Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder affecting children, adolescents, and adults. Its etiology is not well understood, but it is increasingly believed to result from diverse pathophysiologies that affect the structure and function of specific brain circuits. Although one of the best-studied neurobiological abnormalities in ADHD is reduced fronto-striatal-cerebellar gray matter (GM) volume, its specific genetic correlates are largely unknown.In this study, T1-weighted MR images of brain structure were collected from 198 adolescents (63 ADHD-diagnosed). A multivariate parallel independent component analysis (Para-ICA) technique-identified imaging genetic relationships between regional GM volume and single nucleotide polymorphism data.Para-ICA analyses extracted 14 components from genetic data and 9 from MR data. An iterative cross-validation using randomly chosen subsamples indicated acceptable stability of these ICA solutions. A series of partial correlation analyses controlling for age, sex, and ethnicity revealed two genotype–phenotype component pairs significantly differed between ADHD and non-ADHD groups, after a Bonferroni correction for multiple comparisons. The brain phenotype component not only included structures frequently found to have abnormally low volume in previous ADHD studies but was also significantly associated with ADHD differences in symptom severity and performance on cognitive tests frequently found to be impaired in patients diagnosed with the disorder. Pathway analysis of the genotype component identified several different biological pathways linked to these structural abnormalities in ADHD.Some of these pathways implicate well-known dopaminergic neurotransmission and neurodevelopment hypothesized to be abnormal in ADHD. Other more recently implicated pathways included glutamatergic and GABA-eric physiological systems; others might reflect sources of shared liability to disturbances commonly found in ADHD, such as sleep abnormalities. CDH13, GFOD1, FBXO33, and SLC9A9 genes might be associated with ADHD (GRIN2B subunit genes (GRIN2A and GRIN2B are reported to play role in neurodevelopment (Attention deficit hyperactivity disorder (ADHD) is a complex neurodevelopmental disorder  whose etith ADHD . Quantitit genes . Also, Gelopment . While telopment , along welopment .For such a complex disorder, simply identifying associations between genes and the broad diagnostic phenotype might not increase understanding as precisely or as rapidly as identifying links between the genes and specific features of the disorder, such as neuroimaging-measured brain structure . Meta-anNeuroimaging genetics approaches offer potential understanding of biological pathways related to numerous, likely interacting genes and specific mechanisms of brain growth and function that contribute to inherited behavioral and neuropsychiatric diseases. However, it remains statistically challenging to identify such genes. Univariate GWAS methods are constrained by large sample size requirements to detect the weak effects characteristic of common disease/common variant models, given the need to Bonferroni correction for number of SNPs evaluated. In recent years, multivariate analysis techniques, such as parallel independent component analysis (Para-ICA), have been developed. These techniques identify relationships between clusters of interrelated SNPs and complex phenotypic characteristics  in a data-driven manner , 17. Para priori the content of different components within the genetic or the neuroimaging modalities. Instead, components are assigned simple names for convenient labeling  so they can be later described in detail after group-based hypothesis-testing, which determines their relevance to the disorder. To identify genetic neuroimaging relationships that differed between ADHD and non-ADHD, we extracted subject-dependent loading coefficients (LCs) of each IC for random effects statistical testing. Finally, for those component pairs  that differed between study groups, we characterized various molecular biological pathways associated with detected gene aggregates to provide information about possible physiological processes that might have given rise to the ADHD brain structure abnormalities detected. We hypothesized that brain phenotype component depicting ADHD-relevant regions  would be associated with specific gene networks related to brain development and catecholaminergic neurotransmission. Furthermore, we predicted that ADHD subjects would show differences in both brain phenotypes and gene networks when compared to healthy controls. To enrich results interpretation, post hoc tests explored relationships between Para-ICA-derived LCs and ADHD clinical features.Because GWAS analysis are beyond the capability of the typical sample sizes collected in neuroimaging studies, we are not interested in attempting to link genes to broad ADHD behavioral phenotype. However, Para-ICA is ideally suited for identifying novel brain structure intermediate phenotypes in sample of modest size by linking aggregates of SNPs to specific GM volume characteristics already known to be relevant to ADHD. We used Para-ICA to elucidate the relationships between regional GM measurements previously found to be abnormal in ADHD and clusters of SNPs from an arrayof >240,000 putatively functional exomic markers. Specifically, we assessed genetic relationships of structural GM in DSM-IV-combined subtype ADHD with relatively low rates of psychiatric comorbidity and healthy comparison adolescents, simultaneously, by identifying what aspects of brain structure or genotype covaried systematically across the sample to form independent component (IC) aggregates. The study used Illumina HumanExome-12v1-2 chip  for genotyping and a voxel-based morphometry (VBM) approach  to charaAll study procedures were approved by Hartford Hospital’s Institutional Review Board. Written permission was obtained from parents/legal guardians of all participants, and assent was obtained from all participants under the age of 18. The sample comprised 63 community-recruited patients diagnosed with the combined subtype of ADHD (DSM-IV 314.01) and 135 healthy comparison participants. Psychiatric diagnoses for research purposes of all DSM-IV Axis I disorders were made using the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL)  conducteStructural MR images were obtained using a Siemens 3T Allegra MRI scanner at Olin Neuropsychiatry Research Center at Hartford Hospital . MR images were examined and processed using VBM8 toolbox  with def2r = 0.7) to increase independence between markers. Custom Matlab scripts using an algorithm similar to EIGENSTRAT  were considered for further analysis. The total number of SNPs further considered with Para-ICA was 3139 . The entire set of markers was annotated to genes based on their coordinates using ANNOVAR software  cross-validation technique (p < 0.05/(9 × 14)] were examined for post hoc pairwise group differences. To correct for gene size bias and select dominant genes in a component, gene-based association values were calculated using VEGAS software  and Para-ICA-derived genetic and phenotype components, controlling for age and sex. Because these were exploratory post hoc analyses, significant correlations  are reported.For the current analysis, the ratio of sample size to number of SNPs (198/3139) in our study is consistent with validation work showing that Para-ICA will provide accurate results . The numechnique , 37, runsoftware . To defip-value < 0.05 were selected for pathway enrichment analysis. The lists of significant genes of component G2 (after gene size correction) are listed in Table S3 in Supplementary Material. The p-value for each pathway is calculated using a hypergeometric approach based on number of genes in both user-specified gene set and genes associated with each pathway. The significance values were FDR-adjusted to correct for multiple comparison  of genetic ICs and brain phenotype ICs are listed in Table Partial correlation analysis of component coefficients revealed significant associations among five phenotype–genotype component pairs. Three brain phenotype ICs  showed significant correlation with three genetic ICs . Pearson’s correlation coefficients  = 0.03], effort , affect , and working memory  scores. The Brown ADD scale effort score also showed correlation between S1’s LCs . Also, the S2 LCs were correlated with the CPT-II omission  and variability  standardized scores. The LCs of the G1 correlated with CPT-II Omission . Although none of the correlations survived multiple comparison correction when tested as a complete set, these exploratory results reinforce the relevance of these brain phenotype components to clinically relevant ADHD dysfunction. ADHD symptom severity  was uncorrelated with either genotype or phenotype LCs.The S3–G3 pair was less informative for our primary objective. Although knowing what SNPs are associated with this collection of brain regions is valuable, neither its phenotype nor genotype component coefficients differed between groups. Brain regions comprising the S3 component are listed in Table S6 in Supplementary Material and depicted in Figure S2 in Supplementary Material. Figure S2 in Supplementary Material also depicts scatterplots of the other significantly linked brain phenotype and genotype component pairs that are not further considered.p and corrected q values are listed in Table Significant KEGG pathways associated with G2-identified genoptypes along with uncorrected By using multivariate Para-ICA to link specific GM volume measurements often found to be abnormal in ADHD with several genetic pathways, we showed that specific ADHD-relevant GM volume deficits can be linked to constellations of genes implicated in different physiological pathways. The importance of this should not be overlooked, as most prior studies have been able to link single or very small numbers of specific genotypes to the broad ADHD diagnostic phenotype, not comparatively large genotype, aggregates to specific neurobiological features known to be abnormal in the disorder.We discuss two of the three phenotype components , whose pathway involves cell adhesion and regulation of mitogen-activated protein kinase that are important for neural development  -related genotypes that would be associated with the ADHD brain structure abnormalities. The genes in the G1 component implicate a pathway involved with DA-related synaptic structure and function (see Table eceptor)  and DDC ynthesis . There aynthesis , 63. ADHynthesis , and eviynthesis . Althougynthesis , 67.1 and CB2 receptors are expressed most strongly in the basal ganglia that formed parts of the S2 brain phenotype component . However, our results join other pathways implicated in ADHD – included directed neurite growth (CACNA1C, CACNB4, ITGB6, ACE, ADCY9, ADRB2, AGAP1, ARRB1, CREB3L2, FKBP5, HSPA1L, TFRC, and VPS37C. Numerous studies have shown these genes are expressed in brain, responsible for neurogenesis (The multivariate nature of the Para-ICA results is not easily reducible to univariate interpretations about specific gene function, or about single gene contributions directly to ADHD. In other words, individual gene mapped to specific pathways does not prove that each gene has a direct casual role in ADHD risk. Therefore, we focused our discussion on pathways instead of individual genes. In a similar vein, the results should not be viewed as definitive until replication, despite the rigor of prior Para-ICA method validation and the statistical methods we used to assess reliability/consistency. Instead, they are intended to accelerate thinking about both familiar and novel pathways and their etiological role in ADHD. Overall, our pathway results have some similarities with those from previous pathway enrichment analyses in ADHD that were conducted to identify possible biological mechanisms when GWAS-level statistical evidence was not obtained. Both our studies and others have found evidence for both synaptic function and plasticity , 24, 97,e growth , 98, rRNe growth , nucleoce growth , proteine growth , apoptose growth . A reasoogenesis –105, or ogenesis –109.Study limitations include factors like early infant history, nutrition, medication exposure , 59, or Mr. SK was involved in data preprocessing, data analysis, and preparation of manuscript. Drs. GP, VC, and JG was involved in design of study and preparation of manuscript. Dr. JL was involved in data analysis and preparation of manuscript. Miss. KB was involved in data collection. Dr. MS was involved in design of study, data analysis, and preparation of manuscript.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.


After the injection PET data were acquired dynamically while volunteers either stayed still (tonic release experiments) or performed the flanker task (phasic release experiments). PET data were analyzed to measure dynamic changes in ligand binding potential (BP) and other receptor kinetic parameters. The analysis revealed that at rest the ligand BP was significantly higher in the right caudate of ADHD volunteers suggesting reduced tonic release. During task performance significantly lower ligand BP was observed in the same area, indicating increased phasic release. In ADHD tonic release of dopamine is attenuated and the phasic release is enhanced in the right caudate. By characterizing the nature of dysregulated dopamine neurotransmission in ADHD, the results explain earlier findings of reduced or increased dopaminergic activity.It is unclear whether attention deficit hyperactive disorder (ADHD) is a hypodopaminergic or hyperdopaminergic condition. Different sets of data suggest either hyperactive or hypoactive dopamine system. Since indirect methods used in earlier studies have arrived at contradictory conclusions, we directly measured the tonic and phasic release of dopamine in ADHD volunteers. The tonic release in ADHD and healthy control volunteers was measured and compared using dynamic molecular imaging technique. The phasic release during performance of Eriksen’s flanker task was measured in the two groups using single scan dynamic molecular imaging technique. In these experiments volunteers were positioned in a positron emission tomography (PET) camera and administered a dopamine receptor ligand  Converg18F-DOPA , attenua18F-DOPA , correla18F-DOPA , reduced18F-DOPA , and cli18F-DOPA . Some ofout mice  indicateout mice .Another set of data however contradicts the hypodopaminergic concept and suggests that ADHD could be a hyperdopaminergic condition. For example, finding of a positive correlation between levels of dopamine metabolites in the CSF and clinical symptoms of ADHD patients  is inconThus, different sets of data indicate either hypoactive or hyperactive dopamine system in ADHD. The reason for contradictory findings is unclear but it could be due to use of indirect evidence to estimate dopaminergic activity. These estimates do not provide reliable information on the tonic (dopamine release at rest) and phasic (dopamine release during task performance) release of dopamine in the brain. Based on the available data we hypothesized that in ADHD there is attenuation of the tonic and enhancement of phasic release of dopamine. To examine validity of this hypothesis in this study we measured tonic release of dopamine at rest and the phasic release during performance of a modified Eriksen’s flanker task in adult ADHD and healthy control volunteers. We used recently developed single scan dynamic molecular imaging technique –32 for dThis study was approved by Partners IRB Boston, MA 02114 and IRB of the University at Buffalo, NY. All volunteers provided written informed consent approved by the institutional review board.The study consists of separate experiments designed to study either phasic or tonic release of dopamine. A total of 22 adult ADHD and 22 healthy control volunteers of either sex participated in these experiments. All volunteers were right handed by the criteria included in Edinburgh handedness inventory. Healthy control volunteers had no personal or family history of a psychiatric or neurological condition, no history of substance abuse/dependence, and no significant cognitive deficit. Psychopathology in both healthy control and ADHD volunteers was evaluated using Structured Clinical Interview for DSM-IV (SCID)  and neurAs mentioned above, the psychopathology, cognitive deficit, and neurological disorder were excluded using the SCID, MMSE and clinical neurological examination. The SCID was modified to include questions derived from Kiddie-SADS-E  to ensur11C-raclopride (mean injected dose 14.47±0.88 mCi) at high specific activity (mean specific activity 1.76±0.65 Ci/μMol). After the injection PET data were acquired dynamically in list mode.On the day of study volunteers were positioned on the bed of positron emission tomography (PET) camera and administered a single intravenous bolus of a radiolabeled dopamine receptor ligand 11C-raclopride) at high specific activity (mean specific activity 2.60±1.94 Ci/μMol). Mean injected dose of the radioligand was 14.98±0.36 mCi. Immediately after the ligand injection PET data acquisition started and volunteers were asked to stay still in the scanner for 45 min.In experiments on tonic release 10 adult ADHD (mean age 24.7±4.9) and 12 healthy control volunteers of either sex (mean age 22.7±2.4 years) participated. These volunteers were positioned on the bed of positron emission tomography (PET) camera and administered a single intravenous bolus of a radiolabeled dopamine receptor ligand (11C-raclopride (mean injected dose 14.47±0.88 mCi) at high specific activity (mean specific activity 1.76±0.65 Ci/μMol). After the injection PET data were acquired dynamically in list mode. During PET data acquisition volunteers were asked to perform a modified Eriksen’s flanker task under Congruent and Incongruent conditions [The phasic release was studied in 11 adult ADHD (mean age 30.8±12.4) and 11 healthy control (mean age 33.1±8.3) volunteers. After positioned on the bed of PET camera, volunteers received a single intravenous bolus of the ligand nditions . In thisIn this study we dynamically measured values of the receptor kinetic parameters that describe ligand binding and displacement using the single scan dynamic molecular imaging technique –30. The The PET data were preprocessed before using the receptor kinetic models. The preprocessing steps are described in details elsewhere , 37. BriBecause of low inter-subject variance, number of volunteers needed in each group in single scan dynamic molecular imaging technique is generally smaller than those used in other neuroimaging experiments. To arrive at this conclusion we analyzed published –30 and uFig 1). It was higher in the other striatal regions also but the difference was not significant statistically (Table 1). The mean ligand BP of the entire striatum was 27% higher in the ADHD group (3.21±1.30) as compared to that in the healthy control group (2.53±0.85).To estimate the tonic release PET data acquired at rest were analyzed to measure values of the ligand BP in each voxel and in the caudate and putamen of each hemisphere separately. We found that the mean ligand BP in the right caudate of ADHD volunteers (3.19±0.23) was significantly higher  than that of the healthy control  volunteers (-1) from free to the plasma compartment (k2) measured in the striatum was significantly lower (p = 0.029) in the ADHD group (mean 0.22±0.03) than the values obtained in healthy control group (mean 0.25±0.03). We also obtained significantly lower value (p = 0.029) of the ‘apparent’ rate constant for the ligand transfer (min-1) from the receptor to plasma (k2a) in ADHD group (mean 0.06±0.01) in comparison with the value estimated in the healthy control group (mean 0.07±0.01). Further, there was a significant reduction in the rate of ligand delivery to the striatum as compared to the rate in the reference region (cerebellum). The ratio of the rate (R1) in the ADHD group was 0.80±0.10 and 0.96±0.11 in healthy control group. The difference was significant statistically (p = 0.002). Mean values of k2, k2a and R1 were lower in the putamen and caudate of ADHD volunteers but the differences were statistically significant only for k2a and R1.Mean values of the other receptor kinetic parameters measured in the caudate of ADHD volunteers were also significantly different from the values measured in healthy control volunteers. Thus, the rate constant for ligand transfer (minThe phasic release was studied by detecting and mapping dopamine released acutely during performance of a modified Eriksen’s flanker task under Congruent (control) and Incongruent conditions. We observed that ADHD and healthy control volunteers had similar levels of performance in the task. In the Congruent and Incongruent conditions ADHD volunteers made correct responses in 96.9±2.7% and 83.3±26.2% of trials respectively. Healthy control volunteers made 97±0.02% (Congruent) and 91.0±10.1% (Incongruent) correct response. Response times of ADHD and healthy control volunteers were also comparable. In the Congruent condition it was 600±101 (ADHD) and 602±151 msec  and in the Incongruent condition the mean response time was 706±106 msec in ADHD and 695±183 msec in healthy control volunteers. Partial data of the phasic release in healthy control volunteers were reported in an earlier publication . in the Incongruent condition. In addition, there was a significant increase in the rate of ligand displacement from receptor sites in the same areas . Since the ligand BP is proportionally reduced by the amount of endogenously released dopamine and the rate of ligand displacement reflects amount of dopamine released [Figs 6). The mean BP was 2.17±0.55 in ADHD and 2.88±0.46 in the healthy control group. Interestingly, stereotactic coordinates of the left caudate and putamen where maximum change in the rate of ligand displacement was observed during task performance were similar in the ADHD and healthy control groups (Table 2). The ‘apparent’ rate constant for ligand transfer (min-1) from receptor to the plasma (k2a) also increased significantly in the right caudate during task performance (Incongruent condition) in the ADHD but not in healthy control group (Table 3). Further, the rate constant for ligand transfer (min-1) from free to plasma compartment (k2) was higher in ADHD as compared to that in healthy control volunteers but the difference was not significant statistically (Table 4). Thus, during task performance dopamine was released in the right caudate of only ADHD volunteers. There was no change in the phasic release in the healthy control group . Additionally, k2a in the right caudate was significantly higher during task performance in the ADHD but not in healthy control group .As mentioned earlier, the PET data were analyzed using LE-SRRM  and E-SRreleased , 41, thereleased . The ligOur observation of the reduced tonic and enhanced phasic release of dopamine in the right caudate characterizes the nature of dysregulated dopamine neurotransmission in ADHD. This observation is significant because of the controversy concerning status of dopamine neurotransmission in this condition. Based on indirect evidence previous studies have suggested either increased on decreased dopaminergic activity . Another2, and k2a in ADHD (both at rest and during task performance) indicates that the neurons of right caudate do not have normal receptor-ligand binding kinetics. It could be the reason for altered tonic and phasic release. Another potential reason is increased activity of the dopamine transporters (DAT) in ADHD [11C-altropan, significant increase in the ligand binding  was observed only in the right caudate of adult ADHD volunteers [The mechanism, which is responsible for reduced tonic and increased phasic release in the immature right caudate is unclear but our observation of altered values of k in ADHD –48. Sinc in ADHD –48. Intelunteers .If the primary deficit in ADHD is reduced tonic pool of dopamine due to increased DAT activity, the pharmacological agents that block DAT receptors should restore the deficit and provide clinical relief. It indeed appears to be the case. Thus, methylphenidate which is one of the most effective medications for treatment of ADHD symptoms is also a potent DAT blocker ; and levOur finding of dysregulated dopamine neurotransmission in the right caudate indicates that clinical symptoms of inattention and impaired response inhibition in ADHD patients are elicited by disrupted processing of the right frontostriatal circuit. It is unclear whether the disruption is caused by reduced tonic release or increased phasic release because the efficiency of dopamine dependent functions is compromised when the neurotransmitter level is either unusually high or low , 51.The results of this study provide the first direct evidence of dysregulated dopamine neurotransmission in ADHD and characterize the nature of dysregulation. Additionally, by showing enhanced phasic and reduced tonic release in the same area (right caudate), the results validate reciprocal relationship between the tonic and phasic release . This ev


Corporate identity clothes (CI-clothes) are today more and more important for companies and their identity. One important aspect is the appearance of the clothes over the long lifetime. After several washing and wearing cycles the appearance of such clothes should only show low differences between new and worn clothes. To minimize the signs of use many CI-clothes have a water and soil repellent finishing avoiding contamination. This finishing shows often a negative influence on the comfort of the clothing. The aim of the German research project 16365N was to optimize water and soil repellent finishing in combination with high industrial wash ability and high comfort.In the project, typical fabrics of CI- clothes were finished with different auxiliaries for water and soil repellency as one and two side application. The different auxiliaries characterise the plurability of commercial available products (e.g. fluorocarbon dispersions (C6 and C8), fluorocarbon free dispersions, sol-gel based dispersions). The thermophysiological and skin sensorial comfort of the finished fabrics was determined by measurements with established devices: the Hohenstein skin model, a sweating guarded-hot plate and the five Hohenstein methods for the measurement of the skin comfort. For evaluation the thermophysiological comfort vote and the skin sensorial comfort vote was determined. At the end the total wear comfort was calculated.The thermophysiological parameters of the finished fabrics of the fabric in new state and after finishing with different auxiliaries with variation of the finishing parameters and also the skin sensorial parameters were collected. The fabrics in origin state show in every case better thermophysiological properties than the finished fabrics. For all fabrics the total wear comfort of the finished products is lower than of the fabric in new state. The amount of the finishing detergents influenced the properties. In most cases high amounts of the finishing detergents degrade thermophysiological and skin sensorial properties. But with low amounts of the finishing detergents the water and soil repellency is not given.The application of the water and soil repellent finishing on two sides leads to better thermophysiological comfort vote but also to a lower skin sensorial comfort vote. The one side application has the advantage of a better skin sensorial comfort but the thermophysiological comfort is lower caused by additional used thickener of the application. The influence of different water and soil repellent finishing to the total wear comfort are very similar independent on the chemistry of the finishing.The results of the research project show that the physiological comfort of CI-clothes can be influenced by the used water and soil repellent finishing. The application methods (one side coating or two side application via the foulard-process) have an important influence to the thermophysiological and skin sensorial comfort. The comfort vote system which is developed for all day clothes can be also used for CI-clothes but the additional functionalization lead to lower votes. At the moment all finishing auxiliaries for water and soil repellency degrade the thermophysiological and skin sensorial comfort. New developments of auxiliaries are necessary to improve also the wear comfort. In cases of CI-clothes the question to the needs of water and soil repellent finishing must be discussed to improve very easily the wear comfort of such clothes. In the case of PPE water and soil repellent finishing is often necessary and essential for the protection of the worker.


Bartonella strain related B. tribocorum and B. elizabethae. The finding suggests that this Bartonella strain could be spread by infected rats and represents a potential human risk.Lymphadenopathy and fever that developed in a woman in Tbilisi, Georgia, most likely were caused by a ratborne  Bartonella henselae is a major cause of unilateral reginal lymphadenitis in children and adults  and 2 in the posterior cervical region (29 and 38 mm). The largest lymph node had central attenuation with a hypoechoic area suggestive of pus. Laboratory test results were as follows: leukocyte count 9.2 cells/μL (reference 4.0–11.0 cells/μL) with 6.7% (reference 2.5%–7.5%) neutrophils; platelets 358,000/μL ; hemoglobin 15.4 g/dL (reference 14.0–17.5 g/dL); C-reactive protein 16 mg/L (reference 0–10 mg/L); and erythrocyte sedimentation rate 56 mm/h (reference <30 mm/h). Chest radiograph showed no abnormalities. Serum was negative for antibodies against cytomegalovirus, Epstein-Barr virus, Toxoplasma, and HIV. Tuberculin skin test result of 4-mm induration was considered negative.  In 2012, an 18-year-old woman with no major medical history sought care at an outpatient infectious diseases clinic in Tbilisi with a 2-week history of weakness, malaise, fever Ultrasound-guided aspiration of the largest lymph node yielded 2 mL of cloudy yellow fluid. Gram stain, acid-fast stain, bacterial culture, and fungal culture of the aspirate were all negative. Histopathologic examination demonstrated a nonspecific inflammatory response without evidence of granulomas or malignant cells.B. henselae was suspected as the etiologic agent, although the patient denied any contact with cats. The lymph node aspirate was submitted to the National Center for Disease Control & Public Health (Tbilisi) for molecular diagnostic testing for Bartonella. Genomic DNA was extracted from the lymph node aspirate by using a QIAamp tissue kit  and was analyzed by using conventional PCR targeting a 338-bp fragment of the gltA gene , all which have been previously used for Bartonella descriptions . The neighbor-joining method by Kimura 2-parameter distance method was used .The DNA was forwarded to the Bartonella and Rodent-Borne Diseases Laboratory of the US Centers for Disease Control and Prevention’s Division of Vector-Borne Diseases  for further characterization. Seven targets  and was closer to B. elizabethae by all other markers  and by ITS (99.4%). Comparison of concatenated sequences of all 7 loci indicated the identified genotype had a divergence of 3.4% with B. elizabethae and 5.6% with B. tribocorum. Additional sequence queries resulted in identification of the Tel Aviv (TA) strain of Bartonella, which was prevalent and the only identified strain among black rats (Rattus rattus) captured in Tel Aviv, Israel , the genotype identified in the patient was indistinguishable from the TA strain. The gltA sequence from the patient’s aspirate also was indistinguishable by the gltA from Bartonella genotypes identified in a rat from Porto Santo Island, Portugal  commonly infests commensal rats within cities and can readily bite humans without being noticed. The detection of a rat-associated Bartonella species in the capital of Georgia raises public health concerns and highlights the need to further explore its zoonotic potential and pathogenic characteristics.The clinical picture for the patient we report was typical for clinical manifestations of cat scratch disease, which is commonly caused by


A high postoperative serum myoglobin (MyG) concentration predicts the incidence of acute kidney injury (AKI) and need for renal replacement therapy (RRT), as reported in several surgical settings. The incidence of such events in the ICU is reported to be 2 to 5% of all causes of AKI , but canThis is a case series of eight patients  in cardiac surgery on CPBP for 150 minutes and mean aortic cross-clamping of 98 minutes (range 25 to 190). We measured MyG, procalcitonin (PCT), and creatinin (sCr) at ICU admission and, if serum MyG was higher than 600 mg/dl, the patient was treated with CVVHD-EMIC2-citrate anticoagulant within 12 hours of ICU admission for 72 hours and a dose of 2,000 ml/hour. Biochemical assays were obtained at 12, 24, and 72 hours and at ICU discharge.The pretreatment MyG median value was 10,789 ng/ml; it significantly reduced on average 92.8% during CVVHD (see Figure This small experience confirms that serum MyG is likely to increase in post-cardiac surgical high-risk patients and suggests a beneficial effect of CRRT treatments with EMIC2 membranes and citrate on serum MyG, potentially preventing AKI. Further larger assessment can be advised for confirmation.


Attention-Deficit/Hyperactivity Disorder (ADHD) is a disorder characterized by a chronic, pervasive, and developmentally inappropriate levels of impulsivity and in attention. It is associated with adverse academic and social functions and stress to families. Studies provide evidence that family variables are correlated with this disorder and that parenting styles play an important role in its complexity. However, a thorough investigation of the impact of parental affective and relational aspects on the ADHD child’s areas of functioning is still needed. In designing future research on ADHD, we suggest to investigate parenting characteristics to a greater extent by adopting an attachment perspective with a focus on parental reflective functioning as it pertains to the child’s ADHD clinical condition. Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with characteristics of inattention, hyperactivity, and impulsivity. It shows great heterogeneity in symptoms and functioning . Beyond The diverse definitions of parenting can be organized into two dimensions. One pertains to parenting in terms of behaviors, practices or styles, and the other relates to attachment . AccordiOne aspect that has not yet been clearly elucidated is the role of the parent’s attachment characteristics and specifically of parental reflective functioning. This characteristic is the parent’s cognitive capacity in relation to attachment . The aimThe maternal hostility of non-biological (adoptive) mothers toward children with a biological predisposition for ADHD is predictive of an ADHD diagnosis . This coA child’s ADHD challenging behavior can reasonably have an impact on parent behavior and adjustment. Likewise, a parenting style may exacerbate the course of child’s disorder. Over time, both child and parent may be reinforced for maladaptive behaviors, which strengthens the coercive style of relating. In this respect These findings support the exploration of the impact of specific parenting characteristics on shaping the child’s ADHD trajectory. Parenting includes many types of rearing behavior to study . Many diRecent experiments in animal models of disease  show theIn the last decade, numerous behavioral studies conducted on laboratory animals clearly demonstrated that maternal care plays a role in the epigenetic programming of genes function during early life . Most ofClinical studies for identifying biomarkers for developmental disorders in human patients are difficult to conduct because of ethical issues, lack of proper experimental control over the subject’s environment and genetic background, and inaccessibility of brain tissue for analysis. In this regard, animal models are helpful and provide a complementary approach for understanding the processes by which maternal behavior during pregnancy and postpartum period influences the physiology and the psychosocial behavior of offspring. Aberrant maternal behavior during this period of development can result in the development of behavioral and emotional disorders that may persist into adulthood. Sterley and co-workers showed that life stress increases the risk of developing a psychiatric disorder later in life, possibly by altering specific neural networks that have also been implicated in ADHD . In partThe influence of maternal care on epigenetic modifications, gene expression, and neuroendocrine functions in offspring is complex. From an evolutionary point of view the impact of maternal behavior is critical since maternal care styles are transmitted across generations as an early model of social behavior. Therefore, although significant advances in understanding the origin of individual differences in behavior have been made, there are still many open questions on the link between maternal care and altered gene activity that should be explored using a multidisciplinary approach across animal species, when investigating on the causes of a disease.Attachment theory can be conceived as an affect regulation theory . AccordiIn the limited literature on attachment and ADHD, a predictive link between the two has been empirically observed. Specifically, a recent review has emphasized an association between ADHD and a lack of attachment competences . Two maiRegarding the attachment in ADHD children it has been found that insecure attachment representation in adolescents is significantly related to an ADHD clinical condition characterized by major impairments in attentive abilities and impulsive regulation compared with securely attached adolescents . SimilarAs children develop mentalizing capacities, they learn to adapt to different situations and be flexible in their responses. This ability to understand and interpret themselves and others within their environment “affects regulation, impulse control, self-monitoring, and the experience of self agency” . It is iAlthough it is generally accepted that child ADHD is linked to specific parenting characteristics, parental attachment patterns should be analyzed to a greater extent. Several studies have evidenced an association between insecure attachment characteristics in children and adolescence with ADHD and their clinical condition. However, to our knowledge, little research is available regarding the exploration of the parent’s attachment patterns, although intergenerational transmission of attachment patterns has been clearly established. This scarcity of research highlights the importance of deepening our understanding on mother’s and father’s attachment characteristics with their parental reflective functioning in relation to their child’s ADHD clinical condition.A core element of parent’s reflective functioning involves their capacity to reflect upon the child’s uniquely subjective intentions during moments of stress and conflict, opening the child’s possibility to develop affect modulation . MoreoveConflict of Interest Statement: 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.


Although ADHD is known as a childhood disorder, it is prevalent among adults as well. Several studies have been conducted on the etiology of this disorder and its neurobiological and neuroanatomical manifestations in children, but the knowledge of adult ADHD is not enough. The present research was aimed at studying the structural brain abnormalities in adult ADHD cases. Fifteen adult patients diagnosed with ADHD, developed during their childhood, were selected for this study. In addition to clinical interview and Magnetic Resonance Imaging (MRI), all the participants were asked to fill the (ASRS-VI.I). The results indicated that about 40 % of adults with ADHD suffer from structural brain abnormalities. The results of MRI showed that 100% of the individuals with inattentive and combined types of ADHD were structurally damaged but MRI results did not reveal any structural brain abnormalities in hyperactive participants. The results of the present study are somewhat consistent with the results of previous studies. In general, any brain injury in the region related to cognitive processes  and brain circuits related to motor functions and motivation can contribute a role to the induction of ADHD symptoms. It is recommended to conduct more researches in the future with larger samples using other methods that are capable of assessing brain performance and the level and mechanism of the functions of neurotransmitters and neuronal modulators. Attention–Deficit/Hyperactivity Disorder (ADHD) is a common neuropsychological disorder worldwide. It first described as a childhood disorder that affects about 2-18% of school aged children . AlthougADHD has a complex etiology and considering three subtypes of ADHD by APA , helps tConsidering the core symptoms of ADHD, prefrontal brain regions and connections to the striatum may be most important regions involved in ADHD . AlthougIn this study, 15 adults  with pure ADHD recruited from the outpatients of psychiatric clinics in Zahedan and Sari (Iran). ADHD was diagnosed according to the diagnostic criteria of DSM-IV . All parIn addition, for diagnosing and locating possible brain abnormalities the participants were scanned by magnetic resonance imagining (MRI). MRI is a suitable tool for diagnosing different types of structural brain abnormalities such as tumor, abscess, infection, lesion, and brain and brain stem diseases. MRI is noninvasive and sensitive Neuro-imaging technique for examining abnormality of brain structure without using ionizing radiation. MRI provides high quality images using magnetic field and radio waves . In thisThe results of the present study indicate of 15 participants with adult ADHD, 4 show symptoms of attention deficit, 9 show symptoms of hyperactivity/impulsivity, and 2 have combined type symptoms . Based oAs seen in According to the findings of the present study about 40% of adults showing ADHD symptoms suffer from a type of abnormality in the cortical sections or other parts of the brain . The outstanding point of this research is that the MRI results for adults with hyperactivity subtype do not reflect any brain abnormality. However, all the cases with abnormal MRI show inattentive or combined symptoms of ADHD. The current results are somewhat similar to the results of resent studies conducted on children with ADHD . A revieIn neurocognitive approaches and models for ADHD, deficit in one executive function  is considered to be the core of the disorder . IndividThe frontal lobes, especially the prefrontal cortex, have several important functional parts that are associated with ADHD. Orbitofrontal lesions are accompanied by lack of inhibition and inability to control impulses; dorsolateral lesions are accompanied by malfunction of working memory and difficulty in planning; and mesial prefrontal lesions are accompanied by slow self-motivated behaviors .Emotional abnormalities include motivational problems , motor pIn sum, although different brain abnormalities have been reported to be associated with ADHD, and our findings support these reports to some extent, but none of the hyperactive participants showed an abnormality that could be traced by MRI. Nonetheless, this finding does not deny the existence of any brain abnormality in this group, because other abnormalities such as dysfunction of neurons and neurotransmitters which cannot be precisely assessed by MRI, accompany ADHD. Also, a strong relationship between neurotransmiter systems with ADHD has been reported in literature; including the dopamine system , the NE Finally, any structural damage to the brain that disturbs cognitive processes such as memorization, attention, inhibition, and brain circuits associated with reward and punishment, motivation and motion can contribute to the induction of ADHD. Clearly, proper understanding of results reflecting brain abnormalities becomes possible when the results are combined and merged with information on ADHD symptoms and the results of the studies conducted on the method and impact of treatments and accompanying disorders. Therefore, it is recommended to study different neuro-physiopathological, developmental, and genetic aspects of the etiology of ADHD.Given high comorbidity of ADHD with a lot of other disorders, it is very difficult to find adult people with pure ADHD. For this reason, the study was conducted on a small sample size and this is a major limitation of the present study. These results therefore need to be interpreted with caution and more research on this topic needs to be undertaken before the association between ADHD subtypes and brain structural abnormalities is more clearly understood.


Objectives: The aim of this randomized clinical trial was to assess the efficacy of memantine versus methylphenidate in the treatment of children with attention deficit hyperactivity disorder.Method: Forty participants (34 boys and 6 girls) aged 6-11 who were diagnosed with attention deficit hyperactivity disorder based on (DSM-IV-TR) criteria were selected for this study. The participants were randomly assigned to two groups: group one (n = 22) received memantine and the other group (n = 18) received methylphenidate for six weeks. Treatment outcomes were assessed using the Attention Deficit Hyperactivity Rating Scale and Clinical Global Impression- Severity Scale administered at baseline and at weeks 3 and 6 following the treatment. Also, a two-way repeated measures analysis of variance (time- treatment interaction) was used.Results: At 6 weeks, methylphenidate produced a signiﬁcantly better outcome on the Parent Rating Scale scores and Clinical Global Impression- Severity than memantine. Side effects were observed more often in the memantine group. However, with respect to the frequency of side effects, the difference between the memantine and methylphenidate groups was not signiﬁcant. The most common side effects associated with memantine are appetite suppression, headache, vomiting, nausea and fatigue.Conclusion: The results of this study revealed that although memantine was less effective than methylphenidate in the treatment of attention deficit hyperactivity disorder, it may be considered as an alternative treatment. Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric problem in children. According to the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV), this disorder is characterized by symptoms of inattention, hyperactivity and impulsivity .ADHD is a heterogeneous disorder that carries a high risk of comorbidity, and it typically continues from childhood to adolescence and adulthood .The neurobiology of ADHD is not completely understood, although imbalances in dopaminergic and noradrenergic systems have been implicated in the core symptoms that characterize this disorder .Several studies have previously found that central nervous system stimulants, especially methylphenidate (MPH) are the primary choice of drugs in the treatment of ADHD -5. Howevmore recent studies have shown that long acting preparations such as the sustained-release form of dextro- amphetamines (Dexedrine Spansule) are the preferred agents -7. A stuChildren suffering from ADHD respond differentially to treatment with methylphenidate -10. FurtThe consideration of these alternative medications may increase the rate of patients who respond to treatment. Clinicians and researchers are still looking for a medication that has the following characteristics: an immediate onset with benefits throughout the day, few or no side effects, lacking the potential for abuse, effective for most patients and being relatively inexpensive - 3.Several lines of research suggest that the neurotransmitter glutamate may play a role in the pathophysiology of ADHD and was considered as a hypoglutamatergic condition affecting primarily prefrontostriatal pathways . Levels In 2003, the FDA approved memantine for the treatment of Alzheimer's disease. This agent is the first non-cholinesterase inhibitor indicated for this disease. Unlike the cholinesterase inhibitors, which are indicated for the mild to moderate stages of Alzheimer's disease, memantine is indicated for the moderate to severe stages of the disease -30-31 Pharmacokinetic studies in adults have demonstrated that memantine is absorbed completely from the gastrointestinal tract and achieves peak Tmax within 3 to 7 hours. Protein binding is low from 42 to 45 percent and readily crosses the blood–brain barrier with a CSF serum concentration of .52. The elimination half-life of memantine is between 60 to 80 hours and is excreted unchanged in the urine. Steady-state conditions are reached in about 21 days. Memantine is largely excreted unchanged in the urine and the remaining is converted to three minimally active polar metabolites -33-34. IFor Alzheimer’s disease, the recommended target dose of memantine is 20 mg/day (10 mg b.i.d.), achieved from a starting dose of 5 mg/day by upward titration in weekly 5-mg increments . In a poRobert L. and et al. in an open-label, dose-finding, 8-week trial of memantine in outpatients 6–12 years of age with ADHD combined type reported that memantine dose of 20 mg/day may be a safe and possibly effective treatment for pediatric ADHD. There were no discontinuations due to adverse events (AEs), serious AEs, deaths or suicides. Most AEs were mild and occurred during the first week of treatment. .Surman CB and et al. in an open label, 12-week trial reported that memantine was largely well-tolerated and associated with improvement in ADHD symptoms and neuropsychological performance. A total of 44% of the participants had CGI ratings of much or very much improved. There were no severe adverse events, but mild adverse events were common and six participants discontinued the treatment due to adverse effects .The main aim of this study was to evaluate the treatment efficacy of memantine in children and adolescents suffering from ADHD compared to treatment with methylphenidate.Trial SettingThis was a 6-week, parallel group, randomized clinical trial conducted in an outpatient child and adolescent clinic at Roozbeh Psychiatric Hospital in Tehran (Iran) during March 2012 to May 2013.ParticipantsThe participants included 40 outpatients (34 boys and 6 girls) between the ages of 6 and 11 who met the DSM- IV-TR diagnostic criteria for ADHD. At screening, the researchers conducted a psychiatric evaluation with the DSM-IV-TR criteria for ADHD, and the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime diagnostic interview; then, they obtained a complete medical history and physical examination -42. AddiStudy DesignPatients underwent a standard clinical assessment comprising a psychiatric evaluation, a structured diagnostic interview, a medical history and an electrocardiogram (ECG). Patients were randomized to receive tablet of memantine (Ebixa) or methylphenidate  in a 1:1 ratio using a computer-generated code. Both tablets were encapsulated and identical. The assignments were kept in sealed, opaque envelopes until the time of data analysis. The randomization and allocation process was done by a pharmacist at Roozbeh Hospital. All study participants were randomly assigned to receive treatment, using capsules of memantine at a dose of 10–20 mg/day (group 1) or ritalin at a dose of 20–30 mg/day depending on weight (20 mg/day for <30 kg and 30 mg/day for >30 kg (group 2) for a 6 week double blind, randomized clinical trial. Memantine was titrated up during the trial according to the following schedule: Week 1: 10 mg/day (5 mg in the morning and 5 mg at midday); week 2: 20 mg/day (10 mg in the morning and 10 mg at mid-day).Methylphenidate was titrated up during the trial according to the following schedule: Week 1: 10 mg/day (5 mg in the morning and 5 mg at midday); week 2: 20 mg/day (10 mg in the morning and 10 mg at midday); and week 3: 30 mg/ day for children >30 kg . In this schedule, drugs were blindly administered during titration. The person who administrated the medications, the rater and the patients along with their parents were blind to group assignments throughout the study. The principal measure of outcome was the Parent ADHD Rating Scale-IV -44-45-46Statistical AnalysisA two-way repeated measures analysis of variance (time–treatment interaction) was used. The two groups (Ebixa and methylphenidate) as a between- subjects factor (group) and the three measurements during treatment as the within-subjects factor (time) were considered. This was done for the Parent ADHD Rating Scale-IV and Clinical Global Improvement- Severity Scale scores. The results are presented as mean± SD. Differences were considered signiﬁcant with p ≤ 0.05. To compare the demographic data and frequency of side effects between the protocols, Fisher’s exact test was performed. To consider the ﬁnal differences between the two groups, at least a score of 5 on the Parent ADHD Rating Scale, S = 5 and power = 0.8, the sample size was calculated 15 patients in each group. Intention to treat analysis with the last observation carried forward procedure was performed. Response to treatment was considered as those with at least 50% decreases in Parent ADHD Rating Scale score between baseline and treatment culmination.No signiﬁcant difference was found between patients randomly assigned to the two groups with regards to basic demographic data including age, gender and weight .Parent ADHD Rating ScaleThe mean ± SD scores of the two groups are shown in Clinical Global Impression- Severity ScaleThe mean ± SD scores of the two groups are shown in Figure 4 and The differences between the two protocols were not signiﬁcant at the endpoint  .A signiﬁcant difference was observed on the reduction of scores of the Clinical Global Impression- Severity Scale at Week 6 compared to baseline in the two groups .Clinical Complications and Side EffectsA number of probably related the drugs side effects were studied . Twelve ADHD is a neurobehavioral condition with symptoms that include excessive restlessness, poor attention and impulsive acts -49. Most Estimates show that 3% to 7% of school-age children and about 4% of adults have ADHD . DespiteIt has been reported that memantine is possibly effective in the treatment of ADHD -28-56.Clinical characteristics of the patients, such as sex, age and weight and type of ADHD did not differ between groups and could not be considered as confounding factors. The results of this study suggest that administration of memantine has beneﬁcial effects for treatment of ADHD (hyperactivity type) in children and adolescents.In this double blind, randomized, controlled study of children with ADHD, the authors detected a statistically signiﬁcant effect of memantine and methylphenidate on ADHD.No signiﬁcant difference was observed between the two groups on the Parent Rating Scale scores and Clinical global impression- severity Scale. However, the behaviors of the two treatment groups were not similar across time, but Ritalin was more effective. The present results are in agreement with previous studies that have indicated a positive effect of memantine in the treatment of ADHD.With respect to the side effects, no serious side effects were experienced among the memantine or methylphenidate groups. The most common side effects associated with memantine were appetite suppression, headache, vomiting, nausea and fatigue; and common side effects of methylphenidate included appetite suppression and irritability. Thus, children and adolescents suffering from ADHD may benefit from treatment with memantine as an alternative to the traditional stimulant medications employed in the treatment of ADHD children and adolescents.Robert L. Findling, M.D et al. in an open-label, dose-finding, 8-week, trial of memantine in outpatients 6–12 years old with ADHD combined type reported that memantine dose of 20 mg/day may be a safe and effective treatment for pediatric ADHD. There were no discontinuations due to adverse events (AEs), serious AEs, deaths or suicides. Most AEs were mild and occurred during the first week of treatment .Surman CB et al. In an open label, 12-week trial reported that memantine was largely well-tolerated and associated with improvement in ADHD symptoms and neuropsychological performance. A total of 44% of the participants had CGI ratings of much or very much improved. There were no severe adverse events, but mild adverse events were common and six participants discontinued the medication due to adverse effects .LimitationsThe limitations of the present study included the lack of a placebo group and the small number of participants, which should be considered when designing research in this area in the future. However, it should be mentioned that the ethics committees of many countries do not allow the use of placebo group in children with ADHD. The results of this study should be considered as “preliminary”, but they do suggest that memantine may be beneﬁcial in the treatment of ADHD (Hyperactivity type). It will be of interest to researchers to investigate the efﬁcacy of memantine on adult ADHD as well.The results of this study suggest that although memantine was less effective than methylphenidate in treating attention deficit hyperactivity disorder, it may be considered as an alternative treatment.


Response inhibition is one of the executive functions impaired in attention-deficit/hyperactivity disorder (ADHD). Increasing evidence indicates that altered functional and structural neural connectivity are part of the neurobiological basis of ADHD. Here, we investigated if adolescents with ADHD show altered functional connectivity during response inhibition compared to their unaffected siblings and healthy controls.N = 185), their unaffected siblings (N = 111), and controls (N = 125).Response inhibition was assessed using the stop signal paradigm. Functional connectivity was assessed using psycho-physiological interaction analyses applied to BOLD time courses from seed regions within inferior- and superior frontal nodes of the response inhibition network. Resulting networks were compared between adolescents with ADHD  nodes. Stronger connectivity within the response inhibition network was correlated with lower ADHD severity, while stronger connectivity with the DMN was correlated with increased ADHD severity. Siblings showed connectivity patterns similar to controls during successful inhibition and to ADHD subjects during failed inhibition. Additionally, siblings showed decreased connectivity with the primary motor areas as compared to both participants with ADHD and controls.Subjects with ADHD fail to integrate activation within the response inhibition network and to inhibit connectivity with task-irrelevant regions. Unaffected siblings show similar alterations only during failed stop trials, as well as unique suppression of motor areas, suggesting compensatory strategies. These findings support the role of altered functional connectivity in understanding the neurobiology and familial transmission of ADHD. •We investigate the neural connectivity during response inhibition using PPI.•We investigate connectivity in participants with ADHD, their siblings and controls.•Participants with ADHD show lower connectivity within the response inhibition network.•Participants with ADHD show higher connectivity with the default mode network.•Unaffected siblings show unique patterns of compensatory activation. HNeuroimaging studies of response inhibition in healthy subjects have identified a highly interconnected neural network. This involves nodes from the frontal–striatal network such as the inferior frontal gyrus, pre-supplementary motor area, basal ganglia, and suprathalamic nucleus , as wellWhile each of these nodes plays a distinct role in response inhibition, the overall inhibition efficiency may depend on the degree of integration between the different parts of the network. Diminished functional connectivity between the left and right inferior frontal gyrus, caudate/thalamus, cingulate gyrus, and temporal/parietal regions during a response inhibition task has previously been found in adults with ADHD as compared to healthy controls . AdditioIn a previous paper we showed decreased neural activation during response inhibition in left inferior frontal, left superior frontal, and bilateral temporal/parietal areas in adolescents with ADHD and their unaffected siblings as compared to healthy controls . The pri22.1All subjects participated in the NeuroIMAGE project, the Dutch follow-up of the International Multicenter ADHD Genetics (IMAGE) study. Details about ethics approval, recruitment, assessment, and the general testing procedures can be found in the general methods and design paper of the NeuroIMAGE project .In short, ADHD diagnosis was based on semi-structured interviews (the Schedule for Affective Disorders and Schizophrenia for School-Age Children [K-SADS] ) as wellInclusion criteria for MRI participation consisted of the absence of claustrophobia and any metal in the body. Informed consent was acquired from all participants, with parents supplying consent for participants less than 16 years old. Subsequently, 208 participants with ADHD, 116 unaffected siblings, and 129 healthy controls successfully performed the stop signal task within an MRI scanner. Of these, 21 participants only completed three out of four response inhibition runs (12 subjects with ADHD and six unaffected siblings). Six participants were excluded after reaching an accuracy of <70% on the go-trials, indicating inadequate performance on the task and leaving an insufficient number of trials to estimate inhibition measures . Eleven participants were removed after excessive movement (>3 mm within a single run) in the scanner . Sixteen participants were excluded due to incidental neuroradiological findings. This led to a final inclusion of 185 subjects with ADHD, 111 unaffected siblings, and 124 controls in our analyses see .2.2A visual version of the stop signal task  was usedThe Stop Signal Reaction Time (SSRT) was the main measure of response inhibition efficiency, calculated by subtracting the eventual delay between the go and stop signals. Secondary task outcome measures were the intraindividual coefficient of variation , and the total number of errors. We included both omission and commission errors on go-trials in the error scores, since insufficient numbers of either event occurred to model them separately. Both secondary measures are related mainly to attentional processes that indirectly influence the response inhibition performance .2.3To link functional connectivity to behavioral performance, the effects of diagnostic group  on the SST task-outcome measures were analyzed. This was analyzed using General Estimated Equations models in SPSS (SPSS 19.0 Inc.). Family affiliation was added as a between-subject factor to control for relatedness between participants. Age, gender, IQ, and scan-site were added as covariates. Effects of medication use and comorbid disorders such as oppositional defiant disorder, conduct disorder, and reading disorder on stop signal outcome measures were investigated in separate GEE models within the subjects with ADHD (see SI). Further details concerning the analysis of Stop Task outcomes can be found in 2.4Data were acquired at two scanning locations on similar 1.5 Tesla Siemens scanners  using identical protocols, using a T2*weighted echo planar imaging sequence . Each participant's MPRAGE T1 scan  was used for spatial localization and normalization.2.5To investigate functional connectivity, several regions of interest (ROIs) were defined as seed regions. Instead of basing our selection of ROIs on meta-analysis and data from healthy control studies , we sele2.6http://www.fmrib.ox.ac.uk/fsl; fMRI Expert Analysis Tool, version 6.0) was used to determine which voxels co-varied in activation with the seed ROI as a function of task condition, with the valence of the covariance coefficient indicating positive or negative connectivity. The average time series of neural activation was extracted from 6 mm diameter spheres around each ROI and entered as a physiological variable in the psycho-physiological interaction model. The task contrast of interest  was entered as a psychological variable. The psycho-physiological interaction was obtained by modeling a third variable as the interaction term between the latter two variables. Since the main task-contrast is included in the design matrix, the connectivity is effectively calculated over the residuals of the activation maps, ensuring orthogonality of the connectivity data from activation data. For optimal estimation of movement artifacts, the 24 realignment parameters from the first-level analysis were added, as well as spike regressors for all events within 8 s preceding peak movements greater than 1 mm. Runs with total movement exceeding 3 mm were removed from the analysis. To correct for background noise, the signal from cerebral spinal fluid (CSF) and white matter (WM), extracted using FSL CSF and WM probability masks (threshold of >0.8) were also added in the first level design. Age, gender, IQ, and scan-site were included as covariates.A psycho-physiological interaction analysis executed in FSL FEAT . The association between frame-wise displacement and the connectivity values from the nodes indicated in the group contrasts is depicted in supplementary A series of sensitivity analyses were run, given that the participants with ADHD, unaffected siblings, and controls in our study were not a-priori matched on demographic factors and across scanner sites see also . TherefoT-score of the Conners questionnaire, and these connectivity patterns. Age, gender, IQ, and scan-site were also added as covariates in the post-hoc analyses.Finally, we investigated if functional connectivity was associated with response inhibition performance or with ADHD severity. Two sets of GEE analyses were performed; one to test the association between the SST outcome measures and connectivity in the significant nodes from the group contrast and a second to test the associations between ADHD severity, as measured by the 33.1p = .015) and healthy controls , but did not differ between the latter two groups. ICVs were higher in subjects with ADHD (mean = 0.2082) than in unaffected siblings , who showed more variability than controls . Subjects with ADHD made more errors (mean = 6.4) than siblings , who made more errors than controls . No effects of gender, and IQ were found on any of the SST measures, nor did comorbid diagnoses or medication status affect results. Age had a significant main effect on SST performance, though no interaction effects of age with diagnostic group were found (see SI).Significant effects of diagnostic group were found on all SST outcome measures see . SSRT wa3.2Average connectivity patterns over all subjects from the left inferior frontal seed region for the successful stop network and failed stop conditions are shown in 3.3The group differences (i.e. controls vs. probands with ADHD vs. siblings) in connectivity patterns from the left inferior frontal seed regions are depicted in The group differences in the connectivity between healthy controls and ADHD probands or siblings from the superior frontal seed region are shown in The Cohen's d values from No main or interaction effects with group of the covariates IQ, gender, and scan-site were detected within these between-group analyses. Several main effects of age were found, but no significant interaction effects of age with diagnostic group either. Nevertheless, in the SI, findings from several additional sensitivity analyses were added to document the potential influence of these covariates, as well as of medication duration and comorbid disorders. These sensitivity analyses indicated our main effects did not change when these factors were incorporated in the analyses. Connectivity between the left inferior frontal seed and posterior middle temporal as well as middle frontal areas was associated with the average frame-wise displacement values, although these associations did not survive multiple comparisons. Nevertheless, the group comparisons in these nodes was adapted to include the frame-wise displacement as an additional factor in the model, to ensure the between-group results were controlled for motion effects see .3.4Connectivity strength between the left inferior frontal seed region and all other regions was significantly associated with ADHD severity except for connectivity with the middle temporal, occipital, and medial frontal gyrus. Inspection of the B-values from these tests indicated that connectivity strength between the inferior frontal gyrus seed and pre-supplementary motor area was negatively correlated with ADHD severity, while connectivity with the temporal pole, precuneus, and cerebellum was positively correlated with ADHD severity.Connectivity of the left superior frontal seed regions with all other regions except the inferior frontal node was also significantly associated with ADHD severity. B-values indicated negative correlations between thalamus and operculum and ADHD severity, while the nodes in temporal, cerebellum, and precuneus areas were positively correlated with ADHD severity see SI .3.5p < .001, R2 = .044; B = .009, p = .009, R2 = .011; respectively) in the successful-stop condition. Thus, increased connectivity was related to higher variability and poorer response inhibition performance. In the failed-stop condition, a positive association between inferior frontal and medial frontal connectivity and error rates was found , indicating that increased connectivity between these regions was associated with worse task performance, though this latter result did not survive the Bonferonni–Holm correction for multiple-comparisons.Several associations were found between connectivity measures in the nodes indicated in the group-contrast and stop-task outcome measures. Specifically, connectivity between the left inferior frontal seed and the anterior middle temporal gyrus was positively associated with ICV and SSRT . Operculum connectivity was additionally negatively correlated with SSRT  during successful stop trials, though this result did not survive Bonferonni-Holm correction. In other words, higher thalamus connectivity was associated with better task performance , NWO Large Investment Grant 1750102007010 (to Jan Buitelaar), and grants from Radboud University Nijmegen Medical Center, University Medical Center Groningen and Accare, and VU University Amsterdam. Jan K. Buitelaar has been in the past 3 years a consultant to/member of advisory board of/and/or speaker for Janssen Cilag BV, Eli Lilly, Bristol-Myer Squibb, Schering-Plough, UCB, Shire, Novartis, and Servier. He is not an employee of any of these companies and not a stock shareholder of any of these companies. He has no other financial or material support, including expert testimony, patents and royalties. Jaap Oosterlaan has received in the past 3 years an investigator initiated grant from Shire pharmaceuticals. Pieter Hoekstra has been paid consultant of Shire and Eli Lilly and has received unrestricted research funding from Shire.This work was supported by We acknowledge the Department of Pediatrics of the VU University Medical Center for having the opportunity to use the mock scanner for preparation of our participants. The authors thank Roshan Cools for her invaluable input and comments in the preparation of this manuscript.


In the study of health and quality of life in attention deficit/hyperactivity disorder (ADHD), it is of paramount importance to include assessment of functioning. The International Classification of Functioning, Disability and Health (ICF) provides a comprehensive, universally accepted framework for the description of functioning in relation to health conditions. In this paper, the authors outline the process to develop ICF Core Sets for ADHD. ICF Core Sets are subgroups of ICF categories selected to capture the aspects of functioning that are most likely to be affected in specific disorders. The ICF categories that will be included in the ICF Core Sets for ADHD will be determined at an ICF Core Set Consensus Conference, wherein evidence from four preliminary studies  will be integrated. Comprehensive and Brief ICF Core Sets for ADHD will be developed with the goal of providing useful standards for research and clinical practice, and to generate a common language for the description of functioning in ADHD in different areas of life and across the lifespan. Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder of complex origin, with an estimated worldwide prevalence of 5.3 % . It is aA rich body of literature shows that individuals with ADHD of all ages experience functional impairments in many areas of everyday living, such as underachievement in school, difficulty in finding and keeping employment, and poor social relationships , 7. BesiInterestingly, the Danckaerts et al.’s review  suggesteThe WHO has developed the ICF , among oAccording to the ICF model, health condition is a disorder or disease that a person is diagnosed with, for instance ADHD . Body functions are the physiological functions of body systems, while body structures are anatomical parts of the body, such as organs and limbs. For instance, corresponding categories in the case of ADHD include impulse control (b1304) in the body functions component and structure of brain s110) in the body structures component. An activity is the execution of a task or action by an individual, and participation represents the involvement in a life situation. Examples of activities and participation relating to ADHD are focusing attention (d160) and informal relationships with friends (d750). Environmental factors make up the physical, social and attitudinal environment in which people live. With regard to ADHD, relevant environmental factors include medication (e1101) and special education and training services (e5853). Lastly, personal factors are the particular background of a person’s life and living, and they comprise features of the individual that are not part of a health condition , such as0 in the Derived from the ICF in 2007, the ICF Children and Youth version (ICF-CY)  was desiThe ICF and the ICF-CY are part of the WHO’s Family of International Classifications, developed to provide a comprehensive and universally accepted framework to classify the experience of health in individuals as well as populations. Even though the ICD-10 is the most widely used classification system, there is a growing interest in the use of the ICF and ICF-CY [referred to as “ICF(-CY)” from now on] in international health care, particularly with regard to physical disabilities , 20–22. The ICF(-CY) is hierarchically structured and has two parts, each consisting of two components see Fig. . In turnFirst-level chapter: b1 mental functionsSecond-level category: b130 energy and drive functionsThird-level category: b1304 impulse controlThe hierarchical structure of the ICF(-CY) can be seen in the following ADHD example from the body functions component:The ICF(-CY) consists of over 1,400 categories providing a comprehensive and exhaustive classification of an individual’s functioning. However, the extensiveness of the ICF has proven to be both its strength and its weakness, for in its current full version it is too extensive for practical use in daily clinical practice. To address this issue the ICF Research Branch, a partner of the German Collaboration Centre of the WHO Family of International Classifications and the WHO Classification Terminology and Standards (CTS) team, with the support of the International Society of Physical and Rehabilitation Medicine (ISPRM), the World Confederation for Physical Therapy (WCPT), the World Federation of Occupational Therapists (WFOT), and the International Society for Prosthetics and Orthotics (ISPO), initiated the development of so called ICF “Core Sets” , 25. ICFThe aim of this project is to develop official ICF Core Sets for ADHD and to provide a standardized method to classify functioning in individuals with a diagnosis of ADHD (referred to as “clients” from now on) at all ages. These ICF Core Sets for ADHD are unique in that they are developed based on a rigorous scientific protocol and as an official effort in collaboration with the WHO and the ICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI). This process ensures that multiple international perspectives are captured and that a comprehensive picture of functioning is formed, and that the universal character of the ICF(-CY) is preserved by involving experts, clients and clinicians with various professional backgrounds and from all six WHO regions. Moreover, this project adds to the existing research by developing ICF Core Sets for ADHD that are applicable to children, adolescents and adults alike. This makes it possible to follow the functional development of individuals with ADHD using the compatible tools across the entire lifespan. The objective of this paper is to describe and preview the development process of these ICF Core Sets for ADHD.This project is conducted in conformity with the ethical principles of the Declaration of Helsinki. All appropriate study-related documents will be presented to the corresponding Ethics Committees for review and approval, and informed consent will be collected from participants in the qualitative and the empirical cross-sectional study. ICF Core Sets will be developed in a three-phase process: (1) preparatory phase, (2) phase I ; and 3) phase II . The different phases of the development process are presented in Fig.  phase IIDuring the preparatory phase information on functioning in ADHD based on the ICF and ICF-CY will be gathered, and based on this information a pre-selection of relevant ICF(-CY) categories will be made. The pre-selected categories will then be presented to an international panel of ADHD experts at the consensus conference to help them make an informed decision about which of the pre-selected ICF(-CY) categories should be included in the ICF Core Sets. The preparatory phase consists of four scientific studies, each addressing the selection of relevant ICF(-CY) categories from a different perspective:A systematic review of studies published since 1982 will be performed (1) to identify outcome measures in ADHD research, and (2) to link the concepts in these measures to the ICF(-CY). After selection of relevant studies from multiple databases , the data collection process will consist of three consecutive steps: (1) the parameters used in selected studies will be identified; (2) the items of retrieved parameters and their underlying concepts will be specified; and (3) the concepts will be linked to the categories of the ICF(-CY) using established linking rules . Absolutn = ~200) and retrieved concepts will be linked to ICF(-CY) categories using established linking rules  and from each of the six WHO regions . The experts to be included in the survey will be selected by identifying as many key opinion leaders in the field of ADHD as possible with the help of international professional organizations and societies, journal editorial boards, and other networks. Selected experts will be invited to take part in an internet-based survey. Participating experts will be asked to name the concepts they consider most relevant with regard to functioning in ADHD across the lifespan. From their statements a stratified random sample will be drawn  will be employed to guide the discussion in groups of 4–6 people under supervision of a moderator. To ensure the universal applicability of the ICF Core Sets for ADHD, study centers from each of the six WHO regions will be approached for participation in this study. Based on previous ICF Core Set studies, approximately six focus groups are expected to be held per study center. Since the focus groups will include clients of all ages, the questions will be rephrased in an age-appropriate manner according to the age of the focus group participants. Where an individual is unable to take part in a focus group due to the severity of the condition, an individual interview will be performed. The written transcription of the focus group discussions and individual interviews will be analyzed to identify concepts of functioning important to the clients. These concepts will then be linked to ICF(-CY) categories, using established linking rules . Like thA cross-sectional study will be conducted to identify the most common problems in functioning experienced by individuals with ADHD, as reflected by the clinician’s perspective. A total of 200 children, adolescents and adults with ADHD will be selected to take part in this study, preferably from study centers in each of the six WHO regions. Based on information from client records, observations and semi-structured interviews, clinicians will rate the functioning of their clients using a case record form (CRF) based on the extended ICF Checklist 2.1a . The extThe information collected during the preparatory phase will be presented at an international consensus conference, planned to be held in 2016, where a group of 21–25 experts in the field of ADHD from all WHO regions will follow a formal decision-making process to arrive at a consensus on the ICF(-CY) categories to be included in the Comprehensive and Brief ICF Core Sets for ADHD. The Comprehensive Core Set will include the ICF(-CY) categories that reflect the entire spectrum of typical problems that clients may encounter at all ages, and is thereby suitable for a comprehensive and interdisciplinary assessment of functioning in ADHD. Based on decisions to be made by an international steering committee, one or more Brief Core Set will be derived from the Comprehensive Core Set and will capture the essence of a client’s functioning. It is intended to be the starting point for basic clinical documentation, as well as the minimal standard for describing functioning in ADHD in clinical and epidemiological studies. The consensus conference will start with an introduction to the ICF(-CY), the process of developing ICF Core Sets, and the results from the preparatory studies. This introduction will then be followed by a structured decision-making process, involving alternating work group sessions and plenary sessions, in which the participants discuss and vote on the categories to be included in the Comprehensive ICF Core Set. After the Comprehensive ICF Core Set is decided, a ranking process will follow to select the categories for the Brief ICF Core Set.Phase II will consist of validating the ICF Core Sets for ADHD. Specific aims of the Phase II study include (1) to verify whether categories included in the ICF Core Sets for ADHD describe the entire spectrum of typical problems encountered by clients from all over the world; (2) to identify possible relevant categories missing from the ICF Core Sets for ADHD; and (3) to examine the applicability of the categories of the ICF Core Sets in different contexts, for different purposes, and from different perspectives. An international, cross-sectional, multicenter validation study with individuals diagnosed with ADHD will be conducted to study the content validity and feasibility of the ICF Core Sets for ADHD.In this paper, we described the rationale and proposed scientific process for the development of ICF Core Sets for ADHD. The ICF Core Sets for ADHD will be intended to be used as a guide for making recommendations for the practical use of the ICF(-CY) in the context of ADHD, by providing a selection of the most relevant ICF(-CY) categories that facilitate the description of a client’s functioning. In the project described in this paper, both Comprehensive and Brief Core Sets will be developed. The Comprehensive Core Set can provide clinicians with a basis for a thorough and interdisciplinary assessment of functioning, for the formulation of intervention goals, and for the evaluation of progress in treatment. The Brief Core Set can be used when only a brief assessment of functioning is necessary. With a smaller number of categories they capture the essence of functioning of clients.ICF Core Sets for ADHD provide an overview of the aspects of functioning that should be assessed to get a complete picture of the level of functioning of an individual with ADHD. This overview can be translated into various assessment instruments, such as questionnaires, rating systems, structured interviews, observation scales, etc.—depending on the needs and wishes of the user. Neither the Comprehensive nor the Brief Core Sets will be exhaustive, and users are free to add ICF(-CY) categories to enhance assessment of functioning for their specific purposes. Because the assessment instruments based on the ICF Core Sets for ADHD will be translated from the ICF(-CY) categories, this means it will also be possible to translate them back to these categories. This in turn means that assessment instruments based on the ICF Core Sets for ADHD will be easy to compare, even if they are used in different disciplines or countries.The complex nature of ADHD requires a multidisciplinary and multilevel assessment and intervention approach to improve functioning and QoL for individuals with this disorder. The ICF Core Sets for ADHD can meet this need by providing a common basis for communication across different disciplines in ADHD research and clinical practice. In addition to enhancing multi- and trans-disciplinary communication, the ICF Core Sets can provide scientists with terminology and definitions of functioning that are universally applicable and understandable irrespective of country and cultural borders, thus facilitating international studies.Since ICF Core Sets for ADHD will outline “what to measure”, rather than “how to measure”, they will not become ready-to-use instruments for measuring functioning. After Phase II, tools for assessment of functioning will need to be derived from the ICF Core Sets for ADHD, and these tools will need to be validated and implemented to ensure that the framework of the ICF Core Sets will be widely applied. Applications of the ICF framework include quantifying the effect of ADHD on functioning, and evaluating the effectiveness of interventions. Moreover, ICF Core Sets for ADHD can be used to rate the content validity of already existing measures and thereby to select appropriate instruments specifically relevant to ADHD. We envision that the wide application of ICF Core Sets for ADHD in research and clinical practice will lead to improved knowledge about functioning in ADHD, which in turn will lead to interventions that improve functioning and QoL for individuals with ADHD.In preparing the development process of the ICF Core Sets for ADHD, we encountered certain questions and challenges that needed to be considered prior to the preparatory studies. How to best tackle these issues was discussed and determined by an international Steering Committee (SC) during a meeting that took place in Stockholm in May 2013. This SC consists of ADHD experts from different professions and WHO regions and guides the development process of ICF Core Sets for ADHD. One of these issues discussed during the meeting is the fact that ADHD is a developmental condition that often persists across the lifespan, and that symptoms as well as needs may vary in nature and severity with age .This preAnother well-known challenge in ADHD research, which was determined by the SC, is the question of how to handle psychiatric comorbidity and its impact on functioning in individuals with ADHD. The co-occurrence of other neurodevelopmental and psychiatric disorders is the rule rather than the exception in ADHD , 31. ThiIn conclusion, the consensus conference will provide us with a first version of the ICF Core Sets for ADHD, and subsequent testing and validation will be needed before a standardized and universally accepted tool for the classification of functioning in ADHD will be available. The project described in this paper forms the crucial first step towards the achievement of this tool.


P<0.05 for all). This same relationship was observed in patients that received sorafenib treatment for advanced HCC . Moreover, the combination of HTATIP2 and MVD had better power to predict patient death and disease recurrence (P<0.001 for both). We conclude that the combination of HTATIP2 and MVD predicts the converse survival of HCC with or without sorafenib intervention. Our findings can assist in the selection of candidates for personalized treatment with sorafenib.Our previous studies have demonstrated that sorafenib can promote the dissemination of hepatocellular carcinoma (HCC) through downregulation of HTATIP2, a suppressor of tumor growth and metastasis that is associated with inhibition of angiogenesis. Here, we investigated the predictive values of the HTATIP2 level and microvessel density (MVD) with or without sorafenib administration for HCC. Three independent cohorts were included. Using tissue microarray, we assessed the relationship between HTATIP2 expression/MVD and overall survival. The results showed that high HTATIP2 expression and a low MVD value were independent protective prognostic factors after curative HCC resection (297 cases/cohort 1); however, both parameters were converted to independent negative prognostic indicators for patients with postsurgical sorafenib treatment (69/143 cases/cohort 2;  Hepatocellular carcinoma (HCC) is the sixth most prevalent cancer globally and the third most common cause of cancer-related death. The oveCumulative studies have provided evidence and insight that sorafenib and another RTKI, sunitinib, can accelerate the spread of cancer in certain situations-9, suggeHerein, we aimed to investigate the prognostic and/or predictive characteristics of HTATIP2 and MVD, separately and combinatorially, for survival of HCC patients in the presence and absence of sorafenib.r=–0.279, P<0.001 for cohort 1; r=–0.231, P=0.006 for cohort 2; and r=–0.350, P=0.001 for cohort 3; Figure Immunostaining of HTATIP2 was mainly distributed in the cytoplasm of tumor cells or hepatocytes (data not shown). Most of the stromal cells were negative staining; although, sporadic positive staining on them was also observed Figure . SpecifiAs shown in Table P<0.001 for both; Figure P<0.001 for both; Figure P<0.001 and P=0.001, respectively) and RFS  than those with low HTATIP2 expression or high MVD . Positive serum hepatitis B e antigen was also associated with RFS Table . The medD Figure .P=0.008 and P=0.009, respectively; P=0.191 and RFS, P=0.617; P<0.001 and P=0.001, respectively; Sorafenib prolonged postoperative OS and RFS compared with the control  and of RFS  for cohort 1. Unexpectedly, both biomarkers were independent risk factors of OS  and of RFS  for sorafenib-administered patients in cohort 2.Risk factors identified by univariate analysis of cohorts 1 and 2 were pooled into a multivariate Cox proportional hazards analysis Table . Both hiP<0.001 for all; Table Patients (cohort 1 and 69 sorafenib-administered patients in cohort 2) were first categorized into three groups according to their HTATIP2 density and MVD: group I, high HTATIP2 and low MVD; group II, high HTATIP2 and high MVD as well as low HTATIP2 and low MVD; and group III, low HTATIP2 and high MVD. When performing the ROC analysis, group II was further divided into two groups with both high/low levels of the two biomarkers. The prognostic analysis of both cohorts showed significant differences in both OS and RFS among the three groups , and the predictive value of the combinatorial group was the best among all the adopted factors , respectively, and was greater than other factors (Tables S3 and S4).Clinicopathological factors identified by multivariate analysis and the combination of HTATIP2 expression and MVD were included, and their predictive values were studied by ROC analysis . HTATIP2 expression, MVD, and the combination of both parameters precisely predicted death and recurrence for both cohorts . The disease-control rate was 42.2% for the high-MVD group and 30.1% for the low-MVD group  or CC3, typically functions as a tumor suppressor and was initially identified in the highly metastatic human variant small cell lung carcinoma (SCLC) in comparison with the less metastatic classic SCLC cell lines. HTATIP2at of HCC, 23. Oth in vivo , 13, 24. in vivo . In the  in vivo , 23. Her in vivo , 22. ConClinicalTrials.gov), although prometastatic side effects have also been observed was measured according to RECIST  guidelines (v1.1) by indepThe detailed patient survival is summarized in the Supplemental Materials and Methods. The present study was approved by the appropriate ethics committees, and informed consent was obtained from each patient.For cohorts 1 and 2, the postoperative tumor specimens were collected and then constructed into TMAs . TMA construction was performed as described previously, 32. TwoFor cohort 3, the tumor specimens were acquired aseptically through sonographically guided 18-gauge core-needle biopsy of the liver. Next, the samples were collected and made into paraffin sections. All the patients were diagnosed with advanced-stage HCC, as confirmed by independent pathological analysis, before sorafenib administration.Immunohistochemistry in TMAs and other paraffin sections (4-μm thick) was performed by a two-step method as described previously, 33. TheFor all sections, the density of positive staining in whole view was measured using a computerized image system composed of a Leica charge-coupled device camera (DFC500) connected to a Leica DM-IRE2 microscope . Briefly2 test was used to compare qualitative variables, and quantitative variables were analyzed by t or Spearman's test. Data were described by Pearson's correlation coefficient to determine the association between HTATIP2 expression and MVD. Cumulative survival curves were estimated using the Kaplan–Meier method, and differences between the curves were calculated using the log-rank test. Independent prognostic significance of risk factors identified by univariate analysis was computed by the Cox regression model. ROC curve analysis was applied to determine the predictive value among the parameters. Statistical significance was set at a two-sided P value<0.05.Analyses were performed using SPSS 16.0 for Windows. The cutoff point of the HTATIP2 density or MVD for the definition of subgroups (high- versus low-risk groups) was the median value. Pearson's χ