lead and cadmium were both added to the retinal perfusate indicate to us that cadmium and lead both affect the same sensitive site or sites responsible for generating the rod response, but that cadmium affects an additional site that is not sensitive to lead. The depressive effects of lead and of cadmium on the rod response are discussed in terms of the postulated mechanisms of transduction in the vertebrate photoreceptor.

Rapid dark adaptation of bullfrog rods is delayed by barium

With use of sodium aspartate, the late receptor potential of the excised, perfused bullfrog retina was isolated. By means of a two-flash technique, rapid dark adaptation of rods was monitored. As in cones, barium ions were found to delay the onset of rapid dark adaptation of rods, but the rate of recovery, once begun, was virtually unaffected. The effect of barium on the amplitude-intensity relationship of rods was also determined. Unlike its ability to dramatically increase the amplitude of the receptor potential of rods, barium had no effect on the absolute threshold of rods. We propose that barium ions act on the enzyme system postulated to govern the onset of rapid dark adaptation of rods and suggest that a reduction in the activity of an ATP protein kinase might be the basis for this effect.

The influence of calcium on the aspartate-isolated mass receptor potential of bullfrog cones

The aspartate-isolated receptor potential was studied in the excised, perfused bullfrog retina. Cones were monitored without interference from rods by employing conditioning and test stimuli in a manner previously described (23,24). Lowering extracellular calcium by switching from a perfusate containing 0.4mM CaCl2 to one having no added calcium resulted in an increase in cone response amplitude. Conversely, elevating extracellular calcium by perfusing with a Ringer containing 0.8mM CaCl2 resulted in a decrease in cone response amplitude. These changes were sustained and fully reversible. In contrast, perfusing the retina with a Ringer solution containing EGTA resulted in a transient increase in cone response amplitude. Decreasing external calcium by simple depletion also shortened the delay prior to onset of rapid dark adaptation of the cones, thereby hastening the entire process of recovery. Increasing external calcium had little effect on rapid dark adaptation. Decreasing external calcium with EGTA led to extremely rapid response recovery, but the effect was not reversible. In no case did EGTA lead to a complete suppression of the response. The results of this study are interpreted as being inconsistent with the view that calcium is the internal transmitter responsible for the generation of the receptor potential in cones. They are consistent with the view that calcium functions to modulate recovery of the cones' ability to generate a response following a stimulus, perhaps by affecting the activity of a cyclic nucleotide.

Barium delays the onset of rapid dark adaptation in bullfrog cones

The late receptor potential of the excised, perfused bullfrog retina was isolated with sodium aspartate. By employing a three-flash technique, cone responses were monitored without interference from rods. In cones barium ions were found to delay the onset of rapid dark adaptation, but the rate of recovery, once begun, was unaffected. We propose that barium ions act directly upon the enzyme system postulated to govern the onset of rapid dark adaptation of cones. In addition, barium was found to affect the amplitude of the rod receptor potential differently from that of cones, increasing the former but decreasing the latter. The effect of barium upon photoreceptor potential amplitude is discussed in terms of a reduction in the potassium conductance of the photoreceptors and the mechanisms postulated for photoreceptor excitation and rapid dark adaptation.