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Current Psychiatry Research and Reviews


ISSN (Print): 2666-0822
ISSN (Online): 2666-0830

Mini-Review Article

Diagnosis in PANDAS: An Update

Author(s): Brenda Cabrera-Mendoza, Alma Delia Genis-Mendoza and Humberto Nicolini*

Volume 15, Issue 4, 2019

Page: [237 - 247] Pages: 11

DOI: 10.2174/2666082215666190917161514

Price: $65


Background: The last twenty years have seen major advancements in unraveling the etiology and the identification of biological markers of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci (PANDAS). However, this body of evidence has not yet been translated into a clinical setting.

Objective: We will review the most important studies to date on PANDAS, emphasizing those whose advances could improve the diagnosis of these disorders. We also suggest the need for updated diagnosis criteria integrating the recent findings from the hereby included studies.

Methods: Consulting the PubMed database, a literature review of the last twenty-one years (between 1998 and 2019) was carried out using the terms “PANDAS” and “pediatric autoimmune neuropsychiatric disorders” in combination with “diagnosis” and “markers”. The search resulted in 175 hits from which we selected clinical cases, original investigations, and clinical reviews.

Results: This review offers a compilation of the most important studies performed to date regarding the clinical presentation and potential biological markers of PANDAS. Moreover, we suggest the refinement of some aspects in the current diagnosis criteria, such as focusing on specific symptoms and the inclusion of neuroimaging and peripheral markers.

Conclusion: The identification of specific biological markers in PANDAS is crucial for its diagnosis and opportune treatment. Future research will determine whether PANDAS require separated diagnostic and therapeutic measures or if it should be included in recently proposed categories such as Pediatric Acute Neuropsychiatric Syndrome (PANS) or Childhood Acute Neuropsychiatric Syndrome (CANS).

Keywords: OCD, tics, streptococcal infection, autoimmune, early-onset OCD, diagnosis, biomarkers.

Graphical Abstract
Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry 2005; 162(2): 228-38.
[] [PMID: 15677583]
Leckman JF, Bloch MH, King RA. Symptom dimensions and subtypes of obsessive-compulsive disorder: a developmental perspective. Dialogues Clin Neurosci 2009; 11(1): 21-33.
[PMID: 19432385]
Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry 1998; 155(2): 264-71.
[PMID: 9464208]
Swedo SE, Leonard HL, Rapoport JL. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) subgroup: separating fact from fiction. Pediatrics 2004; 113(4): 907-11.
[] [PMID: 15060242]
Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham’s chorea, PANDAS and beyond. Brain Res 2015; 1617: 144-54.
[] [PMID: 25301689]
Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev 2018; 86: 51-65.
[] [PMID: 29309797]
Singer HS, Gilbert DL, Wolf DS, Mink JW, Kurlan R. Moving from PANDAS to CANS. J Pediatr 2012; 160(5): 725-31.
[] [PMID: 22197466]
Baytunca MB, Donuk T, Erermiş S. Evaluation of a Neuropsychiatric Disorder: From PANDAS to PANS and CANS. Turk Psikiyatr Derg 2016; 27(2)
Gabbay V, Coffey BJ, Babb JS, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcus: comparison of diagnosis and treatment in the community and at a specialty clinic. Pediatrics 2008; 122(2): 273-8.
[] [PMID: 18676543]
Chiarello F, Spitoni S, Hollander E, Matucci CM, Pallanti S. An expert opinion on PANDAS/PANS: highlights and controversies. Int J Psychiatry Clin Pract 2017; 21(2): 91-8.
[] [PMID: 28498087]
Gilbert DL, Mink JW, Singer HS. A pediatric neurology perspective on pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection and pediatric acute-onset neuropsychiatric syndrome. J Pediatr 2018; 199: 243-51.
[] [PMID: 29793872]
Wilbur C, Bitnun A, Kronenberg S, et al. PANDAS/PANS in childhood: Controversies and evidence. Paediatr Child Health 2019; 24(2): 85-91.
[] [PMID: 30996598]
Moretti G, Pasquini M, Mandarelli G, Tarsitani L, Biondi M. What every psychiatrist should know about PANDAS: a review. Clin Pract Epidemiol Ment Health 2008; 4: 13.
[] [PMID: 18495013]
Selling L. The role of infection in the etiology of tics. Arch Neurol Psychiatry 1929; 22(6): 1163-71.
Kondo K, Kabasawa T. Improvement in Gilles de la Tourette syndrome after corticosteroid therapy. Ann Neurol 1978; 4(4): 387-413.
[] [PMID: 281893]
Kiessling LS. Tic disorders associated with evidence of invasive group A beta-hemolytic streptococcal disease. Dev Med Child Neurol Suppl 1989; 59: 48.
Swedo SE, Rapoport JL, Cheslow DL, et al. High prevalence of obsessive-compulsive symptoms in patients with Sydenham’s chorea. Am J Psychiatry 1989; 146(2): 246-9.
[] [PMID: 2912267]
Macerollo A, Martino D. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an evolving concept. Tremor Other Hyperkinet Mov (N Y) 2013. tre-03-167-4158-7.
Orefici G, Cardona F, Cox CJ, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) Streptococcus pyogenes: Basic biology to clinical manifestations. Oklahoma City, OK: University of Oklahoma Health Sciences Center 2016.
Matarazzo EB. Tourette’s syndrome treated with ACTH and prednisone: report of two cases. J Child Adolesc Psychopharmacol 1992; 2(3): 215-26.
[] [PMID: 19630633]
Allen AJ, Leonard HL, Swedo SE. Case study: a new infection-triggered, autoimmune subtype of pediatric OCD and Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry 1995; 34(3): 307-11.
[] [PMID: 7896671]
Swedo ES, Leckman JF, Rose NR. From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS (Pediatric Acute Onset Neuropsychiatric Syndrome). Pediatr Therapeut 2012; 2(2): 113.
Swedo SE, Frankovich J, Murphy TK. Overview of treatment of pediatric acute-onset neuropsychiatric syndrome. J Child Adolesc Psychopharmacol 2017; 27(7): 562-5.
[] [PMID: 28722464]
Singer HS, Loiselle C. PANDAS: A commentary. J Psychosom Res 2003; 55(1): 31-9.
[] [PMID: 12842229]
Esposito S, Bianchini S, Baggi E, Fattizzo M, Rigante D. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: An overview. Eur J Clin Microbiol Infect Dis 2014; 33(12): 2105-9.
[] [PMID: 24953744]
Cardona F, Orefici G. Group A streptococcal infections and tic disorders in an Italian pediatric population. J Pediatr 2001; 138(1): 71-5.
[] [PMID: 11148515]
Gamucci A, Uccella S, Sciarretta L, et al. PANDAS and PANS: Clinical, neuropsychological, and biological characterization of a monocentric series of patients and proposal for a diagnostic protocol. J Child Adolesc Psychopharmacol 2019; 29(4): 305-12.
[] [PMID: 30724577]
Cardoso F, Eduardo C, Silva AP, Mota CC. Chorea in fifty consecutive patients with rheumatic fever. Mov Disord 1997; 12(5): 701-3.
[] [PMID: 9380051]
Amador-Patarroyo MJ, Rodriguez-Rodriguez A, Montoya-Ortiz G. How does age at onset influence the outcome of autoimmune diseases? Autoimmune Dis 2012; 2012251730
[] [PMID: 22195277]
Singer HS, Giuliano JD, Zimmerman AM, Walkup JT. Infection: A stimulus for tic disorders. Pediatr Neurol 2000; 22(5): 380-3.
[] [PMID: 10913730]
Cardoso F. Sydenham’s chorea. Handb Clin Neurol 2011; 100: 221-9.
[] [PMID: 21496581]
Hoffman KL, Hornig M, Yaddanapudi K, Jabado O, Lipkin WI. A murine model for neuropsychiatric disorders associated with group: A beta-hemolytic streptococcal infection. J Neurosci 2004; 24(7): 1780-91.
[] [PMID: 14973249]
Macrì S, Ceci C, Onori MP, et al. Mice repeatedly exposed to group-A β-haemolytic streptococcus show perseverative behaviors, impaired sensorimotor gating, and immune activation in rostral diencephalon. Sci Rep 2015; 5: 13257.
[] [PMID: 26304458]
Macrì S, Spinello C, Widomska J, et al. Neonatal corticosterone mitigates autoimmune neuropsychiatric disorders associated with streptococcus in mice. Sci Rep 2018; 8(1): 10188.
[] [PMID: 29976948]
Murphy ML, Pichichero ME. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med 2002; 156(4): 356-61.
[] [PMID: 11929370]
Orlovska S, Vestergaard CH, Bech BH, Nordentoft M, Vestergaard M, Benros ME. Association of streptococcal throat infection with mental disorders: Testing key aspects of the PANDAS hypothesis in a nationwide study. JAMA Psychiatry 2017; 74(7): 740-6.
[] [PMID: 28538981]
Mell LK, Davis RL, Owens D. Association between streptococcal infection and obsessive-compulsive disorder, Tourette’s syndrome, and tic disorder. Pediatrics 2005; 116(1): 56-60.
[] [PMID: 15995031]
Perrin EM, Murphy ML, Casey JR, et al. Does group A beta-hemolytic streptococcal infection increase risk for behavioral and neuropsychiatric symptoms in children? Arch Pediatr Adolesc Med 2004; 158(9): 848-56.
[] [PMID: 15351749]
Schrag A, Gilbert R, Giovannoni G, Robertson MM, Metcalfe C, Ben-Shlomo Y. Streptococcal infection, Tourette syndrome, and OCD: is there a connection? Neurology 2009; 73(16): 1256-63.
[] [PMID: 19794128]
Nielsen MØ, Köhler-Forsberg O, Hjorthøj C, Benros ME, Nordentoft M, Orlovska-Waast S. Streptococcal infections and exacerbations in PANDAS: A systematic review and meta-analysis. Pediatr Infect Dis J 2019; 38(2): 189-94.
[] [PMID: 30325890]
Anderson NW, Buchan BW, Mayne D, Mortensen JE, Mackey TL, Ledeboer NA. Multicenter clinical evaluation of the illumigene group A Streptococcus DNA amplification assay for detection of group A Streptococcus from pharyngeal swabs. J Clin Microbiol 2013; 51(5): 1474-7.
[] [PMID: 23447639]
Blyth CC, Robertson PW. Anti-streptococcal antibodies in the diagnosis of acute and post-streptococcal disease: Streptokinase versus streptolysin O and deoxyribonuclease B. Pathology 2006; 38(2): 152-6.
[] [PMID: 16581656]
Nicolini H, López Y, Genis-Mendoza AD, et al. Detection of anti-streptococcal, antienolase, and anti-neural antibodies in subjects with early-onset psychiatric disorders. Actas Esp Psiquiatr 2015; 43(2): 35-41.
[PMID: 25812540]
Hamilton CS, Swedo SE. Autoimmune-mediated, childhood onset obsessive-compulsive disorder and tics: A review. Clin Neurosci Res 2001; 1: 61-8.
van Toorn R, Weyers HH, Schoeman JF. Distinguishing PANDAS from Sydenham’s chorea: Case report and review of the literature. Eur J Paediatr Neurol 2004; 8(4): 211-6.
[] [PMID: 15261885]
Murphy TK, Sajid M, Soto O, et al. Detecting pediatric autoimmune neuropsychiatric disorders associated with streptococcus in children with obsessive-compulsive disorder and tics. Biol Psychiatry 2004; 55(1): 61-8.
[] [PMID: 14706426]
Dale RC. Autoimmunity and the basal ganglia: New insights into old diseases. QJM 2003; 96(3): 183-91.
[] [PMID: 12615982]
Murphy TK, Kurlan R, Leckman J. The immunobiology of Tourette’s disorder, pediatric autoimmune neuropsychiatric disorders associated with Streptococcus, and related disorders: a way forward. J Child Adolesc Psychopharmacol 2010; 20(4): 317-31.
[] [PMID: 20807070]
Murphy TK, Snider LA, Mutch PJ, et al. Relationship of movements and behaviors to group A Streptococcus infections in elementary school children. Biol Psychiatry 2007; 61(3): 279-84.
[] [PMID: 17126304]
Betancourt YM, Jiménez-León JC, Jiménez-Betancourt CS, Castillo VE. Autoimmune neuropsychiatric disorders associated to infection by streptococcus in the paediatric age: PANDAS. Rev Neurol 2003; 36(Suppl. 1): S95-S107.
[PMID: 12599109]
Bernstein GA, Victor AM, Pipal AJ, Williams KA. Comparison of clinical characteristics of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and childhood obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2010; 20(4): 333-40.
[] [PMID: 20807071]
Giedd JN, Rapoport JL, Leonard HL, Richter D, Swedo SE. Case study: acute basal ganglia enlargement and obsessive-compulsive symptoms in an adolescent boy. J Am Acad Child Adolesc Psychiatry 1996; 35(7): 913-5.
[] [PMID: 8768351]
Giedd JN, Rapoport JL, Garvey MA, Perlmutter S, Swedo SE. MRI assessment of children with obsessive-compulsive disorder or tics associated with streptococcal infection. Am J Psychiatry 2000; 157(2): 281-3.
[] [PMID: 10671403]
Elia J, Dell ML, Friedman DF, et al. PANDAS with catatonia: a case report. Therapeutic response to lorazepam and plasmapheresis. J Am Acad Child Adolesc Psychiatry 2005; 44(11): 1145-50.
[] [PMID: 16239863]
Citak EC, Gücüyener K, Karabacak NI, Serdaroğlu A, Okuyaz C, Aydin K. Functional brain imaging in Sydenham’s chorea and streptococcal tic disorders. J Child Neurol 2004; 19(5): 387-90.
[] [PMID: 15224712]
Kumar A, Williams MT, Chugani HT. Evaluation of basal ganglia and thalamic inflammation in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection and tourette syndrome: a positron emission tomographic (PET) study using 11C-[R]-PK11195. J Child Neurol 2015; 30(6): 749-56.
[] [PMID: 25117419]
Rotge JY, Guehl D, Dilharreguy B, et al. Meta-analysis of brain volume changes in obsessive-compulsive disorder. Biol Psychiatry 2009; 65(1): 75-83.
[] [PMID: 18718575]
Giedd JN, Rapoport JL, Kruesi MJ, et al. Sydenham’s chorea: magnetic resonance imaging of the basal ganglia. Neurology 1995; 45(12): 2199-202.
[] [PMID: 8848193]
Cabrera B, Romero-Rebollar C, Jiménez-Ángeles L, et al. Neuroanatomical features and its usefulness in classification of patients with PANDAS. CNS Spectr 2019; 24(5): 533-43.
[] [PMID: 30428956]
Bruin W, Denys D, van Wingen G. Diagnostic neuroimaging markers of obsessive-compulsive disorder: Initial evidence from structural and functional MRI studies. Prog Neuropsychopharmacol Biol Psychiatry 2019; 91: 49-59.
[] [PMID: 30107192]
Husby G, van de Rijn I, Zabriskie JB, Abdin ZH, Williams RC Jr. Antibodies reacting with cytoplasm of subthalamic and caudate nuclei neurons in chorea and acute rheumatic fever. J Exp Med 1976; 144(4): 1094-110.
[] [PMID: 789810]
Kirvan CA, Swedo SE, Kurahara D, Cunningham MW. Streptococcal mimicry and antibody-mediated cell signaling in the pathogenesis of Sydenham’s chorea. Autoimmunity 2006; 39(1): 21-9.
[] [PMID: 16455579]
Brimberg L, Benhar I, Mascaro-Blanco A, et al. Behavioral, pharmacological, and immunological abnormalities after streptococcal exposure: a novel rat model of Sydenham chorea and related neuropsychiatric disorders. Neuropsychopharmacology 2012; 37(9): 2076-87.
[] [PMID: 22534626]
Cox CJ, Zuccolo AJ, Edwards EV, et al. Antineuronal antibodies in a heterogeneous group of youth and young adults with tics and obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2015; 25(1): 76-85.
[] [PMID: 25658702]
Singer HS, Mascaro-Blanco A, Alvarez K, et al. Neuronal antibody biomarkers for Sydenham’s chorea identify a new group of children with chronic recurrent episodic acute exacerbations of tic and obsessive compulsive symptoms following a streptococcal infection. PLoS One 2015; 10(3)e0120499
[] [PMID: 25793715]
Pavone P, Bianchini R, Parano E, et al. Anti-brain antibodies in PANDAS versus uncomplicated streptococcal infection. Pediatr Neurol 2004; 30(2): 107-10.
[] [PMID: 14984902]
Church AJ, Dale RC, Giovannoni G. Anti-basal ganglia antibodies: a possible diagnostic utility in idiopathic movement disorders? Arch Dis Child 2004; 89(7): 611-4.
[] [PMID: 15210488]
Kiessling LS, Marcotte AC, Culpepper L. Antineuronal antibodies in movement disorders. Pediatrics 1993; 92(1): 39-43.
[PMID: 8516083]
Dale RC, Heyman I, Giovannoni G, Church AW. Incidence of anti-brain antibodies in children with obsessive-compulsive disorder. Br J Psychiatry 2005; 187(4): 314-9.
[] [PMID: 16199788]
Frick LR, Rapanelli M, Jindachomthong K, et al. Differential binding of antibodies in PANDAS patients to cholinergic interneurons in the striatum. Brain Behav Immun 2018; 69: 304-11.
[] [PMID: 29233751]
Dale RC, Candler PM, Church AJ, Wait R, Pocock JM, Giovannoni G. Neuronal surface glycolytic enzymes are autoantigen targets in post-streptococcal autoimmune CNS disease. J Neuroimmunol 2006; 172(1-2): 187-97.
[] [PMID: 16356555]
Church AJ, Cardoso F, Dale RC, Lees AJ, Thompson EJ, Giovannoni G. Anti-basal ganglia antibodies in acute and persistent Sydenham’s chorea. Neurology 2002; 59(2): 227-31.
[] [PMID: 12136062]
Swedo SE, Leonard HL, Mittleman BB, et al. Identification of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections by a marker associated with rheumatic fever. Am J Psychiatry 1997; 154(1): 110-2.
[] [PMID: 8988969]
Hoekstra PJ, Bijzet J, Limburg PC, et al. Elevated D8/17 expression on B lymphocytes, a marker of rheumatic fever, measured with flow cytometry in tic disorder patients. Am J Psychiatry 2001; 158(4): 605-10.
[] [PMID: 11282696]
Murphy TK, Goodman WK, Fudge MW, et al. B lymphocyte antigen D8/17: a peripheral marker for childhood-onset obsessive-compulsive disorder and Tourette’s syndrome? Am J Psychiatry 1997; 154(3): 402-7.
[] [PMID: 9054790]
Chapman F, Visvanathan K, Carreño-Manjarrez R, Zabriskie JB. A flow cytometric assay for D8/17 B cell marker in patients with Tourette’s syndrome and obsessive compulsive disorder. J Immunol Methods 1998; 219(1-2): 181-6.
[] [PMID: 9831399]
Inoff-Germain G, Rodríguez RS, Torres-Alcantara S, Díaz-Jimenez MJ, Swedo SE, Rapoport JL. An immunological marker (D8/17) associated with rheumatic fever as a predictor of childhood psychiatric disorders in a community sample. J Child Psychol Psychiatry 2003; 44(5): 782-90.
[] [PMID: 12831121]
Luo F, Leckman JF, Katsovich L, et al. Prospective longitudinal study of children with tic disorders and/or obsessive-compulsive disorder: relationship of symptom exacerbations to newly acquired streptococcal infections. Pediatrics 2004; 113(6): e578-85.
[] [PMID: 15173540]
Hamilton CS, Garvey MA, Swedo SE. Sensitivity of the D8/17 assay. Am J Psychiatry 2003; 160(6): 1193-4.
[] [PMID: 12777295]
Luleyap HU, Onatoglu D, Yilmaz MB, et al. Association between pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections disease and tumor necrosis factor-α gene-308 g/a, -850 c/t polymorphisms in 4-12-year-old children in Adana/Turkey. Indian J Hum Genet 2013; 19(2): 196-201.
[] [PMID: 24019622]
Rosenblum MD, Remedios KA, Abbas AK. Mechanisms of human autoimmunity. J Clin Invest 2015; 125(6): 2228-33.
[] [PMID: 25893595]
Walls A, Dermody S, Kumaran R, Krishnan N, Harley EH. Characterization of B-Cells in tonsils of patients diagnosed with pediatric autoimmune neuropsychiatric disorder associated streptococcus. Int J Pediatr Otorhinolaryngol 2016; 80: 49-52.
[] [PMID: 26746612]
Walls A, Cubangbang M, Wang H, et al. Pediatric autoimmune neuropsychiatric disorder associated with streptococcus immunology: a pilot study. Otolaryngol Head Neck Surg 2015; 153(1): 130-6.
[] [PMID: 25832830]
Dörner T, Jacobi AM, Lipsky PE. B cells in autoimmunity. Arthritis Res Ther 2009; 11(5): 247.
[] [PMID: 19849820]
Tsubata T. B-cell tolerance and autoimmunity. F1000 Res 2017; 6: 391.
[] [PMID: 28408984]
Kawikova I, Leckman JF, Kronig H, et al. Decreased numbers of regulatory T cells suggest impaired immune tolerance in children with Tourette syndrome: a preliminary study. Biol Psychiatry 2007; 61(3): 273-8.
[] [PMID: 16996487]
Çelik G, Taş D, Tahiroğlu A, et al. Vitamin D deficiency in obsessive-compulsive disorder patients with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: A case control study. Noro Psikiyatri Arsivi 2016; 53(1): 33-7.
[] [PMID: 28360763]
Stagi S, Lepri G, Rigante D, Matucci Cerinic M, Falcini F. cross-sectional evaluation of plasma vitamin D levels in a large cohort of italian patients with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. J Child Adolesc Psychopharmacol 2018; 28(2): 124-9.
[] [PMID: 29112476]
Bodner SM, Morshed SA, Peterson BS. The question of PANDAS in adults. Biol Psychiatry 2001; 49(9): 807-10.
[] [PMID: 11331090]
Church AJ, Dale RC. Antistreptolysin-O titers: Implications for adult PANDAS. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Am J Psychiatry 2002; 159(2): 320.
[] [PMID: 11823288]
Helm CE, Blackwood RA. Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS): Experience at a Tertiary Referral Center. Tremor Other Hyperkinet Mov (N Y) 2015; 5: 270.
[PMID: 26196024]
Rippel CA, Hong JJ, Yoon DY, Williams PN, Singer HS. Methodologic factors affect the measurement of anti-basal ganglia antibodies. Ann Clin Lab Sci 2005; 35(2): 121-30.
Varley J, Brooks DJ, Edison P. Imaging neuroinflammation in Alzheimer’s disease and other dementias: recent advances and future directions. Alzheimers Dement 2015; 11(9): 1110-20.
[] [PMID: 25449529]

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