Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-25T18:48:28.923Z Has data issue: false hasContentIssue false
  • English
  • Français

Acute Cognitive and Behavioral Effects of Systemic Corticosteroids in Children Treated for Inflammatory Bowel Disease

Published online by Cambridge University Press:  19 November 2012

Christine Mrakotsky ,
Peter W. Forbes ,
Jane Holmes Bernstein ,
Richard J. Grand ,
Athos Bousvaros ,
Eva Szigethy  and
Deborah P. Waber
Christine Mrakotsky*
Affiliation:
Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
Peter W. Forbes
Affiliation:
Clinical Research Program, Boston Children's Hospital, Boston, Massachusetts
Jane Holmes Bernstein
Affiliation:
Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
Richard J. Grand
Affiliation:
Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
Athos Bousvaros
Affiliation:
Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
Eva Szigethy
Affiliation:
Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Deborah P. Waber
Affiliation:
Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
*
Correspondence and reprint requests to: Christine Mrakotsky, Department of Psychiatry, Boston Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115. E-mail: [email protected].
Get access Rights & Permissions [Opens in a new window]

Abstract

Systemic corticosteroids are a mainstay of treatment for many pediatric medical conditions. Although their impact on the central nervous system has been well-studied in animal models and adults, less is known about such effects in pediatric populations. The current study investigated acute effects of corticosteroids on memory, executive functions, emotion, and behavior in children and adolescents with inflammatory bowel disease (IBD). Patients 8–17 years with IBD (Crohn's disease, CD; ulcerative colitis, UC) on high-dose prednisone (n = 33) and IBD patients in remission off steroids (n = 33) completed standardized neuropsychological tests and behavior rating scales. In the IBD sample as a whole, few steroid effects were found for laboratory cognitive measures, but steroid-treated patients were rated as exhibiting more problems with emotional, and to a lesser extent with cognitive function in daily life. Steroid effects, assessed by laboratory measures and questionnaires, were more prevalent in CD than UC patients; UC patients on steroids sometimes performed better than controls. Sleep disruption also predicted some outcomes, diminishing somewhat the magnitude of the steroid effects. Corticosteroid therapy can have acute effects on cognition, emotion, and behavior in chronically ill children; the clinical and long-term significance of these effects require further investigation. (JINS, 2012, 19, 1–14)

Keywords

MemoryExecutive functionGlucocorticoidCorticosteroid therapyInflammatory bowel diseaseNeuropsychological assessment
Type
Research Articles
Information
Journal of the International Neuropsychological Society , Volume 19 , Issue 1 , January 2013 , pp. 96 - 109
Copyright
Copyright © The International Neuropsychological Society 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Achenbach, T.M., Rescorla, L.A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.Google Scholar
Anderson, V.A., Anderson, P., Northam, E., Jacobs, R., Mikiewicz, O. (2002). Relationships between cognitive and behavioral measures of executive function in children with brain disease. Child Neuropsychology, 8, 231–240. doi:10.1076/chin.8.4.231.13509CrossRefGoogle ScholarPubMed
Bender, B.G., Lerner, J.A., Kollasch, E. (1988). Mood and memory changes in asthmatic children receiving corticosteroids. Journal of the American Academy of Child & Adolescent Psychiatry, 27(6), 720–725. doi:10.1097/00004583-198811000-00010CrossRefGoogle ScholarPubMed
Benjamini, Y., Hochberg, Y. (1995). Controlling the false discovery rate – a new and powerful approach to multiple testing. Journal of the Royal Statistical Society, Series B, 57, 289–300.Google Scholar
Bermond, B., Surachno, S., Lok, A., ten Berge, I.J., Plasmans, B., Kox, C., Hamel, R. (2005). Memory functions in prednisone-treated kidney transplant patients. Clinical Transplantation, 19(4), 512–517. doi:10.1111/j.1399-0012.2005.00376.xCrossRefGoogle ScholarPubMed
Bernstein, J.H., Waber, D.P. (1996). Developmental scoring system for the Rey-Osterrieth complex figure. Odessa, FL: Psychological Assessment Resources, Inc.Google Scholar
Bodnar, L.E., Prahme, M.C., Cutting, L.E., Denckla, M.B., Mahone, E.M. (2007). Construct validity of parent ratings of inhibitory control. Child Neuropsychology, 13, 345–362. doi:10.1080/09297040600899867CrossRefGoogle ScholarPubMed
Bourdeau, I., Bard, C., Noël, B., LeClerc, I., Cordeau, M.P., Bélair, M., LaCroix, A. (2002). Loss of brain volume in endogenous Cushing's syndrome and its reversibility after correction of hypercortisolism. Journal of Clinical Endocrinology and Metabolism, 87(5), 1949–1954. doi:10.1210/jc.87.5.1949Google ScholarPubMed
Brown, E.S., Beard, L., Frol, A.B., Rush, A.J. (2006). Effect of two prednisone exposures on mood and declarative memory. Neurobiology of Learning and Memory, 86(1), 28–34. doi:10.1016/j.nlm.2005.12.009CrossRefGoogle ScholarPubMed
Brown, E.S., Chandler, P.A. (2001). Mood and cognitive changes during systemic corticosteroid therapy. Primary Care Companion, Journal of Clinical Psychiatry, 3(1), 17–21.Google ScholarPubMed
Brown, E.S., Suppes, T., Khan, D.A., Carmody, T.J. III (2002). Mood changes during prednisone bursts in outpatients with asthma. Journal of Clinical Psychopharmacology, 22(1), 55–61.CrossRefGoogle ScholarPubMed
Brunner, R., Schaefer, D., Hess, K., Parzer, P., Resch, F., Schwab, S. (2005). Effect of corticosteroids on short-term and long-term memory. Neurology, 64(2), 335–337. PMID: 15668434. doi:10.1212/01.WNL.0000149523.35039.4CCrossRefGoogle ScholarPubMed
Cambridge Neuropsychological Test Automated Battery, Version 2 (CANTAB eclipse v2.0™). (2005). Cambridge, UK: Cambridge Cognition Ltd.Google Scholar
Carlsson, A.M. (1983). Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain, 16, 87–101.CrossRefGoogle ScholarPubMed
Cerqueira, J.J., Pego, J.M., Taipa, R., Bessa, J.M., Almeida, O.F., Sousa, N. (2005). Morphological correlates of corticosteroid-induced changes in prefrontal cortex-dependent behaviors. Journal of Neuroscience, 25(34), 7792–7800. doi:10.1523/JNEUROSCI.1598-05.2005CrossRefGoogle ScholarPubMed
Chan, R.C.K., Shum, D., Toulopoulou, T., Chen, E.Y.H. (2008). Assessment of executive functions: Review of instruments and identification of critical issues. Archives of Clinical Neuropsychology, 23, 201–216. doi:10.1016/j.acn.2007.08.010CrossRefGoogle ScholarPubMed
Cohen, M. (1997). Children's Memory Scale (CMS). San Antonio, TX: Psychological Corporation.Google Scholar
Conners, C.K. (2000). Conners’ Continuous Performance Test, Second Edition, V.5. (CPT-II). Los Angeles, CA: Multi-Health Systems Inc.Google Scholar
Delis, D.C., Kaplan, E., Kramer, J.H. (2001). Delis-Kaplan Executive Function System (D-KEFS). San Antonio, TX: Psychological Corporation.Google Scholar
Delis, D.C., Kramer, J.H., Kaplan, E., Ober, B.A. (1994). California Verbal Learning Test – Children's Version (CVLT-C). San Antonio, TX: Psychological Corporation.Google Scholar
Delis, D.C., Kramer, J.H., Kaplan, E., Ober, B.A. (2000). California Verbal Learning Test – Second Edition (CVLT-II). San Antonio, TX: Psychological Corporation.Google Scholar
DeQuervain, D.J., Roozendaal, B., Nitsch, R.M., McGaugh, J.L., Hock, C. (2000). Acute cortisone administration impairs retrieval of long-term declarative memory in humans. Nature Neuroscience, 3(4), 313–314. PMID: 10725918. doi:10.1038/73873CrossRefGoogle Scholar
Deretzi, G., Kountouras, J., Grigoriadis, N., Zavos, C., Chatzigeorgiou, S., Koutlas, E., Tsiptsios, I. (2009). From the “little brain” gastrointestinal infection to the “big brain” neuroinflammation: A proposed fast axonal transport pathway involved in multiple sclerosis. Medical Hypotheses, 73(5), 781–787. doi:10.1016/j.mehy.2009.04.021CrossRefGoogle Scholar
Drigan, R., Spirito, A., Gelber, R.D. (1992). Behavioral side effects of corticosteroids in children with acute lymphoblastic leukemia. Medical and Pediatric Oncology, 20(1), 13–21. doi:10.1002/mpo.2950200104CrossRefGoogle ScholarPubMed
Engstrom, I. (1999). Inflammatory bowel disease in children and adolescents: Mental health and family functioning. Journal of Pediatric Gastroenterology and Nutrition, 28(4), S28–S33.CrossRefGoogle ScholarPubMed
Gioia, G.A., Isquith, P.K., Guy, S.C., Kenworthy, L. (2000). Behavior Rating Inventory of Executive Function (BRIEF). Odessa, FL: Psychological Assessment Resources, Inc.Google Scholar
Guy, S.C., Isquith, P.K., Gioia, G.A. (2004). Behavior Rating Inventory of Executive Function–Self Report Version (BRIEF-SR). Odessa, FL: Psychological Assessment Resources, Inc.Google Scholar
Haroon, E., Raison, C.L., Miller, A.H. (2012). Psychoneuroimmunology meets neuropsychopharmacology: Translational implications of the impact of inflammation on behavior. Neuropsychopharmacology Reviews, 37, 136–162. doi:10.1038/npp.2011.205CrossRefGoogle Scholar
Harris, J.C., Carel, C.A., Rosenberg, L.A., Joshi, P., Leventhal, B.G. (1986). Intermittent high dose corticosteroid treatment in childhood cancer: Behavioral and emotional consequences. Journal of the American Academy of Child Psychiatry, 25, 120–124. doi:10.1016/S0002-7138(09)60608-7CrossRefGoogle ScholarPubMed
Hinds, P.S., Hockenberry, M.J., Gattuso, J.S., Srivastava, D.K., Tong, X., Jones, H., Pui, C.H. (2007). Dexamethasone alters sleep and fatigue in pediatric patients with acute lymphoblastic leukemia. Cancer, 110, 2321–2330. doi:10.1002/cncr.23039CrossRefGoogle ScholarPubMed
Hyams, J.S., Ferry, G.D., Mandel, F.S., Gryboski, J.D., Kibort, P.M., Kirschner, B.S., Lesser, M. (1991). Development and validation of a pediatric Crohn's disease activity index. Journal of Pediatric Gastroenterology and Nutrition, 12(4), 439–447.Google ScholarPubMed
Kadan-Lottick, N.S., Brouwers, P., Breiger, D., Kaleita, T., Dziura, J., Northrup, V., Neglia, J.P. (2009). Comparison of neurocognitive functioning in children previously randomly assigned to intrathecal methotrexate compared with triple intrathecal therapy for the treatment of childhood acute lymphoblastic leukemia. Journal of Clinical Oncology, 27(35), 5986–5992. doi:10.1200/JCO.2009.23.5408CrossRefGoogle ScholarPubMed
Keenan, P.A., Jacobson, M.W., Soleymani, R.M., Mayes, M.D., Stress, M.E, Yaldoo, D.T. (1996). The effect on memory of chronic prednisone treatment in patients with systemic disease. Neurology, 47, 1396–1402.CrossRefGoogle ScholarPubMed
Keenan, P.A., Jacobson, M.W., Soleymani, R.M., Newcomer, J.W. (1995). Commonly used therapeutic doses of glucocorticoids impair explicit memory. Annals of the New York Academy of Sciences, 761, 400–402. doi:10.1111/j.1749-6632.1995.tb31402.xCrossRefGoogle ScholarPubMed
Killgore, W.D. (2010). Effects of sleep deprivation on cognition. Progress in Brain Research, 185, 105–129. doi:10.1016/B978-0-444-53702-7.00007-5CrossRefGoogle ScholarPubMed
King, R.A. (2003). Pediatric inflammatory bowel disease. Child and adolescent psychiatric clinics of North America, 12, 537–550. doi:10.1016/S1056-4993(03)00007-5CrossRefGoogle ScholarPubMed
Klein-Gitelman, M.S., Pachman, L.M. (1998). Intravenous corticosteroids: Adverse reactions are more variable than expected in children. The Journal of Rheumatology, 25, 1995–2002. PMID: 9779857.Google ScholarPubMed
Kovacs, M. (1992). Children's Depression Inventory (CDI). New York, NY: Multi-Health Systems Inc.Google Scholar
Kozarek, R.A., Patterson, D.J., Gelfand, M.D., Botoman, V.A., Ball, T.J., Wilske, K.R. (1989). Methotrexate induces clinical and histologic remission in patients with refractory inflammatory bowel disease. Annals of Internal Medicine, 110(5), 353–356.CrossRefGoogle ScholarPubMed
Kromrey, J.D., Hogarty, K.Y. (2002). FDR_TEST: A SAS macro for calculating new methods of error control in multiple hypothesis testing. Savannah, Georgia: Southeast SAS Users Group.Google Scholar
Lupien, S.J., de Leon, M., de Santi, S., Convit, A., Tarshish, C., Nair, N.P., Meaney, M.J. (1998). Cortisol levels during human aging predict hippocampal atrophy and memory deficits. Nature Neuroscience, 1(1), 69–73. doi:10.1038/271CrossRefGoogle ScholarPubMed
Lupien, S.J., Gillin, C.J., Hauger, R.L. (1999). Working memory is more sensitive than declarative memory to the acute effects of corticosteroids: A dose-response study in humans. Behavioral Neuroscience, 113, 420–430. doi:10.1037/0735-7044.113.3.420CrossRefGoogle Scholar
Mahone, E.M., Hagelthorn, K.M., Cutting, L.E., Schuerholz, L.J., Pelletier, S.F., Rawlins, C., Denckla, M.B. (2002). Effects of IQ on executive function measures in children with ADHD. Child Neuropsychology, 8(1), 52–65. doi:10.1076/chin.8.1.52.8719CrossRefGoogle ScholarPubMed
Maier, S.F. (2003). Bi-directional immune-brain communication: Implications for understanding stress, pain, and cognition. Brain, Behavior, and Immunity, 17(2), 69–85. doi:10.1016/S0889-1591(03)00032-1CrossRefGoogle ScholarPubMed
Markowitz, J., Hyams, J., Mack, D., Leleiko, N., Evans, J., Kugathasan, S.Pediatric IBD Collaborative Research Group (2006). Corticosteroid therapy in the age of infliximab: Acute and 1-year outcomes in newly diagnosed children with Crohn's disease. Clinical Gastroenterology and Hepatology, 4(9), 1124–1129. doi:10.1016/j.cgh.2006.05.011CrossRefGoogle ScholarPubMed
McDonough, A.K., Curtis, J.R., Saag, K.G. (2008). The epidemiology of glucocorticoid-associated adverse events. Current Opinion in Rheumatology, 20, 131–137. doi:10.1097/BOR.0b013e3282f51031CrossRefGoogle ScholarPubMed
Merke, D.P., Giedd, J.N., Keil, M.F., Mehlinger, S.L., Wiggs, E.A., Holzer, S., Chrousos, G.P. (2005). Children experience cognitive decline despite reversal of brain atrophy one year after resolution of Cushing syndrome. Journal of Clinical Endocrinology and Metabolism, 90(5), 2531–2536. doi:10.1210/jc.2004-2488CrossRefGoogle ScholarPubMed
Mittermaier, C., Dejaco, C., Waldhoer, T., Oefferlbauer-Ernst, A., Miehsler, W., Beier, M., Moser, G. (2004). Impact of depressive mood on relapse in patients with inflammatory bowel disease: A prospective 18-month follow-up study. Psychosomatic Medicine, 66(1), 79–84.CrossRefGoogle ScholarPubMed
Monk, C.S., Nelson, C.A. (2002). The effects of hydrocortisone on cognitive and neural function: A behavioral and event-related potential investigation. Neuropsychopharmacology, 26, 505–519. doi:10.1016/S0893-133X(01)00384-0CrossRefGoogle ScholarPubMed
Mrakotsky, C.M., Silverman, L.B., Dahlberg, S.E., Alyman, M.C., Sands, S.A., Queally, J.T., Waber, D.P. (2011). Neurobehavioral side effects of corticosteroids during active treatment for acute lymphoblastic leukemia in children are age-dependent: Report from Dana-Farber Cancer Institute ALL Consortium Protocol 00-01. Pediatric Blood & Cancer, 57(3), 492–498. doi:10.1002/pbc.23060CrossRefGoogle ScholarPubMed
Murch, S.H., Baldassano, R., Buller, H., Chin, S., Griffiths, A.M., Hildebrand, H., Orsi, M. (2004). Inflammatory bowel disease: Working group report of the second world congress of pediatric gastroenterology, hepatology, and nutrition. Journal of Pediatric Gastroenterology and Nutrition, 39(Suppl 2), S647–S654.CrossRefGoogle Scholar
Newcomer, J.W., Craft, S., Hershey, T., Askins, K., Bardgett, M.E. (1994). Glucocorticoid-induced impairment in declarative memory performance in adult humans. The Journal of Neuroscience, 14(4), 2047–2053.CrossRefGoogle ScholarPubMed
Newcomer, J.W., Selke, G., Melson, A.K., Hershey, T., Craft, S., Richards, K., Alderson, A.L. (1999). Decreased memory performance in healthy humans induced by stress-level cortisol treatment. Archives of General Psychiatry, 56(6), 527–533. doi:10.1001/archpsyc.56.6.527CrossRefGoogle ScholarPubMed
Payne, J.M., Hyman, S.L., Shores, E.A., North, K.N. (2011). Assessment of executive function and attention in children with neurofibromatosis type 1: Relationships between cognitive measures and real-world behavior. Child Neuropsychology, 17, 313–329. doi:10.1080/09297049.2010.542746CrossRefGoogle ScholarPubMed
Podolsky, D. (2002). Inflammatory bowel disease. New England Journal of Medicine, 347(6), 417–429. doi:10.1056/NEJMra020831CrossRefGoogle ScholarPubMed
Poznanski, E.O., Mokros, H.B. (1996). Children's Depression Rating Scale, Revised (CDRS-R): Manual. Los Angeles, CA: Western Psychological Services.Google Scholar
Preacher, K.J., Hayes, A.F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36(4), 717–731. doi:10.3758/BF03206553CrossRefGoogle ScholarPubMed
Rufo, P.A., Bousvaros, A. (2006). Current therapy of inflammatory bowel disease in children. Pediatric Drugs, 8(5), 279–302.CrossRefGoogle ScholarPubMed
Sacks, O., Shulman, M. (2005). Steroid dementia: An overlooked diagnosis? Neurology, 64(4), 707–709. doi:10.1212/01.WNL.0000151977.18440.C3CrossRefGoogle ScholarPubMed
Sheslow, D., Adams, W. (2003). Wide-Range Assessment of Memory and Learning, Second Edition (WRAML-2). Wilmington, DE: Wide Range, Inc.Google Scholar
Soliday, E., Grey, S., Lande, M.B. (1999). Behavioral effects of corticosteroids in steroid-sensitive nephrotic syndrome. Pediatrics, 104(4), 51. doi:10.1542/peds.104.4.e51CrossRefGoogle ScholarPubMed
Starkman, M.N., Gebarski, S.S., Berent, S., Schteingart, D.E. (1992). Hippocampal formation volume, memory dysfunction, and cortisol levels in patients with Cushing's syndrome. Biological Psychiatry, 32(9), 756–765. doi:10.1016/0006-3223(92)90079-FCrossRefGoogle ScholarPubMed
Stickgold, R., Fosse, R., Walker, M.P. (2002). Linking brain and behavior in sleep-dependent learning and memory consolidation. Proceedings of the National Academy of Sciences of the United States of America, 99(26), 16519–16521. doi:10.1073/pnas.012689199CrossRefGoogle ScholarPubMed
Stinson, J.N., Kavanagh, T., Yamada, J., Gill, N., Stevens, B. (2006). Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain, 125(1–2), 143–157. doi:10.1016/j.pain.2006.05.006CrossRefGoogle ScholarPubMed
Stuart, F.A., Segal, T.Y., Keady, S. (2005). Adverse psychological effects of corticosteroids in children and adolescents. Archives of Disease in Childhood, 90(5), 500–506. doi:10.1136/adc.2003.041541CrossRefGoogle ScholarPubMed
Szigethy, E.M., Levy-Warren, A., Whitton, S.W., Bousvaros, A., Gauvreau, K., Leichtner, A.M., Beardslee, W. (2004). Depressive symptoms and inflammatory bowel disease in children and adolescents: A cross-sectional study. Journal of Pediatric Gastroenterology and Nutrition, 39(4), 395–403.CrossRefGoogle ScholarPubMed
Uttner, I., Mueller, S., Zinser, C., Maier, M., Sussmuth, S., Claus, A., Tumani, H. (2005). Reversible impaired memory induced by pulsed methylprednisolone in patients with MS. Neurology, 64(11), 1971–1973. doi:10.1212/01.WNL.0000163804.94163.91CrossRefGoogle ScholarPubMed
Van Limbergen, J., Russell, R., Drummond, H.E., Aldhous, M.C., Round, N.K., Nimmo, E.R., Wilson, D.C. (2008). Definition of phenotypic characteristics of childhood-onset inflammatory bowel disease. Gastroenterology, 135(4), 1114–1122. doi:10.1053/j.gastro.2008.06.081CrossRefGoogle ScholarPubMed
Waber, D.P., Carpentieri, S.C., Klar, N., Silverman, L.B., Schwenn, M., Hurwitz, C.A., Sallan, S.E. (2000). Cognitive sequelae in children treated for acute lymphoblastic leukemia with dexamethasone or prednisone. Journal of Pediatric Hematology and Oncology, 22(3), 206–213.CrossRefGoogle ScholarPubMed
Wechsler, D. (1997). Wechsler Adult Intelligence Scale – Third Edition (WAIS-III). San Antonio, TX: Psychological Corporation.Google Scholar
Wechsler, D. (1999). Wechsler Abbreviated Scale of Intelligence (WASI). San Antonio, TX: Psychological Corporation.Google Scholar
Wechsler, D. (2003). Wechsler Intelligence Scale for Children, 4th Edition (WISC-IV). San Antonio, TX: Harcourt Assessment, Inc.Google Scholar
Wolkowitz, O.M., Burke, H., Epel, E.S., Reus, V.I. (2009). Glucocorticoids. mood, memory, and mechanisms. Annals of the New York Academy of Sciences, 1179, 19–40. doi:10.1111/j.1749-6632.2009.04980.xCrossRefGoogle ScholarPubMed
Wolkowitz, O.M., Lupien, S.J., Bigler, E., Levin, R.B., Canick, J. (2004). The “steroid dementia syndrome”: An unrecognized complication of glucocorticoid treatment. Annals of the New York Academy of Sciences, 1032, 191–194. doi:10.1196/annals.1314.018CrossRefGoogle ScholarPubMed
Yehuda, S., Rabinovitz, S., Mostofsky, D.I. (2006). Nutritional deficiencies in learning and cognition. Journal of Pediatric Gastroenterology and Nutrition, 43(Suppl 3), S22–S25. doi:10.1097/01.mpg.0000255847.77034.a4CrossRefGoogle ScholarPubMed
Zanardi, V.A., Magna, L.A., Costallat, L.T. (2001). Cerebral atrophy related to corticotherapy in systemic lupus erythematosus (SLE). Clinical Rheumatology, 2001(20), 245–250. doi:10.1007/s100670170037CrossRefGoogle Scholar