Background and Hypothesis Converging evidence from animal and human studies has implicated gamma-aminobutyric acid (GABA)-ergic dysfunction in the pathophysiology of psychosis spectrum disorders. However, little is known about GABA’s role in the early illness stages. Based on prior research, we hypothesized that GABA levels would already be altered in first episode psychosis patients (FEP), and that they would be associated with patients’ cognitive function and response to treatment. Study Design We used magnetic resonance spectroscopy with a MEGA-PRESS sequence to quantify GABA in the dorsal anterior cingulate cortex (ACC) at baseline and over the course of antipsychotic treatment with risperidone. We compared GABA levels between 79 medication-naïve FEP and 113 healthy controls (HC) longitudinally over a period of 16 weeks and examined their relationships to cognition and treatment response. Study Results We found significantly lower GABA levels in FEP compared to HC at all 3 time points (baseline, 6 weeks, 16 weeks), but did not observe a significant main effect of time or an interaction of group by time. We found no significant correlations between GABA and cognitive scores. Baseline GABA levels of patients considered treatment nonresponders significantly differed from HC, whereas responders did not. Conclusions Our findings suggest that GABA dysfunction in the ACC may be an important feature of the core pathophysiology of psychosis. This dysfunction does not appear to be attenuated by conventional antipsychotic treatment, though baseline levels may be indicative of clinical prognosis in FEP.

ABSTRACT This study examined how lower-body lengthened partial (LP) versus full range of motion (FULL) resistance training affects acute post-exercise signaling, chronic hypertrophy, and cellular adaptations of the vastus lateralis (VL) muscle in resistance-trained men. Eight males (22±1 years old, 5.6±1.4 years training) completed a crossover study whereby VL biopsies were collected pre-exercise and 0, 3, and 24 hours following LP and FULL leg extension bouts for transcriptomic and anabolic signaling analyses (Experiment 1). Another 16 males (26±5 years old; 8.0±4.9 years training) completed an 8-week, twice-weekly lower-body intervention using a within-subject design (Experiment 2). One leg was assigned to FULL and the contralateral leg to LP training across three exercises (leg press, leg extension, and lying leg curl). Pre- and post-intervention outcomes included VL muscle cross-sectional area (mCSA) summed across five equidistant MRI-derived transverse slices and mid-thigh VL biopsy outcomes. As a secondary outcome, other hip and thigh muscles from Experiment 2 MRI scans were assessed. Condition × Time interactions for all outcomes were assessed using linear mixed-effects models. In Experiment 1, both conditions produced similar time-dependent changes in the VL transcriptome and anabolic (mTORC1 and Hippo) signaling, but minimal between-protocol interactions. In Experiment 2, VL summed mCSA significantly increased over time (mean change: 9.3 cm², 95% CI [6.8, 11.8], P<0.001), but there was no clear evidence of differential change between protocols (LP−FULL change: −1.4 cm², 95% CI [−6.1, 3.8], P=0.640). Additionally, no significant interactions existed for type I fiber CSA (P=0.476), type II fiber CSA (P=0.350), type I fiber myonuclei (P=0.813), type II fiber myonuclei (P=0.589), type I and II satellite cell number (P=0.102 and P=0.797, respectively), or total RNA content (P=0.537). Despite these null VL-centric findings, secondary Experiment 2 analyses provided some evidence that whole hamstring hypertrophy was greater following LP versus FULL (LP−FULL change: 3.9 cm², 95% CI [−0.2, 7.9], P=0.058). In conclusion, 8 weeks of LP and FULL resistance training broadly elicit similar acute and chronic VL responses in previously trained men, though secondary hamstring findings suggest that differential responses may depend on exercises included in the resistance training program.

BACKGROUND AND HYPOTHESIS:Glutamatergic abnormalities are among the most consistent neurometabolic findings in psychosis spectrum disorders, but individual variability suggests biologically distinct subgroups. Proton magnetic resonance spectroscopy (1H-MRS) enables in vivo quantification of glutamate (Glu) and related metabolites but has rarely been applied to subgroup discovery in early psychosis. We hypothesized that metabolite-based clustering of hippocampal and anterior cingulate cortex (ACC) measures would identify biologically distinct subtypes differing in symptom severity and cognition. STUDY DESIGN:Single-voxel 1H-MRS data were acquired from the left hippocampus and ACC in 90 antipsychotic-naïve first-episode psychosis (FEP) patients. Metabolites included Glu, composite creatine, composite choline, and N-acetylaspartate, quantified in both regions (eight total measures). K-means clustering was applied to these variables. Classification trees identified the most discriminative features, guiding simplified two-dimens-ional (2D) clustering models. Subgroup differences in demographics, symptoms, and cognition were evaluated using ANOVAs. STUDY RESULTS:Clustering of all eight metabolites revealed two stable subgroups differing in baseline positive symptoms but not cognition or treatment response. Across models, classification trees consistently identified hippocampal Glu as the primary split, with secondary variables varying by method. These pairings guided three 2D clustering models, of which the hippocampal Glu + ACC Cr solution yielded four metabolically distinct subgroups. One subgroup, characterized by intermediate hippocampal Glu and low ACC Cr, showed significantly better cognitive performance after adjusting for age and sex. CONCLUSIONS:Data-driven clustering of hippocampal and ACC metabolites identified subgroups with distinct cognitive profiles in antipsychotic-naïve FEP, supporting 1H-MRS-based biotyping in early psychosis.

BACKGROUND:Functional connectivity (FC) is consistently altered in patients with schizophrenia. The brain's primary inhibitory neurotransmitter, gamma-aminobutyric acid (GABA), and its relationship to FC in psychosis spectrum disorders are under-investigated. The anterior cingulate cortex (ACC) has been implicated in many cognitive functions impaired in psychosis. We hypothesize that the relationships between ACC GABA and FC in key brain networks will be altered in first-episode psychosis (FEP) patients as compared to healthy controls (HC). METHODS:We used magnetic resonance spectroscopy (MRS) with a MEGA-PRESS sequence to quantify ACC GABA levels in 67 antipsychotic medication-naïve FEP patients and 110 HC. Resting state functional magnetic resonance imaging (fMRI) was used to assess positive and negative FC within the default mode (DMN), salience (SN), dorsal attention (DAN), and executive control (ECN) networks. We used linear regressions to test GABA-FC relationships in each network between groups. RESULTS:FEP patients had significantly lower GABA levels compared to HC. We also found several clusters in the ECN, DAN, and DMN where FC differed between groups. Ultimately, we found significant GABA-FC group interactions in two ECN clusters and one SN cluster, where GABA and FC were positively correlated in HC but negatively correlated in FEP. CONCLUSIONS:Our data add to the growing literature supporting GABA's significant role in psychosis spectrum disorders, especially as it relates to FC in key brain networks. Our findings call for further investigation of the mechanisms underlying altered neurometabolic activity and connectivity in psychosis spectrum disorders.

BACKGROUND:Previous findings in psychosis have revealed mixed findings on glutamate (Glu) levels in the dorsal anterior cingulate cortex (dACC). Factors such as illness chronicity, methodology, and medication status have impeded a more nuanced evaluation of Glu in psychosis. The goal of this longitudinal neuroimaging study was to investigate the role of antipsychotics on Glu in the dACC in antipsychotic-naïve first-episode psychosis (FEP) patients. METHODS:We enrolled 117 healthy controls (HCs) and 113 antipsychotic-naïve FEP patients for this study. 3T proton magnetic resonance spectroscopy (1H-MRS; PRESS; TE = 80 ms) data from a voxel prescribed in the dACC were collected from all participants at baseline, 6, and 16 weeks following antipsychotic treatment. Glutamate levels were quantified using the QUEST algorithm and analyzed longitudinally using linear mixed-effects models. RESULTS:We found that baseline dACC glutamate levels in FEP were not significantly different than those of HCs. Examining Glu levels in FEP revealed a decrease in Glu levels after 16 weeks of antipsychotic treatment; this effect was weaker in HC. Finally, baseline Glu levels were associated with decreases in positive symptomology. CONCLUSIONS:We report a progressive decrease of Glu levels over a period of 16 weeks after initiation of treatment and a baseline Glu level association with a reduction in positive symptomology, suggestive of a potential mechanism of antipsychotic drug (APD) action. Overall, these findings suggest that APDs can influence Glu within a period of 16 weeks, which has been deemed as an optimal window for symptom alleviation using APDs.

Barth syndrome (BTHS) is a rare X-linked recessive disorder characterized by mutations in the TAFAZZIN gene, leading to mitochondrial dysfunction, cardioskeletal myopathy, neutropenia, exercise intolerance, and growth delay. While cardiac transplantation can improve heart function in BTHS patients, the metabolic effects of this procedure remain poorly understood. This study aimed to compare skeletal muscle morphology, substrate metabolism, energetics, and exercise tolerance in individuals with BTHS who had undergone cardiac transplantation (BTHS-T) versus BTHS patients without transplantation (BTHS-noT) and healthy controls. Six (n = 6) BTHS-T participants (3 adolescents, 3 adults) were compared with n = 29 BTHS-noT and n = 28 healthy controls. All participants underwent graded exercise testing, echocardiography, body composition analysis, and clinical metabolism studies, including 31P-MRS to assess mitochondrial energetics. No significant differences were observed in fat-free mass between BTHS-T participants and BTHS-noT. Exercise capacity (V̇O2peak) was significantly lower in both BTHS groups compared to controls, with lower heart rate responses during peak exercise. In addition, plasma lactate was higher in both BTHS groups compared to healthy controls. Skeletal muscle energetics showed slower phosphocreatine recovery and reduced ATP production in BTHS participants, regardless of cardiac transplantation status. Findings suggest while cardiac transplantation in BTHS may improve heart function, it may not normalize skeletal muscle mass and energetics, metabolic abnormalities, and exercise intolerance. The study enhances our understanding of long-term metabolic consequences of BTHS and potential limitations of cardiac transplantation in ameliorating these dysfunctions. Further research is needed to explore targeted therapies to address underlying metabolic abnormalities in BTHS patients.

BACKGROUND:Previous studies have implicated hippocampal abnormalities in the neuropathology of psychosis spectrum disorders. Reduced hippocampal volume has been reported across all illness stages, and this atrophy has been hypothesized to be the result of glutamatergic excess. To test this hypothesis, we measured hippocampal subfield volumes and hippocampal glutamate levels in antipsychotic naïve first episode psychosis patients (FEP) and the progression of volume decline and changes in glutamate levels over a 16-week antipsychotic drug (APD) trial. We aimed to determine if subfield volumes at baseline were associated with glutamate levels, and if baseline glutamate levels were predictive of change in subfield volumes over time. METHODS:We enrolled ninety-three medication-naïve FEP participants and 80 matched healthy controls (HC). T1 and T2 weighted images and magnetic resonance spectroscopy (MRS) data from a voxel prescribed in the left hippocampus were collected from participants at baseline and after 6 and 16 weeks of APD treatment. Hippocampal subfield volumes were assessed using FreeSurfer 7.1.1., while glutamate levels were quantified using jMRUI version 6.0. Data were analyzed using linear mixed models. RESULTS:We found regional subfield volume deficits in the CA1, and presubiculum in FEP at baseline, that further expanded to include the molecular and granule cell layer of the dentate gyrus (GC/ML/DG) and CA4 by week 16. Baseline hippocampal glutamate levels in FEP were not significantly different than those of HC, and there was no effect of treatment on glutamate. Glutamate levels were not related to initial subfield volumes or volume changes over 16 weeks. CONCLUSION:We report a progressive loss of hippocampal subfield volumes over a period of 16 weeks after initiation of treatment, suggestive of early progression in neuropathology. Our results do not suggest a role for glutamate as a driving factor. This study underscores the need to further research the mechanism(s) underlying this phenomenon as it has implications for early intervention to preserve cognitive decline in FEP participants.

The objective of this study is to determine characteristics of patients with myofascial pain syndrome (MPS) of the low back and the degree to which the low back pain in the patients examined can be attributed to MPS. Twenty-five subjects with myofascial trigger point(s) [MTrP(s)] on the low back participated in this cross-sectional study. The location, number, and type of selected MTrPs were identified by palpation and verified by ultrasound. Pain pressure threshold, physical function, and other self-reported outcomes were measured. Significant differences were found in Group 1 (Active), 2 (Latent), 3 (Atypical, no twitching but with spontaneous pain), and 4 (Atypical, no twitching and no spontaneous pain) of participants in the number of MTrPs, current pain, and worst pain in the past 24 h (p = .001–.01). There were interaction effects between spontaneous pain and twitching response on reports of physical function, current pain, and worst pain (p = .002–.04). Participants in Group 3 reported lower levels of physical function, and higher levels of current pain and worst pain compared to those in Group 4. Participants in Group 1 and 2 had similar levels of physical function, current pain, and worst pain. The number of MTrPs is most closely associated with the level of pain. Spontaneous pain report seems to be a decisive factor associated with poor physical function; however, twitching response is not.

MRI is a valuable diagnostic tool to investigate spinal cord (SC) pathology. SC MRI can benefit from the increased signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) at ultra-high fields such as 7 T. However, SC MRI acquisitions with routine Cartesian readouts are prone to image artifacts caused by physiological motion. MRI acquisition techniques with non-Cartesian readouts such as rosette can help reduce motion artifacts. The purpose of this study was to demonstrate the feasibility of high-resolution SC imaging using rosette trajectory with magnetization transfer preparation (MT-prep) and compressed sensing (CS) at 7 T. Five healthy volunteers participated in the study. Images acquired with rosette readouts demonstrated reduced motion artifacts compared to the standard Cartesian readouts. The combination of multi-echo rosette-readout images improved the CNR by approximately 50% between the gray matter (GM) and white matter (WM) compared to single-echo images. MT-prep images showed excellent contrast between the GM and WM with magnetization transfer ratio (MTR) and cerebrospinal fluid normalized MT signal (MTCSF) = 0.12 ± 0.017 and 0.74 ± 0.013, respectively, for the GM; and 0.18 ± 0.011 and 0.58 ± 0.009, respectively, for the WM. Under-sampled acquisition using rosette readout with CS reconstruction demonstrated up to 6 times faster scans with comparable image quality as the fully-sampled acquisition.

IntroductionFeline obesity is common, afflicting ~25–40% of domestic cats. Obese cats are predisposed to many metabolic dyscrasias, such as insulin resistance, altered blood lipids, and feline hepatic lipidosis. Fibroblast Growth Factor-21 (FGF21) is an endocrine hormone that mediates the fat-liver axis, and in humans and animals, FGF21 can ameliorate insulin resistance, non-alcoholic fatty liver disease, and obesity. Activation of the FGF21 pathway may have therapeutic benefits for obese cats.MethodsIn this preliminary cross-sectional study, ad libitum fed, purpose-bred, male-neutered, 6-year-old, obese and overweight cats were administered either 10 mg/kg/day of an FGF21 mimetic (FGF21; n = 4) or saline (control; n = 3) for 14 days. Body weight, food, and water intake were quantified daily during and 2 weeks following treatment. Changes in metabolic and liver parameters, intrahepatic triglyceride content, liver elasticity, and gut microbiota were evaluated.ResultsTreatment with FGF21 resulted in significant weight loss (~5.93%) compared to control and a trend toward decreased intrahepatic triglyceride content. Cats treated with FGF21 had decreased serum alkaline phosphatase. No significant changes were noted in liver elasticity, serum, liver, or metabolic parameters, or gut microbiome composition.DiscussionIn obese and overweight cats, activation of the FGF21 pathway can safely induce weight loss with trends to improve liver lipid content. This exploratory study is the first to evaluate the FGF21 pathway in cats. Manipulation of the FGF21 pathway has promising potential as a therapeutic for feline obesity. Further studies are needed to see if FGF21-pathway manipulation can be therapeutic for feline hepatic lipidosis.

Magnetic resonance spectroscopic imaging (MRSI) provides information about the spatial distribution of metabolites in the brain. These metabolite maps can be valuable in diagnosing central nervous system pathology. However, MRSI generally suffers from a long acquisition time, poor spatial resolution, and a low metabolite signal-to-noise ratio (SNR). Ultrahigh field strengths (≥ 7 T) can benefit MRSI with an improved SNR and allow high-resolution metabolic mapping. Non-Cartesian spatial-spectral encoding techniques, such as rosette spectroscopic imaging, can efficiently sample spatial and temporal domains, which significantly reduces the imaging time and enables high-resolution metabolic mapping in a clinically relevant scan time. In the current study, high-resolution (in-plane resolution of 2 × 2 mm2 ) mapping of proton (1 H) metabolites in the human brain at 7 T, is demonstrated. Five healthy subjects participated in the study. Using a time-efficient rosette trajectory and short TR/TE free induction decay MRSI, high-resolution maps of 1 H metabolites were obtained in a clinically relevant imaging time (6 min). Suppression of the water signal was achieved with an optimized water suppression enhanced through T1 effects approach and lipid removal was performed using L2 -regularization in the postprocessing. Spatial distributions of N-acetyl-aspartate, total choline, creatine, N-acetyl-aspartyl glutamate, myo-inositol, and glutamate were generated with Cramer-Rao lower bounds of less than 20%.

We examined how set-volume equated resistance training using either the back squat (SQ) or hip thrust (HT) affected hypertrophy and various strength outcomes. Untrained college-aged participants were randomized into HT (n = 18) or SQ (n = 16) groups. Surface electromyograms (sEMG) from the right gluteus maximus and medius muscles were obtained during the first training session. Participants completed 9 weeks of supervised training (15–17 sessions), before and after which gluteus and leg muscle cross-sectional area (mCSA) was assessed via magnetic resonance imaging. Strength was also assessed prior to and after the training intervention via three-repetition maximum (3RM) testing and an isometric wall push test. Gluteus mCSA increases were similar across both groups. Specifically, estimates [(−) favors HT (+) favors SQ] modestly favored the HT versus SQ for lower [effect ±SE, −1.6 ± 2.1 cm2; CI95% (−6.1, 2.0)], mid [−0.5 ± 1.7 cm2; CI95% (−4.0, 2.6)], and upper [−0.5 ± 2.6 cm2; CI95% (−5.8, 4.1)] gluteal mCSAs but with appreciable variance. Gluteus medius + minimus [−1.8 ± 1.5 cm2; CI95% (−4.6, 1.4)] and hamstrings [0.1 ± 0.6 cm2; CI95% (−0.9, 1.4)] mCSA demonstrated little to no growth with small differences between groups. mCSA changes were greater in SQ for the quadriceps [3.6 ± 1.5 cm2; CI95% (0.7, 6.4)] and adductors [2.5 ± 0.7 cm2; CI95% (1.2, 3.9)]. Squat 3RM increases favored SQ [14 ± 2 kg; CI95% (9, 18),] and hip thrust 3RM favored HT [−26 ± 5 kg; CI95% (−34, −16)]. 3RM deadlift [0 ± 2 kg; CI95% (−4, 3)] and wall push strength [−7 ± 12N; CI95% (−32, 17)] similarly improved. All measured gluteal sites showed greater mean sEMG amplitudes during the first bout hip thrust versus squat set, but this did not consistently predict gluteal hypertrophy outcomes. Squat and hip thrust training elicited similar gluteal hypertrophy, greater thigh hypertrophy in SQ, strength increases that favored exercise allocation, and similar deadlift and wall push strength increases.

Blood-brain barrier (BBB) dysfunction is associated with a number of central nervous system diseases. This study demonstrates the application of a novel noninvasive technique to measure the BBB permeability in the human brain at 7 T. The technique exploits the fact that, when tissue macromolecules are saturated by off-resonance RF pulse, the intravascular and the extravascular (tissue) water experience different magnetization transfer effects. This principle was combined with arterial spin labeling to distinguish between the intravascular and the tissue water, and was used to calculate perfusion, water extraction fraction (E), and BBB permeability surface area product for water (PS). Simultaneous coregistered magnetization transfer ratio maps were also generated that can provide valuable additional information. Eighteen healthy volunteers (seven females), age = 27 ± 11 years and weight = 65 ± 9 kg, participated in the study. Average perfusion was 67 ± 5 and 29 ± 4 ml/100 g/min (p < 0.05); and E was 0.921 ± 0.025 and 0.962 ± 0.015 (p < 0.05) in the gray matter (GM) and the white matter (WM), respectively. PS was higher in the GM (171 ± 20 ml/100 g/min) compared with the WM (95 ± 18 ml/100 g/min) (p < 0.05). The parameters exhibited good reliability with test re-test experiments. The sensitivity of this technique was demonstrated by 200 mg caffeine intake, which resulted in a decrease in the resting PS by ~31%.

BACKGROUND:Nonalcoholic fatty liver disease (NAFLD) is a leading cause of end-stage liver disease. NAFLD diagnosis and follow-up relies on a combination of clinical data, liver imaging, and/or liver biopsy. However, intersite imaging differences impede diagnostic consistency and reduce the repeatability of the multisite clinical trials necessary to develop effective treatments. PURPOSE/HYPOTHESIS:The goal of this pilot study was to harmonize commercially available 3 T magnetic resonance imaging (MRI) measurements of liver fat and stiffness in human participants across academic sites and MRI vendors. STUDY TYPE:Cohort. SUBJECTS:Four community-dwelling adults with obesity. FIELD STRENGTH/SEQUENCE:1.5 and 3 T, multiecho 3D imaging, PRESS, and GRE. ASSESSMENT:Harmonized proton density fat fraction (PDFF) and magnetic resonance spectroscopy (MRS) protocols were used to quantify the FF of synthetic phantoms and human participants with obesity using standard acquisition parameters at four sites that had four different 3 T MRI instruments. In addition, a harmonized magnetic resonance elastography (MRE) protocol was used to quantify liver stiffness among participants at two different sites at 1.5 and 3 T field strengths. Data were sent to a single data coordinating site for postprocessing. STATISTICAL TESTS:Linear regression in MATLAB, ICC analyses using SAS 9.4, one-sided 95% confidence intervals for the ICC. RESULTS:PDFF and MRS FF measurements were highly repeatable among sites in both humans and phantoms. MRE measurements of liver stiffness in three individuals at two sites using one 1.5 T and one 3 T instrument showed repeatability that was high although lower than that of MRS and PDFF. CONCLUSIONS:We demonstrated harmonization of PDFF, MRS, and MRE-based quantification of liver fat and stiffness through synthetic phantoms, traveling participants, and standardization of postprocessing analysis. Multisite MRI harmonization could contribute to multisite clinical trials assessing the efficacy of interventions and therapy for NAFLD. LEVEL OF EVIDENCE:2 TECHNICAL EFFICACY STAGE: 2.

The purpose of the present study was to demonstrate a new sequence and determine the repeatability of simultaneous dynamic measurements of blood flow, venous oxygen saturation (SvO2 ), and relative perfusion (change from resting perfusion) in calf muscle during recovery from plantar flexion exercise. The feasibility of near simultaneous measurement of bio-energetic parameters was also demonstrated. A sequence was developed to simultaneously measure arterial blood flow using flow-encoded projection, SvO2 using susceptibility-based oximetry, and relative perfusion using arterial spin labeling in combination with dynamic plantar flexion exercise. The parameters were determined at rest and during recovery from single leg plantar flexion exercise. Test-retest repeatability was analyzed using Bland-Altman analysis and intraclass correlation coefficients (ICC). The mitochondrial capacity of skeletal muscle was also measured immediately afterwards with dynamic phosphorus magnetic resonance spectroscopy. Eight healthy subjects participated in the study for test-retest repeatability. Popliteal artery blood flow at rest was 1.79 ± 0.58 ml/s and increased to 11.18 ± 3.02 ml/s immediately after exercise. Popliteal vein SvO2 decreased to 45.93% ± 6.5% from a resting value of 70.46% ± 4.76% following exercise. Relative perfusion (change from rest value) was 51.83 ± 15.00 ml/100 g/min at the cessation of exercise. The recovery of blood flow and SvO2 was modeled as a single exponential with time constants of 38.03 ± 6.91 and 71.19 ± 14.53 s, respectively. All the measured parameters exhibited good repeatability with ICC ranging from 0.8 to 0.95. Bioenergetics measurements were within normal range, demonstrating the feasibility of near simultaneous measurement of hemodynamic and energetic parameters. Clinical feasibility was assessed with Barth syndrome patients, demonstrating reduced oxygen extraction from the blood and reduced mitochondrial oxidative capacity compared with healthy controls. The proposed protocol allows rapid imaging of multiple parameters in skeletal muscle that might be affected in disease.

Identification of individuals at high risk for rapid progression of motor and cognitive signs in Parkinson disease (PD) is clinically significant. Postural instability and gait dysfunction (PIGD) are associated with greater motor and cognitive deterioration. We examined the relationship between baseline clinical factors and the development of postural instability using 5-year longitudinal de-novo idiopathic data ( n = 301) from the Parkinson’s Progressive Markers Initiative (PPMI). Logistic regression analysis revealed baseline features associated with future postural instability, and we designated this cohort the emerging postural instability (ePI) phenotype. We evaluated the resulting ePI phenotype rating scale validity in two held-out populations which showed a significantly higher risk of postural instability. Emerging PI phenotype was identified before onset of postural instability in 289 of 301 paired comparisons, with a median progression time of 972 days. Baseline cognitive performance was similar but declined more rapidly in ePI phenotype. We provide an ePI phenotype rating scale (ePIRS) for evaluation of individual risk at baseline for progression to postural instability.