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Rosman NP, Vassar R, Doros G, DeRosa J, Froman A, DiMauro A, Santiago S, Abbott J. Association of Prenatal Ultrasonography and Autism Spectrum Disorder. JAMA Pediatr 2018; 172:336-344. [PMID: 29435580 PMCID: PMC5875374 DOI: 10.1001/jamapediatrics.2017.5634] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 12/07/2017] [Indexed: 12/28/2022]
Abstract
Importance The prevalence of autism spectrum disorder (ASD) has been increasing rapidly, with current estimates of 1 in 68 children affected. Simultaneously, use of prenatal ultrasonography has increased substantially, with limited investigation into its safety and effects on brain development. Animal studies have demonstrated that prenatal ultrasonography can adversely affect neuronal migration. Objective To quantify prenatal ultrasound exposure by the frequency, timing, duration, and strength of ultrasonographic scans in children with later ASD, developmental delay, and typical development. Design, Setting, and Participants This case-control study included 107 patients with ASD, 104 control individuals with developmental delay, and 209 controls with typical development. Participants were identified from medical records based on prenatal care and delivery at Boston Medical Center, a diverse, academic, safety-net medical center, from July 1, 2006, through December 31, 2014, with a gestational age at birth of at least 37 weeks. Data were analyzed from May 1, 2015, through November 30, 2017. Exposures Ultrasonographic exposure was quantified by the number and timing of scans, duration of exposure, mean strength (depth, frame rate, mechanical index, and thermal index), and time of Doppler and 3- and 4-dimensional imaging. Main Outcomes and Measures Among participants with ASD and controls with developmental delay and typical development, ultrasound exposure was quantified and compared per trimester and for the entire pregnancy, with adjustment for infant sex, gestational age at birth, and maternal age. Results A total of 420 participants were included in the study (328 boys [78.1%] and 92 girls [21.9%]; mean age as of January 1, 2016, 6.6 years; 95% CI, 6.5-6.8 years). The ASD group received a mean of 5.9 scans (95% CI, 5.2-6.6), which was not significantly different from the 6.1 scans (95% CI, 5.4-6.8) in the developmental delay group or the 6.3 scans (95% CI, 5.8-6.8) in the typical development group. Compared with the typical development group, the ASD group had shorter duration of ultrasound exposure during the first (290.4 seconds [95% CI, 212.8-368.0 seconds] vs 406.4 seconds [95% CI, 349.5-463.3 seconds]) and second (1687.6 seconds [95% CI, 1493.8-1881.4 seconds] vs 2011.0 seconds [95% CI, 1868.9-2153.1 seconds]) trimesters but no difference in the number of scans. The ASD group had greater mean depth of ultrasonographic penetration than the developmental delay group in the first trimester (12.5 cm [95% CI, 12.0-13.0 cm] vs 11.6 cm [95% CI, 11.1-12.1 cm]). The ASD group had greater mean depth than the typical development group during the first (12.5 cm [95% CI, 12.0-13.0 cm] vs 11.6 cm [95% CI, 11.3-12.0 cm]) and the second (12.9 cm [95% CI, 12.6-13.3 cm] vs 12.5 cm [95% CI, 12.2-12.7 cm]) trimesters. Conclusions and Relevance This study found significantly greater mean depth of ultrasonographic penetration in the ASD group compared with the developmental delay group in the first trimester and compared with the typical development group in the first and second trimesters. Further research is needed to determine whether other variables of ultrasound exposure also have adverse effects on the developing fetus.
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Affiliation(s)
- N. Paul Rosman
- Department of Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Division of Pediatric Neurology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Departments of Pediatrics and Neurology, Division of Pediatric Neurology, Boston Medical Center, Boston, Massachusetts
| | - Rachel Vassar
- medical student at Boston University School of Medicine, Boston, Massachusetts
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - James DeRosa
- graduate student at Boston University School of Public Health, Boston, Massachusetts
| | - Allison Froman
- graduate student at Boston University School of Public Health, Boston, Massachusetts
| | - Audrey DiMauro
- medical student at Boston University School of Medicine, Boston, Massachusetts
- Department of Pediatrics, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Sherry Santiago
- Division of Pediatric Neurology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Division of Pediatric Neurology, Puerto Rico Children’s Hospital, Bayamón, Puerto Rico
| | - Jodi Abbott
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
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Hertz-Picciotto I, Schmidt RJ, Krakowiak P. Understanding environmental contributions to autism: Causal concepts and the state of science. Autism Res 2018; 11:554-586. [PMID: 29573218 DOI: 10.1002/aur.1938] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 11/06/2022]
Abstract
The complexity of neurodevelopment, the rapidity of early neurogenesis, and over 100 years of research identifying environmental influences on neurodevelopment serve as backdrop to understanding factors that influence risk and severity of autism spectrum disorder (ASD). This Keynote Lecture, delivered at the May 2016 annual meeting of the International Society for Autism Research, describes concepts of causation, outlines the trajectory of research on nongenetic factors beginning in the 1960s, and briefly reviews the current state of this science. Causal concepts are introduced, including root causes; pitfalls in interpreting time trends as clues to etiologic factors; susceptible time windows for exposure; and implications of a multi-factorial model of ASD. An historical background presents early research into the origins of ASD. The epidemiologic literature from the last fifteen years is briefly but critically reviewed for potential roles of, for example, air pollution, pesticides, plastics, prenatal vitamins, lifestyle and family factors, and maternal obstetric and metabolic conditions during her pregnancy. Three examples from the case-control CHildhood Autism Risks from Genes and the Environment Study are probed to illustrate methodological approaches to central challenges in observational studies: capturing environmental exposure; causal inference when a randomized controlled clinical trial is either unethical or infeasible; and the integration of genetic, epigenetic, and environmental influences on development. We conclude with reflections on future directions, including exposomics, new technologies, the microbiome, gene-by-environment interaction in the era of -omics, and epigenetics as the interface of those two. As the environment is malleable, this research advances the goal of a productive and fulfilling life for all children, teen-agers and adults. Autism Res 2018, 11: 554-586. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY This Keynote Lecture, delivered at the 2016 meeting of the International Society for Autism Research, discusses evidence from human epidemiologic studies of prenatal factors contributing to autism, such as pesticides, maternal nutrition and her health. There is no single cause for autism. Examples highlight the features of a high-quality epidemiology study, and what comprises a compelling case for causation. Emergent research directions hold promise for identifying potential interventions to reduce disabilities, enhance giftedness, and improve lives of those with ASD.
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Affiliation(s)
- Irva Hertz-Picciotto
- Department of Public Health Sciences, MIND Institute (Medical Investigations of Neurodevelopmental Disorders), University of California, Davis, Davis, California
| | - Rebecca J Schmidt
- Department of Public Health Sciences, MIND Institute (Medical Investigations of Neurodevelopmental Disorders), University of California, Davis, Davis, California
| | - Paula Krakowiak
- Department of Public Health Sciences, MIND Institute (Medical Investigations of Neurodevelopmental Disorders), University of California, Davis, Davis, California
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Sivanesan S, Tan A, Jeyaraj R, Lam J, Gole M, Hardan A, Ashkan K, Rajadas J. Pharmaceuticals and Stem Cells in Autism Spectrum Disorders: Wishful Thinking? World Neurosurg 2017; 98:659-672. [DOI: 10.1016/j.wneu.2016.09.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 09/24/2016] [Accepted: 09/26/2016] [Indexed: 12/21/2022]
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McLennan A. Ultrasound and Autism Spectrum Disorder. Australas J Ultrasound Med 2016; 19:131-132. [DOI: 10.1002/ajum.12033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Andrew McLennan
- Discipline of Obstetrics, Gynaecology and Neonatology; University of Sydney; Camperdown New South Wales Australia
- Sydney Ultrasound for Women; Chatswood New South Wales Australia
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Webb SJ, Garrison MM, Bernier R, McClintic AM, King BH, Mourad PD. Severity of ASD symptoms and their correlation with the presence of copy number variations and exposure to first trimester ultrasound. Autism Res 2016; 10:472-484. [PMID: 27582229 DOI: 10.1002/aur.1690] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 04/07/2016] [Accepted: 07/21/2016] [Indexed: 01/13/2023]
Abstract
Current research suggests that incidence and heterogeneity of autism spectrum disorder (ASD) symptoms may arise through a variety of exogenous and/or endogenous factors. While subject to routine clinical practice and generally considered safe, there exists speculation, though no human data, that diagnostic ultrasound may also contribute to ASD severity, supported by experimental evidence that exposure to ultrasound early in gestation could perturb brain development and alter behavior. Here we explored a modified triple hit hypothesis [Williams & Casanova, ] to assay for a possible relationship between the severity of ASD symptoms and (1) ultrasound exposure (2) during the first trimester of pregnancy in fetuses with a (3) genetic predisposition to ASD. We did so using retrospective analysis of data from the SSC (Simon's Simplex Collection) autism genetic repository funded by the Simons Foundation Autism Research Initiative. We found that male children with ASD, copy number variations (CNVs), and exposure to first trimester ultrasound had significantly decreased non-verbal IQ and increased repetitive behaviors relative to male children with ASD, with CNVs, and no ultrasound. These data suggest that heterogeneity in ASD symptoms may result, at least in part, from exposure to diagnostic ultrasound during early prenatal development of children with specific genetic vulnerabilities. These results also add weight to on-going concerns expressed by the FDA about non-medical use of diagnostic ultrasound during pregnancy. Autism Res 2017, 10: 472-484. © 2016 International Society for Autism Research, Wiley Periodicals, Inc.
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Affiliation(s)
- Sara Jane Webb
- Center on Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.,Departments of Psychiatry & Behavioral Science, Neurological Surgery, Seattle, Washington
| | - Michelle M Garrison
- Center on Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.,Departments of Psychiatry & Behavioral Science, Neurological Surgery, Seattle, Washington
| | - Raphael Bernier
- Departments of Psychiatry & Behavioral Science, Neurological Surgery, Seattle, Washington
| | - Abbi M McClintic
- Departments of Psychiatry & Behavioral Science, Neurological Surgery, Seattle, Washington
| | - Bryan H King
- Center on Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Pierre D Mourad
- Departments of Psychiatry & Behavioral Science, Neurological Surgery, Seattle, Washington.,Division of Engineering and Mathematics, University of Washington, Seattle, Washington
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Casanova MF. Autism as a sequence: from heterochronic germinal cell divisions to abnormalities of cell migration and cortical dysplasias. Med Hypotheses 2014; 83:32-8. [PMID: 24780284 PMCID: PMC4070182 DOI: 10.1016/j.mehy.2014.04.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/11/2014] [Accepted: 04/06/2014] [Indexed: 02/07/2023]
Abstract
The considerable heterogeneity in the number and severity of symptoms observed in autism spectrum disorders (ASD) has been regarded as an obstacle to any future research. Some authors believe that clinical heterogeneity results from the complex interplay of the many genetic and environmental factors that themselves define a condition as multifactorial. However, it is important to note that neuropathological findings in both idiopathic and syndromic autism suggests a single pathophysiological mechanism acting during brain development: the heterochronic division of germinal cells and subsequent migrational abnormalities of daughter cells to their target fields. Multiple exogenous (e.g., viruses, drugs) and endogenous (e.g., genetic mutations) factors are known to disrupt the division of germinal cells and provide for an autism phenotype. The variety of endogenous and exogenous factors, their timing of action during brain development, and the genetic susceptibility of affected individuals (a Triple Hit hypothesis) may all account for the clinical heterogeneity of ASD.
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Affiliation(s)
- Manuel F Casanova
- Department of Psychiatry, University of Louisville, 500 South Preston Street, Building A, Room 217, Louisville, KY 40202, United States.
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McClintic AM, King BH, Webb SJ, Mourad PD. Mice exposed to diagnostic ultrasound in utero are less social and more active in social situations relative to controls. Autism Res 2013; 7:295-304. [PMID: 24249575 DOI: 10.1002/aur.1349] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/20/2013] [Indexed: 11/05/2022]
Abstract
Clinical use of diagnostic ultrasound imaging during pregnancy has a long history of safety and diagnostic utility, as supported by numerous human case reports and epidemiological studies. However, there exist in vivo studies linking large but clinically relevant doses of ultrasound applied to mouse fetuses in utero to altered learning, memory, and neuroanatomy of those mice. Also, there exists a well-documented significant increase in the likelihood of non-right-handedness in boys exposed to diagnostic ultrasound in utero, potentially relevant given the increased prevalence of autism in males, and reports of excess non-right-handedness in this population. Motivated by these observations, we applied 30 minutes of diagnostic ultrasound to pregnant mice at embryonic day 14.5 and assayed the social behavior of their male pups 3 weeks after their birth. The ultrasound-exposed pups were significantly (P < 0.01) less interested in social interaction than sham-exposed pups in a three-chamber sociability test. In addition, they demonstrated significantly (P < 0.05) more activity relative to the sham-exposed pups, but only in the presence of an unfamiliar mouse. These results suggest that fetal exposure to diagnostic ultrasound applied in utero can alter typical social behaviors in young mice that may be relevant for autism. There exist meaningful differences between the exposure of diagnostic ultrasound to mice versus humans that require further exploration before this work can usefully inform clinical practice. Future work should address these differences as well as clarify the extent, mechanisms, and functional effects of diagnostic ultrasound's interaction with the developing brain.
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Affiliation(s)
- Abbi M McClintic
- Department Neurological Surgery, University of Washington, Seattle, Washington
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Etiopathogenesis of autism spectrum disorders: fitting the pieces of the puzzle together. Med Hypotheses 2013; 81:26-35. [PMID: 23622947 DOI: 10.1016/j.mehy.2013.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/26/2013] [Accepted: 04/01/2013] [Indexed: 12/19/2022]
Abstract
Autism spectrum disorders (ASD) are disorders of the central nervous system characterized by impairments in communication and social reciprocity. Despite thousands of studies on this topic, the etiopathogenesis of these disorders remains unclear, apart from a general belief that they derive from an interaction between several genes and the environment. Given the mystery surrounding the etiopathogenesis of ASD it is impossible to plan effective preventive and treatment measures. This is of particular concern due to the progressive increase in the prevalence of ASD, which has reached a figure as high as 1:88 children in the USA. Here we present data corroborating a novel unifying hypothesis of the etiopathogenesis of ASD. We suggest that ASD are disorders of the immune system that occur in a very early phase of embryonic development. In a background of genetic predisposition and environmental predisposition (probably vitamin D deficiency), an infection (notably a viral infection) could trigger a deranged immune response which, in turn, results in damage to specific areas of the central nervous system. If proven, this hypothesis would have dramatic consequences for strategies aimed at preventing and treating ASD. To confirm or refute this hypothesis, we need a novel research approach, which unlike former approaches in this field, examine the major factors implicated in ASD (genetic, infections, vitamin D deficiency, immune system deregulation) not separately, but collectively and simultaneously.
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Are prenatal ultrasound scans associated with the autism phenotype? Follow-up of a randomised controlled trial. J Autism Dev Disord 2013; 42:2693-701. [PMID: 22456820 DOI: 10.1007/s10803-012-1526-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
An existing randomised controlled trial was used to investigate whether multiple ultrasound scans may be associated with the autism phenotype. From 2,834 single pregnancies, 1,415 were selected at random to receive ultrasound imaging and continuous wave Doppler flow studies at five points throughout pregnancy (Intensive) and 1,419 to receive a single imaging scan at 18 weeks (Regular), with further scans only as indicated on clinical grounds. There was no significant difference in the rate of Autism Spectrum Disorder between the Regular (9/1,125, 0.8 %) and Intensive (7/1,167, 0.6 %) groups, nor a difference between groups in the level of autistic-like traits in early adulthood. There is no clear link between the frequency and timing of prenatal ultrasound scans and the autism phenotype.
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Zeidán-Chuliá F, Rybarczyk-Filho JL, Salmina AB, de Oliveira BHN, Noda M, Moreira JCF. Exploring the Multifactorial Nature of Autism Through Computational Systems Biology: Calcium and the Rho GTPase RAC1 Under the Spotlight. Neuromolecular Med 2013; 15:364-83. [DOI: 10.1007/s12017-013-8224-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 02/16/2013] [Indexed: 01/08/2023]
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Abramowicz JS. Ultrasound and autism: association, link, or coincidence? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1261-1269. [PMID: 22837291 DOI: 10.7863/jum.2012.31.8.1261] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Autism spectrum disorders (ASDs) affect an estimated 1% of children in the United States. The etiology is probably multifactorial, including genetic components and exposure to infections, toxins, and other environmental factors, particularly unfavorable perinatal and neonatal conditions. There has been an increase in the frequency of diagnosis of ASDs over the last 20 years with a parallel increase in the use of obstetric diagnostic ultrasound, with prenatal ultrasound exposure mentioned as the possible main etiology for autism "epidemics." Central nervous system alterations have been described in ASDs, and certain similar changes have been described in animals after exposure to ultrasound. However, analysis of in utero exposure in humans has failed to show harmful effects in neonates or children, particularly in school performance, attention disorders, and behavioral changes. There is no independently confirmed peer-reviewed published evidence that a cause-effect relationship exists between in utero exposure to clinical ultrasound and development of ASDs in childhood. Ultrasound is a form of energy with effects in the tissues it traverses, and its use should be restricted to medical indications, by trained professionals, for as short a period and as low an intensity as compatible with accurate diagnosis.
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Affiliation(s)
- Jacques S Abramowicz
- Department of Obstetrics and Gynecology and Rush Fetal and Neonatal Medicine Center, Rush University, Chicago, Illinois 60612, USA.
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Abstract
While a distinct minicolumnar phenotype seems to be an underlying factor in a significant portion of cases of autism, great attention is being paid not only to genetics but to epigenetic factors which may lead to development of the conditions. Here we discuss the indivisible role the molecular environment plays in cellular function, particularly the pivotal position which the transcription factor and adhesion molecule, β-catenin, occupies in cellular growth. In addition, the learning environment is not only integral to postnatal plasticity, but the prenatal environment plays a vital role during corticogenesis, neuritogenesis, and synaptogenesis as well. To illustrate these points in the case of autism, we review important findings in genetics studies (e.g., PTEN, TSC1/2, FMRP, MeCP2, Neurexin-Neuroligin) and known epigenetic factors (e.g., valproic acid, estrogen, immune system, ultrasound) which may predispose towards the minicolumnar and connectivity patterns seen in the conditions, showing how one-gene mutational syndromes and exposure to certain CNS teratogens may ultimately lead to comparable phenotypes. This in turn may shed greater light on how environment and complex genetics combinatorially give rise to a heterogenetic group of conditions such as autism.
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Affiliation(s)
- Emily L. Williams
- Department of Anatomical Sciences and Neurobiology, University of Louisville, Louisville, KY 40202, USA
| | - Manuel F. Casanova
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY 40202, USA
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Chance SA, Clover L, Cousijn H, Currah L, Pettingill R, Esiri MM. Microanatomical Correlates of Cognitive Ability and Decline: Normal Ageing, MCI, and Alzheimer's Disease. Cereb Cortex 2011; 21:1870-8. [DOI: 10.1093/cercor/bhq264] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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