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Anning KL, Langley K, Hobson C, van Goozen SHM. Cool and hot executive function problems in young children: linking self-regulation processes to emerging clinical symptoms. Eur Child Adolesc Psychiatry 2024; 33:2705-2718. [PMID: 38183461 PMCID: PMC11272683 DOI: 10.1007/s00787-023-02344-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/28/2023] [Indexed: 01/08/2024]
Abstract
Self-regulation (SR) difficulties are implicated in a wide range of disorders which develop in childhood, including attention deficit hyperactivity disorder (ADHD), oppositional defiance disorder (ODD), anxiety and depression. However, the integration of the existing research evidence is challenging because of varying terminology and the wide range of tasks used, as well as the heterogeneity and comorbidity within and across diagnostic categories. The current study used the Research Domain Criteria (RDoC) framework to guide the examination of different SR processes in young children showing a wide range of symptomatology. Children (aged 4-8) referred by teachers for moderate-to-high conduct, hyperactivity and/or emotional problems at school (assessed using the Strengths and Difficulties Questionnaire (SDQ) subscales; n = 212), and children in SDQ typical ranges (n = 30) completed computerised cognitive control and decision-making tasks. Parents completed questionnaires to assess ADHD, ODD, anxiety and depression symptoms (n = 191). Compared to children with no teacher-reported difficulties, those with moderate-to-high problems showed poorer visuomotor control and decision-making. A factor analysis revealed that task variables adhered to RDoC dimensions and predicted variance in specific disorders: difficulties in cognitive control predicted ADHD symptoms, low reward-seeking was associated with depression and high reward-seeking was associated with ODD. This study highlights how the assessment of cognitive processes positioned within the RDoC framework can inform our understanding of disorder-specific and transdiagnostic difficulties in SR which are associated with diverse clinical symptoms in children.
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Affiliation(s)
- Kate L Anning
- School of Psychology, Cardiff University, Cardiff, UK.
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.
| | - Kate Langley
- School of Psychology, Cardiff University, Cardiff, UK
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2
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Alghamdi MA, O'Donnell‐Luria A, Almontashiri NA, AlAali WY, Ali HH, Levy HL. Classical phenylketonuria presenting as maternal PKU syndrome in the offspring of an intellectually normal woman. JIMD Rep 2023; 64:312-316. [PMID: 37701331 PMCID: PMC10494492 DOI: 10.1002/jmd2.12384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 09/14/2023] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism resulting from a deficiency of phenylalanine hydroxylase (PAH). If untreated by dietary restriction of phenylalanine intake, impaired postnatal cognitive development results from the neurotoxic effects of excessive phenylalanine (Phe). Signs and symptoms include severe intellectual disability and behavior problems with a high frequency of seizures and variable microcephaly. Maternal PKU syndrome refers to fetal damage resulting in congenital abnormalities when the mother has untreated PKU during pregnancy. Here, we report an intellectually normal 32-year-old female who presented with recurrent pregnancy loss and two neonatal deaths with congenital heart disease, microcephaly, intrauterine growth restriction, and respiratory distress. She was diagnosed with PKU through exome sequencing performed for carrier testing with a homozygous pathogenic variant in the PAH gene, c.169_171del, p.(Glu57del) that is associated with classical PKU. Consistent with the genetic finding, she had a markedly increased plasma phenylalanine concentration of 1642 μmol/L (normal <100). This case demonstrates that recurrent pregnancy loss due to untreated maternal PKU may present as an initial finding in otherwise unsuspected classical PKU and illustrates that extreme degrees of variable expressivity may occur in classical PKU. Moreover, this case illustrates the value of genomic sequencing of women who experience recurrent pregnancy loss or neonatal anomalies.
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Affiliation(s)
- Malak Ali Alghamdi
- Harvard Medical SchoolBostonMassachusettsUSA
- Medical Genetic Division, Pediatric DepartmentCollege of Medicine, King Saud UniversityRiyadhSaudi Arabia
- Program in Medical and Population GeneticsBroad Institute of MIT and HarvardCambridgeMassachusettsUSA
| | - Anne O'Donnell‐Luria
- Harvard Medical SchoolBostonMassachusettsUSA
- Program in Medical and Population GeneticsBroad Institute of MIT and HarvardCambridgeMassachusettsUSA
- Division of Genetics and GenomicsBoston Children's HospitalBostonMassachusettsUSA
| | - Naif A. Almontashiri
- Center for Genetics and Inherited Diseases (CGID)Taibah UniversityMadinahSaudi Arabia
| | - Wajeih Y. AlAali
- Dr. Sulaiman Al Habib Medical GroupArryan HospitalRiyadhSaudi Arabia
| | - Hebatallah H. Ali
- Research Center, College of MedicineKing Saud UniversityRiyadhSaudi Arabia
| | - Harvey L. Levy
- Harvard Medical SchoolBostonMassachusettsUSA
- Program in Medical and Population GeneticsBroad Institute of MIT and HarvardCambridgeMassachusettsUSA
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3
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Theron M, Jeannesson E, Canton M, Namour F, Oussalah A, Feillet F, Wiedemann A. Blood phenylalanine fluctuation in phenylketonuric children treated by BH4 or low-phenylalanine diet from birth. Sci Rep 2023; 13:9559. [PMID: 37308610 DOI: 10.1038/s41598-023-36550-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 06/06/2023] [Indexed: 06/14/2023] Open
Abstract
The prognosis of phenylketonuria (PKU) is related to the quality of metabolic control all life-long. PKU treatment is based on a low-Phe diet, 6R-tetrahydrobiopterin (BH4) treatment for the BH4-responsive PKU patients or enzyme replacement therapy. Fluctuations in blood phenylalanine (Phe) concentrations may be an important determinant of intellectual outcome in patients with early and continuously treated phenylketonuria (PKU). The aim of this work is to study the fluctuation of Blood Phe in patients treated by BH4 from birth in comparison with patients treated by low-Phe diet. We conducted a retrospective study in a national reference center for PKU management. We compared mean phenylalanine blood concentration and its fluctuation in 10 BH4-responder patients (BH4R) and in 10 BH4 non-responder patients (BH4NR) treated from birth. The mean blood Phe concentration is similar between the two groups before 10 years of age (290 ± 135 (BH4R) vs. 329 ± 187 µmol/L, p = 0.066 (BH4NR)) while it is lower in the BH4R group after 10 years of age. (209 ± 69 vs. 579 ± 136 µmol/L, p = 0.0008). Blood Phe fluctuation is significantly lower in the BH4R group compared to the BH4NR group (70.2 ± 75.6 vs. 104.4 ± 111.6 µmol/L, p < 0.01) before 6 years of age. There are no significant differences observed on nutritional status, growth, and neuropsychological tests between the two groups. BH4 introduced in the neonatal period is associated with less blood Phe fluctuation before 6 years. Additional time and patients are required to determine if the decrease in Phe fluctuation would positively impact the long-term outcome of PKU patients.
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Affiliation(s)
- Maurane Theron
- Pediatric Unit, Reference Center for Inborn Errors of Metabolism, University Hospital of Nancy, Nancy, France
| | - Elise Jeannesson
- Department of Molecular Medicine, Division of Biochemistry, University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Marie Canton
- Pediatric Unit, Reference Center for Inborn Errors of Metabolism, University Hospital of Nancy, Nancy, France
| | - Farès Namour
- Department of Molecular Medicine, Division of Biochemistry, University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Abderrahim Oussalah
- Department of Molecular Medicine, Division of Biochemistry, University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France
| | - François Feillet
- Pediatric Unit, Reference Center for Inborn Errors of Metabolism, University Hospital of Nancy, Nancy, France.
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France.
| | - Arnaud Wiedemann
- Pediatric Unit, Reference Center for Inborn Errors of Metabolism, University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France
- Pediatric Intensive Care Unit, University Hospital of Nancy, Nancy, France
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4
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Rovelli V, Longo N. Phenylketonuria and the brain. Mol Genet Metab 2023; 139:107583. [PMID: 37105048 DOI: 10.1016/j.ymgme.2023.107583] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
Classic phenylketonuria (PKU) is caused by defective activity of phenylalanine hydroxylase (PAH), the enzyme that coverts phenylalanine (Phe) to tyrosine. Toxic accumulation of phenylalanine and its metabolites, left untreated, affects brain development and function depending on the timing of exposure to elevated levels. The specific mechanisms of Phe-induced brain damage are not completely understood, but they correlate to phenylalanine levels and on the stage of brain growth. During fetal life, high levels of phenylalanine such as those seen in maternal PKU can result in microcephaly, neuronal loss and corpus callosum hypoplasia. Elevated phenylalanine levels during the first few years of life can cause acquired microcephaly, severe cognitive impairment and epilepsy, likely due to the impairment of synaptogenesis. During late childhood, elevated phenylalanine can cause alterations in neurological functioning, leading to ADHD, speech delay and mild IQ reduction. In adolescents and adults, executive function and mood are affected, with some of the abnormalities reversed by better control of phenylalanine levels. Altered brain myelination can be present at this stage. In this article, we review the current knowledge about the consequences of high phenylalanine levels in PKU patients and animal models through different stages of brain development and its effect on cognitive, behavioural and neuropsychological function.
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Affiliation(s)
- Valentina Rovelli
- Clinical Department of Pediatrics, University of Milan, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy.
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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5
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Costa-Lathan C, Vazquez-Agra N, Marques-Afonso AT, Cruces-Sande A, Martinez-Olmos MA, Araujo-Vilar D, Hermida-Ameijeiras A. The role of phenylalanine levels in the neuropsychological and neuroanatomical status of adult patients with phenylketonuria: The impact of fluctuations. J Investig Med 2023; 71:149-158. [PMID: 36647337 DOI: 10.1177/10815589221143485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We aimed to evaluate the role of plasma phenylalanine (Phe) levels and its fluctuations in some neurocognitive domains and brain magnetic resonance imaging (MRI) findings in adult patients with phenylketonuria (PKU). It was an observational study that included patients older than 18 years with early-treated classical PKU. Plasma Phe levels were measured every other month throughout 2 years and predictor variables were the mean, maximum (max), minimum (min), range (min-max), and plasma Phe levels at the time of cognitive testing. Patients were evaluated for executive function, processing speed, visual attention, and fluid cognitive abilities using the Trail Making Test (TMT) and for the presence of brain MRI abnormalities. In all, 22 patients with a mean age of 34 years were included, of which 18 (81%) were women. Patients with higher range and maximum Phe levels had a poorer time-based performance on TMT form A and form B. Patients with brain MRI abnormalities had higher range, maximum, and mean Phe levels. Range of Phe levels showed a good performance for MRI abnormalities (area under the curve (AUC): 0.881, standard error (SE): 0.095, 95% CI: 0.695-0.999, p = 0.044) and for the poorest time-based performances on TMT form A (AUC: 0.822, SE: 0.092, 95% CI: 0.641-0.999, p = 0.024) and B (AUC: 0.816, SE: 0.094, 95% CI: 0.632-0.999, p = 0.021). Greater Phe variability may have a negative impact on some neurocognitive domains and could be related to the severity of brain structural damage in adult patients with PKU.
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Affiliation(s)
| | - Nestor Vazquez-Agra
- Department of Internal Medicine, University Hospital of Santiago de Compostela, A Coruña, Spain
| | | | - Anton Cruces-Sande
- Laboratory of Neurochemistry, Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Santiago de Compostela, A Coruña, Spain
| | - Miguel-Angel Martinez-Olmos
- Division of Endocrinology and Nutrition, University Hospital of Santiago de Compostela, A Coruña, Spain.,CIBER Pathophysiology of Obesity and Nutrition (CIBERobn), Carlos III Health Institute, Madrid, Spain
| | - David Araujo-Vilar
- Division of Endocrinology and Nutrition, University Hospital of Santiago de Compostela, A Coruña, Spain.,UETeM-Molecular Pathology Group, Department of Medicine, IDIS-CIMUS, University of Santiago de Compostela, A Coruña, Spain
| | - Alvaro Hermida-Ameijeiras
- Department of Internal Medicine, University Hospital of Santiago de Compostela, A Coruña, Spain.,UETeM-Molecular Pathology Group, Department of Medicine, IDIS-CIMUS, University of Santiago de Compostela, A Coruña, Spain
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6
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Thomas L, Olson A, Romani C. The impact of metabolic control on cognition, neurophysiology, and well-being in PKU: A systematic review and meta-analysis of the within-participant literature. Mol Genet Metab 2023; 138:106969. [PMID: 36599257 DOI: 10.1016/j.ymgme.2022.106969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
Phenylketonuria (PKU) is a metabolic disease where Phenylalanine (Phe) rises much above normal levels. Cross-sectional and correlational studies provide valuable information on the importance of maintaining low blood-Phe to achieve good outcomes, but they may be confounded, at least partially, by differences in participant demographics. Moreover, the effect of Phe at older ages is difficult to ascertain because of strong associations between Phe levels across ages. Within-participant studies avoid confounding issues. We have reviewed these studies. We followed PRISMA guidelines to search the literature for studies reporting the impact of Phe changes within participants. Phe was either increased or decreased through diet relaxation/resumption or through pharmacological interventions. Forty-six separate articles reported, singly or in combination, results on cognition (N = 37), well-being (N = 22) and neurophysiological health (N = 14). For all studies, we established, in a binary way, whether a benefit of lower Phe was or was not demonstrated and compared numbers showing benefit versus a null or negative outcome. We then analyzed whether critical parameters (e.g., length of the study/condition for the change, size of Phe change achieved) influenced presence or absence of benefit. For a subset of studies that reported quantitative cognitive outcomes, we carried out a meta-analysis to estimate the size of change in cognitive performance associated with a change in Phe and its significance. There were significantly more studies with benefits than no benefits, both for cognitive and well-being outcomes, and a trend in this direction for neurophysiological outcomes. The meta-analysis showed a highly significant effect size both overall (0.55) and when studies with adults/adolescents were considered separately (0.57). There was some indication that benefits were easier to demonstrate when differences in Phe were larger and achieved across a longer period, but these effects were not always consistent. These results reinforce results from the literature by demonstrating the importance of lower Phe in children as well as in adolescents and adults, even when confounding factors in group composition are eliminated. The field would benefit from further studies where Phe levels are contrasted within-participants to ascertain how much Phe needs to be changed and for how long to see a difference and which measures demonstrate a difference (e.g., which cognitive tasks).
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Brown AA, Clocksin HE, Abbene EE, Ursery M, Christ SE. The relationship between metabolic control and basal ganglia morphometry and function in individuals with early-treated phenylketonuria. Mol Genet Metab 2022; 137:249-256. [PMID: 36209659 DOI: 10.1016/j.ymgme.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
Abstract
Abnormalities of the cortical white matter are the most prominent and widely-reported neurological findings in individuals with early-treated phenylketonuria (ETPKU). Much less is known regarding the effects of ETPKU on gray matter structures in the brain such as the basal ganglia. Previous findings on basal ganglia in ETPKU have been mixed. The current study was designed to further elucidate the effects of ETPKU and elevated phe levels on the morphometry of basal ganglia structures (i.e., putamen, caudate nucleus, nucleus accumbens, and globus pallidus). High resolution magnetic resonance imaging (MRI) data was collected from a sample of 37 adults with ETPKU and a demographically-matched comparison group of 33 individuals without PKU. No overall group differences (ETPKU vs. non-PKU) in basal ganglia volumes were observed. However, within the ETPKU group, poorer metabolic control (as reflected by higher blood phenylalanine levels) was associated with larger putamen volume. Vertex-wise shape analysis revealed that the volume increase was accompanied by shape changes in the middle left putamen. Consistent with this area's role in motor control, a significant correlation between left putamen volume and motor performance was also observed. Additional research is needed to fully understand the cellular level processes underlying this effect as well as to better understand the clinical impact of these morphometric changes and their potential relation to treatment response.
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Affiliation(s)
- Alexander A Brown
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Hayley E Clocksin
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Emily E Abbene
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Mikayla Ursery
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA.
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Ben Abdelaziz R, Tangour N, Ben Chehida A, Haj Taieb S, Feki M, Azzouz H, Tebib N. Morning specimen is not representative of metabolic control in Tunisian children with phenylketonuria: a repeated cross-sectional study. J Pediatr Endocrinol Metab 2020; 33:/j/jpem.ahead-of-print/jpem-2020-0025/jpem-2020-0025.xml. [PMID: 32653876 DOI: 10.1515/jpem-2020-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/04/2020] [Indexed: 11/15/2022]
Abstract
Objective and methods To evaluate variation of capillary phenylalanine concentrations over the day in patients treated for phenylketonuria and the reliability of the morning sample to assess metabolic control, we conducted a repeated cross-sectional study in 25 Tunisian patients on phenylalanine-low diet. For each patient, we collected nine capillary samples over the day. Phenylalanine was dosed by fluorimetry. Results There was a wide variability of phenylalanine concentrations over the day (p<0.001). Compared to morning sample, phenylalanine concentration was significantly lower before lunch (p=0.038), after lunch (p=0.025), before dinner (p<0.001), after dinner (p=0.035) and at 4:00 a.m. (p=0.011). Compared to the 24 h sampling, the morning sample had a 68% to identify unbalanced patients. 60% of patients, had peak phenylalanine concentration after the morning. Half of the patients with normal morning phenylalanine concentration had low phenylalanine values over 8-20 h. Percentages of high phenylalanine concentrations over the last semester were higher in patients with poor metabolic control over the 24 h (21% ± 43 vs. 0% ± 9%); p=0.043. Conclusion A single morning sample gives an incomplete information on metabolic control in phenylketonuric patients. Using four pre-prandial samples on the day should be considered as alternative in patients with good metabolic control.
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Affiliation(s)
- Rim Ben Abdelaziz
- Department of Pediatrics, La Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis Elmanar, Tunis, Tunisia
- Research Laboratory LR12SPO2, Ministry of High Education, Tunis, Tunisia
| | - Nizar Tangour
- Department of Pediatrics, La Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis Elmanar, Tunis, Tunisia
- Research Laboratory LR12SPO2, Ministry of High Education, Tunis, Tunisia
| | - Amel Ben Chehida
- Department of Pediatrics, La Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis Elmanar, Tunis, Tunisia
- Research Laboratory LR12SPO2, Ministry of High Education, Tunis, Tunisia
| | - Sameh Haj Taieb
- Biochemistry Laboratory, La Rabta Hospital, Jabbari, 1007, Tunis, Tunisia
| | - Moncef Feki
- Faculty of Medicine of Tunis, University of Tunis Elmanar, Tunis, Tunisia
- Biochemistry Laboratory, La Rabta Hospital, Jabbari, 1007, Tunis, Tunisia
| | - Hatem Azzouz
- Department of Pediatrics, La Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis Elmanar, Tunis, Tunisia
- Research Laboratory LR12SPO2, Ministry of High Education, Tunis, Tunisia
| | - Neji Tebib
- Department of Pediatrics, La Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis Elmanar, Tunis, Tunisia
- Research Laboratory LR12SPO2, Ministry of High Education, Tunis, Tunisia
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Trimarco B, Manti F, Nardecchia F, Melogno S, Testa M, Meledandri G, Carducci C, Penge R, Leuzzi V. Executive functioning, adaptive skills, emotional and behavioral profile: A comparison between autism spectrum disorder and phenylketonuria. Mol Genet Metab Rep 2020; 23:100577. [PMID: 32181141 PMCID: PMC7066217 DOI: 10.1016/j.ymgmr.2020.100577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 02/22/2020] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Influential theories maintain that some of Autism Spectrum Disorder (ASD) core symptoms may arise from deficits in executive functions (EF). EF deficits are also considered a neuropsychological marker of early treated individuals with phenylketonuria (PKU). Aims of this study were: to verify the occurrence and patterns of specific EF impairments in both clinical groups; to explore the coexistence of EF alterations with adaptive, behavioral and emotional problems in each clinical condition. MATERIAL AND METHODS We assessed EF, adaptive, behavioral and emotional profile in 21 participants with ASD, 15 early treated PKU individuals, comparable for age and IQ, and 14 controls, comparable for age to the clinical groups (age range: 7-14 years). RESULTS ASD and PKU participants presented two different, but partially overlapping patterns of EF impairment. While ASD participants showed a specific deficit in cognitive flexibility only, PKU individuals showed a more extensive impairment in EF with a weaker performance in two core EF domains (inhibition, cognitive flexibility) as compared to healthy controls. Psychological and adaptive profile was typical in PKU participants, while ASD participants experienced behavioral (externalizing symptoms), emotional (internalizing symptoms) and adaptive disorders (general, practical, social domains). CONCLUSIONS Present results support the view of a relative disengagement of adaptive and emotional-behavioral profile with respect to EF skills and suggest that other dysfunctions contribute to the multidimensional phenotype of ASD participants.
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Affiliation(s)
- Barbara Trimarco
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - Filippo Manti
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - Francesca Nardecchia
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - Sergio Melogno
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - Mara Testa
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - Giovanni Meledandri
- Department of Human Science, “Università degli Studi Guglielmo Marconi”, Via Plinio 44, 00193 Rome, Italy
| | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Viale del policlinico 155, 00161 Rome, Italy
| | - Roberta Penge
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
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10
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Nardecchia F, Manti F, De Leo S, Carducci C, Leuzzi V. Clinical characterization of tremor in patients with phenylketonuria. Mol Genet Metab 2019; 128:53-56. [PMID: 31208951 DOI: 10.1016/j.ymgme.2019.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is due to the deficit of the enzyme phenylalanine hydroxylase, the first step of dopamine synthesis. If not early treated the disease results in severe neurological impairment. Minor neurological signs have been reported in early treated PKU (ETPKU) subjects. Prolactin level is affected by (and reflects) brain dopamine availability. Object of the study was to assess the occurrence, age at onset, distribution, associated neurological signs, and possible pathogenetic biomarkers of tremor in ETPKU. METHODS Fifty-nine ETPKU and 43 control subjects (age range 7-54) underwent individual and familiar tremor history, clinical assessment of tremor by means of the Fahn-Tolosa-Marin Tremor Rating Scale, and IQ evaluation. Historical and concomitant biochemical data (blood levels of Phe) and serum prolactin were included in the analysis. RESULTS Thirty-two percent of ETPKU patients were affected by postural and kinetic tremor. We found a significant correlation between severity of tremor and: prolactin level at the day of examination (part A: rs = 0.320; p = .014; part C: rs = 0.319; p = .014), Phe fluctuations from 12 years onwards (part B: rs = 0.300; p = .036). We also found a significant correlation between prolactin (18.2 ± 9.6 ng/ml) and Phe levels (852 ± 472 μmol/l) on the day of assessment (rs = 0.470; p < .001). CONCLUSIONS The main clinical features of tremor in ETPKU evoke those of essential tremor, although with a higher prevalence and an earlier onset than in general population. The severity of tremor was related to concomitant prolactin rather than Phe levels. This pattern suggests that metabolic alterations associated with PKU may result in an anticipation of the tremor onset in subjects who are possibly prone to this disorder.
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Affiliation(s)
| | - Filippo Manti
- Department of Human Neuroscience, Sapienza University of Rome, Italy
| | - Sabrina De Leo
- Department of Internal Medicine and Clinical Nutrition, Sapienza University of Rome, Italy
| | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Sapienza University of Rome, Italy.
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11
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Neuropsychological Profile of Children with Early and Continuously Treated Phenylketonuria: Systematic Review and Future Approaches. J Int Neuropsychol Soc 2019; 25:624-643. [PMID: 31030702 DOI: 10.1017/s1355617719000146] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To provide a comprehensive systematic review of the literature by examining studies published on all cognitive aspects of children with early and continuously treated phenylketonuria (ECT-PKU) included in the databases Medline, PsycINFO, and PsycARTICLE. METHOD In addition to a classical approach, we summarized methodology and results of each study in order to discuss current theoretical and methodological issues. We also examined recent advances in biochemical markers and treatments of PKU, with implications for future research on metabolic control and its role as a determinant of neuropsychological outcome. RESULTS Consistent with previous reviews, the hypothesis of a specific and central executive impairment in children with ECT-PKU was suggested. However, findings are inconclusive regarding the nature of executive impairments as well as their specificity, impact on everyday life, persistence over time, and etiology. CONCLUSION Given the current state of the science, we suggest future directions for research that utilizes a developmental and integrative approach to examine the effects of recent advances in biochemical markers and treatment of PKU. (JINS, 2019, 25, 624-643).
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Qu J, Yang T, Wang E, Li M, Chen C, Ma L, Zhou Y, Cui Y. Efficacy and safety of sapropterin dihydrochloride in patients with phenylketonuria: A meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2019; 85:893-899. [PMID: 30720885 PMCID: PMC6475685 DOI: 10.1111/bcp.13886] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/08/2019] [Accepted: 01/19/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS The aim of the present meta-analysis was to evaluate the efficacy and safety of sapropterin dihydrochloride in phenylketonuria (PKU) patients. METHODS The following databases were searched for randomized controlled trials (RCT) regarding PKU patients treated with sapropterin dihydrochloride: PubMed, Embase, Cochrane Library and clinicaltrials. Two authors independently selected studies, assessed the risk of bias and extracted data. The meta-analysis was performed in RevMan 5.3 provided by the Cochrane Collaboration. RESULTS Four studies met the inclusion criteria. In PKU patients with low blood phenylalanine (Phe) concentration, no significant difference was indicated for the decrease of Phe level (weighted mean difference (WMD) = -7.75 μmol L-1 ; 95% confidence intervals (CI): -82.63 to 67.13, P = 0.84, I2 = 0%), however, the dietary Phe tolerance was significantly improved in the sapropterin group (WMD = 19.89 mg kg-1 d-1 ; 95% CI: 10.26 to 29.52, P < 0.0001, I2 = 0%). In PKU patients with high blood Phe level, sapropterin showed a significant lowering in blood Phe concentration (WMD = -225.31 μmol L-1 ; 95% CI: -312.28 to -138.34, P < 0.00001, I2 = 0%). There was no significant difference for adverse events. CONCLUSIONS Sapropterin could bring benefit for PKU patients with high or low Phe level, due to Phe reduction in a short time or dietary Phe tolerance improvement respectively. Sapropterin has an acceptable safety profile.
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Affiliation(s)
- Jinghan Qu
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Ting Yang
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
| | - Ente Wang
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Min Li
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Chaoyang Chen
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
| | - Lingyun Ma
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
| | - Ying Zhou
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
| | - Yimin Cui
- Department of PharmacyPeking University First Hospital8 Xishiku Street, Xicheng DistrictBeijing100034China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical SciencesPeking University Health Science Center38 Xueyuan Rd, Haidian District100191China
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Daly A, Evans S, Chahal S, Santra S, Pinto A, Gingell C, Rocha JC, van Spronsen F, Jackson R, MacDonald A. The Effect of Glycomacropeptide versus Amino Acids on Phenylalanine and Tyrosine Variability over 24 Hours in Children with PKU: A Randomized Controlled Trial. Nutrients 2019; 11:nu11030520. [PMID: 30823411 PMCID: PMC6471794 DOI: 10.3390/nu11030520] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 01/09/2023] Open
Abstract
Introduction: In phenylketonuria (PKU), evidence suggests that casein glycomacropeptide supplemented with rate-limiting amino acids (CGMP-AA) is associated with better protein utilisation and less blood phenylalanine (Phe) variability. Aim: To study the impact of CGMP-AA on blood Phe variability using 3 different dietary regimens in children with PKU. Methods: This was a 6-week randomised controlled cross-over study comparing CGMP-AA vs. Phe-free l-amino acids (l-AA) assessing blood Phe and tyrosine (Tyr) variability over 24 h in 19 children (7 boys) with PKU, with a median age of 10 years (6–16). Subjects were randomised to 3 dietary regimens: (1) R1, CGMP-AA and usual dietary Phe (CGMP + Phe); (2) R2, CGMP-AA − Phe content of CGMP-AA from usual diet (CGMP − Phe); and (3) R3, l-AA and usual dietary Phe. Each regimen was administered for 14 days. Over the last 48 h on days 13 and 14, blood spots were collected every 4 h at 08 h, 12 h, 16 h, 20 h, 24 h, and 04 h. Isocaloric intake and the same meal plan and protein substitute dosage at standardised times were maintained when blood spots were collected. Results: Eighteen children completed the study. Median Phe concentrations over 24 h for each group were (range) R1, 290 (30–580), R2, 220 (10–670), R3, 165 (10–640) μmol/L. R1 vs. R2 and R1 vs. R3 p < 0.0001; R2 vs. R3 p = 0.0009. There was a significant difference in median Phe at each time point between R1 vs. R2, p = 0.0027 and R1 vs. R3, p < 0.0001, but not between any time points for R2 vs. R3. Tyr was significantly higher in both R1 and R2 [70 (20–240 μmol/L] compared to R3 [60 (10–200) μmol/L]. In children < 12 years, blood Phe remained in the target range (120–360 μmol/L), over 24 h, for 75% of the time in R1, 72% in R2 and 64% in R3; for children aged ≥ 12 years, blood Phe was in target range (120–600 μmol/L) in R1 and R2 for 100% of the time, but 64% in R3. Conclusions: The residual Phe in CGMP-AA increased blood Phe concentration in children. CGMP-AA appears to give less blood Phe variability compared to l-AA, but this effect may be masked by the increased blood Phe concentrations associated with its Phe contribution. Reducing dietary Phe intake to compensate for CGMP-AA Phe content may help.
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Affiliation(s)
- Anne Daly
- Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham B4 6 NH, UK.
| | - Sharon Evans
- Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham B4 6 NH, UK.
| | - Satnam Chahal
- Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham B4 6 NH, UK.
| | - Saikat Santra
- Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham B4 6 NH, UK.
| | - Alex Pinto
- Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham B4 6 NH, UK.
| | - Cerys Gingell
- Nottingham Queen's Medical Centre, University Hospital, Derby Road, Nottingham NG7 2UH, UK.
| | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto (CHUP), 4099-028 Porto, Portugal.
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHUP, 4099-001 Porto, Portugal.
- Center for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal.
| | - Francjan van Spronsen
- Beatrix Children's Hospital, University Medical Centre of Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | | | - Anita MacDonald
- Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham B4 6 NH, UK.
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Boot E, Hollak CEM, Huijbregts SCJ, Jahja R, van Vliet D, Nederveen AJ, Nieman DH, Bosch AM, Bour LJ, Bakermans AJ, Abeling NGGM, Bassett AS, van Amelsvoort TAMJ, van Spronsen FJ, Booij J. Cerebral dopamine deficiency, plasma monoamine alterations and neurocognitive deficits in adults with phenylketonuria. Psychol Med 2017; 47:2854-2865. [PMID: 28552082 DOI: 10.1017/s0033291717001398] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Phenylketonuria (PKU), a genetic metabolic disorder that is characterized by the inability to convert phenylalanine to tyrosine, leads to severe intellectual disability and other cerebral complications if left untreated. Dietary treatment, initiated soon after birth, prevents most brain-related complications. A leading hypothesis postulates that a shortage of brain monoamines may be associated with neurocognitive deficits that are observable even in early-treated PKU. However, there is a paucity of evidence as yet for this hypothesis. METHODS We therefore assessed in vivo striatal dopamine D2/3 receptor (D2/3R) availability and plasma monoamine metabolite levels together with measures of impulsivity and executive functioning in 18 adults with PKU and average intellect (31.2 ± 7.4 years, nine females), most of whom were early and continuously treated. Comparison data from 12 healthy controls that did not differ in gender and age were available. RESULTS Mean D2/3R availability was significantly higher (13%; p = 0.032) in the PKU group (n = 15) than in the controls, which may reflect reduced synaptic brain dopamine levels in PKU. The PKU group had lower plasma levels of homovanillic acid (p < 0.001) and 3-methoxy-4-hydroxy-phenylglycol (p < 0.0001), the predominant metabolites of dopamine and norepinephrine, respectively. Self-reported impulsivity levels were significantly higher in the PKU group compared with healthy controls (p = 0.033). Within the PKU group, D2/3R availability showed a positive correlation with both impulsivity (r = 0.72, p = 0.003) and the error rate during a cognitive flexibility task (r = 0.59, p = 0.020). CONCLUSIONS These findings provide further support for the hypothesis that executive functioning deficits in treated adult PKU may be associated with cerebral dopamine deficiency.
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Affiliation(s)
- E Boot
- Department of Nuclear Medicine,Academic Medical Center,Amsterdam,The Netherlands
| | - C E M Hollak
- Division of Endocrinology and Metabolism, Department of Internal Medicine,Academic Medical Center,Amsterdam,The Netherlands
| | - S C J Huijbregts
- Department of Clinical Child and Adolescent Studies & Leiden,Institute for Brain and Cognition, Leiden University,Leiden,The Netherlands
| | - R Jahja
- Division of Metabolic Diseases,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital,Groningen,The Netherlands
| | - D van Vliet
- Division of Metabolic Diseases,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital,Groningen,The Netherlands
| | - A J Nederveen
- Department of Radiology,Academic Medical Center,Amsterdam,The Netherlands
| | - D H Nieman
- Department of Psychiatry,Academic Medical Center,Amsterdam,The Netherlands
| | - A M Bosch
- Department of Pediatrics,Emma Children's Hospital, Academic Medical Center,Amsterdam,The Netherlands
| | - L J Bour
- Department of Neurology and Clinical Neurophysiology,Academic Medical Center,Amsterdam,The Netherlands
| | - A J Bakermans
- Department of Radiology,Academic Medical Center,Amsterdam,The Netherlands
| | - N G G M Abeling
- Laboratory for Genetic Metabolic Diseases,Academic Medical Center,Amsterdam,The Netherlands
| | - A S Bassett
- The Dalglish Family 22q Clinic for Adults with 22q11.2 Deletion Syndrome, andCenter for Mental Health, University Health Network,Toronto, Ontario,Canada
| | - T A M J van Amelsvoort
- Department of Psychiatry and Psychology,Maastricht University,Maastricht,The Netherlands
| | - F J van Spronsen
- Division of Metabolic Diseases,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital,Groningen,The Netherlands
| | - J Booij
- Department of Nuclear Medicine,Academic Medical Center,Amsterdam,The Netherlands
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15
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Bisiacchi P, Mento G, Tarantino V, Burlina A. Subclinical executive function impairment in children with asymptomatic, treated phenylketonuria: A comparison with children with immunodeficiency virus. Cogn Neuropsychol 2017; 35:200-208. [PMID: 29117799 DOI: 10.1080/02643294.2017.1396207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In this study we compared the neuropsychological profile of phenylketonuria (PKU) and human immunodeficiency virus (HIV) to examine the specificity of the executive function (EF) impairment reported in these two patologies. A total of 55 age-matched children and adolescents were assessed, including 11 patients with PKU, 16 patients with HIV and 28 healthy controls, underwent a neuropsychological assessment. Although neither the PKU nor the HIV group scored below the normative ranges, both groups showed lower scores in neuropsychological tests engaging EFs than controls. In addition, compared to patients with PKU the HIV group performed significantly worse in the Trail-Making Test A, Corsi Span and Verbal Fluency. These findings suggest that EF impairments in PKU (a) are limited to EFs (i.e., working memory and attentional shifting), (b) are not simply due to generalized processing speed deficits and
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Affiliation(s)
- Patrizia Bisiacchi
- a Department of General Psychology , University of Padua , Padua , Italy
| | - Giovanni Mento
- a Department of General Psychology , University of Padua , Padua , Italy
| | | | - Alberto Burlina
- c Division of Inherited Metabolic Diseases , University Hospital Padua
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16
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Manti F, Nardecchia F, Paci S, Chiarotti F, Carducci C, Carducci C, Dalmazzone S, Cefalo G, Salvatici E, Banderali G, Leuzzi V. Predictability and inconsistencies in the cognitive outcome of early treated PKU patients. J Inherit Metab Dis 2017; 40:793-799. [PMID: 28836033 DOI: 10.1007/s10545-017-0082-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 01/30/2023]
Abstract
Long-term cognitive outcome and treatment of adult early treated (ET)PKU patients is a main issue in PKU research. We questioned whether the intellectual development of ETPKU patients is stable and to what extent its variation may be predicted by the quality of metabolic control. The aims of the present longitudinal retrospective study were to assess in young adult ETPKU patients: i) the relationship between IQ and metabolic control during the first two decades of life; and ii) the intra- and interindividual variability in the developmental trajectory which cannot be predicted by the disease's biomarkers. We collected biochemical data from 65 ETPKU patients (diagnostic blood Phe > 360 μmol/l) who were assessed twice for IQ (Wechsler Intelligence Scale) during their lifetime (mean age: 10.2 and 19.6 years, respectively). Results show that in ETPKU patients IQ over the second decade of life remained stable in about half of the patients (51%); while the rest experienced a gain (7 to 15 points) or loss (7 to 28 points) in IQ scores (23 and 26% respectively) whatever the quality of metabolic control was. The main factor affecting the second IQ was the value of the first IQ (p < 0.000) whose effect overruled that of the markers of metabolic control. Looking at the developmental trajectory of our ETPKU patients, the present study disclosed a remarkable interindividual variability in their cognitive outcome and also an inconsistent linkage between cognitive performances and biochemical control, thus supporting the hypothesis of an individual resilience or vulnerability to Phe in young adult ETPKU.
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Affiliation(s)
- Filippo Manti
- Department of Pediatrics and Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy
| | - Francesca Nardecchia
- Department of Pediatrics and Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy
| | - Sabrina Paci
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Flavia Chiarotti
- Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Dalmazzone
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Graziella Cefalo
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Elisabetta Salvatici
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Giuseppe Banderali
- Department of Pediatrics, University of Milan, San Paolo Hospital, Santi Paolo e Carlo ASST, Via Antonio Di Rudinì 8, 20142, Milan, Italy
| | - Vincenzo Leuzzi
- Department of Pediatrics and Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy.
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Singh RH, Cunningham AC, Mofidi S, Douglas TD, Frazier DM, Hook DG, Jeffers L, McCune H, Moseley KD, Ogata B, Pendyal S, Skrabal J, Splett PL, Stembridge A, Wessel A, Rohr F. Updated, web-based nutrition management guideline for PKU: An evidence and consensus based approach. Mol Genet Metab 2016; 118:72-83. [PMID: 27211276 DOI: 10.1016/j.ymgme.2016.04.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2014, recommendations for the nutrition management of phenylalanine hydroxylase deficiency were published as a companion to the concurrently published American College of Medical Genetics and Genomics guideline for the medical treatment of phenylketonuria (PKU). These were developed primarily from a summary of findings from the PKU scientific review conference sponsored by the National Institutes of Health and Agency for Healthcare Research & Quality along with additional systematic literature review. Since that time, the Genetic Metabolic Dietitians International and the Southeast Regional Newborn Screening and Genetics Collaborative have partnered to create a web-based technology platform for the update and development of nutrition management guidelines for inherited metabolic disorders. OBJECTIVE The purpose of this PKU guideline is to establish harmonization in treatment and monitoring, to guide the integration of nutrition therapy in the medical management of PKU, and to improve outcomes (nutritional, cognitive, and developmental) for individuals with PKU in all life stages while reducing associated medical, educational, and social costs. METHODS Six research questions critical to PKU nutrition management were formulated to support guideline development: Review, critical appraisal, and abstraction of peer-reviewed studies and unpublished practice literature, along with expert Delphi survey feedback, nominal group process, and external review from metabolic physicians and dietitians were utilized for development of recommendations relevant to each question. Recommendations address nutrient intake, including updated protein requirements, optimal blood phenylalanine concentrations, nutrition interventions, monitoring parameters specific to life stages, adjunct therapies, and pregnancy and lactation. Recommendations were graded using a rigorous system derived from the Academy of Nutrition and Dietetics. RESULTS AND CONCLUSION These guidelines, updated utilizing a thorough and systematic approach to literature analysis and national consensus process, are now easily accessible to the global community via the newly developed digital platform. For additional details on specific topics, readers are encouraged to review materials on the online portal: https://GMDI.org/.
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Affiliation(s)
- Rani H Singh
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA; Nutrition Health Sciences Program, Graduate Division of Biological and Biomedical Sciences, Emory University School of Arts and Sciences, Atlanta, GA, USA.
| | - Amy C Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112, USA.
| | - Shideh Mofidi
- Inherited Metabolic Disease Center, Maria Fareri Childrens Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Teresa D Douglas
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA.
| | - Dianne M Frazier
- Division of Genetics and Metabolism, University of North Carolina School of Medicine, 1100 Manning Drive, Chapel Hill, NC 27599, USA.
| | | | - Laura Jeffers
- Cleveland Clinic, Center for Human Nutrition, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| | - Helen McCune
- Pediatric Genetics and Metabolism, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32607, USA.
| | - Kathryn D Moseley
- Genetics Division, USC/Keck School of Medicine, 1801 Marengo St. Rm. 1G-24, Los Angeles, CA 90033, USA.
| | - Beth Ogata
- University of Washington, Department of Pediatrics, UW-CHDD, Box 357920, Seattle, WA 98195, USA.
| | - Surekha Pendyal
- Division of Genetics and Metabolism, University of North Carolina School of Medicine, 1100 Manning Drive, Chapel Hill, NC 27599, USA.
| | - Jill Skrabal
- Department of Medical Genetics, University of Nebraska Medical Center/Children's Hospital and Medical Center, 981200 Nebraska Medical Center, Omaha, NE. 68198-1200, USA.
| | - Patricia L Splett
- Evaluation Consultant Splett & Associates, LLC, 399 Badger Blvd W., Stanchfield, MN 55080, USA.
| | - Adrya Stembridge
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA.
| | - Ann Wessel
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Frances Rohr
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
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Manti F, Nardecchia F, Chiarotti F, Carducci C, Carducci C, Leuzzi V. Psychiatric disorders in adolescent and young adult patients with phenylketonuria. Mol Genet Metab 2016; 117:12-8. [PMID: 26655635 DOI: 10.1016/j.ymgme.2015.11.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 11/12/2015] [Accepted: 11/12/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Psychiatric symptoms are a challenging aspect in adolescent and adult early treated phenylketonuric (ETPKU) patients. To assess the occurrence of psychiatric disorders we explored the presence of symptoms requiring intervention and further investigated the link between psychiatric disorders, the quality of biochemical control and cognitive functioning. PATIENTS AND METHODS Forty-six ETPKU patients (aged 12 to 44) and 30 age-matched healthy controls were subjected to cognitive and psychiatric assessment by means of self-report questionnaires and psychiatric interview. Psychiatric diagnoses, if detected, were made according to DSM-5 criteria. Concomitant IQ, historical and concurrent biochemical metabolic controls were included in the statistical analysis. RESULTS Twenty-five out of 46 ETPKUs showed clinical scores on at least one scale of the psychiatric assessment (7/30 in controls); anxiety and withdrawal were the most frequent self-reported symptoms. Seventeen patients (and no controls) met criteria for a psychiatric diagnosis, most of them belonging to the Anxiety Disorders category. The occurrence of psychiatric symptoms was not associated with the life-long and concurrent quality of metabolic control but patients with good metabolic control (≤ 500 μM) in the first 11 years of life showed higher frequency of psychiatric diagnosis (Fisher's exact p=.0300). DISCUSSION/CONCLUSION ETPKUs show a higher than normal vulnerability to psychiatric disorders, which cannot be explained by the usual biochemical alterations influencing intellectual outcome. Our data support the hypothesis that the burden of the disease acts as psychological stress for children and their families. Possible involvement of neuromediators in the pathogenesis of these complex symptoms requires further investigation.
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Affiliation(s)
- Filippo Manti
- Department of Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy.
| | - Francesca Nardecchia
- Department of Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy; Department of Physiology and Pharmacology, SAPIENZA University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
| | - Flavia Chiarotti
- Istituto Superiore di Sanità, Department of Cell Biology and Neuroscience, Viale Regina Elena 299, 00161 Rome, Italy.
| | - Claudia Carducci
- Department of Experimental Medicine, SAPIENZA University of Rome, Viale del Policlinico 155, 00161 Roma, Italy.
| | - Carla Carducci
- Department of Experimental Medicine, SAPIENZA University of Rome, Viale del Policlinico 155, 00161 Roma, Italy
| | - Vincenzo Leuzzi
- Department of Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy.
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19
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Bosch AM, Burlina A, Cunningham A, Bettiol E, Moreau-Stucker F, Koledova E, Benmedjahed K, Regnault A. Assessment of the impact of phenylketonuria and its treatment on quality of life of patients and parents from seven European countries. Orphanet J Rare Dis 2015; 10:80. [PMID: 26084935 PMCID: PMC4542123 DOI: 10.1186/s13023-015-0294-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 06/09/2015] [Indexed: 01/26/2023] Open
Abstract
Background The strict and demanding dietary treatment and mild cognitive abnormalities seen in PKU treated from a young age can be expected to affect the health-related quality of life (HRQoL) of patients and their families. Our aim was to describe the HRQoL of patients with PKU from a large international study, using generic HRQoL measures and an innovative PKU-specific HRQoL questionnaire (PKU-QOL). Analyses were exploratory, performed post-hoc on data collected primarily to validate the PKU-QOL. Methods A multicentre, prospective, non-interventional, observational study conducted in France, Germany, Italy, The Netherlands, Spain, Turkey and the UK. Patients diagnosed with PKU aged ≥9 years old and treated with a Phe-restricted diet and/or Phe-free amino acid protein supplements and/or pharmacological therapy were included in the study; parents of at least one patient with PKU aged <18 years were also included. HRQoL was assessed by generic measures (Pediatric Quality-of-Life Inventory; Medical Outcome Survey 36 item Short Form; Child Health Questionnaire 28 item Parent Form) and the newly developed PKU-QOL. Mean generic domain scores were interpreted using published reference values from the general population. PKU-QOL domain scores were described overall and in different subgroups of patients defined according to severity of PKU, overall assessment of patient’s health status by the investigator and treatment with tetrahydrobiopterin (BH4). Results Data from 559 subjects were analysed: 306 patients (92 children, 110 adolescents, 104 adults) and 253 parents. Mean domain scores of generic measures in the study were comparable to the general population. The highest PKU-QOL impact scores (indicating greater impact) were for emotional impact of PKU, anxiety about blood Phe levels, guilt regarding poor adherence to dietary restrictions or Phe-free amino acid supplement intake and anxiety regarding blood Phe levels during pregnancy. Patients with mild/moderate PKU and those receiving BH4 reported lower practical and emotional impacts of the diet and Phe-free amino acid supplement intake. Conclusion Patients with PKU showed good HRQoL in the study, both with the generic and PKU-specific measures. Negative impacts of PKU on a patient’s life, including the emotional impact of PKU and its management, was delineated by the PKU-QOLs across all age groups. Electronic supplementary material The online version of this article (doi:10.1186/s13023-015-0294-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annet M Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands.
| | - Alberto Burlina
- Division of Metabolic Disorders, Department of Paediatrics, University Hospital of Padova, Padova, Italy.
| | - Amy Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Esther Bettiol
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Ekaterina Koledova
- Mapi, Health Economics & Outcomes Research and Strategic Market Access, Lyon, France
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20
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Liemburg GB, Jahja R, van Spronsen FJ, de Sonneville LMJ, van der Meere JJ, Bosch AM, Hollak CEM, Rubio-Gozalbo ME, Brouwers MCGJ, Hofstede FC, de Vries MC, Janssen MCH, van der Ploeg AT, Langendonk JG, Huijbregts SCJ. Is BRIEF a useful instrument in day to day care of patients with phenylketonuria? Mol Genet Metab 2015; 114:425-30. [PMID: 25541101 DOI: 10.1016/j.ymgme.2014.12.302] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/05/2014] [Accepted: 12/05/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Despite early and continuous treatment many patients with phenylketonuria (PKU) still experience neurocognitive problems. Most problems have been observed in the domain of executive functioning (EF). For regular monitoring of EF, the use of the Behavior Rating Inventory of Executive Function (BRIEF) has been proposed. The aim of this study was to investigate whether the BRIEF is indeed a useful screening instrument in monitoring of adults with PKU. STUDY DESIGN Adult PKU patients (n = 55; mean age 28.3 ± 6.2 years) filled out the BRIEF-A (higher scores=poorer EF) and performed computerized tasks measuring executive functions (inhibition, cognitive flexibility, and working memory). The outcome of the BRIEF-A questionnaire was compared with the neurocognitive outcome as measured by three tasks from the Amsterdam Neuropsychological Tasks (ANT). RESULTS Forty-two percent of the PKU patients scored in the borderline/clinical range of the BRIEF-A. Six of the 55 patients (11%) scored >1 SD above the normative mean, mostly on the Metacognition Index. With respect to ANT measurements, patients mainly showed deficits in inhibitory control (34-36%) and cognitive flexibility (31-40%) as compared to the general Dutch population. No significant correlations between the two methods were found, which was confirmed with the Bland-Altman approach where no agreement between the two methods was observed. Only with respect to inhibitory control, patients scored significantly worse on both BRIEF-A and ANT classifications. No other associations between classification according to the BRIEF-A and classifications according to the ANT tasks were found. CONCLUSIONS Patients reporting EF problems in daily life are not necessarily those that present with core EF deficits. The results of this study suggest that regular self-administration of the BRIEF-A is not a sufficient way to monitor EF in adult PKU patients.
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Affiliation(s)
- Geertje B Liemburg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rianne Jahja
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Leo M J de Sonneville
- Department of Clinical Child and Adolescents Studies, Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | - Jaap J van der Meere
- Department of Developmental and Clinical Neuropsychology, University of Groningen, Groningen, The Netherlands
| | - Annet M Bosch
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Carla E M Hollak
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Estela Rubio-Gozalbo
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine and Endocrinology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Floris C Hofstede
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maaike C de Vries
- Department of Pediatrics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Ans T van der Ploeg
- Department of Pediatrics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Janneke G Langendonk
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stephan C J Huijbregts
- Department of Clinical Child and Adolescents Studies, Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands.
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Wager K, Mahmood F, Russell C. Modelling inborn errors of metabolism in zebrafish. J Inherit Metab Dis 2014; 37:483-95. [PMID: 24797558 DOI: 10.1007/s10545-014-9696-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 02/13/2014] [Accepted: 02/17/2014] [Indexed: 12/22/2022]
Abstract
The majority of human inborn errors of metabolism are fatal multisystem disorders that lack proper treatment and have a poorly understood mechanistic basis. Novel technologies are required to address this issue, and the use of zebrafish to model these diseases is an emerging field. Here we present the published zebrafish models of inborn metabolic diseases, discuss their validity, and review the novel mechanistic insights that they have provided. We also review the available methods for creating and studying zebrafish disease models, advantages and disadvantages of using this model organism, and successful examples of the use of zebrafish for drug discovery and development. Using a zebrafish to model inborn errors of metabolism in vivo, although still in its infancy, shows promise for a deeper understanding of disease pathomechanisms, onset, and progression, and also for the development of specific therapies.
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Affiliation(s)
- Kim Wager
- Department of Comparative Biomedical Sciences, Royal Veterinary College, Royal College Street, London, NW1 0TU, UK
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22
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Cleary M, Trefz F, Muntau AC, Feillet F, van Spronsen FJ, Burlina A, Bélanger-Quintana A, Giżewska M, Gasteyger C, Bettiol E, Blau N, MacDonald A. Fluctuations in phenylalanine concentrations in phenylketonuria: a review of possible relationships with outcomes. Mol Genet Metab 2013; 110:418-23. [PMID: 24090706 DOI: 10.1016/j.ymgme.2013.09.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/03/2013] [Indexed: 11/21/2022]
Abstract
Fluctuations in blood phenylalanine concentrations may be an important determinant of intellectual outcome in patients with early and continuously treated phenylketonuria (PKU). This review evaluates the studies on phenylalanine fluctuations, factors affecting fluctuations, and if stabilizing phenylalanine concentrations affects outcomes, particularly neurocognitive outcome. Electronic literature searches of Embase and PubMed were performed for English-language publications, and the bibliographies of identified publications were also searched. In patients with PKU, phenylalanine concentrations are highest in the morning. Factors that can affect phenylalanine fluctuations include age, diet, timing and dosing of protein substitute and energy intake, dietary adherence, phenylalanine hydroxylase genotype, changes in dietary phenylalanine intake and protein metabolism, illness, and growth rate. Even distribution of phenylalanine-free protein substitute intake throughout 24h may reduce blood phenylalanine fluctuations. Patients responsive to and treated with 6R-tetrahydrobiopterin seem to have less fluctuation in their blood phenylalanine concentrations than controls. An increase in blood phenylalanine concentration may result in increased brain and cerebrospinal fluid phenylalanine concentrations within hours. Although some evidence suggests that stabilization of blood phenylalanine concentrations may have benefits in patients with PKU, more studies are needed to distinguish the effects of blood phenylalanine fluctuations from those of poor metabolic control.
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Affiliation(s)
- Maureen Cleary
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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A comparison of phenylketonuria with attention deficit hyperactivity disorder: do markedly different aetiologies deliver common phenotypes? Brain Res Bull 2013; 99:63-83. [PMID: 24140048 DOI: 10.1016/j.brainresbull.2013.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/04/2013] [Accepted: 10/07/2013] [Indexed: 01/21/2023]
Abstract
Phenylketonuria (PKU) is a well-defined metabolic disorder arising from a mutation that disrupts phenylalanine metabolism and so produces a variety of neural changes indirectly. Severe cognitive impairment can be prevented by dietary treatment; however, residual symptoms may be reported. These residual symptoms appear to overlap a more prevalent childhood disorder: Attention Deficit/Hyperactivity Disorder (ADHD). However, the aetiology of ADHD is a vast contrast to PKU: it seems to arise from a complex combination of genes; and it has a substantial environmental component. We ask whether these two disorders result from two vastly different genotypes that converge on a specific core phenotype that includes similar dysfunctions of Gray's (Gray, 1982) Behavioural Inhibition System (BIS), coupled with other disorder-specific dysfunctions. If so, we believe comparison of the commonalities will allow greater understanding of the neuropsychology of both disorders. We review in detail the aetiology, treatment, neural pathology, cognitive deficits and electrophysiological abnormalities of PKU; and compare this with selected directly matching aspects of ADHD. The biochemical and neural pathologies of PKU and ADHD are quite distinct in their causes and detail; but they result in the disorder in the brain of large amino acid levels, dopamine and white matter that are very similar and could explain the overlap of symptoms within and between the PKU and ADHD spectra. The common deficits affect visual function, motor function, attention, working memory, planning, and inhibition. For each of PKU and ADHD separately, a subset of deficits has been attributed to a primary dysfunction of behavioural inhibition. In the case of ADHD (excluding the inattentive subtype) this has been proposed to involve a specific failure of the BIS; and we suggest that this is also true of PKU. This accounts for a substantial proportion of the parallels in the superficial symptoms of both disorders and we see this as linked to prefrontal, rather than more general, dysfunction of the BIS.
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Eijgelshoven I, Demirdas S, Smith TA, van Loon JMT, Latour S, Bosch AM. The time consuming nature of phenylketonuria: a cross-sectional study investigating time burden and costs of phenylketonuria in the Netherlands. Mol Genet Metab 2013; 109:237-42. [PMID: 23731533 DOI: 10.1016/j.ymgme.2013.05.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is a rare inborn error of metabolism that affects the ability of patients to metabolise phenylalanine (Phe). Lifelong management of blood Phe levels is required in order to avoid the complications associated with PKU. This constitutes a severely protein restricted diet, and regular monitoring of Phe levels. Management of PKU may be costly and time-consuming for adult patients or caregivers of PKU-affected children. A cross-sectional study was performed with patients or their caregivers in the Netherlands to gain insight into the personal time burden and cost of living with PKU. METHODS A systematic literature review was performed to identify all aspects of PKU management that may pose a financial or time burden on patients or caregivers. Findings were confirmed through interviews with PKU experts and feedback from patients and caregivers, and consolidated into a questionnaire that aimed to evaluate the impact of each of these factors. Early and continuously treated adult patients and caregivers from seven metabolic centres were recruited to complete the questionnaire online. RESULTS 22 adult patients and 24 caregivers participated in the study. Managing a Phe-restricted diet represented an extra time burden of 1 h and 24 min for caregivers and 30 min for adult patients per day. Caregivers reported a significantly higher time burden than adult patients. The median total out-of-pocket cost (OOPC) for patients was €604 annually, with 99% of expenditure on low-protein food products. Greater disease severity was significantly associated with increased OOPC and time burden for both adult patients and caregivers. CONCLUSIONS Management of PKU is associated with a considerable time burden for both caregivers of children with PKU and adult patients. Caregivers of PKU-affected children reported a significantly higher time burden than adult patients. The OOPC of caregivers and patients was mainly driven by the expenditure on low protein food.
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Huijbregts SCJ, Gassió R, Campistol J. Executive functioning in context: Relevance for treatment and monitoring of phenylketonuria. Mol Genet Metab 2013; 110 Suppl:S25-30. [PMID: 24206933 DOI: 10.1016/j.ymgme.2013.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/02/2013] [Accepted: 10/02/2013] [Indexed: 11/21/2022]
Abstract
This paper presents findings from studies of EF in individuals with early-treated PKU within the context of recent advances in neuropsychological theory and research. It focuses on means of assessment, contexts of assessment, and the best way to define and investigate EF. Several conclusions can be drawn based on the findings presented here. The first conclusion is that there is clear evidence for phenylalanine-related EF-deficits in early-treated PKU, particularly with respect to prepotent response inhibition and the manipulation or monitoring component of working memory. An important note, however, is that measurement of EF in PKU has become too fragmented, as different researchers and clinicians use different definitions of EF, and subsequently, different instruments to measure EF. This appears to be one of the most important causes of mixed results. A second conclusion is that there appears to be a need to incorporate at least one specific, relatively new taxonomy of EF in PKU-research, i.e. the taxonomy that distinguishes hot and cool EFs, where hot EF is associated with regulation of affect/emotions and motivation, or regulatory functions when the context contains such elements, while cool EF concerns decontextualized regulatory abilities. PKU in adults is increasingly associated with different mental health problems, despite supposedly good treatment standards and adherence throughout childhood and adolescence. Since hot EF is strongly associated with such mental health problems, it is recommended that the hot-cool taxonomy will feature more prominently in future PKU-studies.
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Affiliation(s)
- Stephan C J Huijbregts
- Department of Clinical Child and Adolescent Studies, Leiden University, Leiden, The Netherlands; Leiden Institute for Brain and Cognition, Leiden University Medical Center, Leiden, The Netherlands.
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Hoffmann B, Dragano N, Schweitzer-Krantz S. Living situation, occupation and health-related quality of life in adult patients with classic galactosemia. J Inherit Metab Dis 2012; 35:1051-8. [PMID: 22447152 DOI: 10.1007/s10545-012-9469-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 02/14/2012] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Galactose-1-phosphate uridyltransferase deficiency is well known as the underlying defect in classic galactosemia. However, little is known about the consequences of this defect beyond physical disease. AIM To evaluate psychosocial, educational and occupational outcome as well as health-related quality of life (HRQOL) in adult German patients with galactosemia and to compare information with data from patients with phenylketonuria as well as the general German population. METHODS Members of the German patient support group for galactosemia received invitation, informed consent form and questionnaires by regular mail from the patient support group. Participation was voluntary. RESULTS Forty-one out of 66 invited patients participated in this study. Nearly 2/3 of the patients were singles, and the majority of patients were still living with their parents. Frequently, patients had no school leaving certificate, and 30% of the patients had never started or never completed an apprenticeship. Getting along with galactosemia was rated as 'very good' or 'good' although following the diet was a burden. Social well-being and social functioning was lower compared to patients with PKU. DISCUSSION Patients with galactosemia need a multi-professional team not only focusing on physical and/or biochemical aspects of disease but including also psycho-social dimensions of life.
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Affiliation(s)
- Björn Hoffmann
- Department of General Pediatrics, University Children's Hospital, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
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Abstract
Phenylalanine hydroxylase deficiency is an autosomal recessive disorder that results in intolerance to the dietary intake of the essential amino acid phenylalanine. It occurs in approximately 1:15,000 individuals. Deficiency of this enzyme produces a spectrum of disorders including classic phenylketonuria, mild phenylketonuria, and mild hyperphenylalaninemia. Classic phenylketonuria is caused by a complete or near-complete deficiency of phenylalanine hydroxylase activity and without dietary restriction of phenylalanine most children will develop profound and irreversible intellectual disability. Mild phenylketonuria and mild hyperphenylalaninemia are associated with lower risk of impaired cognitive development in the absence of treatment. Phenylalanine hydroxylase deficiency can be diagnosed by newborn screening based on detection of the presence of hyperphenylalaninemia using the Guthrie microbial inhibition assay or other assays on a blood spot obtained from a heel prick. Since the introduction of newborn screening, the major neurologic consequences of hyperphenylalaninemia have been largely eradicated. Affected individuals can lead normal lives. However, recent data suggest that homeostasis is not fully restored with current therapy. Treated individuals have a higher incidence of neuropsychological problems. The mainstay of treatment for hyperphenylalaninemia involves a low-protein diet and use of a phenylalanine-free medical formula. This treatment must commence as soon as possible after birth and should continue for life. Regular monitoring of plasma phenylalanine and tyrosine concentrations is necessary. Targets of plasma phenylalanine of 120-360 μmol/L (2-6 mg/dL) in the first decade of life are essential for optimal outcome. Phenylalanine targets in adolescence and adulthood are less clear. A significant proportion of patients with phenylketonuria may benefit from adjuvant therapy with 6R-tetrahydrobiopterin stereoisomer. Special consideration must be given to adult women with hyperphenylalaninemia because of the teratogenic effects of phenylalanine. Women with phenylalanine hydroxylase deficiency considering pregnancy should follow special guidelines and assure adequate energy intake with the proper proportion of protein, fat, and carbohydrates to minimize risks to the developing fetus. Molecular genetic testing of the phenylalanine hydroxylase gene is available for genetic counseling purposes to determine carrier status of at-risk relatives and for prenatal testing.
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Abstract
AIM The purpose of this review was to provide an update on cognitive function in individuals with mild hyperphenylalaninemia (mHPA), the most clinically and biochemically benign form of phenylketonuria. METHOD A review was conducted of the existing literature on mHPA. Individuals with mHPA, whose plasma phenylalanine concentration had always remained lower than 360 μmol/L without dietary restriction, were considered. RESULTS The review of the literature indicated that there is no consensus concerning the definition of mHPA. There are few studies regarding the cognitive functions of individuals with mHPA, results are contradictory, and samples are difficult to compare from one study to another. Most studies focus only on descriptions of IQ when assessing cognitive functions. The existing literature indicates that, in general, children with mHPA do not show significant cognitive impairments, but usually achieve scores between those of individuals with phenylketonuria and those of comparison groups with regard to the cognitive functions assessed. INTERPRETATION When assessing cognitive functions in individuals with hyperphenylalaninemia, it is not enough to measure only IQ, as deficits in executive functions can be present even when an individual's IQ is within a normal range. Further studies are needed of individuals with mHPA, using consistent selection criteria, in order to make it possible to exclude the presence of cognitive impairment and to establish a consensus regarding the level of phenylalanine that necessitates dietary treatment.
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Affiliation(s)
- Jaume Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
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Huijbregts S, Swaab H, de Sonneville L. Cognitive and motor control in neurofibromatosis type I: influence of maturation and hyperactivity-inattention. Dev Neuropsychol 2011; 35:737-51. [PMID: 21038163 DOI: 10.1080/87565641.2010.508670] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Thirty children and adolescents with Neurofibromatosis Type 1 (NF1) and thirty controls performed neuropsychological tasks with varying cognitive control demands. Group differences, indicating poorer performance of individuals with NF1, increased as a function of cognitive control demands. Group by age interactions indicated greater differences among younger participants with respect to inhibitory control and motor function. When more cognitive control was required, particularly in working memory tasks, group differences were present across different ages. Excluding children with an attention deficit hyperactivity disorder (ADHD) diagnosis, which is highly prevalent among individuals with NF1, and further statistical control for hyperactivity-inattention, also reduced group differences regarding motor function and inhibition, but a cognitive control deficit remained evident for children and adolescents with NF1.
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Affiliation(s)
- Stephan Huijbregts
- Department of Clinical Child and Adolescent Studies, Leiden University, Leiden, the Netherlands.
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ten Hoedt AE, de Sonneville LMJ, Francois B, ter Horst NM, Janssen MCH, Rubio-Gozalbo ME, Wijburg FA, Hollak CEM, Bosch AM. High phenylalanine levels directly affect mood and sustained attention in adults with phenylketonuria: a randomised, double-blind, placebo-controlled, crossover trial. J Inherit Metab Dis 2011; 34:165-71. [PMID: 21153445 PMCID: PMC3026661 DOI: 10.1007/s10545-010-9253-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 11/09/2010] [Accepted: 11/17/2010] [Indexed: 11/21/2022]
Abstract
The main debate in the treatment of Phenylketonuria (PKU) is whether adult patients need the strict phenylalanine (Phe)-restricted diet. Physicians and patients lack evidence-based guidelines to help them make well-informed choices. We have carried out the first randomised double-blind placebo-controlled trial into the effects of short-term elevation of Phe levels on neuropsychological functions and mood of adults with PKU. Nine continuously treated adults with PKU underwent two 4-week supplementation periods: one with Phe, mimicking normal dietary intake, and one with placebo in randomly allocated order via a randomisation coding list in a double-blind cross-over design. A set of neuropsychological tests (Amsterdam Neuropsychological Tasks) was administered at the end of each study period. In addition, patients and for each patient a friend or relative, completed weekly Profile of Mood States (POMS) questionnaires, evaluating the patients' mood. Phe levels were measured twice weekly. Mean plasma Phe levels were significantly higher during Phe supplementation compared with placebo (p = 0.008). Neuropsychological tests demonstrated an impairment in sustained attention during Phe supplementation (p = 0.029). Both patients and their friend or relative reported lower scores on the POMS questionnaires during Phe supplementation (p = 0.017 and p = 0.040, respectively). High plasma Phe levels have a direct negative effect on both sustained attention and on mood in adult patients with PKU. A Phe-restricted "diet for life" might be an advisable option for many.
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Affiliation(s)
- Amber E. ten Hoedt
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | - Baudouin Francois
- Department of Metabolic Diseases, Centrum Pinocchio, Diepenbeek, Belgium
| | - Nienke M. ter Horst
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mirian C. H. Janssen
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M. Estela Rubio-Gozalbo
- Department of Pediatrics and Laboratory Genetic Metabolic Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frits A. Wijburg
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Carla E. M. Hollak
- Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Annet M. Bosch
- Department of Pediatrics (H7-270), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Enns GM, Koch R, Brumm V, Blakely E, Suter R, Jurecki E. Suboptimal outcomes in patients with PKU treated early with diet alone: revisiting the evidence. Mol Genet Metab 2010; 101:99-109. [PMID: 20678948 DOI: 10.1016/j.ymgme.2010.05.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/27/2010] [Accepted: 05/28/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The National Institute of Health (NIH) published a Consensus Statement on the screening and management of Phenylketonuria (PKU) in 2000. The panel involved in the development of this consensus statement acknowledged the lack of data regarding the potential for more subtle suboptimal outcomes and the need for further research into treatment options. In subsequent years, the approval of new treatment options for PKU and outcome data for patients treated from the newborn period by dietary therapy alone have become available. We hypothesized that a review of the PKU literature since 2000 would provide further evidence related to neurocognitive, psychosocial, and physical outcomes that could serve as a basis for reassessment of the 2000 NIH Consensus Statement. METHODS A systematic review of literature residing in PubMed, Scopus and PsychInfo was performed in order to assess the outcome data over the last decade in diet-alone early-treated PKU patients to assess the need for new recommendations and validity of older recommendations in light of new evidence. RESULTS The majority of publications (140/150) that contained primary outcome data presented at least one suboptimal outcome compared to control groups or standardized norms/reference values in at least one of the following areas: neurocognitive/psychosocial (N=60; 58 reporting suboptimal outcomes); quality of life (N=6; 4 reporting suboptimal outcomes); brain pathology (N=32; 30 reporting suboptimal outcomes); growth/nutrition (N=34; 29 reporting suboptimal outcomes); bone pathology (N=9; 9 reporting suboptimal outcomes); and/or maternal PKU (N=19; 19 reporting suboptimal outcomes). CONCLUSIONS Despite the remarkable success of public health programs that have instituted newborn screening and early introduction of dietary therapy for PKU, there is a growing body of evidence that suggests that neurocognitive, psychosocial, quality of life, growth, nutrition, bone pathology and maternal PKU outcomes are suboptimal. The time may be right for revisiting the 2000 NIH Consensus Statement in order to address a number of important issues related to PKU management, including treatment advancements for metabolic control in PKU, blood Phe variability, neurocognitive and psychological assessments, routine screening measures for nutritional biomarkers, and bone pathology.
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Affiliation(s)
- G M Enns
- Division of Medical Genetics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Stanford, CA 94305-5208,USA.
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Neuropsychological speed tests and blood phenylalanine levels in patients with phenylketonuria: A meta-analysis. Neurosci Biobehav Rev 2009; 33:414-21. [DOI: 10.1016/j.neubiorev.2008.11.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 10/31/2008] [Accepted: 11/01/2008] [Indexed: 11/18/2022]
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van Spronsen FJ, Burgard P. The truth of treating patients with phenylketonuria after childhood: the need for a new guideline. J Inherit Metab Dis 2008; 31:673-9. [PMID: 18690552 DOI: 10.1007/s10545-008-0918-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Revised: 06/23/2008] [Accepted: 06/25/2008] [Indexed: 11/30/2022]
Abstract
In recent years, an increasing number of national guidelines on the treatment of phenylketonuria (PKU) have emerged. Most of these guidelines are dedicated to the care of children, while less attention is paid to the care of adults, although all guidelines underline the importance of diet for life. This review aims to summarize issues that need to be addressed within a guideline on the treatment of PKU, especially when care for patients beyond childhood is concerned. In this respect, it is of importance that adult patients, both willing and unwilling to be treated, need a guideline for care and follow-up. In PKU there is certainly a need for an improved unified guideline, especially after childhood, although many of the considerations in this article also apply to recommendations for treatment of children. Such a guideline will be a tool to improve treatment in PKU patients but should also include recommendations for collecting data for clinical and research purposes. Guideline development should also focus on nutritional, neuropsychological and psychosocial issues and not only on target plasma phenylalanine concentrations. In addition, guidelines must address not only what has to be done but also how it can be done, thereby improving concordance with the recommendations for treatment and management.
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Affiliation(s)
- F J van Spronsen
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
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Diamond A. Consequences of variations in genes that affect dopamine in prefrontal cortex. Cereb Cortex 2007; 17 Suppl 1:i161-70. [PMID: 17725999 PMCID: PMC2238775 DOI: 10.1093/cercor/bhm082] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patricia Goldman-Rakic played a groundbreaking role in investigating the cognitive functions subserved by dorsolateral prefrontal cortex and the key role of dopamine in that. The work discussed here builds on that including: 1) Studies of children predicted to have lower levels of prefrontal dopamine but otherwise basically normal brains (children treated for phenylketonuria [PKU]). Those studies changed medical guidelines, improving the children's lives. 2) Studies of visual impairments (in contrast sensitivity and motion perception) in PKU children due to reduced retinal dopamine and due to excessive phenylalanine during the first postnatal weeks. Those studies, too, changed medical guidelines. 3) Studies of working memory and inhibitory control differences in typically developing children due to differences in catechol-O-methyltransferase (COMT) genotype, which selectively affect prefrontal dopamine levels. 4) Studies of gender differences in the effect of COMT genotype on cognitive performance in older adults. 5) A hypothesis about fundamental differences between attention deficit hyperactivity disorder (ADHD) that includes hyperactivity and ADHD of the inattentive type. Those disorders are hypothesized to differ in the affected neural system, underlying genetics, responsiveness to medication, comorbidities, and cognitive and behavioral profiles. These sound quite disparate but they all grew systematically out the base laid down by Patricia Goldman-Rakic.
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Affiliation(s)
- Adele Diamond
- Department of Psychiatry, University of British Columbia, BC Children's Hospital, Vancouver, Canada.
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Waisbren SE, Noel K, Fahrbach K, Cella C, Frame D, Dorenbaum A, Levy H. Phenylalanine blood levels and clinical outcomes in phenylketonuria: a systematic literature review and meta-analysis. Mol Genet Metab 2007; 92:63-70. [PMID: 17591452 DOI: 10.1016/j.ymgme.2007.05.006] [Citation(s) in RCA: 211] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 05/10/2007] [Accepted: 05/10/2007] [Indexed: 12/21/2022]
Abstract
Blood phenylalanine (Phe) levels provide a practical and reliable method for the diagnosis and monitoring of metabolic status in patients with phenylketonuria (PKU). To assess the reliability of blood Phe levels as a predictive biomarker of clinical outcomes in the development of treatments for PKU, a systematic literature review and meta-analysis of published trials of PKU, which included Phe level and neurological and dietary compliance outcome measures, was conducted. Within-study correlations between Phe level and intelligence quotient (IQ) were extracted from 40 studies. Significant, proportional correlations were found during critical periods (from 0 to 12 years of age) for early-treated patients with PKU (r=-0.35; 95% confidence interval [CI]: -0.44 to -0.27), where each 100 micromol/l increase in Phe predicted a 1.3- to 3.1-point reduction in IQ. Similar significant correlations were observed between IQ and mean lifetime Phe level for early-treated patients (r=0.34; 95% CI: -0.42 to -0.25), where each 100 micromol/l increase in Phe predicted a 1.9- to 4.1-point reduction in IQ. Moderate correlations were found between concurrent Phe level and IQ for early-treated patients. In conclusion, these results confirm a significant correlation between blood Phe level and IQ in patients with PKU, and support the use of Phe as a predictive biomarker for IQ in clinical trials.
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Affiliation(s)
- Susan E Waisbren
- Children's Hospital Boston, 1 Autumn Street, Room 525, Boston, MA 02115, USA.
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Levy HL, Milanowski A, Chakrapani A, Cleary M, Lee P, Trefz FK, Whitley CB, Feillet F, Feigenbaum AS, Bebchuk JD, Christ-Schmidt H, Dorenbaum A. Efficacy of sapropterin dihydrochloride (tetrahydrobiopterin, 6R-BH4) for reduction of phenylalanine concentration in patients with phenylketonuria: a phase III randomised placebo-controlled study. Lancet 2007; 370:504-10. [PMID: 17693179 DOI: 10.1016/s0140-6736(07)61234-3] [Citation(s) in RCA: 224] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early and strict dietary management of phenylketonuria is the only option to prevent mental retardation. We aimed to test the efficacy of sapropterin, a synthetic form of tetrahydrobiopterin (BH4), for reduction of blood phenylalanine concentration. METHODS We enrolled 89 patients with phenylketonuria in a Phase III, multicentre, randomised, double-blind, placebo-controlled trial. We randomly assigned 42 patients to receive oral doses of sapropterin (10 mg/kg) and 47 patients to receive placebo, once daily for 6 weeks. The primary endpoint was mean change from baseline in concentration of phenylalanine in blood after 6 weeks. Analysis was on an intention-to-treat basis. The study is registered with ClinicalTrials.gov, number NCT00104247. FINDINGS 88 of 89 enrolled patients received at least one dose of study drug, and 87 attended the week 6 visit. Mean age was 20 (SD 9.7) years. At baseline, mean concentration of phenylalanine in blood was 843 (300) micromol/L in patients assigned to receive sapropterin, and 888 (323) micromol/L in controls. After 6 weeks of treatment, patients given sapropterin had a decrease in mean blood phenylalanine of 236 (257) micromol/L, compared with a 3 (240) micromol/L increase in the placebo group (p<0.0001). After 6 weeks, 18/41 (44%) patients (95% CI 28-60) in the sapropterin group and 4/47 (9%) controls (95% CI 2-20) had a reduction in blood phenylalanine concentration of 30% or greater from baseline. Blood phenylalanine concentrations fell by about 200 micromol/L after 1 week in the sapropterin group and this reduction persisted for the remaining 5 weeks of the study (p<0.0001). 11/47 (23%) patients in the sapropterin group and 8/41 (20%) in the placebo group experienced adverse events that might have been drug-related (p=0.80). Upper respiratory tract infections were the most common disorder. INTERPRETATION In some patients with phenylketonuria who are responsive to BH4, sapropterin treatment to reduce blood phenylalanine could be used as an adjunct to a restrictive low-phenylalanine diet, and might even replace the diet in some instances.
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Affiliation(s)
- Harvey L Levy
- Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
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van Rijn M, Hoeksma M, Sauer P, Szczerbak B, Gross M, Reijngoud DJ, van Spronsen F. Protein metabolism in adult patients with phenylketonuria. Nutrition 2007; 23:445-53. [PMID: 17507200 DOI: 10.1016/j.nut.2007.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Revised: 03/28/2007] [Accepted: 03/28/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Protein intake recommendations in phenylketonuria (PKU) are frequently the subject of discussion. For healthy adults, the recommended daily allowance (RDA) is 0.8 g.kg(-1).d(-1), which is generally lower than that observed in the general Western population. We investigated whether whole-body protein metabolism in patients with PKU is comparable to that of healthy controls at a RDA rate of protein intake. METHODS Six adult patients with well-controlled PKU and six healthy subjects of comparable age, height, and weight were studied using a primed continuous infusion of [1-(13)C]-valine for 8 h after an overnight fast before and during frequent meals. Normal protein was given to controls, whereas patients with PKU received a combination of an amino acid mixture and natural protein. RESULTS No significant differences were observed between patients with PKU and controls in preprandial and prandial rates of valine appearance and oxidation and protein breakdown, protein synthesis, and net protein balance. Feeding resulted in a significant (P < 0.01) decrease in protein breakdown (PKU: 94 +/- 15 micromol.kg(-1).h(-1) preprandial to 49 +/- 10 micromol.kg(-1).h(-1) prandial; controls: 97 +/- 10 micromol.kg(-1).h(-1) preprandial to 55 +/- 10 micromol.kg(-1).h(-1) prandial), whereas no effects were observed in protein synthesis (PKU: 77 +/- 10 micromol.kg(-1).h(-1) preprandial to 73 +/- 7 micromol.kg(-1).h(-1) prandial; controls: 76 +/- 8 micromol.kg(-1).h(-1) preprandial to 71 +/- 5 micromol.kg(-1).h(-1) prandial). Net protein balance increased from negative prandial to positive preprandial values (PKU: -17 +/- 6 micromol.kg(-1).h(-1) preprandial to +23 +/- 8 micromol.kg(-1).h(-1) prandial; controls: -21 +/- 4 micromol.kg(-1).h(-1) preprandial to +16 +/- 9 micromol.kg(-1).h(-1) prandial). CONCLUSION Whole-body protein metabolism in adult patients with PKU is fully comparable to that in healthy controls at the RDA level of protein intake.
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Affiliation(s)
- Margreet van Rijn
- Section of Metabolic Diseases, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Moyle JJ, Fox AM, Arthur M, Bynevelt M, Burnett JR. Meta-Analysis of Neuropsychological Symptoms of Adolescents and Adults with PKU. Neuropsychol Rev 2007; 17:91-101. [PMID: 17410469 DOI: 10.1007/s11065-007-9021-2] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 12/08/2006] [Indexed: 10/23/2022]
Abstract
Phenylketonuria (PKU; OMIM 261600) is an autosomal recessive inborn error of phenylanaline metabolism. PKU is characterized by deficient or defective phenylalanine hydroxylase activity and persistantly increased levels of the essential amino acid phenylalanine in the circulation. The present article examines current understanding of the etiology of PKU, along with a meta-analysis examining neuropsychological and intellectual presentations in continuously treated adolescents and adults. Patients with PKU differed significantly from controls on Full-Scale IQ, processing speed, attention, inhibition, and motor control. Future research utilizing an integrative approach and detailed analysis of specific cognitive domains will assist both the scientist and clinician, and ultimately the patient.
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Affiliation(s)
- J J Moyle
- School of Psychology, The University of Western Australia, Perth, Australia.
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Amorim T, Gatto SP, Boa-Sorte N, Leite MEQ, Fontes MIMM, Barretto J, Acosta AX. Aspectos clínicos da fenilcetonúria em serviço de referência em triagem neonatal da Bahia. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2005. [DOI: 10.1590/s1519-38292005000400009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVOS: descrever as características clínicas dos pacientes com hiperfenilalaninemia acompanhados no Serviço de Referência em Triagem Neonatal (SRTN) do estado da Bahia. MÉTODOS: estudo descritivo transversal, tendo como amostra todos os pacientes com diagnóstico conhecido de Hiperfenilalaninemia residentes no estado da Bahia e acompanhados no SRTN até setembro de 2005. Tal população é composta de 46 famílias, num total de 51 pacientes. A análise dos dados foi descritiva, incluindo medidas de tendência central e dispersão. RESULTADOS: houve discreto predomínio do gênero feminino (52,9%). A maioria dos pacientes (78,4%) teve seu diagnóstico estabelecido através da triagem neonatal, tendo, portanto, tratamento precoce. Consangüinidade foi registrada em 32,6% das famílias. A média de início do tratamento entre os pacientes diagnosticados pela triagem neonatal foi de 56,6 37,8 dias, enquanto que entre os pacientes com diagnóstico tardio, foi de 7,1 anos. CONCLUSÕES: o estudo descreve um grupo de pacientes representativo de uma patologia incluída no Programa Nacional de Triagem Neonatal (PNTN), sendo, portanto, de relevância para a saúde pública. Entre os dados clínicos, chama a atenção a média de idade do início do tratamento, superior ao recomendado na literatura, alertando para a necessidade de um maior enfoque no diagnóstico precoce.
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Affiliation(s)
| | - Sara P.P. Gatto
- Fundação Bahiana para o Desenvolvimento das Ciências, Brasil
| | - Ney Boa-Sorte
- Fundação Bahiana para o Desenvolvimento das Ciências, Brasil
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Buizer AI, de Sonneville LMJ, van den Heuvel-Eibrink MM, Veerman AJP. Chemotherapy and attentional dysfunction in survivors of childhood acute lymphoblastic leukemia: effect of treatment intensity. Pediatr Blood Cancer 2005; 45:281-90. [PMID: 15806539 DOI: 10.1002/pbc.20397] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Central nervous system (CNS) directed chemotherapy is replacing prophylactic cranial irradiation in treatment protocols for childhood acute lymphoblastic leukemia (ALL), mainly to reduce long-term neuropsychological sequelae. We evaluated the effects of chemotherapy on attentional function in survivors of ALL and examined whether possible deficits are related to treatment intensity. METHODS In a multi-center study, we compared attentional function in 36 children at least 1 year after finishing treatment with chemotherapy only for ALL, with a cancer control group consisting of 39 Wilms tumor patients and with 110 healthy children. We differentiated between standard- and intensified ALL treatment. The role of previously reported risk factors for neuropsychological deficits was also assessed. RESULTS After chemotherapy, attentional deficits were detected in patients with ALL, but not in Wilms tumor patients. Children treated according to standard ALL protocols performed worse than healthy controls on only 1 of 10 outcome measures (P = 0.004), while those who had received intensified treatment performed worse on four outcome measures (0.0001 < P < 0.004). Higher treatment intensity, young age at diagnosis, and female gender were associated with worse performance. CONCLUSIONS CNS-directed chemotherapy, even in the absence of cranial irradiation, is associated with attentional dysfunction in survivors of childhood ALL, particularly in case of intensified treatment protocols. These sequelae stress the importance of reducing doses of neurotoxic chemotherapy as much as possible in the design of future treatment protocols for ALL.
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Affiliation(s)
- Annemieke I Buizer
- Department of Pediatrics, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Günther T, Herpertz-Dahlmann B, Konrad K. Reliabilität von Aufmerksamkeits- und verbalen Gedächtnistests bei gesunden Kindern und Jugendlichen - Implikationen für die klinische Praxis. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2005; 33:169-79. [PMID: 16097265 DOI: 10.1024/1422-4917.33.3.169] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung: Fragestellung: Die neuropsychologische Diagnostik eignet sich zur differenzierten Beschreibung von kognitiven Leistungen bei Patienten mit kinder- und jugendpsychiatrischen Erkrankungen. In dieser Arbeit werden zunächst ein kurzer theoretischer Hintergrund für die neuropsychologischen Funktionen Aufmerksamkeit und verbales Gedächtnis gegeben und ausgewählte klinische Befunde dargestellt. Des Weiteren wird ein Beispiel einer neuropsychologischen Testbatterie vorgestellt, die im Kinder- und Jugendbereich eingesetzt werden kann. Methodik: Die Retest-Reliabilität dieser Testbatterie wurde in einem Wiederholungszeitraum von 6 Wochen bei 33 gesunden Kindern untersucht. Ergebnisse: Generell konnte eine gute Reliabilität nachgewiesen werden, obwohl es zwischen einigen abhängigen Variablen Unterschiede gab. Lerneffekte aufgrund der Wiederholung wurden vornehmlich bei den jüngeren Kindern nachgewiesen. Schlussfolgerung: Die ausgewählten neuropsychologischen Tests scheinen für die klinische Anwendung geeignet zu sein, wie z. B. die Untersuchung von kognitiven Defiziten und die Evaluierung von psychopharmakologischen Behandlungen. Es ist jedoch zu beachten, dass in Abhängigkeit vom Alter die Retest-Reliabilität unterschiedlich ist.
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Affiliation(s)
- Thomas Günther
- Klinik für Kinder- und Jugendpsychiatrie und -psychotherapie, Universitätsklinikum Aachen.
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Abstract
Newborn screening for phenylketonuria began 35 to 40 years ago in most industrialized countries. Because of this initiative, which resulted in early institution of phenylalanine-restricted diets, there are now many young adults with this disease who have normal or near-normal intellectual function. In North America alone, 200 patients with phenylketonuria enter adulthood every year. Most expert panels recommend following a phenylalanine-restricted "diet for life." However, there are few adult physicians dedicated to continuing care of this group, with the possible exception of maternal phenylketonuria. Up to 10% of adults with classic phenylketonuria, and possibly 50% of those with milder variants, may not need treatment; after adolescence, intelligence does not appear to deteriorate, at least into early adulthood, even if diet therapy is discontinued or not in good control. However, neuropsychological and psychosocial problems develop frequently, needing focused and intensive support by health care providers. New investigative methods and treatment options are on the horizon. There is an urgent need for physicians who will orchestrate the care of adults with phenylketonuria.
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Affiliation(s)
- W B Hanley
- Phenylketonuria Programme, Division of Clinical and Biochemical Genetics, Department of Pediatrics and the Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.
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Acosta MT, Arcos-Burgos M, Muenke M. Attention deficit/hyperactivity disorder (ADHD): complex phenotype, simple genotype? Genet Med 2004; 6:1-15. [PMID: 14726804 DOI: 10.1097/01.gim.0000110413.07490.0b] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Complex genetic traits refer to those phenotypes not fitting patterns of Mendelian segregation and/or assortment but exhibiting a preferential familial clustering that cannot be explained by cultural or environmental causes. Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood and probably the most controversial. ADHD has been considered a complex genetic trait based upon the absence of a clear-cut boundary between affected and unaffected status. Furthermore, its high comorbidity with other disorders strongly suggests complex epistatic or pleiotropic effects acting in common with the environmental influences. This implies that the same gene or genes is or are associated with different and concurrently occurring phenotypes. In this study, we will review clinical and epidemiological aspects related to the ADHD phenotype, which are considered either as categorical or continuous traits. We also will discuss genetic models underlying the complexity of this behavioral phenotype and the probable role of epistatic interactions between major genes contributing to the ADHD phenotype.
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Affiliation(s)
- Maria Teresa Acosta
- Department of Neurology, Children's National Medical Center, Washington, DC, USA
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Huijbregts SCJ, de Sonneville LMJ, van Spronsen FJ, Licht R, Sergeant JA. The neuropsychological profile of early and continuously treated phenylketonuria: orienting, vigilance, and maintenance versus manipulation-functions of working memory. Neurosci Biobehav Rev 2002; 26:697-712. [PMID: 12479843 DOI: 10.1016/s0149-7634(02)00040-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In this paper, we review neuropsychological test results of early and continuously treated Phenylketonuria (PKU) patients. To increase insight into the neuropsychological profile of this population, we have attempted to place the results within an attentional network model [Images of the mind, 1994], which proposes interacting but dissociable attentional networks for orienting, vigilance, and executive control of attention. Executive control of attention is discussed against the background of the process-specific theory of working memory (WM) [Handbook of neuropsychology, 1994], which postulates a distinction between the 'maintenance'-function of WM and the 'manipulation and monitoring'-function. Neuropsychological results are presented for 67 early and continuously treated PKU patients and 73 controls aged 7-14 years. Four neuropsychological tasks were employed to measure orienting, mnemonic processing, interference suppression, and top-down control in visual search. No differences were found in orienting and the maintenance-function of WM. In addition to previously reported impairments in sustained attention/vigilance and inhibition of prepotent responding, PKU patients exhibited deficits when top-down control was required in a visual search task, but showed no impairment when interference suppression was required. It is discussed how the specific neuropsychological impairments in PKU may be a consequence of mid-dorsolateral prefrontal cortex (DLPFC) dysfunctioning due to deficiencies in catecholamine modulation.
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Affiliation(s)
- S C J Huijbregts
- Department of Clinical Neuropsychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands.
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