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Bullens K, Sleurs C, Blommaert J, Lemiere J, Jacobs S. A systematic review of interventions for neurocognitive dysfunctions in patients and survivors of a pediatric brain tumor. Pediatr Blood Cancer 2024:e31327. [PMID: 39300698 DOI: 10.1002/pbc.31327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 09/02/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024]
Abstract
Due to a high burden of neurocognitive impairment on patients with a pediatric brain tumor, interventions mitigating these symptoms are highly needed. Currently, evidence on the efficacy and feasibility of such interventions remains scarce. A systematic literature study was performed based on four different databases (PubMed, Web of Science Core Collection, Embase, and PsycArticles). Resulting articles (n = 2232) were screened based on title and abstract, and full text. We included 28 articles, investigating cognitive effects of either a lifestyle intervention (n = 6), a cognitive training (n = 15), or pharmacological intervention (n = 7). The most frequently studied interventions were the Cogmed and methylphenidate. Most interventions showed short-term efficacy. Fewer interventions also showed long-term maintenance of positive results. Despite positive trends of these interventions, results are heterogeneous, suggesting relatively limited efficacy of existing interventions and more potential of more individualized as well as multimodal approaches for future interventions.
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Affiliation(s)
| | - Charlotte Sleurs
- Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | | | - Jurgen Lemiere
- Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Sandra Jacobs
- Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium
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Drabek-Maunder ER, Mankad K, Aquilina K, Dean JA, Nisbet A, Clark CA. Using diffusion MRI to understand white matter damage and the link between brain microstructure and cognitive deficits in paediatric medulloblastoma patients. Eur J Radiol 2024; 177:111562. [PMID: 38901074 DOI: 10.1016/j.ejrad.2024.111562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/09/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE Survivors of medulloblastoma face a range of challenges after treatment, involving behavioural, cognitive, language and motor skills. Post-treatment outcomes are associated with structural changes within the brain resulting from both the tumour and the treatment. Diffusion magnetic resonance imaging (MRI) has been used to investigate the microstructure of the brain. In this review, we aim to summarise the literature on diffusion MRI in patients treated for medulloblastoma and discuss future directions on how diffusion imaging can be used to improve patient quality. METHOD This review summarises the current literature on medulloblastoma in children, focusing on the impact of both the tumour and its treatment on brain microstructure. We review studies where diffusion MRI has been correlated with either treatment characteristics or cognitive outcomes. We discuss the role diffusion MRI has taken in understanding the relationship between microstructural damage and cognitive and behavioural deficits. RESULTS We identified 35 studies that analysed diffusion MRI changes in patients treated for medulloblastoma. The majority of these studies found significant group differences in measures of brain microstructure between patients and controls, and some of these studies showed associations between microstructure and neurocognitive outcomes, which could be influenced by patient characteristics (e.g. age), treatment, radiation dose and treatment type. CONCLUSIONS In future, studies would benefit from being able to separate microstructural white matter damage caused by the tumour, tumour-related complications and treatment. Additionally, advanced diffusion modelling methods can be explored to understand and describe microstructural changes to white matter.
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Affiliation(s)
- Emily R Drabek-Maunder
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Kristian Aquilina
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Jamie A Dean
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Andrew Nisbet
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Chris A Clark
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
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Skocic J, Richard L, Ferkul A, Cox E, Tseng J, Laughlin S, Bouffet E, Mabbott DJ. Multimodal imaging with magnetization transfer and diffusion tensor imaging reveals evidence of myelin damage in children and youth treated for a brain tumor. Neurooncol Pract 2024; 11:307-318. [PMID: 38737604 PMCID: PMC11085850 DOI: 10.1093/nop/npae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background The microstructural damage underlying compromise of white matter following treatment for pediatric brain tumors is unclear. We use multimodal imaging employing advanced diffusion tensor imaging (DTI) and magnetization transfer imaging (MTI) MRI methods to examine chronic microstructural damage to white matter in children and adolescents treated for pediatric brain tumor. Notably, MTI may be more sensitive to macromolecular content, including myelin, than DTI. Methods Fifty patients treated for brain tumors (18 treated with surgery ± chemotherapy and 32 treated with surgery followed by cranial-spinal radiation; time from diagnosis to scan ~6 years) and 45 matched healthy children completed both MTI and DTI scans. Voxelwise and region-of-interest approaches were employed to compare white matter microstructure metrics (magnetization transfer ratio (MTR); DTI- fractional anisotropy [FA], radial diffusivity [RD], axial diffusivity [AD], mean diffusivity [MD]) between patients and healthy controls. Results MTR was decreased across multiple white matter tracts in patients when compared to healthy children, P < .001. These differences were observed for both patients treated with radiation and those treated with only surgery, P < .001. We also found that children and adolescents treated for brain tumors exhibit decreased FA and increased RD/AD/MD compared to their healthy counterparts in several white matter regions, Ps < .02. Finally, we observed that MTR and DTI metrics were related to multiple white matter tracts in patients, Ps < .01, but not healthy control children. Conclusions Our findings provide evidence that the white matter damage observed in patients years after treatment of pediatric posterior fossa tumors, likely reflects myelin disruption.
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Affiliation(s)
- Jovanka Skocic
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Logan Richard
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ashley Ferkul
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Cox
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Julie Tseng
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suzanne Laughlin
- Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
- Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Donald James Mabbott
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
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Ainslie AP, Klaver M, Voshart DC, Gerrits E, den Dunnen WFA, Eggen BJL, Bergink S, Barazzuol L. Glioblastoma and its treatment are associated with extensive accelerated brain aging. Aging Cell 2024; 23:e14066. [PMID: 38234228 PMCID: PMC10928584 DOI: 10.1111/acel.14066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024] Open
Abstract
Progressive neurocognitive dysfunction is the leading cause of a reduced quality of life in patients with primary brain tumors. Understanding how the human brain responds to cancer and its treatment is essential to improve the associated cognitive sequelae. In this study, we performed integrated transcriptomic and tissue analysis on postmortem normal-appearing non-tumor brain tissue from glioblastoma (GBM) patients that had received cancer treatments, region-matched brain tissue from unaffected control individuals and Alzheimer's disease (AD) patients. We show that normal-appearing non-tumor brain regions of patients with GBM display hallmarks of accelerated aging, in particular mitochondrial dysfunction, inflammation, and proteostasis deregulation. The extent and spatial pattern of this response decreased with distance from the tumor. Gene set enrichment analyses and a direct comparative analysis with an independent cohort of brain tissue samples from AD patients revealed a significant overlap in differentially expressed genes and a similar biological aging trajectory. Additionally, these responses were validated at the protein level showing the presence of increased lysosomal lipofuscin, phosphorylated microtubule-associated protein Tau, and oxidative DNA damage in normal-appearing brain areas of GBM patients. Overall, our data show that the brain of GBM patients undergoes accelerated aging and shared AD-like features, providing the basis for novel or repurposed therapeutic targets for managing brain tumor-related side effects.
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Affiliation(s)
- Anna P. Ainslie
- Department of Radiation OncologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- European Research Institute for the Biology of AgeingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Myrthe Klaver
- Department of Radiation OncologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- European Research Institute for the Biology of AgeingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Daniëlle C. Voshart
- Department of Radiation OncologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Emma Gerrits
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Wilfred F. A. den Dunnen
- Department of Pathology and Medical BiologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Bart J. L. Eggen
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Steven Bergink
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- University College Groningen, University of GroningenGroningenThe Netherlands
| | - Lara Barazzuol
- Department of Radiation OncologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Biomedical Sciences of Cells and SystemsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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Grosshans D, Thomas R, Zhang D, Cronkite C, Thomas R, Singh S, Bronk L, Morales R, Duman J. Subcellular functions of tau mediates repair response and synaptic homeostasis in injury. RESEARCH SQUARE 2024:rs.3.rs-3897741. [PMID: 38464175 PMCID: PMC10925419 DOI: 10.21203/rs.3.rs-3897741/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Injury responses in terminally differentiated cells such as neurons is tightly regulated by pathways aiding homeostatic maintenance. Cancer patients subjected to neuronal injury in brain radiation experience cognitive declines similar to those seen in primary neurodegenerative diseases. Numerous studies have investigated the effect of radiation in proliferating cells of the brain, yet the impact in differentiated, post-mitotic neurons, especially the structural and functional alterations remain largely elusive. We identified that microtubule-associated tau is a critical player in neuronal injury response via compartmentalized functions in both repair-centric and synaptic regulatory pathways. Ionizing radiation-induced injury acutely induces increase in phosphorylated tau in the nucleus and directly interacts with histone 2AX (H2AX), a DNA damage repair (DDR) marker. Loss of tau significantly reduced H2AX after irradiation, indicating that tau may play an important role in neuronal DDR response. We also observed that loss of tau increases eukaryotic elongation factor levels after irradiation, the latter being a positive regulator of protein translation. This cascades into a significant increase in synaptic proteins, resulting in disrupted homeostasis. Consequently, novel object recognition test showed decrease in learning and memory in tau-knockout mice after irradiation, and electroencephalographic activity showed increase in delta and theta band oscillations, often seen in dementia patients. Our findings demonstrate tau's previously undefined, multifunctional role in acute responses to injury, ranging from DDR response in the nucleus to synaptic function within a neuron. Such knowledge is vital to develop therapeutic strategies targeting neuronal injury in cognitive decline for at risk and vulnerable populations.
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Voshart DC, Oshima T, Jiang Y, van der Linden GP, Ainslie AP, Reali Nazario L, van Buuren-Broek F, Scholma AC, van Weering HRJ, Brouwer N, Sewdihal J, Brouwer U, Coppes RP, Holtman IR, Eggen BJL, Kooistra SM, Barazzuol L. Radiotherapy induces persistent innate immune reprogramming of microglia into a primed state. Cell Rep 2024; 43:113764. [PMID: 38358885 DOI: 10.1016/j.celrep.2024.113764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
Over half of patients with brain tumors experience debilitating and often progressive cognitive decline after radiotherapy treatment. Microglia, the resident macrophages in the brain, have been implicated in this decline. In response to various insults, microglia can develop innate immune memory (IIM), which can either enhance (priming or training) or repress (tolerance) the response to subsequent inflammatory challenges. Here, we investigate whether radiation affects the IIM of microglia by irradiating the brains of rats and later exposing them to a secondary inflammatory stimulus. Comparative transcriptomic profiling and protein validation of microglia isolated from irradiated rats show a stronger immune response to a secondary inflammatory insult, demonstrating that radiation can lead to long-lasting molecular reprogramming of microglia. Transcriptomic analysis of postmortem normal-appearing non-tumor brain tissue of patients with glioblastoma indicates that radiation-induced microglial priming is likely conserved in humans. Targeting microglial priming or avoiding further inflammatory insults could decrease radiotherapy-induced neurotoxicity.
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Affiliation(s)
- Daniëlle C Voshart
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Takuya Oshima
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Yuting Jiang
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Gideon P van der Linden
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Anna P Ainslie
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands; European Research Institute for the Biology of Ageing (ERIBA), University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Luiza Reali Nazario
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Fleur van Buuren-Broek
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Ayla C Scholma
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Hilmar R J van Weering
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Nieske Brouwer
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Jeffrey Sewdihal
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Uilke Brouwer
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Rob P Coppes
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands
| | - Inge R Holtman
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Bart J L Eggen
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Susanne M Kooistra
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands
| | - Lara Barazzuol
- Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, the Netherlands; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, the Netherlands.
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Baudou É, Ryan JL, Cox E, Nham L, Johnston K, Bouffet É, Bartels U, Timmons B, de Medeiros C, Mabbott DJ. Optimizing an exercise training program in pediatric brain tumour survivors: Does timing postradiotherapy matter? Neurooncol Pract 2024; 11:69-81. [PMID: 38222057 PMCID: PMC10785595 DOI: 10.1093/nop/npad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Background While exercise training (ET) programs show positive outcomes in cognition, motor function, and physical fitness in pediatric brain tumor (PBT) survivors, little is known about the optimal timing of intervention. The aim of this work was to explore the feasibility and benefits of ET based on its timing after radiotherapy. Methods This retrospective analysis (ClinicalTrials.gov, NCT01944761) analyzed data based on the timing of PBT survivors' participation in an ET program relative to their completion of radiotherapy: <2 years (n = 9), 2-5 years (n = 10), and > 5 years (n = 13). We used repeated measures analysis of variance to compare feasibility and efficacy indicators among groups, as well as correlation analysis between ET program timing postradiotherapy and preliminary treatment effects on cognition, motor function and physical fitness outcomes. Results Two to five years postradiotherapy was the optimal time period in terms of adherence (88.5%), retention (100%), and satisfaction (more fun, more enjoyable and recommend it more to other children). However, the benefits of ET program on memory recognition (r = -0.379, P = .047) and accuracy (r = -0.430, P = .032) decreased with increased time postradiotherapy. Motor function improved in all groups, with greater improvements in bilateral coordination (P = .043) earlier postradiotherapy, and in running (P = .043) later postradiotherapy. The greatest improvement in pro-rated work rate occurred in the < 2-year group (P = .008). Conclusion Participation in an ET program should be offered as part of routine postradiotherapy care in the first 1-2 years and strongly encouraged in the first 5 years.
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Affiliation(s)
- Éloïse Baudou
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L Ryan
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Cox
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lisa Nham
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Krista Johnston
- Divisions of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Éric Bouffet
- Divisions of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ute Bartels
- Divisions of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian Timmons
- Department of Pediatrics, Child Health and Exercise Medicine Program, McMaster University, Hamilton, ON, Canada
| | - Cynthia de Medeiros
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donald J Mabbott
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
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