Heading Soccer Balls and Brain Injury

A study shows that heading a soccer ball can result in brain injury resembling a concussion.

Researchers at Albert Einstein College of Medicine of Yeshiva University have shown that soccer players who frequently head the ball have brain abnormalities resembling those found in patients with concussion (mild traumatic brain injury). The study, which used advanced imaging techniques and cognitive tests that assessed memory, published online today in the journalRadiology.

"We studied soccer players because soccer is the world's most popular sport," said Michael L. Lipton, M.D., Ph.D., associate director of Einstein's Gruss Magnetic Resonance Research Center and medical director of MRI services at Montefiore, the University Hospital and academic medical center for Einstein. "Soccer is widely played by people of all ages and there is concern that heading the ball -- a key component of the sport -- might damage the brain." Dr. Lipton is also associate professor of radiology, of psychiatry and behavioral sciences and in the Dominick P. Purpura Department of Neuroscience at Einstein.

On average, soccer players head the ball six to 12 times during games, where balls can travel at speeds of more than 50 miles per hour. During practice drills, players commonly head the ball 30 or more times. The impact from a single heading is unlikely to cause traumatic brain damage such as laceration of nerve fibers. But scientists have worried that cumulative damage from heading's repeated subconcussive impacts might be clinically significant. "Repetitive heading could set off a cascade of responses that leads to degeneration of brain cells over time," noted Dr. Lipton.

To study possible brain injury from heading, the researchers used diffusion tensor imaging (DTI), an advanced MRI-based imaging technique, on 37 amateur adult soccer players (median age 31 years) who had all played the sport since childhood. Participants reported playing soccer for an average of 22 years and had played an average of 10 months over the previous year. Researchers ranked the players based on heading frequency and then compared the DTI brain images of the most frequent headers with those of the remaining players. All participants also underwent cognitive testing.

DTI "sees" the movement of water molecules within and along axons, the nerve fibers that constitute the brain's white matter. This imaging technique allows researchers to measure the uniformity of water movement (called fractional anisotropy, or FA) throughout the brain. Abnormally low FA within white matter indicates axon damage and has previously been associated with cognitive impairment in patients with traumatic brain injury.

"The DTI findings pertaining to the most frequent headers in our study showed white-matter abnormalities similar to what we've seen in patients with concussion," said Dr. Lipton. "Soccer players who headed the ball above a threshold between 885 to 1,550 times a year had significantly lower FA in three areas of the temporal-occipital white matter." Dr. Lipton noted that players with more than 1,800 headings per year were also more likely to demonstrate poorer memory scores compared to participants with fewer yearly headings.

"Our study provides compelling preliminary evidence that brain changes resembling mild traumatic brain injury are associated with frequently heading a soccer ball over many years," said Dr. Lipton. "While further research is clearly needed, our findings suggest that controlling the amount of heading that people do may help prevent brain injury that frequent heading appears to cause."

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Asthma shown to be a risk factor for obstructive sleep apnea

A study found that asthma significantly increases the likelihood of developing obstructive sleep apnea.

There are several risk factors associated with obstructive sleep apnea that are long-standing and well-known. They include lifestyle and health factors such as obesity or excess body weight, high-blood pressure, and alcohol and tobacco use, as well as genetic and demographic factors such as family history of the disease, being older, and being male. Now, thanks to new research, we may have a new OSA risk factor to add to this list: asthma.

Researchers at the University of Wisconsin investigated the influence of asthma in the development of obstructive sleep apnea. They found a significantly elevated risk for OSA among people with asthma. Those people who'd developed asthma as children were at particularly elevated risk. Researchers observed 773 adult men and women over a period of eight years. All were participants in the Wisconsin Sleep Cohort study, and were between ages 30-60 at the time the study began. Of the 773 participants, 201 had asthma at the beginning of the study period, and 61 of them had developed asthma during childhood. None of the participants had obstructive sleep apnea. Every four years, the subjects participated in laboratory sleep evaluations, clinical health assessments, and health questionnaires. After adjusting for other risk factors for sleep apnea, including age, gender, body-mass index, smoking, and nasal congestion, researchers found that the presence of asthma significantly increased the risk for sleep apnea:

• People with asthma were 1.70 times more likely to develop sleep apnea over the eight-year study period than those without asthma.


• Among those in the study who had developed asthma during childhood, the risk was even higher. These people had 2.34 times the risk of developing obstructive sleep apnea, compared to those without asthma.


• Researchers found that the longer asthma had been present, the higher the risk for sleep apnea. Every five-year period a person had asthma was associated with a 10 percent increase to their risk of developing obstructive sleep apnea.


• Among the participants, 45 developed asthma during the study observation period. Researchers found that these people were 48 percent more likely to develop sleep apnea than those without asthma. The size of this group was too small for researchers to demonstrate a statistical significance to these results. In their discussion of the study's results, researchers pointed to this particular finding as an important one for follow-up investigation.

This latest study is not the first to demonstrate a link between asthma and sleep apnea. Previous research has shown connections between the two conditions:

• In a study of more than 4,500 adults ages 20-69, asthma was found associated with symptoms common to sleep apnea, including snoring, apneas, and daytime sleepiness.


• Researchers at Israel's Technion-Israel Institute of Technology investigated whether difficult-to-control asthma might influence the onset of sleep apnea. They found that patients with unstable, hard-to-control asthma were at significantly higher risk for obstructive sleep apnea.


• Researchers at the University of Wisconsin also looked at the risk of sleep apnea among patients with poorly controlled asthma, and found these patients were at higher risk for obstructive sleep apnea after adjusting for other sleep apnea risk factors, including obesity.

These and other previous studies have identified an association between the two disorders, asthma and sleep apnea. The latest study comes an important step closer to establishing a causal link between the two conditions, by examining specifically the direction of the relationship between the two. The presence of asthma in people later identified as being more likely to develop sleep apnea suggests that asthma may actually contribute to the onset of sleep apnea.

Asthma is a lung disease that causes difficulty breathing, shortness of breath, coughing, and wheezing. Some people can experience these symptoms at night, and they can interfere with sleep. Establishing asthma as a risk factor for OSA is an important public health development. More than 25 million Americans suffer from asthma, including seven million children. If these adults and children are at higher risk for obstructive sleep apnea because of their asthma, they are also at risk for the complications that come with sleep apnea. Obstructive sleep apnea is associated with increased risk for a number of health problems, including heart disease, diabetes, and some cancers. Children can experience apnea and sleep-disordered breathing as well, and children have their own set of health risks associated with the condition, including problems with emotional, social, and cognitive development.

Finding new ways to identify and prevent obstructive sleep apnea is critical to the sleep and overall health of millions of Americans who suffer from this serious sleep disorder. The research into the role of asthma is an important step in this direction.

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Drug targets both autism and fetal alcohol disorder

A new drug targets autism and fetal alcohol disorder showing the disorders may be treated by similar mechanisms.

In a surprising new finding, a Northwestern Medicine® study has found a common molecular vulnerability in autism and fetal alcohol spectrum disorder. Both disorders have symptoms of social impairment and originate during brain development in utero.

This the first research to explore a common mechanism for these disorders and link their molecular vulnerabilities.

The study found male offspring of rat mothers who were given alcohol during pregnancy have social impairment and altered levels of autism-related genes found in humans. Female offspring were not affected.

Alcohol Damage is Reversible

But the alcohol damage can be reversed. A low dose of the thyroid hormone thyroxin given to alcohol consuming rat mothers at critical times during their pregnancy alleviated social impairments and reversed the expression of autism-related genes in their male offspring, the study reports.

Could Novel Drug Treat Both Disorders?

"The beneficial effects of thyroxin in this animal model raises an exciting question -- whether novel drug targets and treatments could be developed for both these disorders," said Eva Redei, the senior author of the study and professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine.

The study will be published June 13, 2013 in the journal Alcoholism: Clinical & Experimental Research.
Redei stressed caution in interpreting these results for their relevance to treatments in human fetal alcohol spectrum disorder and autism spectrum disorder.

"Human studies are needed to establish that the parallel we saw in the animal model exists in these diseases," Redei said. The study does not mean alcohol consumed by the mother is the cause of autism, she emphasized.

"The novel finding here is that these two disorders share molecular vulnerabilities and if we understand those we are closer to finding treatments," said Redei, also the David Lawrence Stein Professor of Psychiatric Diseases Affecting Children and Adolescents.

Redei decided to investigate a possible link between the two disorders when she observed similarities between the two. Both are neurodevelopmental, have symptoms of social impairment and affect males more or differently than females. Autism affects males versus females in a nine to one ratio; social impairment in this model of alcohol spectrum disorder is male specific.

In a previous study, Redei and colleagues administered a much larger dose of thyroid hormone to alcohol consuming rat mothers during their pregnancy and found that the male offsprings' learning and memory deficit was reversed by this treatment.

In the current study, Redei wanted to find the smallest dose of thyroid hormone that effectively reverses the behavioral consequences of fetal alcohol spectrum disorder.

"We wanted to find the smallest dose to correct the behavioral abnormalities that wouldn't create an overly high level of thyroid hormones during development, which can be detrimental," Redei said.

Thyroid Hormone Prevents Deficit in Genes and Social Behavior

In the study, Northwestern scientists administered alcohol to pregnant female rats. Then they examined the levels of ten genes known to be vulnerability genes in human autism in the brains of the male offspring. They found the levels of those same genes were affected.

To test the offspring's behavior, the rats were put in a cage with a small, non-threatening rat pup. A normal social interaction is for the rat to spend a lot of time sniffing and engaging the pup. These rats, however, hardly sniffed the pups compared to the control rats, indicating their impaired social behavior.

In a second experiment, low doses of thyroxin were administered to alcohol consuming pregnant rats. When their male offspring subsequently were put in a cage with a rat pup, the offspring exhibited normal sniffing behavior and their brains showed normal levels of the autism-related genes.

"The thyroxin reversed the deficit both in the level of their genes and their social behavior," Redei said.
Elif Tunc-Ozcan, the lead study author and a graduate student in Redei's lab, is researching how prenatal thyroid hormone supplementation reverses the behavioral deficits in the fetal alcohol spectrum disorder model.

"If our study proves to be relevant to human fetal alcohol spectrum disorder and, perhaps, even for autism spectrum disorder, it could help those suffering from these disorders," Tunc-Ozcan said.

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Poor sleep worsens heart issues in women

The progression of heart disease in women seems to be worsened by poor sleep. This effect was not seen in men.

Poor sleep appears to contribute to the progression of heart disease in women by raising their inflammation levels, but this effect was not seen in men, researchers say.

"Inflammation is a well-known predictor of cardiovascular health," lead author Aric Prather, a clinical health psychologist and assistant professor of psychiatry at the University of California, San Francisco, said in a university news release.

"Now we have evidence that poor sleep appears to play a bigger role than we had previously thought in driving long-term increases in inflammation levels and may contribute to the negative consequences often associated with poor sleep," Prather added.

Previous research has shown that sleeping fewer than six hours per night may raise the risk of chronic health problems, including heart disease, and is associated with higher levels of inflammation.

This new study included nearly 700 men (average age 66) and women (average age 64) with coronary heart disease. Among the women, poor sleep quality was significantly associated with increases in markers of inflammation over five years. However, this was not the case among men.

Most of the women in the study were postmenopausal and their lower levels of estrogen could help explain the link between poor sleep and higher levels of inflammation, the study authors suggested.

"It is possible that testosterone, which is at higher levels in men, served to buffer the effects of poor subjective sleep quality," Prather's team wrote in the study published online June 5 in the Journal of Psychiatric Research.

The researchers said their findings reveal potentially important gender differences and provide evidence that increased inflammation may be a major way that poor sleep contributes to the progression of heart disease in women.

Although the study found an association between self-reported poor sleep quality and increased signs of inflammation among older women with heart disease, it did not prove a cause-and-effect relationship.

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Bedtimes help with obstructive sleep apnea

This article discusses obstructive sleep apnea and how adhering to a consistent bedtime helps with sleep apnea treatment.

Obstructive sleep apnea (OSA) occurs when the upper airway collapses during sleep. It is the most common type of sleep-disordered breathing, and chances of it occurring are greater in obese people. OSA is the second most prevalent sleep disorder among adults.

The first line of treatment for sleep apnea is a noninvasive, in-home treatment called CPAP -- continuous positive airway pressure therapy. However, if patients do not use the treatment consistently for the majority of sleep hours each night, it cannot help.

"It has been shown that routine is important for adherence when it comes to medication, and routine is also relevant to CPAP adherence," said Amy M. Sawyer, assistant professor ofnursing, who will report her results at SLEEP 2013, the annual meeting of the Associated Professional Sleep Societies, in Baltimore on June 5.

The researchers define CPAP adherence as using the treatment for at least four hours each night. They found that if a patient's bedtime was consistent within 45 minutes, they were significantly more likely to use the CPAP machine for at least four hours each night. A patient whose bedtime was inconsistent -- varying by an hour and five minutes or more -- was much less likely to adhere to treatment.

The researchers found that adults whose bedtime varied by more than 75 minutes or more per night, were 3.2 times more likely to use CPAP less than four hours per night after one month of treatment. For every 30-minute increase in bedtime variability, or inconsistency, the odds of nonadherence to CPAP treatment were 1.8 times greater.

Sawyer and her colleague Tonya King, professor of public health sciences, Penn State College of Medicine, are the first to study the consistency of bedtime and its correlation to treatment adherence.

The researchers asked 97 volunteers who were about to begin CPAP treatment to keep a sleep diary beginning seven days prior to starting treatment. The volunteers recorded the time they went to bed and the time they woke up each day for seven consecutive days.

Each CPAP machine had a microprocessor built in that sent CPAP-use information every 24 hours to the researchers. The microprocessor recorded the patient as using the CPAP machine when breathing through the CPAP mask was detected for longer than 20 minutes.

While the researchers found that regularity of bedtime before beginning CPAP use did not influence adherence during the first week of treatment, it did affect adherence for the first month.

"Unlike many other treatments, CPAP treatment adds new complexity to a person's daily routines," said Sawyer. She and King think that using CPAP is a learned behavior that needs to become a habit.

Sawyer indicated that next steps include figuring out ways to help patients incorporate CPAP use into their daily routine and also studying other consistencies or lack thereof in bedtime routine -- beyond what time a person goes to bed that may influence a person's ability to regularly use CPAP.

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Cardiac events in children with epilepsy

A new study claims that cardiac events are predictable in children with epilepsy.

Cardiopulmonary abnormalities were associated with predictable patient and seizure characteristics in in children with epilepsy, researchers reported here.

Seizure-related apnea was associated with younger age, symptomatic-generalized seizure (versus primary-generalized seizure), seizure duration, anti-epileptic drug use, and seizure-related bradycardia, according to Kanwaljit Singh, MD, of Boston Children's Hospital, and colleagues.

Seizure-related tachypnea was associated with age, right-sided seizure, and was inversely related to anti-epileptic drug use, Singh said in a poster presentation during the Associated Professional Sleep Societies meeting.

Prior research has not extensively explored cardiopulmonary abnormalities that may result in sudden unexpected death in epilepsy (SUDEP) in pediatric epileptic seizures, the authors noted.

They recorded cardiopulmonary changes in 26 pediatric patients during 101 epileptic seizures through pulse oximetry, EKG, and respiratory inductance to provide associations between those changes with seizure and patient characteristics.

The researchers found significant associations between patient and seizure characteristics with seizure-related apnea, bradycardia, bradypnea, tachypnea, bradycardia, post-seizure bradycardia, and tachycardia.

Seizure-related apnea was significantly associated with:

• Younger age (P=0.01)
• Occurrence in the temporal lobe (P=0.0005)
• Left-sided seizure (P=0.003)
• Symptomatic-generalized seizure versus primary-generalized seizure (P=0.01)
• Longer seizure duration (P=0.0002)
• Desaturation (P<0.0001)
• Seizure-related bradycardia (P=0.02)
• Greater use of anti-epileptic drugs (P=0.006)

Apnea approached significance in male patients (P=0.08), in a comparison of symptomatic-generalized versus complex-partial seizures (P=0.08), and in complex-partial versus primary generalized seizures (P=0.08). There was a decreased prevalence of apnea in patients who had frontal lobe seizures (P=0.004).

Seizure-related bradypnea was significantly elevated in those whose seizures were left-sided (P=0.04) and symptomatic-generalized versus complex-partial and primary-generalized seizures (P=0.005 for both). This association showed a trend in those whose seizures occurred in the temporal lobe (P=0.07), whose seizures were lesional (P=0.09), in those with desaturation (P=0.07), and among those who received more anti-epileptic drugs (P=0.07).

Similarly, decreased prevalence trended among those with frontal lobe seizures (P=0.07).

Ictal-tachypnea was significantly associated with older age (P=0.01), frontal lobe versus nontemporal lobe foci (P=0.02), right-sided seizure (P=0.0008), and use of fewer anti-epileptic drugs (P=0.005). There also was a trend toward ictal-tachypnea with female gender (P=0.05) and frontal lobe seizure versus temporal lobe seizure (P=0.09).

Bradycardia in pediatric patients with epileptic seizures was significantly tied to male gender (P=0.03), longer seizure duration (P=0.03), desaturation (P=0.001), and use of more anti-epileptic drugs (P=0.04). There was also a trend with younger age (P=0.09) and a decreased association in those with frontal-lobe seizures (P=0.01).

Tachycardia in the population elevated among female patients (P=0.001) and trended among older patients (P=0.08) and those with frontal lobe seizures (P=0.06). There was a significantly decreased association in those who had lesional seizures (P=0.01) and who received more anti-epileptic drugs (P=0.01).

The authors also found that desaturation increased with longer seizures (P<0.0001), in those with seizure-related apnea (P<0.0001), in those with seizure-related bradycardia (P=0.001), and in those who received more anti-epileptic drugs (P=0.001).

Singh concluded that understanding the patient and seizure characteristics associated with pediatric seizures may allow for future prevention strategies in patients at risk for SUDEP and may help identify the underlying mechanisms of the condition.

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Sleep disorders in children can hurt their development

This article discusses how detrimental sleep disorders can be to children and their development.

Sleep behaviors are one of the most common concerns parents of young children discuss with their pediatricians. In infancy and early childhood, the developing brain requires more time asleep than it does awake.As a result, sleep quality is extremely important in the overall well-being of a child. Children suffering from lack of quality sleep or sleep-related disorders can jeopardize their cognitive, emotional and physical development. Pediatric sleep problems don’t just affect the child - they often have a negative impact on other siblings’ quality of sleep and the entire family dynamic.

Sleep disturbances are diagnosed in 25 to 30 percent of infants and children. Causes can include an inconsistent bedtime routine, sleepwalking, sleep apnea, narcolepsy and epilepsy. Not surprisingly, pediatric sleep disorders are often overlooked because presenting symptoms of negative behavior, moodiness, irritability, lack of motivation, inability to focus, lethargy are misdiagnosed as behavioral or emotional problems, not a physical, medical condition. Severe or chronic sleep disorders can even cause adverse cardiovascular and metabolic effects as well as failure to thrive.

Common pediatric symptoms

Symptoms of sleep disorders in children can be obvious or subtle and often present with one or more of these symptoms on a regular basis:

 ongoing bedtime resistance

 nightly awakenings

 sleepwalking

 nightmares

 bedwetting

 insomnia

 chronic snoring/breathing difficulties

How to proceed if you suspect a sleep disorder

First, consult with your pediatrician to rule out any acute or chronic medical conditions. Once medically cleared, it may be helpful to clinically observe and monitor your child in a sleep center that offers pediatric diagnosis and treatment services. These centers offer comfortable bedroom like settings where sleep patterns are evaluated and diagnosed during an overnight stay.A parent accompanies the child during the stay to provide comfort and alleviate anxiety.A sleep technologist applies small painless sensors designed to monitor your child’s brainwaves, muscle activity, heart rhythms, respiratory activity and oxygen saturation levels throughout the night. The results are then analyzed by a pediatric sleep medicine physician, who will determine a diagnosis and recommend the most appropriate treatment for your child, if necessary. Once properly diagnosed, this and other sleep-related medical conditions can be successfully treated to restore and continue the child’s normal development process. If you suspect your child may have a sleep issue, see your pediatrician and discuss a sleep study evaluation.

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