Background: Cocaine use disorder (CUD) is a growing public health concern, but so far no effective pharmacotherapies have been demonstrated. Stimulant medications have proved to be promising in CUD treatment. The self-medication hypothesis (SMH) can help to explain this phenomenon better, especially in cases where CUD co-occurs with adult attention deficit hyperactivity disorder (A-ADHD). Methods: In the present retrospective study, a sample of 20 consecutive patients (aged from 18 to 65 years) with dual disorder (A-ADHD/CUD), under treatment with methylphenidate (MPH) or atomoxetine (ATM) medications, was followed to study the effects of A-ADHD treatment on cocaine use. Patients were followed for a mean period of 7 months . All individuals were assessed with standardized questionnaires to evaluate diagnosis, treatment efficacy, and clinical improvement. Results: the results showed that behaviors reflecting cocaine addiction were sharply reduced during the stimulant treatment of A-ADHD, and were not correlated with age, gender, familiarity, length of treatment, or medication used. CUD improvement was closely correlated with the A-ADHD improvement. This study supports the validity of the SMH in ADHD patients with co-occurring CUD. Cocaine use disorder (CUD) is a growing public health concern. As estimated in the annual World Drug Report for 2018 of the United Nations Office for Drugs and Crime (WDR 2018), in 2016, the number of past-year cocaine users increased globally by almost 7% from the previous year to 18.2 million (range: 13.9–22.9 million). More than half of all cocaine users live in the Americas, mostly North America . Almost one-quarter of the world total for users reside in Europe, especially in Western and Central Europe, which alone account for about one-fifth of the total number. Africa and, to a lesser extent, Asia and Oceania, taken together, may account for the remaining quarter of all cocaine users, although these estimates are biased by a significant lack of data for these geographical areas.These figures for all age groups include about 2.3 million young adults aged 15–34 (1.9% of this age group) who have used the drug in the last year. Over the past few decades, the role of attention deficit hyperactivity disorder (ADHD) in the development and persistence of problematic substance behaviours up to the addictive level has been given extensive clinical attention, while studies have shown an increasing prevalence of ADHD  [To better explain the association between ADHD and SUD, primarily focusing on cocaine use disorder (CUD), the self-medication hypothesis (SMH) could help. The drug SMH was developed by Khantzian, who suggested that the drive to take drugs may be thought of by the user as the best practical solution to relieve suffering and distress, especially with reference to heroin and cocaine.It has been suggested that there is a considerable degree of psychopharmacological specificity in the selected used substances ,5. The dConsequently, as stated by the SMH, patients use drugs as a way to suppress ADHD symptoms. Stimulants including cocaine, can, however paradoxically, act to calm and counteract hyperactivity, emotional lability, and inattention in ADHD individuals .Similarly, Holtmann et al.  and GudjHowever, the data made available so far are inadequate and inconclusive, often considering SUD overall regardless of the specific type of drug, and are mostly limited to childhood and late adolescence. One major drawback has been that little is known about ADHD and CUD in adulthood.Aims: In the present retrospective case series study, a sample of 20 consecutive patients (age range 18−65) with adult ADHD (A-ADHD) and co-occurring CUD, under treatment with methylphenidate (MPH) or atomoxetine (ATM), was followed for a mean period of 7 months  to study the effects of ADHD treatment on cocaine use.Research information on patients included in the present study came from the A-ADHD Clinic (A-ADHD outpatient clinic) study, a cohort study including information on individual patients admitted to stimulant medication treatment for A-ADHD at the Second Psychiatric Unit of Santa Chiara University Hospital, University of Pisa, Italy. For the aims of the present study, data collected at the time of enrolment into the study (baseline) and at the last available evaluation, invariably including the presence of a condition of cocaine use in each patient, were extracted from the A-ADHD-Clinic dataset. Extracted information was analyzed following a cross-sectional design to estimate the magnitude of differences between patients in terms of the clinical global impression of A-ADHD and addictive behavior (amount of cocaine used). All the subjects examined signed an informed consensus document that allowed them to participate in the A-ADHD-Clinic study. Both the consent form and the experimental procedures were approved by the ethics committee of the University of Pisa , in accordance with internationally accepted criteria for ethical research. Aims, data gathered, and the future perspectives of this case series study are summarized in Not having been diagnosed in childhood/adolescenceFirst diagnosis of ADHD in adulthoodComorbidity of substance use disorder, with patient choice of cocaine as the primary substance of use.Treatment for almost a month.Compliance with treatment confirmed by a family informantNot under treatment with the combination of atomoxetine (ATM)/metylphenidate (MPH)All patients had to satisfy the following inclusion criteria:All patients had received stable and comparable psychopharmacological treatment during the whole observational period, except for stimulants. Patients with current psychotic symptoms, hypomanic or manic states, and cardiovascular comorbidities were excluded.The selected sample included 20 subjects. Eighteen (90.0%) were males, 16 (80.0%) were single, and all had had an education lasting at least eight years. Six (30.0%) were white-collar workers, 2 (10.0%) were blue-collar workers, and 12 (60.0%) were unemployed. Eighteen (90.0%) reported an adequate economic level. Only three (15.0%) were living alone. Age was 30 ± 11 years (range: 16−61).Both A-ADHD and the CUD diagnosis were made with the Structured Clinical Interview for DSM-5 (SCID-5), following DSM-5 criteria. A diagnosis of ADHD was at first investigated with the A-ADHD Self-Report Scale (ASRS) screening test and confirmed by using the Structured Diagnostic Interview for A-ADHD (DIVA). All individuals were assessed with standardized questionnaires to evaluate treatment efficacy and clinical improvement  and cocaine addiction severity .The Structured Clinical Interview for DSM-5 (SCID-5)  is a semThis scale is a self-reported instrument consisting of the 18 DSM−5 criteria. Six of the 18 questions were found to be those that best predicted ADHD symptoms. These six questions are the basis for the ASRS v1. Part B of the Symptom Checklist contains the remaining 12 questions . We usedThe DIVA is the first structured Dutch interview for ADHD in adults; it was developed by Kooij and Francken and is the successor of the earlier Semi-Structured Interview for ADHD in adults . In ordeWhenever possible, the DIVA should be completed by the psychiatrist face to face with an adult patient in the presence of a partner and/or family member, to promote the provision of retrospective and collateral information. The DIVA usually takes around one and a half hours to complete. The DIVA only asks about the core symptoms of ADHD that are required for the formulation of a diagnosis of ADHD, regardless of co-occurring psychiatric disorders. The DIVA is divided into three parts, each applied both to childhood and adulthood: the criteria for attention deficit (A1), the criteria for hyperactivity–impulsivity (A2), and age at onset and impairment. Information received from the partner and immediate family is mainly meant to supplement the information obtained from the patient, and so provide the psychiatrist with an accurate account of both current and childhood behaviour. Caregiver information is particularly useful for childhood, since many patients usually struggle to recall their behaviour retrospectively. For each criterion, the researcher should decide its presence or absence in both the main stages of life, taking into account the information obtained from all the parties involved. If collateral information cannot be made available, the diagnosis should be based on the patient’s own recollection alone. If school reports are available, these can help to give an idea of the symptoms noticed in the classroom and can be used to support the diagnosis. Symptoms are considered clinically relevant when they occur at a more severe degree, more frequently than in the peer group, and inducing greater impairment of the individual’s skills. We used the Italian version .Clinical Global Impression is a questionnaire designed by Guy . It is aThe Cocaine Problem Severity Index (CPSI) is a test designed to help determine the extent of patients’ involvement with cocaine . The tesThe assessments were scheduled at baseline and every month (±15 days) for the first three months, then at intervals of three months (±1 month). The CGI was administered using A-ADHD and CUD by two researchers who were mutually blinded and also blinded with respect to the previous evaluations. Control over bias from different evaluators was partially ensured by the supervision of a senior psychiatrist (I. Maremmani). The baseline/last-evaluation differences for each of the A-ADHD and CUD CGI-S, CGI-C, CGI-E, and CPSI questionnaire items and for their total were tested by the Wilcoxon signed-rank test, which was used to compare a paired difference in a single sample when the population could not be assumed to be normally distributed.r corrected by baseline values. We compared, using the Mann–Whitney test (the non-parametric test for independent samples), last-evaluation ADHD-CUD CGI-S, CGI-C, and CGI-E with a set of subgroups  to test whether our results were correlated with them.The correlations between the CGI-S, CGI-C, and CGI-E at the last evaluation of ADHD and CUD were calculated with partial correlation analysis using Pearson’s We used Statistical routines of SPSS (v25.0)  to elaborate our data. ADHD combined with a predominantly inattentive presentation was the main finding in three (15.0%) patients. All patients met the psychiatric comorbidity criteria for bipolar 1 disorder. Regarding the co-presence of other SUDs, eight (40.0%) patients were affected by cannabis use disorder; six (30.0%) by opioid use disorder (OUD) in agonist opioid treatment (AOT); one (5.0%) by alcohol use disorder (AUD); and two (10.0%) by hallucinogen use disorder. We followed up with 12 patients (60.0%) for less than 6 months and with eight (40.0%) for more than 6 months . We treated 11 (55.0) patients with MPH (nine patients with MPH extended release and two patients with MPH immediate release) and nine (45.0%) with ATM. Patients were also treated with standard doses of ADHD medication, adding valproic acid and low dosages of benzodiazepines according to the stage of their bipolar illness. In Italy the standard dose of ATM is 1.2 mg/kg/day, the maximum dosage of immediate release MPH is 60 mg/day, and the standard dose of extended release MPH is 60–90 mg/day.Regarding family history, five (25.0%) patients did not show psychiatric or SUD familiarity. Nine (45.0%) patients showed both psychiatric and SUD familiarity. Six (30.0%) showed only a psychiatric comorbidity. Regarding ADHD, after evaluation by the CGI-S, one patient (5.0%) was mildly ill, three (15.0%) were moderately ill, six (30.0%) were markedly ill, eight (40.0%) were severely ill, and two (10.0%) were among the most extremely ill patients. Moreover, regarding CUD, three (15.0%) were moderately ill, seven (35.0%) were markedly ill, seven (35.0%) were severely ill, and three (15.0%) were among the most extremely ill patients we had observed in our entire clinical practice.As to the length of use, all patients had been cocaine-dependent for more than one year and nine (45.0%) for more than five years. Regarding the degree of severity, according to the CPSI total score, 19 (95.0%) patients were classified as affected by “cocaine dependence requiring assistance”. In this kind of patient, cocaine abuse is generally a serious problem. One patient was in the phase of “severe dependence”. In general, with these patients, it may be difficult for them to regain control of their life without hospitalization.Regarding the other CPSI items, none of our patients showed a severity worsening (positive ranking), with the exception of two patients who increased their alcohol use, two who worsened their working condition, and one who improved despite more use of cocaine in his peer group.z = −3.603 p < 0.001). Ninety percent of our patients improved, and 10.0% showed no change in the CUD-CGI severity index .In passing from baseline to end point, 80.0% of our patients improved, 5.0% worsened, and 15.0% showed an unchanged ADHD-CGI severity index , much improved in eight patients (40.0%), and only minimally improved in nine patients (45.0%). None of them showed any side effects that could have interfered with their functioning. The efficacy index of CUD-CGI turned out to have greatly improved in four patients (20.0%), much improved in 10 patients (50.0%), and minimally improved in six patients (30.0%). None of them showed any side effects that could have interfered with their functional skills.z = −0.97, p = 0.442; z = −0.80, p = 0.516; z = −1.08, p = 0.379, respectively), younger/older age , short-term/long-term treatment , and baseline polysubstance use . Last-evaluation CUD-CGI-S, CUD-CGI-C, and CUD-CGI-E were not correlated with gender , younger/older age , or short-term/long-term treatment . CUD-CGI-S was higher in polyusers , while CUD-CGI-C and CUD-CGI-E did not differ statistically .z = −1.68 p = 0.092; ADHD-CGI-C: z = −1.61, p = 0.872; ADHD-CGI-E: z = −0.28, p = 0.774; CUD-CGI-S: z = −0.04 p = 0.968; CUD-CGI-C: z = −0.66, p = 0.508; CUD-CGI-E: z = −0.75, p = 0.480).CGI outcomes were also not correlated with MPH/ATM use  and CUD  CGI-C showed no statistically significant differences between patients with and without psychiatric or SUD familiarity. ADHD  and had a significantly higher proportion of drug-negative urine samples compared to the placebo group (p = 0.047), including more amphetamine-negative urine samples (p = 0.019) and better retention in treatment (p = 0.032).As shown by Schubiner et al. , long-acAn earlier double-blind study compared MPH, bupropion, and placebo . No advaSome controlled randomized trials with short- and long-acting standard doses of MPH showed no improvement in SUD symptoms ,20,21. ITherefore, while comparing our results to these controversial data, our clinical impression is that the dramatic reduction of CUD symptoms in patients with concomitant ADHD might be due to the specific craving investigated in our subjects. According to Khantzian’s theory, all of them may use stimulant drugs to reduce their ADHD inattentive symptoms, aiming for an improvement in their attention as well as relief from their restlessness. Thus, we might do better to define this desire for cocaine as a craving for relief from the cognitive and emotional distress arising from ADHD, which leads to severe impairment of the quality of life while drastically compromising social and professional functionality. This type of craving is different from the type usually reported by cocaine users who are free from ADHD, as the latter are mainly driven by the recreational and rewarding effects induced by the stimulant. In one of our studies we demonstrated that bipolar patients can use stimulants during the hypomanic or manic phase for rewarding reasons , but in Moreover, we detected no significant differences in effectiveness between ATM and MPH, whether evaluated by clinicians or patients, through CGI and CPSI, respectively. Hence, the two different medications seem to exert similar positive influences on cocaine addiction in terms of severity and long-term outcomes. These results are not influenced by patients’ familiarity.According to the results of our study, we propose the following pathophysiological model: subjects with A-ADHD, when taking cocaine, can reduce their symptoms of inattention and, therefore, implement this “relief craving” by continuing to consume the substance. Over time, cocaine, which is fast-acting, has a dysphoric but addictive action. So, the two diseases could be said to sum their respective negative effects; in any case, we should bear in mind that the initially strong euphoric effect of cocaine is amply exceeded by the dysphoric effect brought into play by the intoxication/withdrawal syndrome. When therapeutic stimulants, which take a long time to become effective and therefore have no dysphoric effect, reduce inattentiveness, the “need” for cocaine is reduced in proportion to the reduction of the inattentive symptoms that are induced by the ADHD disease, and of the dysphoric symptoms induced by cocaine addiction.The clinical implications of this hypothesis include the possibility of identifying this type of subject at the beginning of patients’ drug addiction practice and in the real world. At our first interview with them, all our patients reported an action of cocaine on themselves other than that observed in their peers, because they felt less excited and more active. It is therefore essential to investigate the rewarding or relieving action of cocaine at the beginning of the drug addiction experience, both to deliver a diagnosis of A-ADHA as early as possible and to prevent cocaine dependence by treating ADHD with the kinetics of slow-acting stimulants. In our sample, the use of cocaine did not stop completely and tended to remain occasional. Previous study found that adults treated with MPH resulted in significant increases in post- vs. pre-treatment heart rate and systolic blood pressure as compared to placebo . CombinaMore specifically, we postulate that the use of extended-release (ER) medications such as MPH ER, and ATM could offer an effective treatment for these patients, reproducing the same effect as cocaine, but with slower kinetics. Consequently, greater tonic dopamine release due to these dopamine agonists might prevent relapses in CUD patients, in a way similar to the action of opioid agonists such as methadone and buprenorphine (long-acting agonists) in heroin (a fast-acting drug) use disorder. This study indirectly confirms the SMH in A-ADHD patients with co-occurring CUD.Limitations: This study had some limits. The small sample size is the first to be mentioned. Consequently, further studies are needed to effectively confirm our hypothesis by increasing the number of enrolled patients. Secondly, this is a retrospective rather than a double-blind study. In exploring the comparison between two different treatments, MPH and ATM, our data might have been influenced by the factor of having two different stimulants available for use in treating each patient. It could have occurred that patients with less severe ADHD were treated with ATM, while MPH was set aside to treat the most severe cases.Our findings suggest that the pharmacological therapy for DD A-ADHD/CUD patients is not only useful in improving inattention and hyperactivity but could also have a positive impact on cocaine-use prognosis and outcome by reducing the use of cocaine from intense to occasional. In addition, these data are not in contrast to Khantzian’s self-medication hypothesis.


Fenugreek is one of the important edible and medicinal vegetables that have a long history of cultivation and consumption. Characterize the extent of the genetic diversity among landraces will provide a good context for future breeding programs and genetic resource preservation. Genetic diversity and population structure of 88 individuals of eight landraces of Iranian fenugreek evaluated based on SRAP markers. Seventy-two bands generated from 6 primers in which 56 (80.11%) band were polymorph. Hamadan landrace showed the lowest values of percentage of polymorphic loci (67.86), Nei's gene diversity index (0.24), number of effective alleles (1.40) and Shannon’s Information index (0.36). Nei’s genetic distance matrix revealed the highest genetic distance between Hamadan and Yazd (0.203) and the highest genetic similarity between Mahallat and Varamin (0.036) landraces. The most gene flow was between Mahallat and Varamin landraces (Nm=8.36) and the least was between Shiraz and Hamadan landraces (Nm=0.66). An extent admixture of alleles between the Iranian fenugreek landraces was observed by the population structure. Mantel test indicated that the genetic differentiation and gene flow is not associated with geographic distance in Iranian fenugreek landraces. Our observations indicated SRAP is an efficient technique to reveal genetic diversity and population structure of Iranian fenugreek landrace. Trigonella foenum-graecum L.) is an annual, herbaceous, dicotyledonous, diploid, self-pollinated plant which belongs to the subfamily Papilionaceae in Fabaceae family . The number of migrants per generation (Nm) was estimated using the following formula in Excel file [Polymorphic information content (PIC) of SRAP primers was calculated in Excel using the formula; PICi=2 ft makers , 31. Gent makers  was usedt makers , Shannoncel file -36; Mantel tests were performed in GenAlEx with 9999 permutations between pairwise Nm values and geographic distance (km) for all landraces: STRUCTURE software ver. 2.3.4 , which iThe six primer combinations amplified a total of 72 alleles, of which 56 polymorphic bands were detected  and 3. Ta, Ne, Nei's gene diversity index (h) and (I)  and lowest (67.86%) values of PPL were observed in Kerman and Hamadan landraces, respectively. Values of the Shannon's information index (I) ranged from 0.36 (Hamadan) to 0.45 (Mashhad), indicating a moderate allelic frequency and uneven distribution. The highest (0.35) and lowest (0.24) values of h were observed in Yazd and Hamadan landraces, respectively. The value of Na varied from 1.45 (Varamin) to 1.68 (Kerman), and the Ne ranged from 1.40 (Hamadan) to 1.65 (Yazd)  . The ave5 (Yazd) , which ilandrace . According to the Pearson correlation analysis there was a positive significant relationship between diversity measures , that waAMOVA indicated that most significant genetic diversity (86%) is ascribed to within landraces variation rather than among the landraces (14%), with a value of 0.14 for PhiPT (P<0.001) . The genThe principal coordinate analysis was used to further assess genetic relationships among fenugreek landraces. The two-dimensional scatter plot has indicated that the first two PCoA axes accounted for 41.96% and 28.43% of the genetic variation, respectively . This analysis separated the fenugreek landraces into four groups that are indicated in figure 1.A dendrogram was generated based on Nei’s genetic distance matrix of the SRAP data using the Neighbor-joining algorithm . Based on the dendrogram, Iranian fenugreek landraces were clustered into four clusters. The clustering results according to genetic distance were consistent with the results from PCoA analysis. Each cluster contained two landraces. Cluster 1 (C1) contained Sanandij and Kerman landraces. Cluster 2 (C2) contained Varamin and Mahallat landraces. Cluster 3 (C3) cluster included Yazd and Shiraz landraces. Mashhad and Hamadan landraces placed in Cluster 4 (C4). ΔK was found at K=4 , and this was considered as an optimum number of population for Iranian fenugreek landraces. The STRUCTURE analysis results were consistent with the pattern of diversity revealed by the NJ based trees and PCoA analyses of the fenugreek landraces, which were not separated into different groups based on their geographical distance. STRUCTURE plot indicated close genetic relation between Yazd and Shiraz landraces (contain mostly blue colored segments), Mashhad and Hamadan landraces (contain mostly green colored segments), and Sanandij and Kerman landraces (contain mostly yellow colored segments) . The results of K=3 was similar to K=4, except that at K=3 two cluster (C1 and C2) had been merged, so Sanandij, Kerman, Varamin, and Mahallat landraces placed in a common population. Based on the result of K=5, five populations could be assigned for all the landraces. Based on K=5, the fifth population can be generated by the separation of Mahallat landrace (contain mostly blue colored segments) from Varamin landrace, which already were placed together in the same group at K=4. Based on the structure plot, there were not any salient appearance of similarity between Mahallat and Varamin landraces , in spite of low genetic distance  between them (The structure results of K=3 to K=5 are shown in Figure 4. Maximum een them . Substantially, fenugreek is a self-pollinated crop and it is expected to observe low genetic diversity within landraces, however, in the present study, a high value of genetic diversity within the studied landraces was observed. Self-pollination intended to diminish genetic diversity in a landrace but many factors can affect this phenomenon, like migration, cross-pollination, and etc. Moreover, the existence of high genetic diversity among and within the studied genotypes proposes Iran as one of the centers of origin or diversity of this crop. Sadeghzade Ahari et al.,  also repThe average percent of polymorphic bands produced by each primer combination was 80.11% . PercentV. ficifolia populations. Also, according to the Mantel test, genetic differentiation and gene flow were not associated with geographic distance in Iranian fenugreek landraces. Hence, gene flow among studied landraces did not restraint and stop by geographic distances and may be affected by other factors like human effect. Previous genetic diversity investigations by other molecular markers on fenugreek also obtained similar results [The AMOVA showed a high proportion of the variability was due to within-landraces diversity. This result was confirmed with previous studies on the genetic diversity of fenugreek with different origins , 15. The results , 14, 17.The population structure of the Iranian fenugreek landraces displayed a very high admixture of alleles and none of them identified as a pure line, which could be connected to cases such as gene flow, cross-pollination among the landraces, and ancestral common genetic content . In conclusion, the application of morphological, biochemical, physiological markers, and other molecular marker techniques on more landraces from growing regions of Iran, highly recommended to fully characterize the extent of the genetic diversity among landraces which provides a good context for future breeding programs and genetic resources preservation.The present study is the first report of using the SRAP markers for evaluating genetic diversity and population genetic structure in fenugreek landraces. In light of the obtained results, it can be said that SRAP is an effective technique in revealing allelic differences and may, therefore, be used in future studies on the genetic diversity of fenugreek crop.


Objective: The primary goal of this study was to assess current maintenance intravenous fluid (mIVF) prescribing practices of pediatric hospitalists after the release of the American Academy of Pediatrics Clinical Practice Guideline (AAP CPG), specifically assessing the rates of various isotonic vs. hypotonic solutions used in discrete age groups and in common clinical scenarios associated with anti-diuretic hormone (ADH) excess and hyponatremia. We hypothesized that isotonic fluids would be selected in most cases outside of the neonatal period.Methods: A voluntary and anonymous survey was distributed to the LISTSERV® for the AAP Section on Hospital Medicine.Results: There were 402 total responses (10.1% response rate) with the majority of respondents being pediatric hospitalists. Isotonic solutions were preferred by respondents in older children compared to younger age groups, at 87.8% for the 1–18 years age group compared to 66.3% for the 28 days to 1 year age group and 10.6% for the younger than 28 days age group . When presented with disease states associated with ADH excess, isotonic fluids were preferred in higher percentages in all age groups except in children younger than 28 days when 0.45% sodium chloride was preferred; 0.2% sodium chloride was rarely chosen.Conclusions: Overall, based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH. Isotonic fluids use seems to be higher with increasing age and hypotonic fluids are more commonly chosen in the neonatal period. Maintenance intravenous fluids (mIVF) are currently a popular topic among pediatric hospitalists. Risk factors for excess secretion of anti-diuretic hormone (ADH) have been increasingly described, placing hospitalized children at risk for hyponatremia . NumerouSeveral published surveys have assessed prescribing practices for mIVF in children with high rates of hypotonic fluids selected. Way et al. surveyed anesthesiologists in the United Kingdom in 2006 and showed that most chose a hypotonic fluid post-operatively . Davies No survey has focused on pediatric hospitalists and no survey has been published since the release of the AAP CPG. Our primary goal of this survey was to assess current mIVF prescribing practices among pediatric hospitalists after the release of this guideline, specifically assessing the prescribing rates of isotonic vs. hypotonic fluids. We hypothesized that isotonic fluids would be selected in most cases outside of the neonatal period. As a secondary objective, we sought to assess if hospital practice or year of training completion influenced mIVF choices.A voluntary and anonymous survey using Research Electronic Data Capture was distributed to the LISTSERV® for the AAP Section on Hospital Medicine . This LIIn the survey, respondents were asked to provide demographic data including their primary job/specialty, hospital practice category, and period of residency completion. Next, they were asked their primary fluid choice for children younger than 28 days, 28 days to 1 year, and 1–18 years of age. Prior to data analysis, it was decided that isotonic solutions would include 0.9% sodium chloride, Ringer's lactate, and Plasma-Lyte 148. Hypotonic solutions would include 0.2% sodium chloride and 0.45% sodium chloride. Finally, respondents were presented four clinical scenarios and asked to pick their mIVF choice if the patient was a 27 day-old neonate, a 6 month-old infant, or a 13 year-old adolescent (if applicable) for each scenario . In the clinical scenarios, the respondents were asked to assume that dextrose and potassium would be added to the fluids as needed and the patients were: (1) average weight for age, (2) euvolemic with adequate urine output after 1–2 boluses, if needed, (3) without electrolyte disturbances, and (4) unable to tolerate enteral fluids. See Statistical analysis was performed using the chi-squared test to assess differences between specific groups. The primary author's institutional review board approved this study.p values < 0.0001). 0.45% saline was the preferred mIVF in the younger than 28 days age group (80.0%).The demographic data of the respondents are detailed in p = 0.0055). The influence of time of training completion on primary mIVF chosen, demonstrated a statistical difference only in patients 1–18 years of age, with residency training completed in 2010 or later showing a higher rate of an isotonic fluid choice (90.7%) compared to those who completed training prior to 2010 . When presented with specific scenarios associated with ADH excess, the overall use of isotonic fluids increased to 64.4%, with higher usage with increasing age in the three groups .Comparing the primary mIVF chosen for each age range by hospital practice location, isotonic fluids were more likely to be used in children younger than 28 days old in children's hospitals  at 13.1% compared to non-children's hospitals at 3.1% (p = 0.0076) and bronchiolitis  and 13 year-old with meningitis . The opposite was true in the post-surgical case for the 27 day-old when those who completed training prior to 2010 were more likely to choose isotonic fluids (32.6%) compared to those who completed training after 2010 .When the scenarios were divided by time of training completion, response rates were higher for isotonic fluids in those who finished training in 2010 or later compared to those who completed their training prior to 2010 for the following cases: 6 month-old with gastroenteritis  were uncommonly chosen in any scenario and both had much lower rates compared to 0.9% sodium chloride. Though there is limited adult data to support the use of balanced isotonic fluids, there is scarce data on this topic for mIVF in pediatrics, which we suspect contributed to these low rates . LimitatOverall, based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH. Isotonic fluids use seems to be higher with increasing age and hypotonic fluids are more commonly chosen in the neonatal period. What remains to be determined from the change in mIVF from hypotonic to isotonic fluid is if it will result in unintended consequences, such as hypernatremia, and how often electrolytes need to be monitored. An ongoing multicenter quality improvement project will help address this issue.The datasets generated for this study are available on request to the corresponding author.AH and MM contributed conception and design of the study. AH collected and organized the data and wrote the first draft of the manuscript. All authors contributed to data analysis, interpretation, manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bartonella spp. infection has been reported in association with neoplastic and non-neoplastic vasoproliferative lesions in animals and humans. The objective of this study was to determine the prevalence of Bartonella spp. in conjunction with two other hemotropic pathogens, Babesia spp. and hemotropic Mycoplasma spp., in tissues and blood samples from 110 dogs with histopathologically diagnosed HSA from throughout the United States. This was a retrospective, observational study using clinical specimens from 110 dogs with HSA banked by the biospecimen repository of the Canine Comparative Oncology and Genomics Consortium. Samples provided for this study from each dog included: fresh frozen HSA tumor tissue (available from n = 100 of the 110 dogs), fresh frozen non-tumor tissue (n = 104), and whole blood and serum samples (n = 108 and 107 respectively). Blood and tissues were tested by qPCR for Bartonella, hemotropic Mycoplasma, and Babesia spp. DNA; serum was tested for Bartonella spp. antibodies. Bartonella spp. DNA was amplified and sequenced from 73% of dogs with HSA (80/110). In contrast, hemotropic Mycoplasma spp. DNA was amplified from a significantly smaller proportion  and Babesia spp. DNA was not amplified from any dog. Of the 100 HSA tumor samples submitted, 34% were Bartonella PCR positive . Of 104 non-tumor tissues, 63% were Bartonella PCR positive . Of dogs with Bartonella positive HSA tumor, 76% were also positive in non-tumor tissue. Bartonella spp. DNA was not PCR amplified from whole blood. This study documented a high prevalence of Bartonella spp. DNA in dogs with HSA from geographically diverse regions of the United States. While 73% of all tissue samples from these dogs were PCR positive for Bartonella DNA, none of the blood samples were, indicating that whole blood samples do not reflect tissue presence of this pathogen. Future studies are needed to further investigate the role of Bartonella spp. in the development of HSA.Hemangiosarcoma (HSA), a locally invasive and highly metastatic endothelial cell neoplasm, accounts for two-thirds of all cardiac and splenic neoplasms in dogs.  Helicobacter pylori, for example, colonizes and replicates within the gastric mucosa, resulting in a chronic pro-inflammatory response that promotes cancer risk and oncogenesis of gastric cancer by altering epithelial cell proliferation and apoptosis. Th,9 Th8,9]Splenic HSA is often difficult to diagnose without resorting to splenectomy, a major invasive abdominal surgery.,17 MoreoIn vitro, HSA cells produce growth factors promoting angiogenesis, including vascular endothelial growth factor-A (VEGF-A), platelet-derived growth factor-β (PDGF-β), and basic fibroblast growth factor (bFGF), and genes involved in inflammation, angiogenesis, and cellular adhesion and invasion can distinguish HSA cells from non-malignant endothelial cells.[Despite substantial research, the etiology and pathogenesis of canine HSA remains unclear. As a malignant tumor of vascular endothelial cells, factors that have been hypothesized to contribute to the pathogenesis of HSA include chronic inflammation, macrophage activation, hypoxia, and angiogenesis. In vitroal cells.,21Bartonella spp. were significantly more common than Babesia spp. or hemotropic Mycoplasma spp. in formalin-fixed, paraffin embedded biopsy samples from splenic HSA: 26% of dogs were positive for Bartonella spp. compared to 2% for Babesia spp. (p < 0.001) and 6% for hemotropic Mycoplasma spp. (p = 0.006). Moreover, Bartonella spp. were found more often in splenic HSA biopsy samples compared to samples from a non-neoplastic inflammatory disorder of the spleen  and histologically normal splenic tissue from specific-pathogen-free dogs.[Bartonella spp. DNA can be amplified from angioproliferative lesions in cats, cows, dogs and horses.[Bartonella spp.  can induce the in vitro production of VEGF.[Bartonella spp. can cause endothelial proliferative disorders, including bacillary angiomatosis and peliosis hepatis, in dogs and humans.[Bartonella spp. in the initiation and/or progression of vascular endothelial neoplasia in dogs.Because of established links between chronic intracellular infections, inflammation, and angiogenesis, efforts are being made to determine if chronic intravascular infection with bacteria or protozoa could contribute to HSA development in dogs. One previous study from our laboratory examined the molecular prevalence of blood (erythrocyte)-borne pathogens in a small cohort of dogs from the southeastern United States with and without splenic pathology. We foundree dogs. We have d horses. In addit of VEGF.–25 Bartod humans. In combiBartonella spp. infection and HSA,[Bartonella spp. exposure in dogs can be seen throughout the United States, and there are relatively small but statistically significant regional differences in seroprevalence.[Bartonella spp. DNA in splenic tissue could potentially by explained by the spleen’s role in removal of hemotropic parasites from systemic circulation, or by Bartonella spp. bacteremia at the time of splenic specimen collection. To address these outstanding questions, this study sought to further clarify the potential involvement of Bartonella spp. in HSA in a broader anatomic and geographic context.However, in our previous case control study demonstrating an association between  and HSA, samples evalence.,33 AdditBartonella spp. in conjunction with two other hemotropic pathogens, Babesia spp. and hemotropic Mycoplasma spp., in tissues and blood samples from dogs with histopathologically diagnosed HSA from throughout the United States. Our hypotheses were: 1) the prevalence of Bartonella spp. infection in dogs with HSA would be greater than the prevalence of Babesia or hemotropic Mycoplasma spp., and 2) the prevalence of Bartonella spp. infection in dogs with HSA in the spleen will be similar to prevalence in dogs with HSA in other anatomic locations, such as cardiac muscle.The objective of this study was to determine the prevalence of This was a retrospective, observational, descriptive study of 110 dogs with HSA. Specimens used for this study were previously collected and banked by the Canine Comparative Oncology and Genomics Consortium (CCOGC) based on previously published standard operating procedures.. BrieflyFor this study, samples from dogs diagnosed with HSA were provided by the CCOGC repository to the investigators. Four sample types were provided for pathogen testing: fresh frozen HSA tumor tissue, fresh frozen non-tumor tissue, whole blood, and serum. Two sample types were provided for histopathological confirmation of tissue type and tumor presence included: formalin-fixed HSA tumor tissue and formalin-fixed non-tumor tissue. Any dog that had a diagnosis of HSA (as determined by the CCOGC SOP), and had an adequate amount of fresh frozen tissue stored in the biorepository at the time of the investigators’ request for specimens, was included. This study, therefore, included 110 dogs with samples collected between May 2008 and November 2011.Because of previous sample requests or lack of submission of all requested samples to the CCOGC, there were samples missing when provided to the investigators. Of the 110 dogs, 91 had a complete set of the 4 sample types for pathogen testing  provided to the investigators. No dog was missing more than one sample type, and all dogs had at least one fresh-frozen tissue sample  available for testing. For this reason, dogs with missing samples for pathogen testing were not excluded from the study. Similarly, of the 110 dogs only 37 had a complete set of the 2 sample types for histopathological confirmation  provided to the investigators. Of the 110 dogs, 37 had formalin-fixed HSA tumor tissue and 93 had formalin-fixed non-tumor tissue provided. There were no formalin-fixed samples of HSA tumor or non-tumor tissue from cardiac tumors available for independent histopathologic review. Because a large proportion of dogs were missing formalin-fixed samples for independent histopathological confirmation, the subgroups of tissues with independent histopathologic confirmation of tissue type and tumor presence was analyzed separately.The CCOGC provided demographic information for each dog, including age (years), breed, weight (kg) and sex and neuter status. The date and geographic location  of sample collection was also provided. The anatomic location of tumor and non-tumor tissue samples for each dog was also provided.When possible, information provided by the CCOGC was independently confirmed by the investigators for this study. Histopathology reports providing the diagnosis of hemangiosarcoma were provided for 102 dogs; these were reviewed by one author (EL) to confirm hemangiosarcoma diagnosis and tumor location.For dogs with formalin-fixed biopsy samples provided (see above), biopsies were independently evaluated by a board-certified veterinary pathologist (KL) to confirm the tissue and tumor origin of the biopsy. Formalin fixed tissues were submitted to the NCSU College of Veterinary Medicine histology laboratory  and tissues were embedded in paraffin blocks (FFPE blocks). Slides containing 5 um sections were prepared from the FFPE blocks and stained with hematoxylin and eosin (H&E). Samples were categorized by organ type and HSA tumor or non-tumor tissue based on H&E staining. If the tissue of origin was not able to be determined from the biopsy (5 tumor samples and 2 non-tumor tissues), or if no formalin-fixed sample was provided (68 tumor samples and 14 non-tumor tissues), the tissue of origin was categorized by the information provided by the CCOGC and the original diagnostic histopathology reports. Non-tumor tissues from skin or various subcutaneous tissues  were categorized as skin/SQ for analysis.® Blood and Tissue kit  following the manufacturer’s protocols. For each tissue sample (HSA tumor and non-tumor), a 25 mg piece of tissue was excised from the entire sample using a new, prepackaged sterile scalpel. DNA yield and quality was assessed by spectrophotometry .DNA was extracted from EDTA anti-coagulated blood and fresh frozen tissue samples using a Qiagen DNeasyBartonella spp. DNA using conventional and qPCR, and Babesia spp. and hemotropic Mycoplasma spp. using qPCR. Bartonella qPCR was performed using primers targeting the 16S-23S intragenic transcribed spacer (ITS) region of Bartonella species as described previously[Bartonella qPCR was performed at two dilutions for each sample (using 1 uL and 5 uL of template DNA respectively). PCR screening for Babesia spp. and hemotropic Mycoplasma spp. were carried out as described previously.[5’ GCCCATATTCCTACGGGAAGCAGCAGT 3’) and Myco16S-938as (5’ CTCCACCACTTGTTCAGGTCCCCGTC 3’) were used as forward and reverse primers respectively for hemotropic Mycoplasma spp. DNA amplification. Oligonucleotides Piro18S-144s (5’ GATAACCGTGSTAATTSTAGGGCTAATACATG 3’) and Piroplasma18S-722as (5’ GAATGCCCCCAACCGTTCCTATTAAC 3’) were used as forward and reverse primers respectively for Babesia spp. DNA amplification.Each DNA sample was screened for the presence of reviously, in conjeviously. Briefly,® DNA Technology), 7.1 μl of molecular–grade water, and 5 μl of DNA from each sample tested. PCR negative controls were prepared using 5 μl of DNA from blood of a healthy dog. Positive controls for PCR were prepared by using 5 μl of DNA from previously characterized positive dog . Conventional PCR was performed in an Eppendorf Mastercycler EPgradient® under the following conditions: a single hot-start cycle at 95°C for 2 minutes followed by 55 cycles of denaturing at 94°C for 15 seconds, annealing at 68°C for 15 seconds, and extension at 72°C for 18 seconds. Amplification was completed by an additional cycle at 72°C for 1 minute, and products were analyzed by 2% agarose gel electrophoresis with detection using ethidium bromide under ultraviolet light.Amplification was performed in a 25-μl final volume reaction containing 12.5 μl of MyTaq Premix (Bioline), 0.2 μl of 100 μM of each forward primer, reverse primer  were positive . Stringent processing methods were used to avoid DNA carryover during tissue processing.[Validation of positive results was performed by Sanger sequencing of amplicons followed by chromatogram evaluation and sequence alignment using Contig-Express and Align X software . For bacterial species identification, DNA sequences were analyzed for nucleotide sequence homology at NCBI nucleotide database using BLAST version 2.0. A sample was considered ocessing. SpecificBartonella antibodies were determined using 3 cell culture grown Bartonella spp.  as antigens and following standard immunofluorescent antibody assay (IFA) techniques.[For IFA testing, chniques.,38 BriefBartonella PCR positive cases reported previously in dogs with HSA,[Bartonella spp. DNA in canine cardiac vs. splenic HSA (assuming samples were split evenly between the two tumor locations) if 49% or more, or 7% or less of the cardiac samples were Bartonella PCR positive. In addition, assuming the prevalence of each hemotropic pathogen reported previously in dogs with HSA,[Mycoplasma and 80 cases for Babesia spp.An initial power calculation was based on a request for samples from 150 HSA cases from the CCOGC. With 150 HSA cases, assuming the prevalence of with HSA, using anwith HSA, using anBartonella PCR positive and negative dogs were determined using the Wilcoxon Rank-Sum test for continuous variables , and Fisher’s exact tests for categorical variables. Multivariable logistic regression was used to identify associations between Bartonella infection and anatomic location of tissue sample, with potential demographic confounders included as explanatory variables . Odds ratios (adjusted ORs) and 95% confidence intervals (95% CIs) were calculated. To determine agreement between tests on two different samples within the same dog, the kappa statistic was calculated.[https://www.R-project.org/).Descriptive statistics were obtained for demographic factors . We assessed statistical differences in the proportion of dogs PCR positive for each hemotropic pathogen using the Chi-squared test of independence . We also assessed statistical differences in the proportion of samples PCR positive from each anatomic location using the Chi-squared test of independence . Differences between demographic factors for lculated. Data anaDemographic characteristics of the included dogs are shown in The number of samples of each type  provided by the CCOGC is shown in Bartonella spp. PCR positive in at least one fresh frozen tissue sample. No dog was Bartonella spp. PCR positive on whole blood and only 6 (6%) were IFA seroreactive to B. henselae, B. vinsonii subsp. berkhoffii, or B. koehlerae antigens . The proportion of Bartonella spp. PCR positive dogs from each geographic location, based on the location of the submitting veterinary college, is shown in Bartonella spp. between geographic locations  compared to Bartonella spp. (Mycoplasma spp. DNA was amplified from two non-tumor tissues (one skin/SQ and one cardiac), and one HSA tumor (spleen). The 2 hemotropic Mycoplasma spp. positive non-tumor tissues were both also Bartonella spp. PCR positive; the hemotropic Mycoplasma positive tumor tissues was Bartonella spp. PCR negative. Hemotropic Mycoplasma spp. DNA was amplified from whole blood of two dogs, neither of which had hemotropic Mycoplasma spp. DNA in their tissues. Babesia spp. DNA was not amplified from any whole blood or tissue specimen (Fresh frozen tissues from only 3 dogs were hemotropic lla spp. . Hemotrospecimen .Bartonella spp. PCR positive for each anatomic location is summarized in Bartonella spp. PCR positive (63%) was significantly higher than the proportion of HSA tumors that were Bartonella spp. PCR positive 34%, (p < 0.001). The proportion of Bartonella spp. PCR positive HSA tumor samples did not differ significantly between anatomic location (p = 0.083). Based on the multivariable logistic regression model, the anatomic location of the HSA tumor was not associated with Bartonella spp. PCR positivity. The proportions of non-tumor tissues Bartonella spp. PCR positive were significantly different based on anatomic location (p < 0.0001), with a higher proportion of non-tumor cardiac samples positive for Bartonella spp. PCR compared to non-tumor spleen samples when adjusted for possible demographic confounders .The proportion of HSA tumor and non-tumor tissues Bartonella spp. PCR results for HSA tumor and non-tumor tissues, there was only slight agreement between the two samples (kappa = 0.14). Only 36% of dogs with a Bartonella spp. PCR positive non-tumor tissue sample had a positive HSA tumor, whereas 76% of dogs with a positive HSA tumor sample were positive in non-tumor tissue.When comparing the Bartonella species identified was B. henselae. Homologies ranged from 99.3% to 100%  with B. henselae CAL1 and SA2 . Of the HSA tumors, 27 contained B. henselae (including 2 co-infected with B. henselae and B. koehlerae), 1 contained only B. koehlerae , 1 contained Bartonella apis  and 3 had a Bartonella species that was most closely related to B. henselae (with homology ranging from 95% to 98% with either B. henselae CAL1 or SA2). In non-tumor tissues, 58 contained B. henselae, 1 contained B. koehelerae , 6 contained a Bartonella species that was most closely related to B. henselae (with homology ranging from 95% to 98% with either B. henselae CAL1 or SA2), and 1 contained a Bartonella species that was unable to be identified to the species level.In both tumor and non-tumor samples, the most common Bartonella spp. DNA by PCR  compared to HSA tumors tissues (34%).Overall, in this study 73% of dogs with HSA were us study, the propBartonella prevalence between HSA tumor and non-tumor tissues. It is possible that in large vascular splenic tumors there are necrotic or infarcted regions that contain fewer organisms, placing these samples below the level of PCR detection. This possibility is supported by amplification of Bartonella spp. DNA from 75% of non-tumor tissues obtained from the 32 dogs that were PCR positive from their HSA tumors. It is also possible that the high prevalence of Bartonella DNA in non-tumor tissues reflects asymptomatic carriage and is not associated with HSA. However since all 110 dogs had HSA, the higher prevalence in non-tumor tissue does not necessarily contradict the hypothesis that Bartonella infection is associated with HSA–rather, in the absence of a control group of dogs without HSA, we cannot conclude whether this high prevalence is seen in the absence of HSA as well. Further studies using a case-control or cohort design to compare Bartonella spp. PCR prevalence between dogs with HSA and without HSA will be needed to determine if this is the case.There are several potential explanations for the difference in Bartonella spp. DNA in one or more tissue samples was surprisingly high, no dog had Bartonella DNA amplified from a blood sample. This suggests that Bartonella DNA found in any given tissue is not due to blood contamination of the tissue, but rather that the Bartonella may be intracellularly localized within that tissue. Similar results have been reported previously: in one case dogs experimentally infected with Bartonella spp. failed to become detectably bacteremic, despite Bartonella spp. being isolated from tissues (bone marrow and lung) post-mortem; in another, a dog had B. henselae DNA amplified from biopsies of vasculitis lesions and normal skin, but no Bartonella DNA on multiple sequential blood samples.[Bartonella DNA is not found in blood samples from dogs with Bartonella present in tissue could include intermittent bacteremia, rapid clearance of bacteremia by the dogs’ immune system, or low levels of bacteremia that are below the current limit of PCR detection. Regardless, Bartonella blood PCR does not effectively predict whether a dog is infected with a Bartonella spp. Similarly, Bartonella spp. serology was also positive in only a small fraction of those dogs with positive Bartonella spp. PCR in tissue. Previous results documenting poor agreement between Bartonella spp. exposure based on IFA, and Bartonella spp. bacteremia in dogs have been reported.[Bartonella in our previous study, Bartonella testing on fresh-frozen splenic HSA tumors yielded very slightly higher levels of detection (26% of fixed tissue vs. 28–32% of fresh frozen tissue). Based upon this study, we recommend that when possible, fresh frozen tissue biopsies from either the affected organ, or unaffected skin, be collected and submitted for PCR testing to maximize the potential for detection of Bartonella spp. Future studies will be needed to guide medical decision making when Bartonella spp. infection is documented in a dog with HSA.While the proportion of dogs with  samples.,41 Reasoreported.,43 FinalBartonella spp. DNA is found in high proportions of dogs’ spleens due to the spleen’s role in immunologic clearance of bacteria or infected erythrocytes from circulation, we tested multiple other organs for the presence of Bartonella DNA. Rather than seeing the highest proportions of splenic tissue positive for Bartonella DNA, in both tumor and non-tumor tissues we found cardiac tissues to have a higher proportion positive. This may reflect a tissue tropism of Bartonella for cardiac tissue, which would be compatible with the known ability of Bartonella to infect heart valves as a cause of endocarditis .[Bartonella compared to spleen samples. This may reflect an alternative tissue tropism for the bacteria, which is vector-borne and relies on the bite of an arthropod vector for transmission. Establishing latent infection in the skin could be an evolutionary response to enhance the likelihood of uptake during blood feeding by arthropod vectors. Based on the results presented here, it is unlikely that the high proportion of dog spleen samples positive for Bartonella spp. DNA on PCR reflect solely splenic clearance of bacteria or infected erythrocytes.To address the possibility that arditis).–47 AdditBartonella DNA in tissue samples in this study, and the well-established ability of Bartonella spp. to induce angiogenesis and chronic inflammation in vivo and in vitro, we speculate that B. henselae could be a cause or cofactor in the development of HSA in dogs. Angiogenesis is a fundamental component of primary tumor cell proliferation and metastasis, particularly in HSA.[In vitro, B. henselae induces angiogenesis and proliferation of endothelial cells in part by stimulating production of VEGF.[Bartonella spp. cause the non-neoplastic endothelial proliferative disorders bacillary angiomatosis and peliosis hepatis in humans, and there have also been rare reports of these conditions in dogs infected with Bartonella spp.[Bartonella spp.: B. vinsonii subsp. berkhoffii was isolated from a dog with hemangiopericytoma, and from humans residing on three continents with epithelioid hemangioendothelioma.[Bartonella DNA in tissues from dogs with HSA supports the need for further studies on the mechanistic basis of a potential link between Bartonella spp. infection and vascular endothelial cancers like HSA.Because of the surprisingly high proportion of dogs with HSA with y in HSA.,48–52 Spy in HSA. , so diagnosis relied on the histopathologic reports from the submitting veterinary colleges. This may have led to misclassification of cardiac tissues as tumor or non-tumor. However due to the biological behavior of HSA in the heart, with most tumors presenting as a mass involving the right atrium (even in dogs with concurrent splenic HSA), correct classification of tissue as HSA (mass in right atrium) or non-tumor (other unaffected cardiac tissue) at the time of sample collection was assumed to be accurate. This study was also limited by using IFA to detect Bartonella spp. antibodies. IFA is known to have low sensitivity and may underestimate the true seroprevalence of Bartonella spp. in dogs.[Bartonella infection of tumors from different anatomic locations (splenic vs. cardiac) was based on 75 splenic and 75 cardiac cases. In fact, we received many fewer cardiac samples than expected, which decreased the power of this aim of the study. With the sample size used (69 splenic and 13 cardiac), the study was underpowered to detect the empiric difference that was found (33% Bartonella PCR positive for splenic and 54% for cardiac). In contrast, because all 105 dogs were able to be tested for each pathogen, despite the slightly smaller sample size than expected this aim was adequately powered to detect the empiric differences found .Limitations of this study include the use of archived specimens, which precluded systematic sampling from particular organs of interest. This study was designed to be descriptive, and as such there was no control group consisting of dogs without HSA. Because of the lack of control group in this study, we cannot determine whether  in dogs.,59–62 ThBartonella in the development of HSA, particularly with well controlled epidemiologic studies and mechanistic research to identify how this genus may contribute to tumor development. Ultimately, the development of a vaccine to protect dogs against Bartonella infection could potentially decrease the prevalence of this highly malignant neoplasm.We conclude that our findings strengthen the need to further investigate the role of


The global prevalence of low birth weight (LBW) is 16%, representing more than 20 million infants worldwide, of which 96% are born in low-income countries. This study aimed to determine the prevalence, predictors and perinatal outcomes of LBW newborns.We conducted a retrospective analysis of data obtained from the hospital's obstetric and neonatal database. Descriptive statistics and multivariate logistic regression were performed with 95% confidence intervals (CI).The prevalence of LBW was 21%  and two-thirds of these were delivered at term. Seven percent of newborns were stillbirths and 2% died within 24hrs after birth. Logistic regression revealed that primigravida and grand multiparity were associated with LBW . Having <4 antenatal care (ANC) visits was associated with increased odds of LBW . Regression models revealed an independent association between LBW and increased odds of stillbirths , low Apgar score  and early neonatal deaths .The prevalence of LBW was high and was associated with extreme maternal age groups, grand multiparity, low maternal education, low number of ANC visits and obstetrics risks factors and complications. Both LBW and prematurity were independently associated with poor perinatal outcome. Future interventions should focus on improving the quality of ANC and integrating peripartum emergency obstetric and neonatal care. The World Health Organization (WHO) defines low birth weight (LBW) as a newborn weighing is less than 2,500 grams, with the measurement taken within the first hours of life, before significant postnatal weight loss has occurred . GloballHaving LBW imposes a 20-times higher likelihood of death during infancy compared to newborns who had normal birth weight ; therefoStudy design, sampling and participants: A descriptive retrospective study to determine the prevalence and predictors of LBW was undertaken at MNH from February 2010 to September 2015. During the study period there were 48,918 deliveries, the details of which were prospectively recorded in the delivery book and then entered on the database. Out of these, 9,819 births were excluded due to their having incomplete records or a gestational age of less than 28 weeks. Thus, 39,099 deliveries were included in the analyses.Study site: MNH is a teaching hospital of Muhimbili University of Health and Allied Sciences (MUHAS). It is situated in the main commercial city of Dar es Salaam, which has a population of about 5 million people and an annual population growth rate of 5.6% [ of 5.6% . Annual  of 5.6% . Qualifi of 5.6% ,19. MateStudy variables: The variables included were: maternal age in complete years; education level; marital status; ANC attendance; and pregnancy and delivery complications, all of which were taken from their ANC card on admission. Others were: parity; gestational age; and area of residence. Gestational age was estimated from Naegele's rule of last normal menstrual period (LNMP) and a first trimester ultrasound. Gestational age was then dichotomised into preterm and term. Birth weight was measured within the first hour of life and dichotomised as LBW and normal birth weight, according to the WHO definitions . In this paper we considered LBW and normal birth weight against various predictors, while for gestational age we added a regression model to control for its potential confounding effect. Outcome measures were birth weight, stillbirth (a baby born with no signs of life at or after 28 weeks' gestation) and the status of the baby after 24 hours, recorded as normal, admitted to neonatal unit, or dead.Data management and analysis: Data were retrieved from the obstetric database, cleaned and analysed using Statistical Package for the Social Sciences . The characteristics of the study participants were calculated using descriptive statistics. Bivariate analyses were completed by comparing each of the variables with birth weights, and by conducting χ2 analysis and odds ratio (OR) calculations with 95% confidence intervals (CI). Regression analysis was completed to identify and quantify predictors of LBW and significance was set at a p-value of less than 0.05.Ethical clearance and ethical consideration: Ethical clearance was sought from the MNH Institutional Review Board (IRB) to use the electronic obstetric database . The board has approved the publication of these findings. Anonymity and confidentiality of the information was guaranteed and as data did not include maternal identity, such as names, consent was not needed.Maternal-related characteristics: We analysed 39,099 deliveries that met the inclusion criteria. The majority (81.6%) of the participants were aged between 20-35 years. Ninety-seven percent of women were ever-married  was 2,940g (702g). The prevalence of LBW was 21% . The prevalence of stillbirths (both fresh and macerated) and very early neonatal deaths was 6.9% and 1.8%, respectively, of the live births who later died, making the total number of deaths about 9%.Mode of delivery: Caesarean section (CS) delivery was performed in 55%  of all included deliveries, and one-fifth of these were performed electively. Premature deliveries accounted for only 3.9% and 2.4% of all CS and elective deliveries, respectively.Birth weights, gestational age and perinatal outcomes: Gestational age (GA) at delivery ranged from 28 to 43 weeks with the mean and median GA of 38 and 39 weeks, respectively. About 93.6% were term, 6.4% were preterm, and less than 0.1% were post-term deliveries. Of the term pregnancies, 15.0% were small for gestational age (SGA), sometimes referred to as intrauterine growth restriction (IUGR), 82.4% were appropriate for gestational age (AGA) and only 2.6% were large for gestational age (LGA). In both term and preterm categories, LBW was associated with adverse perinatal outcomes, although the rates were much higher among preterm deliveries, as shown in Birth weights and mothers' sociodemographic characteristics: Mothers residing in semi-urban areas had 23% higher odds of delivering an LBW baby compared to those in urban areas (p = 0.001). LBW deliveries were associated with lower levels of education . LBW deliveries varied with age, whereby adolescents and mothers aged above 35 years were more likely to deliver LBW babies compared to those aged 20-35 years. Also, ever-married mothers had 25% decreased odds of delivering LBW babies compared to never-married mothers (p = 0.001), as shown in Birthweights and mothers' obstetric histories: In this study, the prevalence of LBW deliveries was higher among mothers with recorded ANC problems but lower among those with a history of caesarean section. Mothers of LBW babies were more than two times more likely to have a maternal history of anaemia, hypertension, multiple gestation and PROM. Mothers who delivered by caesarean section were 40% less likely to have an LBW delivery in the index delivery (p < 0.001). Primigravida and grand multiparous (> 4 deliveries) mothers had increased odds of delivering an LBW infant compared to mothers with 2-4 children (p<0.001). On ANC attendance, those who attended less than four times were more than 3 times more likely to deliver LBW compared to those who attended four or more times (p < 0.001). A one-week increase in gestational age was associated with 3.4 times higher odds of delivering a normal birth baby (p < 0.001).Birthweights and outcomes: Stillborn babies had an almost 7 times higher chance of being born with LBW (p < 0.001), and those dying within 24 hours were three times more likely to be born with LBW (p < 0.001) as well those with an Apgar score of less than 7 at the first and fifth minute (p < 0.001).Multivariate regression analysis: Two models of multivariate logistic regression were completed. The first model was designed to identify and quantify true predictors of LBW and control for potential confounders, including gestational age dichotomised into preterm and term. The variables were added in two blocks of socio-demographic characteristics and predictors. For maternal age, the adolescent mothers remained at risk of having LBW babies compared to those aged 35 years and above. All ANC problems were associated with LBW, except for HIV infection, which had no effect on LBW and previous caesarean section, which was associated with reduced risk of LBW. Parity of 2-3 children was associated with a reduced risk of LBW compared with primigravida and having 4 or more children. Having attended less than four ANC visits was associated with an increased risk of LBW. In the second model, outcomes were combined into a single block. Stillbirths had increased odds of being LBW babies. Also, LBW babies were more likely to have an Apgar score of less than 7 at the first and fifth minute compared to normal weight babies. Baby girls were marginally at increased risk of being born with LBW compared to boys. The details are shown in One out of five newborns at MNH had LBW. There was also a high incidence of stillbirths and early neonatal deaths within 24 hours. LBW babies were more likely to die before birth, during labour and within 24 hours as compared to normal-weight babies. The LBW rate 21%) found in this study was higher than that reported in similar studies globally  . Also, t% found iTeenage pregnancies are also more likely to be primigravida, whereby the first pregnancy has higher odds of the mother delivering an LBW baby compared to subsequent pregnancies . The finStrength of the study: This study used a large database that has been designed and monitored continuously over a lengthy period by experienced researchers [earchers ,18,28.Limitations of the study: First, this is a hospital-based study; hence the prevalence of LBW is high, as MNH is a tertiary health facility that receives women affected by complicated pregnancies and deliveries, most of whom live in Dar es Salaam and its neighboring regions. Secondly, there was a significantly substantial number of clients with incomplete data (nearly 20%), but we believe that the sample size was still large enough to make the results internally valid.The prevalence of LBW was high and was independently associated with extreme maternal age groups, grand multiparity, low maternal education, low ANC visits, and obstetrics risks factors and complications. Both LBW and prematurity were independently associated with poor perinatal outcome. Future interventions should focus on improving quality of ANC and integrating peripartum emergency obstetric and neonatal care to prevent LBW and improve the survival rate.There is an unmet demand of health resources for care of low birth weight in sub-Saharan Africa, including Tanzania, that cares for more than 90% of low birth weight newborn globally;Low birth weight is associated with poor perinatal outcomes and morbidity in childhood and adulthood, however, limited literature addresses risk factors, disease burden and complications of low birth weight;Antenatal risk factors such as hypertension and premature rupture of membranes, antenatal screening, are independently associated with both low birth weight and poor perinatal outcome.The prevalence of low birth was found to be even higher at tertiary heath facility demand for prioritizing health resource for care of low birth weight and premature new-born at referrals hospitals.Low birth weight leads to poor perinatal outcomes demands for the quality of antenatal and peripartum care at tertiary health facilities;A feedback loop of motivators and challenges for meeting standards for antenatal screening and Emergency Obstetric and Neonatal Care intervention need to be integrated in the Reproductive Maternal Newborn and Child Health policy;The use of routine hospital statistics as a means of identifying target areas for quality improvement in maternal and newborn care within the referral chain.The authors declare no competig interests.


Attention deficit hyperactivity disorder (ADHD) is one of the most frequent neurocognitive impairments in neurofibromatosis type 1 (NF1) and a well-known risk factor for intellectual dysfunction in general. Since NF1 is per se associated with intellectual difficulties, this comorbidity may be crucial for the cognitive development of affected patients. In our study, we investigated if attention deficits are associated with intellectual functioning in NF1 and if children with NF1 plus ADHD differ in their intellectual and attention profiles from children affected by NF1-only or ADHD only.  111 children aged between 6 and 12 years  performed the German version of the intelligence test WISC-IV and a continuous performance test (T.O.V.A.) to assess attention functions. Parents completed questionnaires about everyday attention and executive functions . p < .001), and intellectual functioning correlated significantly with attention performance in NF1 (p < .001). As compared to NF1-only, attention, and executive functioning were impaired on several dimensions  in NF1 plus ADHD. ADHD-only was associated with significantly higher problem scores regarding hyperactivity/impulsivity and inattention (Conners 3®). NF1-only was associated with inattentiveness when compared to the normative sample of the T.O.V.A.  Children with NF1 plus ADHD showed significantly lower intelligence test scores  than patients with NF1-only (full-scale IQ: 101.14 [1.98];  NF1 is associated with variable attention problems. Severe attention deficits appear to be a risk factor for intellectual dysfunction in NF1, more than NF1 without attention deficit. NF1 plus ADHD presents a specific cognitive profile, which differs from that of NF1 and from neurotypical ADHD. Neurofibromatosis type 1 (NF1) is an autosomal dominant single-gene disorder, affecting the nervous system. It has an incidence rate of one in 2600–3000 individuals. While approximately 50% of NF1 cases are caused by an inherited defect of the NF1 gene, the remainder traces back to spontaneous mutations [Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [NF1 is characterized by a wide range of physical complications . Apart f(DSM-IV) . Since tADHD) provide evidence that, similar as in ADHD-only, pharmaceutical interventions with methylphenidate (MPH) have positive effects on the core symptoms of ADHD [ADHD, there is tentative evidence that MPH might even lead to intellectual improvement [The etiology of attention deficits in NF1-associated ADHD must be assumed to differ from that in ADHD in neurotypical children without NF1 (ADHD-only). While genetic factors seem to explain a high percentage of phenotype variance in ADHD-only , the inc of ADHD . Specifirovement , 12.Regarding their cognitive profile, it is well known that patients with NF1 do not represent a homogeneous group . There sADHD score significantly lower in intelligence tests than healthy (sibling-) controls [ADHD as well as for ADHD-only [ADHD, including deficits in inhibition, sustained attention, verbal fluency, and especially working memory deficits, which are well described in both populations [Similar to patients with ADHD-only , patientcontrols –16 and scontrols , 14, 17.DHD-only , 19, medDHD-only . Executiulations , 22.ADHD, NF1-only, and ADHD-only [So far, few studies directly compared children with NF1DHD-only , 17. PotADHD and ADHD-only: In a treatment study by Mautner and colleagues, children with NF1ADHD seemed especially impaired in impulse control, whereas children with ADHD-only displayed more deficits in sustained attention. Both groups, however, were impaired in response time and variability of response time [ADHD and ADHD-only. Children with NF1ADHD showed lower overall performances in the areas of intensive, selective, and executive attention, while children with ADHD-only showed slower response times in a sustained attention task. The authors conclude that the condition NF1ADHD is not only the sum of NF1 plus ADHD, and that ADHD symptomatology does not contribute to all attention deficits of patients with NF1 [ADHD, NF1-only, and ADHD-only.Furthermore, the specific profile of attention functions seems to differ between NF1nse time . A more with NF1 . To backADHD, NF1-only, and ADHD-only in a prospective approach. Our study may help to substantiate NF1-typical cognitive characteristics and to elaborate differences between NF1ADHD and NF1-only, as well as NF1ADHD and ADHD-only:ADHD. Additionally,(a) we expected patients with NF1-only and ADHD-only to perform significantly better on measures of intellectual functions than patients with NF1(b) we expected intellectual performance to be correlated with attention performance in patients with NF1.(1) Firstly, we assumed that ADHD symptoms are a specific risk factor for intellectual functioning in NF1. Therefore, ADHD, and ADHD-only on measures of inattention, hyperactivity, impulsivity, and executive functions.(2) Regarding the attention profile, we expected significant differences between NF1-only, NF1The aim of our study was to compare the intellectual and the attention profile of children with NF1To this end, we recruited patients within the normal and borderline range of intelligence, so that the sample would be representative for NF1 and ADHD regarding intelligence.ADHD, (2) patients with NF1 without ADHD (NF1control), and (3) patients with neurotypical ADHD without NF1 (ADHDcontrol). Participants for the NF1 groups were consecutively recruited between 2013 and 2016 at the University Children's Hospital Tübingen and the University Medical Center Hamburg-Eppendorf. For the ADHDcontrol group, all participants were recruited at the University Hospital Tübingen. All participants were native speakers of the German language. NF1 was diagnosed according to the National Institute of Health Consensus Development Conference statement [Three groups of patients were recruited for this study: (1) patients with NF1tatement , ADHD watatement  and clinADHD, 1 NF1control, 4 ADHDcontrol), falling outside the predefined range of intelligence , or—in the ADHDcontrol group—for no longer meeting the diagnostic criteria for ADHD at the time of the assessment (4 participants). This left 53 children in the NF1ADHD group, 28 in the NF1control group, and 30 in the ADHDcontrol group for analysis. Thirteen participants with NF1 had asymptomatic optic nerve glioma in the absence of other intracranial pathology as evidenced by MRI. Nine participants  received stimulant medication prior to the study, but not on the assessment day, allowing a wash out period of ≥24 hours. Approval of the local ethics review board (655/2012BO1), patients' assent and written informed consent of their caregivers were obtained prior to the investigations.Altogether, 126 children, aged between 6 and 12 years, were recruited. Fifteen participants were excluded after the assessment because of comorbid autistic disorders   and the The socio-economic status (SES) was measured with the Winkler-Index , taking ADHD; NF1control; ADHDcontrol) served as between subject factor and full-scale IQ, sex, and age as covariates, where appropriate. Due to high intercorrelation, full-scale IQ was excluded as covariate from the analysis on the WISC-IV subscales. The level of significance was set at p < 0.05 for all tests and adjusted by Bonferroni corrections for multiple comparisons. There were no relevant missing data , and the affected cases were excluded from the analyses.Data were analyzed using the 25th version of the IBM Statistical Package for Social Science (SPSS). Group  were analyzed for group differences with two-tailed univariate and multivariate analyses of covariance ((M) ANCOVAs). Additionally, the correlation between full-scale IQ and attention performance index (API) of the T.O.V.A. was tested across both NF1 groups with a second-order partial correlation analysis (Pearson's correlation coefficient).To test our second hypothesis, all parameters of the T.O.V.A.  and the subscales Inattention and Hyperactivity/Impulsivity of the Conners 3® were tested for group differences with two-tailed multivariate analyses of covariance (MANCOVAs). The global executive composite (GEC) score , the Behavioral Regulation Index, and the Metacognition Index of the BRIEF® were tested for group differences with a two-tailed univariate and a two-tailed multivariate analysis of covariance ((M)ANCOVAs). Additionally, frequencies of subnormal performances (scores <85) on the parameters of the T.O.V.A. were compared between the ADHD patient groups with nonparametric chi-square tests. NF1 patients without ADHD were included in the analyses as a control group.control group and significantly more profound ADHD symptoms in the ADHDcontrol group than in the NF1ADHD group.F = 12.031, MSE = 103.06, p < .001), while the covariates sex and age did not have a significant effect on the dependent variable. Planned pairwise comparisons showed that the NF1ADHD group scored significantly lower than the NF1control group and the ADHDcontrol group  = 8.064, p = .005), with girls performing better on processing speed than boys in both ADHD groups. After correcting for the effect of the covariate, significant main effects were observed for all four WISC-IV subscales  = 5.498, MSE = 106.80, p = .005; perceptual reasoning: F = 5.094, MSE = 137.36, p = .008; working memory: F = 7.858, MSE = 131.03, p = .001; processing speed: F = 5.842, MSE = 163.78, p = .004), with the NF1ADHD group performing significantly worse than the NF1control group on all subscales and also performing worse than the ADHDcontrol group on the subscale working memory  for the combined NF1 sample  = 5.208,p = .001) and sex  = 7.842,p < .001). After accounting for the effects of the covariates, there was no significant main effect of group on the parameters of the T.O.V.A.  = 6.422, p = 013). Also, the NF1ADHD group showed significantly more reduced performances on response time variability  = 5.781, p = .020) and omission errors  = 6.658, p = .011) than the NF1controlgroup. Between the ADHDcontrol group and the NF1controlgroup, there were no significant differences on any parameter of the T.O.V.A. regarding the frequencies of subnormal performances  = 8.607, p = .004), with girls being rated as more inattentive than boys in both ADHD groups. Full-scale IQ and age were not related to group differences on the Conners 3® subscales. After correcting for the effect of sex, significant main effects for group were found on the subscales inattention  = 37.877, MSE = 34.87, p < .001) and Hyperactivity/Impulsivity  = 13.146, MSE = 79.06, p < .001) of the Conners 3®. Planned pairwise comparisons showed that both ADHD groups were rated significantly worse than the NF1control group on Inattention and Hyperactivity/Impulsivity, but did not differ significantly from each other  were missing, because the questionnaire BRIEF® was not applied to patients that were assessed in the University Medical Center Hamburg-Eppendorf. The analyses of the BRIEF® scales showed a significant effect of group for the GEC score  = 15.382, MSE = 93.30, p < .001) and for the behavioral regulation index  = 6.117, MSE = 133.85, p = .004), as well as the metacognition index  = 17.843, MSE = 97.06, p < .001). The covariates full-scale IQ, sex, and age had no influence on the dependent variables. Planned pairwise comparisons revealed that the NF1control group was rated as significantly better than both other groups on the GEC score and the metacognition index. Additionally, the NF1control group was rated as significantly better on the behavioral regulation index than the ADHDcontrol group . From this finding we conclude that even subclinical attention problems are negatively associated with intellectual performance .Regarding the profile of intellectual abilities, we found an uneven profile in patients with NF1, similarly to Potvin et al., . The NF1ADHD group. In the NF1ADHD group, 47.2 percent showed impaired working memory skills  compared to 10.7 percent in the NF1control group and 10.0 percent in the ADHDcontrol group. Our results suggest that problems in executive functioning and short-term memory are associated with NF1, but also that these problems are exacerbated by additional ADHD symptoms. Since our measures on other executive functions apart from working memory were retrieved from questionnaires, a differentiated profile of executive deficits could not be evaluated, and our assumptions must stay on a global level. However, a simple summation of negative effects of NF1 and ADHD symptoms on working memory skills in NF1ADHD is unlikely considering the low numbers of patients with NF1-only and ADHD-only showing reduced working memory skills in our study. Apparently it is the combination of NF1 and ADHD that leads to an additional cognitive burden.In the present study, working memory had the lowest scores of the subscales of the WISC-IV in all three patient groups, but the performance was far more decreased in the NF1control scored, as a group, at the population mean of intellectual functioning, which somewhat contradicts the consistent findings of earlier research of generally reduced intellectual functioning in NF1 [ADHD [One very interesting finding of our study is that patients with NF1g in NF1 . HoweverF1 [ADHD , 17. Ourcontrol group reveals mild inattention , but no deficits in hyperactivity/impulsivity or executive functions. No significant differences between mean scores of specific attention domains were found. However, a closer look into the samples reveals a more detailed picture.In the neurotypical population, ADHD is a heterogeneous condition with a variety of profiles in attention and executive functions . Assumincontrol group showed a reduced performance on response time. These results are in line with the findings of a recent study, where neurotypical patients with ADHD showed inferior response times to patients with NF1ADHD in a sustained attention task [Both ADHD groups presented slightly subnormal mean scores on response time variability (reflecting distractibility) and omission errors (reflecting inattention), but additionally, the ADHDion task .ADHD (62.3%) than patients with ADHDcontrol (33.3%) showed subnormal performances on Omission Errors (reflecting inattention). Response Time Variability was also more often reduced in the NF1ADHD group than in the ADHDcontrolgroup, even though there were no significant differences.The frequencies of subnormal performances show an important and significant difference between patients with ADHD with and without NF1 in the T.O.V.A. Nearly twice as many patients with NF1ADHD group is also reflected in the mean scores and these results together lead to the strong assumption that the attention profiles of patients with NF1ADHDdiffer from those of patients with ADHDcontrol. Patients with NF1ADHD seem to be especially affected regarding inattention, as is the case with patients with NF1 without ADHD. Our results confirm previous research showing that symptoms of inattention are more prevalent in NF1 [Overall, the significantly higher number of patients with impaired performance on Omission Errors in the NF1t in NF1  and theyt in NF1 , 33.control group is high, especially in the areas of distractibility and inattention. Furthermore, there were no statistical differences between patients with NF1-only and patients with ADHD-only in the frequencies of subnormal performances. Altogether, this leads to the conclusion that subclinical attention problems are prevalent among patients with NF1 without an ADHD diagnosis and might be an inherent cognitive feature of the NF1 condition. Affected inattention/sustained attention in patients with NF1 was found before [Even if there is still a marked difference between NF1 patients with and without an additional ADHD diagnosis, the number of below average performances in the NF1d before , but affRas (Rat sarcoma) and dopamine activity in specific combinations are proposed to contribute to diverse cognitive profiles in NF1: High levels of Ras activity plus slightly reduced levels of dopamine might lead to severe spatial learning and memory deficits, while high levels of Ras activity plus heavily reduced levels of dopamine might result in severe attention problems and mild learning deficits [Ras, dopamine or other neurotransmitters on learning, memory, and attention deficits in NF1, further research is needed.The heterogeneity of the incidence of subclinical attention problems or ADHD in the NF1 population might be explained by different phenotype expressions. Even if NF1 is a monogenetic disorder, this does not mean that it is a homogeneous medical condition. Evidence rather suggests that factors like sex, age, specific cell type, genomic modifiers, and micro-environmental influences determine the cognitive and behavioral phenotype triggered by the NF1 condition. Different levels of deficits . AdditioSome limitations have to be considered in the interpretation of our results. We acknowledge that we partly recruited patients, who had an indication for clinical neuropsychological diagnostics because of developmental, behavioral, or academic problems. Therefore, the intellectual and attention performance of these patients might be worse than that of other patients with NF1 or ADHD. Additionally, we excluded NF1 patients with intracranial complications, which might limit the representativeness of our NF1 patient group. However, since intracranial complications in NF1  are rarFurthermore, we used only one continuous performance test and one attention questionnaire to assess the attention profile of our patients. Although the T.O.V.A. test is very good in predicting ADHD in individuals, it might not measure specific attention functions differentiated enough to distinguish between ADHD in NF1 and ADHD-only. For further studies on this topic the use of more elaborate test batteries is recommended, to address different domains of attention and also executive functions and to gain a more detailed picture of the profiles of ADHD in NF1 and ADHD-only.Regarding executive dysfunctions, there is a limitation in that we only used external ratings of everyday functioning and no test measures to assess them. As a consequence, we have a high rate of missing data for this area. For a comprehensive evaluation of executive functions further studies should include both types of measurement, since it is well known that data of external ratings and test measures have the tendency to differ from each other  and are control group was rather small considering the prevalence of ADHD. Therefore, it was not possible to differentiate between ADHD subtypes in our patient groups. Even though the distribution of subtypes did not differ significantly between the NF1ADHD group and the ADHDcontrol group, slight differences in the frequency of the subtypes could have had an effect on the results. Moreover, we cannot contribute to the open questions of diverse distributions of ADHD symptoms and ADHD subtypes in NF1 and ADHDcontrol. Also, the sex distribution was uneven in all three patient groups and was nearly reversed in the ADHDcontrol group compared to the NF1control group. Even though we used sex as a covariate in our analyses, the qualitative differences between boys and girls regarding ADHD symptomatology and eventually also cognitive dysfunction in NF1 could still have influenced our results.Another limitation is that we investigated three patient groups of very different group sizes, which might limit the statistical power of our analyses and might affect type II error rates. Additionally, the ADHDADHD differs from that of ADHD-only, which goes along with a different distribution of ADHD subtypes in the two groups. Both findings indicate that ADHD in NF1 is not only a simple comorbidity and that the condition NF1ADHD comes with an additional cognitive burden. Furthermore, there seem to exist  attention deficits in NF1, which are rather associated with the NF1 condition than with a comorbid ADHD diagnosis. Assuming that there are—at least–two distinct profiles of NF1 with one group being more affected than the other, this would encourage further investigations on neurobiological causes of cognitive dysfunction in NF1 and entail implications for potential treatment options [First of all, our findings support the hypothesis that NF1 per se might not lead to globally impaired intellectual functioning, but that attention deficits are a specific additional risk factor for suboptimal intellectual performance in NF1, like ADHD is in the general population . Second, options , 37.