In children with ADHD/ODD, mean effects were d = 0.64 (95% CI 0.31–0.96) for WM and d = 0.46 (95% CI 0.07–0.84) for IC. Studies on reward-related IC and FL were lacking. Effects on ODD and ADHD symptoms were d = 0.40 (95% CI − 0.23 to 1.03) and d = 0.28 (95% CI − 0.08 to 0.64), respectively. Interventions targeting multiple EFs and using interpersonal cognitive scaffolding approaches showed large and statistically significant effects on ADHD and ODD symptoms. In preschool children of the general population and in those with ADHD/ODD (symptoms), interventions led to an improvement of EF performance. In children with ADHD and ODD, cognitive scaffolding interventions were most effective in terms of reducing ADHD and ODD symptoms. However, more well-controlled studies need to be conducted before any firm conclusions can be drawn.Many interventions targeting executive function (EF) development in the preschool period, where malleability might be particularly high, have been created and evaluated. We conducted a meta-analysis of randomized controlled trials (RCTs) on the effects of these interventions on (a) EFs in preschool children from the general population as well as preschool children with (symptoms of) attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and (b) ADHD and ODD symptoms in preschool children with ADHD/ODD (symptoms). Literature search yielded 35 RCTs. Risk of bias of the individual studies was assessed. A random-effects model was used. Moderator effects were tested using mixed model analyses. The overall effects on EFs were:  From the preschool years onwards, children with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) have consistently been found to show deficits in executive functions (EFs). Specifically, studies demonstrated reduced inhibitory control (IC) capacity in the “cool”, non-reward-related context and in the “hot”, reward-related context, a low working memory capacity, and low set-shifting ability , 2. ThesEFs are regarded as complex cognitive processes that serve purposes of behavioral regulation and goal-directed action . TheoretEFs involve the so-called executive control network, i.e. a set of frontal and parietal brain structures including regions of the prefrontal cortex (PFC), the insula, parts of the supplementary motor area and the anterior cingulate, the intraparietal sulcus, and other areas , 13. In In recent years, many intervention programs targeting EFs have been developed and evaluated. Several years ago, Diamond and Lee  reviewedd = 0.79, p < 0.001) and a medium effect on visuospatial WM . In children younger than 10 years, effect sizes for verbal and visuospatial WM were d = 1.41 (p < 0.01) and d = 0.46 (p < 0.01), respectively. Transfer effects to the Stroop measure (interference control) and to other cognitive abilities were small. Two further meta-analyses analyzed training effects on EFs in children with ADHD and high ADHD symptoms. Rapport et al. [d = 0.63, p < 0.05), and the training of mixed EFs (three studies) showed no noteworthy effect (d = 0.06). Far transfer effects on objective outcomes (e.g. cognitive tests) were modest. Wass et al. [Meta-analyses of the interventions for preschool children have not yet been performed. However, several meta-analyses on WM training (targeting the short-term memory component of WM) have been conducted. Melby-Lervåg and Hulme  analyzedt et al.  includeds et al.  analyzedd = 0.64 (p < 0.05). To control for the influences of expectancy effects of patients, parents, and researchers (i.e. more favorable ratings of responses to treatment by those who were invested in the therapy), mean effect sizes were estimated exclusively for studies with (probably) blinded assessments of ADHD symptom outcomes . The weighted mean effect size of the five respective studies was d = 0.24 and did not reach statistical significance. The meta-analysis by Rapport et al. [d = 0.48 (p < 0.05) and d = 0.12 (not significant), respectively. Comparably, Cortese et al. [d = 0.37, p < 0.05) on ADHD symptoms in children with ADHD and a decrease to d = 0.20 (p < 0.05) when exclusively blinded studies were considered. These authors suggested a possible advantage of programs targeting multiple EF deficits.Three recent meta-analyses studied the effects of cognitive training on ADHD symptoms in ADHD patients. Sonuga-Barke et al.  includedt et al.  analyzede et al.  found a Taken together, there is broad evidence regarding the significance of EFs in social adjustment development and psychopathology. In children with ADHD and externalizing symptoms, poor EF development has frequently been found, and has been assumed to be involved in the development of ADHD and ODD symptoms. Cognitive training of EFs in the preschool period was expected to be particularly effective, including the reduction of ADHD and externalizing symptoms. In recent years, specific intervention programs tailored to preschool children have been developed and evaluated (see description/definition of interventions below). In many cases, these programs focus on multiple core EFs and contain elements which target the facilitation of transfer. However, a meta-analysis summarizing the current results of this research has not yet been conducted.In the present meta-analysis, we, therefore, examined the following hypotheses: (1) cognitive interventions targeted at EFs (as defined by Diamond and Lee ) in presTo be included in the meta-analysis, a study had to fulfill the following criteria: (1) the study tested the effectiveness of an intervention which was developed to improve EFs in preschool and kindergarten children using a mainly cognitive approach . (2) ThThe meta-analysis follows the suggestions of the PRISMA statement . A literk = 8) of the studies were coded independently by the two coders to assess inter-coder agreement. Kappa coefficients for the categorical variables ranged between 0.74 and 1.0, and Kendall’s Tau-b correlations for the continuous variables ranged between 0.79 and 1.0, indicating excellent inter-coder reliability. Statistics necessary for effect size calculation were extracted by the second author (C.M.) and independently checked by the first author (U.P.-P.) in all cases. Divergence was solved by renewed inspection and discussion where necessary.Besides information necessary for effect size calculations (see below), the variables listed below (moderator variables section) were coded. For this purpose, a standardized coding sheet was developed. Coding was carried out by two psychologists (first and second author). 20% , ADHD, and ODD/externalizing symptoms measured at the first post-intervention assessment. In most instances (32 of 35 studies), a pretest–posttest control group design was used. To take advantage of the strengths of this design, the difference between the standardized mean change for the treatment and control group was used as primary effect size (see statistics section for further details).Several studies used more than one single task to assess one EF or symptom domain to increase the reliability of measurement. In some of the studies, composite scores had already been computed and listed in the article. Otherwise, we calculated the weighted mean effect size of the multiple tests per outcome domain. In cases where multiple scores were reported for a single test (e.g. error and accuracy scores), we used the score which most precisely reflected the outcome domain. If more than one independent study was reported in one article, all eligible studies were coded separately  dirIn cases of significant heterogeneity of effect sizes, we analyzed potential influences of sample and intervention characteristics. We considered the following sample characteristics: (a) mean age of the sample and (b) percentage of boys. The following intervention characteristics were considered: (a) duration of the intervention in weeks, (b) the intensity of the intervention in minutes per week, (c) the setting (group vs. single child), and (d) the delivery of the intervention by teacher (classroom curriculum) vs. trainer/therapist.Regarding risk of bias, the meta-analysis follows the suggestions of the Cochrane Collaboration’s tool  as well For the assessment of publication bias, we used funnel plots and Egger’s test for funnel plot asymmetry. As funnel plot asymmetry can be caused by heterogeneity of effect sizes , we contd coefficient) was used as the primary effect size metric. According to Morris [The difference between the standardized mean change for the treatment and control group  and on ADHD and ODD/externalizing symptoms, random effects models were used because between-studies variability of effect sizes is assumed. The amount of heterogeneity was estimated with the restricted maximum-likelihood estimator and tested by Cochran’s Q test .To explore differences between the four approaches, we used mixed effects analyses. For the analyses of other moderator effects, mixed effects analyses also were performed. Calculations were carried out with “metafor” version 1.9–2 of R version 3.1.0 .The procedure was as follows: hypothesis 1: (1) for each of the EF outcome domains , the overall weighted mean effect size of the interventions was estimated. Heterogeneity of effect sizes was tested. (2) The weighted mean effect size for the studies with ADHD/ODD samples was estimated and compared with the mean effect in the general population samples. (3) The weighted mean effect size for the internally valid studies was estimated. (4) Differences between intervention approaches were explored. (5) Further moderator effects were tested if heterogeneity of the overall weighted mean effect size was significant. Hypothesis 2: (1) for the two outcome domains , the overall weighted mean effect sizes in the studies with ADHD/ODD samples were estimated. Heterogeneity of effect sizes was tested. (2) The weighted mean effect size for the internally valid studies was estimated. (3) Differences between intervention approaches were explored. (4) The moderator effects were tested if heterogeneity was significant.k = 35 independent RCTs (k = 35) reported in 29 articles. In all, n = 3068 children participated in these studies. Table Figure In 23 studies, the effect of a cognitive training intervention on WM was analyzed. Fourteen studies focused on direct WM training, seven on cognitive scaffolding, no study on attention-directing strategies, and two studies analyzed programs with a minor EF component . Inter-study heterogeneity of effect sizes was significant . The mean effect size of these studies did not differ from that in studies of children from the general population . The moderator effects by internal validity was statistically significant (Q(1) = 4.94; p = 0.026; k = 23), indicating a higher mean effect size of the more rigorously controlled studies. Intervention approaches did not significantly differ  = 0.04, k = 22) or mean age of sample (Q(1) = 0.21, k = 23). Among the characteristics of the intervention, there were also no significant moderator effects (delivery by trainer/therapist vs. teacher: Q(1) = 2.17, k = 23, duration of intervention in weeks: Q(1) = 2.71, k = 23, intensity: Q(1) = 0.42, k = 21, group vs. single-child setting: Q(1) = 0.00, k = 23). The funnel plot for the mixed model meta-analysis  did not show significant asymmetry . Seven of the 26 studies were classified as highly valid.d = 0.30 (p < 0.001), with no significant inter-study heterogeneity of effect sizes (Table d = 0.46 (p = 0.015). In the highly valid studies, the mean weighted effect size was d = 0.39 (p < 0.001). Moderator effects by study sample (Q(1) = 0.69) and validity (Q(1) = 0.72) were not significant. Effect sizes of the three intervention approach categories (with more than one study) did not significantly differ . Between-study heterogeneity of effect sizes was significant  = 0.21; percentage of boys: Q(1) = 0.76; duration of intervention: Q(1) = 0.85; doses/intensity: Q(1) = 0.01; delivery (teacher vs. trainer/therapist): Q(1) = 0.09; all interventions used a group setting). An analysis of funnel plot asymmetry was not appropriate due to the low number of studies.Further moderator analyses yielded no significant results . Heterogeneity was statistically significant (Table d = 0.84 (p < 0.001). The moderator effect by validity of the study design was significant (Q(1) = 9.40, p < 0.01), indicating larger effects of the more rigorously controlled studies. No significant differences emerged between the intervention approaches  = 1.17; percentage of boys: Q(1) = 0.59; duration of intervention Q(1) = 2.02; intensity of intervention: Q(1) = 0.03; setting: Q(1) = 0.26; delivery: Q(1) = 0.15). When controlling for the significant moderator effect by study validity, the Egger test for funnel plot asymmetry was significant . The other RCT analyzed a program with a minor EF component. The effect was not significant . There was no significant heterogeneity of the effect sizes of the studies. No study fulfilled all validity criteria. However, one study used a blinded assessment of the ADHD outcome and another study used an active control condition  while the mean effect size of the three RCTs on direct EF training was d = 0.17 (not significant). Analysis of funnel plot asymmetry was inappropriate due to the low number of studies.In four studies, the effect of a cognitive training intervention  on the ADHD symptoms of preschoolers with high symptoms or a diagnosis of ADHD, ODD, or externalizing disorders was analyzed Table . Two stu28 p = 0.3. There EFs have been found to predict social adjustment development in childhood and adolescence and are assumed to be causally involved in the pathogenesis of ADHD and ODD. The core EFs of WM, IC, and FL show major normative developmental improvements in preschool years. They are presumed to be particularly malleable by cognitive training interventions in this developmental period. The number of studies analyzing this hypothesis has increased considerably in recent years. However, this research has not yet been systematically reviewed and summarized by means of a meta-analysis.We analyzed the effectiveness of EF training interventions developed specifically for preschool children regarding the improvement of core EFs and the reduction of ADHD and ODD symptoms. The main findings were as follows: based on the RCTs with the lowest risk of bias , we found a significant, medium effect on WM, and a significant small to medium effect on cool IC. There were no highly valid studies on hot IC and only four on FL. In preschoolers with ADHD/ODD (symptoms), significant  medium-sized effects on WM and cool IC emerged. With the exception of hot IC, there were no differences between the intervention approaches. Hot IC, however, showed greater improvements from interventions focusing on attention-directing strategies and cognitive scaffolding. In children with ADHD/ODD (symptoms), overall small to medium sized, not statistically significant effects on ODD and ADHD symptoms emerged. Effects of cognitive scaffolding programs were large, while the effects of programs using direct training of EFs or programs with a minor EF component were negligible.d = 0.30 (cool IC) and d = 0.47 (FL). The effect on WM  is comparable with the findings of meta-analyses on WM/attention training by Cortese et al. [d = 0.51, p < 0.05; visual WM: d = 0.47, p < 0.05) in children/adolescents with ADHD and by Melby-Lervåg and Hulme [d = 0.46, p < 0.01) in children from diverse populations. In the present meta-analysis, in all instances, the mean effect size was larger in the trials with the highest internal validity (low risk of bias). In the domains of WM and FL, the moderator effect by study validity reached statistical significance. This finding is unsurprising given that controlling for unsystematic errors leads to a closer link between the experimental conditions and the outcome variable. Moreover, the finding underscores the methodological quality (i.e. no systematic biases in favor of the interventions) of the included studies. This latter aspect is probably due to the use of neuropsychological tests (i.e. no subjective ratings) for the assessment of the outcomes. Overall, it can be concluded that the interventions lead to a substantial improvement in preschoolers’ WM and cool IC. Due to publication bias, however, the effect on FL should be interpreted with caution.The overall weighted mean effect sizes in the four EF domains ranged between e et al.  . NevertIn previous research, transfer effects of improvements in EFs after direct (often computerized) cognitive training were rather low. Even if participants increased, for instance, their WM capacity, generalization to other EFs and cognitive abilities (near transfer effects) or to academic skills and subjective ratings of e.g. ADHD symptoms (far transfer effects) were poor , 22. ManIn the preschool period, during which ADHD and ODD symptoms emerge, the not yet full-blown disorders are hard to distinguish. ADHD and ODD symptoms often occur together and only over the course of time do they differentiate into the subtypes of ADHD, ODD, and the combination thereof . For thiIn samples of children with ADHD and ODD/externalizing symptoms, the overall effects on the ADHD symptoms (four RCTs) and the ODD/externalizing symptoms (two RCTs) were not statistically significant. In both domains, a RCT on a cognitive scaffolding program showed significant, large effects, while effects of direct (computerized) training of EFs or a program with a minor EF component were negligible and not statistically significant. Cognitive scaffolding programs usually aim at multiple EFs, comprise elements which target the facilitation of transfer to everyday life, and take place in everyday interpersonal contexts. These programs might, therefore, be better tailored to the probably multiple EF deficits of children with ADHD and ODD, and might better represent the everyday context in which the symptoms appear.Nevertheless, these conclusions need to be seen as tentative. Of the six RCTs, only two RCTs on ADHD samples showed good internal validity . Even though these two well-controlled studies showed an almost medium effect size on average, statistical significance was not reached due to large differences in the single effects. More research is needed in this area. Based on our results, RCTs on cognitive scaffolding programs with blinded assessments of the ADHD and ODD outcomes would be particularly worthwhile.As mentioned above, some findings of the meta-analysis are limited by the insufficient number of eligible studies. Specifically, more studies are needed which use blinded assessments of subjective ratings of ADHD and ODD symptoms, and analyze the effects on hot IC. Moreover, it is necessary to analyze the mediation effects by the core EFs on the ADHD and ODD/externalizing outcomes on the level of single studies. As the number of studies on this topic is insufficient, the question of whether the improved EFs actually lead to a reduction of the ExtD symptoms must remain unanswered. The results of the current meta-analysis are compatible with such mediation processes (as effect sizes on EFs and ADHD symptoms were significant) but, as mentioned, they do not prove mediation. Regarding FL, we found indications of publication bias. As shown by the funnel plot (Appendix), there were relatively few small studies reporting small, non-significant effects. The finding points to the need for the publication of well-controlled trials with FL outcome measures, irrespective of the significance of the results.To conclude, although we found many well-controlled RCTs on the effectiveness of preschool interventions aiming at EFs, more research is needed. The meta-analysis revealed significant, mostly medium-sized effects of the preschool interventions on core EFs in studies showing a low risk of bias. In children with ADHD and ODD, cognitive scaffolding interventions were most effective in terms of reducing ADHD and ODD symptoms. However, these findings need to be confirmed in future research. Such research appears to be worthwhile given the indications that these interventions could adequately support preschool children who show ADHD/ODD (symptoms).


Diabetic cardiomyopathy (DCM) is characterized by microvascular pathology and interstitial fibrosis that leads to progressive heart failure. The mechanisms underlying DCM pathogenesis remain obscure, and no effective treatments for the disease have been available. In the present study, we observed that STK35, a novel kinase, is decreased in the diabetic human heart. High glucose treatment, mimicking hyperglycemia in diabetes, downregulated STK35 expression in mouse cardiac endothelial cells (MCEC). Knockdown of STK35 attenuated MCEC proliferation, migration, and tube formation, whereas STK35 overexpression restored the high glucose-suppressed MCEC migration and tube formation. Angiogenesis gene PCR array analysis revealed that HG downregulated the expression of several angiogenic genes, and this suppression was fully restored by STK35 overexpression. Intravenous injection of AAV9-STK35 viral particles successfully overexpressed STK35 in diabetic mouse hearts, leading to increased vascular density, suppression of fibrosis in the heart, and amelioration of left ventricular function. Altogether, our results suggest that hyperglycemia downregulates endothelial STK35 expression, leading to microvascular dysfunction in diabetic hearts, representing a novel mechanism underlying DCM pathogenesis. Our study also emerges STK35 is a novel gene therapeutic target for preventing and treating DCM. Diabetes mellitus is a metabolic disease characterized by high blood glucose levels –3. UntreThe serine-threonine kinase 35 (STK35), also known as CLIK1 and STK35L1, is a novel kinase, mainly localizes in the nucleus and nucleolus and binds to nuclear actin –11. STK3In the present study, we observed that the expression of STK35 is decreased in the diabetic human heart. High glucose (HG) decreased STK35 expression in mouse cardiac endothelial cells (MCEC) and MCEC proliferation, migration, and tube formation. Interestingly, replenishing STK35 expression restored HG-suppressed MCEC migration and tube formation. PCR array analyses revealed that HG-downregulated angiogenic gene expression was fully restored by STK35 overexpression. Furthermore, intravenous injection of AAV9-STK35 viral particles successfully overexpressed STK35 in the diabetic mouse heart and led to an increase in heart microvascular density, suppression of interstitial fibrosis, and amelioration of left ventricular functions. Altogether, our data reveal that HG-suppression of endothelial STK35 expression and associated microvascular dysfunction represents a novel mechanism underlying DCM pathogenesis.2/95% air in a humidified environment.Human heart tissue specimens were obtained from diabetic patients at the time of transplantation at the Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, and immediately frozen in liquid nitrogen and stored at −80°C until use. Non-diabetic hearts were obtained from donor hearts (not used for transplantation) and were collected and stored in the same manner. All tissues were collected under an approved protocol by the Houston Methodist Research Institutional Review Board. MCEC was purchased from Cedarlane (Cat#CLU510) and cultured in Dulbecco's modified Eagle's medium  with 10% fetal calf serum (ATCC) at 37°C and 5% COi.p. injection of streptozotocin  to induce diabetes, or citric acid buffer vehicle (non-diabetic mice)  under a controlled 12-h light to 12-h dark cycle and had free access to water and a standard diet. The mice received a single ic mice) –21. Diab® Beckman tubes. The tubes were centrifuged in type 70 Ti Beckman rotor at 60,000 rpm for 2 h. The iodixanol gradient layer containing the viral vector was extracted and purified by 5 PBS washes in Apollo concentrators. A dot-blot assay was performed to determine the final concentration of the viral vector using the known STK35 plasmid concentrations as the standards with a denatured probe. rAAV9-STK35 , transgene-null vector (rAAV9-null), or saline vehicle control were administered via a single tail-vein injection (The customized STK35-GFP-CMV-AAV Vector (mouse CMV) construct was purchased from ABM company  and cloned into a recombinant adeno-associated virus (rAAV) plasmid with a GFP, packaged into pseudotype-9 capsids (rAAV9)  22, 23), 2322, 2njection .To mimic hyperglycemia, MCEC at confluent density were cultured for 48 h in DMEM media supplemented with 30 mmol/L D-glucose . D-Mannitol was used as an osmotic control .Briefly, cells or tissues were homogenized using a trizol lysis reagent. RNA was isolated from the homogenized samples using the miRNeasy Mini Kit (Qiagen). First-strand cDNA was synthesized using the TaqMan miRNA Reverse Transcription Kit following the vendor's instructions . qRT-PCR was performed using the Step-One Plus system (Life Technologies) following the manufacturer's instructions. The expression of the target gene was normalized to the GAPDH for comparison –27.Western blotting of protein lysate from cultured cells was performed as previously described –29. BrieSTK35 in MCEC, the cells were transduced with lentiviral-based STK35 specific short hairpin RNA (mission shrna transduction particles NM_183262/TRCN0000026703)  or non-specific control-shRNA (SHC005V)  in the presence of hexadimethrine bromide  as described in our previous publication . The cell proliferation rate was determined by A450nm minus the background control signal.The mitogenic activity of STK35 on MCEC was measured by the Cell Counting Kit 8 (WST-8 / CCK8) . In brief, the STK35 knockdown or STK35 overexpression MCECs at 105 cells) in 100 μl of chemotaxis buffer were added to the upper compartment (transwell inserts with 8-μm pores [Costar]). After incubation at 37°C for 18 h, the filters were removed. The cells that migrated through the pores to the bottom chamber were stained with Hema-3® stain kit  counted manually in 5 random fields in each well. All groups were studied at least in triplicate.The migration of MCEC toward VEGF165 stimulation was performed in a 24-well Boyden chamber Transwell plate . Briefly4 MCEC per well was seeded in a 48-well plate precoated with 40 ul per well growth factor reduced Matrigel . After 6 h in culture, capillary-like tube formation was photographed by a phase-contrast microscope. The cumulative length of the formed tubes was quantified using ImageJ software.MCEC expressing STK35-shRNA, pcDNA3.4-TOPO-STK35, or respective scramble control were cultured for 48 h. Then, the conditioned media was collected and mixed in equal quantities of fresh medium (1:1), and 300 ul of the medium with 1.5 × 102 Profiler™ PCR Array  according to the manufacturer's instruction.To determine the potential molecules by which STK35 promotes angiogenesis, MCEC with STK35 overexpression were cultured in normal or high glucose for 48 h, and then collected for expression profiling of genes that modulate angiogenesis using Mouse Angiogenesis RTi.v. injection. The mice were anesthetized with a mixture of 1.5% isoflurane and oxygen (1 l/min). M-mode tracings were used to measure the end-systolic diameter (LVESD), and end-diastolic diameter (LVEDD) and percent ejection fraction (%EF) was calculated as previously described  equipped with a 30 MHz transducer. Echocardiographic studies were performed before (baseline) and at 8 weeks post-rAAV9-STK35 escribed , 28.Histopathological assessment of cardiac fibrosis was performed as previously described , 28. The+ stained capillaries was assessed in 10 randomly selected high-power visual fields.Immunofluorescence staining of tissue sections was performed as described previously , 28. Tist-test was performed to determine statistical significance. When involving more than two groups, ANOVA with Tukey post-hoc test was used to analyze the data. Probability (P) values of <0.05 were considered a significant difference.Data are presented as mean ± SE. Between two groups of mice, an unpaired Student's In previous studies, we uncovered STK35 plays a key role in maintaining the functions of human CD34+ progenitor cells in the ischemia heart . To explhttps://www.proteinatlas.org/ENSG00000125834-STK35/celltype). We found STK35 expression is the highest in the cardiac endothelial cells and fibroblasts (https://tabula-muris.ds.czbiohub.org/). Cardiac endothelial cells are more abundant than fibroblasts in human and mouse hearts, and our previous study showed that STK35 promotes human umbilical endothelial cells (HUVEC) proliferation and tube formation . In the initial study, we mined cell-type STK35 expression in the human heart in THE HUMAN PROTEIN ATLAS  play critical pathophysiological roles through the phosphorylation and activation of relevant effectors, such as cell-cycle regulators, growth factors, and transcription activators, to regulate signaling pathways and cellular homeostasis , 32. Curin situ differentiation of bone marrow-derived endothelial progenitor cells into endothelial cells, and significant improvements in cardiac function, thus suggesting the critical role of VEGF in the pathophysiology of DCM  for the publication of any potentially identifiable images or data included in this article.DJ, YZ, MW, KN, MC, RT, KY, XS, DR, JL, RK, and LW conducted the experiments, acquisition, and analysis of the results. DJ, PK, and LW designed the experiments, interpreted the data, and drafted the manuscript. All authors reviewed the results and approved the final version of the manuscript.This work was supported by NIH R01 HL093339, U01 CA225784, 1RF1 AG074289 and 1RF1 AG069039 (LW), American Heart Association postdoctoral grant 16POST30780010 (DJ) and R01GM124108 and R01HL158515 (JL).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Age-related decline in visual perception is usually attributed to optical factors of the eye and neural factors. However, the detection of light by cones converting light into neural signals is a crucial intermediate processing step of vision. Interestingly, a novel functional approach can evaluate many aspects of the visual system including the detection of photons by cones. This approach was used to investigate the underlying cause of age-related visual decline and found that the detection rate of cones was considerably affected with healthy aging. This functional test enabling to evaluate the detection of photons by cones could be particularly useful to screen for retinal pathologies affecting cones such as age-related macular degeneration. However, the paradigm used to functionally measure the detection of photons was complex as it was evaluating many other properties of the visual system. The aim of the current mini review is to clarify the underlying rationale of functionally evaluating the detection of photons by cones, describe a simpler approach to evaluate it, and review the impact of aging on the detection rate of cones. Age-related macular degeneration (AMD) is a widespread age-related retinal pathology that can severely impair vision by progressively damaging the macula of the retina responsible for central vision. A study on AMD patients found a decline in the ability of retinal photoreceptors to detect light years before the atrophic changes occur , which sWe recently developed a psychophysical paradigm to evaluate many components of the visual system  includinHowever, the quantification of the number of photons detected by cones was embedded into a complex psychophysical paradigm developed to evaluate many components of the visual system, which makes the evaluation of only the number of photons detected by cones unnecessarily complex. The first purpose of this mini review is to summarize and clarify how the number of photons detected by cones can be assessed based on two functional measures of contrast sensitivity. The second section reviews the impact of healthy aging on the number of photons detected by cones that was observed using this functional approach.The current section shows how the number of photons detected by cones can be evaluated by measuring contrast sensitivity under two specific visual conditions. The basic rationale is that the number of photons detected by cones varies in time and this variability [referred to as photon noise ] directlV) is equal to the expected number of photons detected (N):There is a direct relation between the expected number of photons detected by cones and the variability in the number of photons detected. Given that each photon entering the eye has a probability of being detected by a cone, the number of photons detected is stochastic: even when the luminance intensity is constant, the number of photons detected varies with time. This variability is a source of internal noise, named photon noise , that coThus, knowing the variability in the number of photons detected by cones indicates the number of photons detected on average.If the variation in the number of photons detected by cones  were the only source of internal noise, then contrast sensitivity would be expected to be proportional to the square root of the luminance intensity , which cthen the standard deviation in the number of photons detected in a Poisson distribution is equal to the square root of the expected number of photons detected:L)Given that the number of photons detected by cones is proportional to the retinal luminance intensity , the standard deviation would be inversely proportional to the square root of the luminance intensityandConsequently, if the variability in the number of photons detected were the only source of internal noise affecting contrast sensitivity, contrast sensitivity would be proportional to the square root of the luminance intensity .Under some visual conditions, the variability in the number of photons detected by cones  is the dominant noise limiting contrast sensitivity. At high luminance intensities, contrast sensitivity is generally independent of luminance intensity .However, the impact of an internal noise source on contrast sensitivity does not only depend on the level of the noise, it can also be modulated by a contrast gain preceding this noise source . Indeed,Nonetheless, the detection of light by cones is not preceded by any neural processes, so the only contrast gain preceding the detection of photons by cones is due to optical factors: the MTF of the eye, which reduces the contrast of high spatial frequencies. Thus, if the signal is composed of only low spatial frequencies that are not noticeably affected by the MTF , then the contrast of the signal would not be affected prior to the detection of photons by cones. For static stimuli, contrast sensitivity was found to be limited by the variability in the number of photons detected by cones at high spatial frequencies  because observers were wearing an artificial pupil  equating the number of photons entering the eye. Furthermore, the lower photon detection rate cannot be entirely due to cataract development of the lens reducing the number of short-wavelength photons reaching the retina, because a similar age-related effect was observed even when using only high wavelengths that are little affected by cataract development of the lens. Consequently, these two recent studies suggest that the age-related decline in the detection of photons by cones is not explained by a reduced retinal luminance intensity.Another ocular factor to consider is intraocular scattering caused by cataract development of the lens, which affects the MTF of the eye by reducing the contrast of high spatial frequencies . In the The current mini review highlights a new approach to non-invasively evaluate the detection rate of photons by cones. This functional approach enables to address a crucial visual process: the transduction of light into neural signals by cones. By measuring contrast sensitivity with and without external noise in specific conditions in which the variability in the number of photons detected by cones is limiting contrast sensitivity, the number of photons detected by cones can be evaluated. The current review therefore provides a simple functional paradigm to evaluate the efficiency of cones to detect light.Other traditional techniques are also sensitive to the number of photons detected. For instance, imaging densitometry e.g.,  and subjWhen studying age-related physiological alterations in the retina, it is often relevant to seek for functional correlates to quantify the impact of physiological alterations on visual functions. Typically, visual functions  are evaluated at high luminance intensities at which performance depends little on luminance intensity. For instance, contrast sensitivity saturates at high luminance intensities (Weber law), which implies that it is independent of the amount of light detected by cones. Consequently, a lower detection rate of light would likely have little impact on contrast sensitivity at high luminance intensities. The fact that all visual functions require the phototransduction of light into neural signals does not imply that a lower detection rate of light would necessarily affect performance. To address the ability of cones to detect photons, a visual function should be evaluated under conditions in which performance critically depends on the number of photons detected by cones. The current mini review shows that it is possible to evaluate the detection of light by cones by measuring contrast sensitivity under two specific visual conditions. This novel approach provides a new way to assess the efficiency of cones to detect light.Surprisingly, healthy aging was found to have a considerable impact on the detection rate by cones. Some age-related physiological changes at the retinal level could explain the decline in detection rate of photons by cones. One possible age-related alteration is a morphological one: the degeneration of the rods with aging induces a loss of alignment of the cones which lose their support  and reduA common symptom in early AMD is the difficulty under dim light conditions, which is consistent with the hypothesis that early AMD affects the detection rate of photons  despite AB, MR, and RA co-wrote the mini review. DS and AA proofread the review. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Attention deficit hyperactivity disorder (ADHD) is one of the most common syndromes of childhood. While in the past, ADHD was assumed to be a condition that disappears with maturation and is non-existent in adulthood, it is nowadays understood that ADHD persists into adulthood. Although there is a discussion about the actual percentage of children with ADHD who will still suffer from the disorder in adulthood, there is little doubt that it is a substantial proportion. Data from epidemiologic and follow-up studies indicate a persistence of ADHD across adolescence into adulthood in one to two thirds of diagnosed children with ADHD. The key defining symptoms of ADHD are inattention, hyperactivity and impulsivity, however, motor symptoms of hyperactivity/impulsivity were shown to be less dominant in adult ADHD, whereas attention deficits were found to become more pronounced in adults with ADHD. These core symptoms are pervasive and lead to severe functional impairments of affected adults. Besides these core symptoms, ADHD in adults can produce a wide range of additional cognitive deficits as well as motivational, affective, and social symptoms which can affect nearly every aspect of real-life functioning. In this context, it has to be considered that typical symptoms of ADHD may affect various domains of real-life functioning at the same time. For example, impulsivity of an adult with ADHD may have a negative impact on his or her social relationships, food choice and consumption, risk behaviour, handling of money, etc. Conversely, a specific domain of real-life functioning, such as driving a motor vehicle, may at the same time be adversely affected by various symptoms of ADHD, including impulsivity, inattention, distractibility and lack of flexibility, for instance. High rates of comorbidity further contribute to the impairment in real-life functioning. Real-life functioning is a complex and resource demanding process which requires the integrity of a number of abilities in a dynamic environment with constantly changing requirements. Such abilities include, among others, cognition, self-awareness, coping with stress and flexibility/adaptability. Typical domains of real-life functioning comprise among others social relationships, parenting, diet, social media use, mobility such as driving a motor vehicle, financial planning and decision-making, risk-taking, and vocational functioning.As real-life functioning is typically impaired in adults with ADHD, this special issue has been put together with the goal of highlighting the significance of real-life functioning of adults with ADHD and the problems they experience. Furthermore, the prerequisites of successful everyday functioning  and the related concepts  are considered in the current issue. Various scholars who are experts in their fields contributed to this endeavour by providing their up-to-date applied or fundamental research results. The result is a comprehensive overview of present research activities examining the impact of ADHD on real-life functioning in adults.Guo and colleagues present data about the neuropsychological functioning of individuals at clinical evaluation of adult ADHD.Diaz Orueta and colleagues systematically review the literature regarding cognitive functions of adults with ADHD.Butzbach and colleagues study metacognition in adult ADHD by examining the subjective and objective perspectives on self-awareness of cognitive functioning.Asadi and colleagues examine unique predictions of general risk-taking behaviour in adult ADHD.Koerts and colleagues discuss financial judgement determination in adults with ADHD.Barra and colleagues present a study on the role of stress-coping strategies for life impairments in ADHD.Godfrey and colleagues examine public perceptions of adult ADHD as indications of stigma.Young and colleagues review the literature on ADHD and offending.Fuermaier and colleagues study the nature of work-related problems and impairments of adults with ADHD and explore the association to ADHD symptoms and neuropsychological test performance.Werling and colleagues investigate screen media use before, during and after the COVID-19 lockdown in ADHD.Becke and colleagues discuss a new validity index embedded in the Conners’ Adult ADHD Rating Scales and provide information about its development and validation.Harrison and colleagues perform a comparison of the self-report patterns of analogue versus real world malingerers of ADHD.Fuermaier and colleagues investigate feigning of ADHD and stimulant misuse among Dutch university students.Mucci and colleagues perform a naturalistic review of the literature about ADHD treatment across the lifespan.Young and colleagues review key research in the literature on the assessment and treatment of substance use in adults with ADHD.Tamburin and colleagues explore whether cognitive dysfunction differs in high-dose benzodiazepine/Z-drug users with and without adult ADHD and the impact of cognitive deficits and adult ADHD on quality of life in this substance-use disorder.Faltraco and colleagues examine circadian gene expression in ADHD and the influence of norepinephrine, dopamine, atomoxetine and remdesivir.We hope that this special issue will reflect the wide range of scientific efforts in this exciting field and inspires all those who work in the field of adult ADHD, or plan to do so.


Attention-deficit/hyperactivity disorder (ADHD) affects approximately 5–7% of school-age children. ADHD is usually marked by an ongoing pattern of inattention or hyperactivity–impulsivity, leading to functioning or developmental problems. A common ADHD assessment tool is the Swanson, Nolan, and Pelham (SNAP) questionnaire. However, such scales provide only a subjective perspective, and most of them are used to evaluate therapeutic effects at least 3–12 months after medication initiation. Therefore, we employed an objective assessment method to provide more accurate evaluations of therapeutic effects in 25 children with ADHD (23 boys and 2 girls). To evaluate the participants’ improvement and treatment’s effectiveness, the pixel subtraction technique was used in video analysis. We compared the efficacy of 1-month Ritalin or Concerta treatment by evaluating the movement in each video within 3 h of medication administration. The movement value was defined as the result of a calculation when using the pixel subtraction technique. Based on behavior observation and SNAP scores, both parent- and teacher-reported scores decreased after 1 month of medication . Specifically, the parent-reported hyperactivity subscale and teacher-reported oppositional subscale decreased more significantly. By contrast, the reduction rate was 39.27%, as evaluated using the average movement value (AMV). Considering symptomatic improvement as a >25% reduction in scores, the result revealed that the AMV decreased in 18 patients (72%) compared with only 44% and 56% of patients based on parent- and teacher-reported hyperactivity subscale scores. In conclusion, the pixel subtraction method can serve as an objective and reliable evaluation of the therapeutic effects of ADHD medication in the early stage. Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood neurodevelopmental disorders and is characterized by an ongoing pattern of inattention or hyperactivity–impulsivity, leading to functioning or developmental problems . ADHD isADHD can profoundly affect children’s academic achievements, well-being, and social interactions . With thSymptomatic improvement in ADHD is a critical component for assessing the course of ADHD. The American Academy of Pediatrics 2019 guidelines mentioned that regardless of treatment, children with ADHD aged 4–18 demonstrated a 25% symptom reduction at 6–12 months from baseline, as measured using the Vanderbilt ADHD Diagnostic Rating Scale, which is considered a symptomatic improvement .After receiving the diagnosis of ADHD, the participants started their 1-month treatment with Ritalin  10 mg/day (17 patients) or Concerta  18 mg/day (8 patients). In addition, to monitor the drug compliance of the participants, self-reporting and medication measurement by parents were used to ensure medication regimen adherence. To ensure more precise monitoring of their response to the psychostimulants, they were asked to take morning doses after breakfast. Before the day of starting the psychostimulants, the behaviors of the participants were assessed using the following two methods: the SNAP-IV rating scales and movement detection using the pixel subtraction method. The SNAP-IV questionnaire was completed by both parents and teachers, either at home or school, and the pixel subtraction method required the capture of video footage during their first consultation by a pediatric neurologist. After 1 month of receiving the treatment with psychostimulants, they were assessed again with the same methods. The SNAP-IV questionnaire was completed by parents and teachers. During the day of consultation, they had taken the medicines before the visit within 3 h of medication administration.The SNAP-IV comprises 26 items that are rated on a 4-point scale from 0  to 3 (very much). The items are divided between three subscales: inattention (nine items), hyperactivity–impulsivity (nine items), and oppositional defiant disorder symptoms (eight items) specified in the DSM-V. Subscale scores are determined by calculating the average of the item scores per subscale. Each subscale score indicates the symptoms exhibited by the patients and helps in the categorization of the three ADHD subtypes: inattentive , hyperactive–impulsive , or combined .Movement detection by using the pixel subtraction method was performed by analyzing the captured videos that were obtained in the consultation room. We compared the efficacy of 1-month Ritalin or Concerta treatment by evaluating the movement in each video within 3 h of medication administration. The video recorder was placed in a fixed position in the consultation room and was unnoticed by the patients . In the According to the study by Wolraich et al., the symptomatic improvement in patients with ADHD was defined as a 25% reduction in symptoms from baseline, as measured using the Vanderbilt ADHD Diagnostic Rating Scale . In the i and j are the pixel x and y coordinates.After obtaining a series of grayscale images in sequence, the first c and secIn our proposed method, when there was no movement difference, the pixel values of the two consecutive images were considered equal. Thus, the output pixel value was zero after pixel subtraction, and the pixel of the output image was displayed as black. By contrast, if there was any change or movement occurring between the two input images, the output pixel indicated movement through a light color. The light part of the subtracted image e indicatθ) for the pixel value. When the difference between pixel values, Q, exceeded the threshold θ, D was set as 1; otherwise, it was set as 0. In dynamic image processing, all pixels in D with the value of 1 were considered to be the result of object movement [Using this method, movement was identified and tracked only at the specific regions of movement or at selected areas of the subtracted images. We defined the selected area as the rectangular region of the participant’s movement e. To tramovement .(2){D(iθ = 100), which was considered to indicate significant movement [D provided the feature for the participants. This feature characterizes the movement of the patient in the entire video. A movement measure, M, was defined as the following equation:In the pixel subtraction technique, we excluded effects such as image noise or tiny movements of the patient while running the MATLAB analysis; the threshold pixel value in this paper was set as 100  . Data are presented as the mean ± standard deviation. To analyze for any significant difference between the movement of the patient pre- and post-medication, we conducted a paired We recruited 25 patients (23 boys and 2 girls) for analyzing the therapeutic effectiveness of ADHD medication by using SNAP-IV scores and movement analysis.p = 0.013), but the difference in teacher-reported scores (16.38%: 38.08 ± 17.09 before and 31.84 ± 18.08 after treatment) was not significant compared with the parents’ scores (p = 0.074).The average parent-reported SNAP scores before and after treatment were 43.6 ± 11.35 and 35.08 ± 13.14, respectively, indicating a significant reduction of 19.61%  of all patients before and after 1 month of treatment  indicated a significant difference , was higher than that obtained in the traditional approach using SNAP-IV scores. Using SNAP-IV rating scales by parents and teachers, fewer children showed an improvement trend. More than 50% of parents noticed that their children did not show a significant improvement after treatment. For instance, based on parents’ ratings in hyperactive and oppositional subscales, only 11 and 9 children, respectively, exhibited >25% reduction after treatment. Similarly, based on the teachers’ ratings in the hyperactive subscale, 14 exhibited symptomatic improvement (>25% reduction). The correlation coefficient between AMV and SNAP scores parent-reported was −0.144. The correlation coefficient between AMV and SNAP scores teacher-reported was −0.094. There was no significant correlation between AMV and SNAP scores. Regarding to the consistency between the treatment response evaluated using AMV and SNAP, the consistency between AMV and the hyperactivity subscale from parents was 88%; the consistency between AMV and the hyperactivity subscale from teachers was 68% by a kappa statistic measurement.On the basis of the result presented in In this study, the SNAP-IV scores for the hyperactivity subscale from parents and the oppositional subscale from teachers decreased significantly. By contrast, the reduction rate was 39.27%, as evaluated using the AMV. With improvement considered as a reduction of more than 25%, the results revealed that the AMV decreased in 18 patients (72%), of whom only 11 patients (44%) and 14 patients (56%) improved by more than 25% according to the SNAP hyperactivity subscales obtained from parents and teachers.According the findings of the study, the average parent-reported SNAP scores indicated a significant reduction compared with teacher-reported scores. This indicates there were inconsistent reports between parents and teachers. The 26-item SNAP-IV has been widely used as a standard behavioral rating scale for the diagnostic assessment and core symptom management of ADHD in the current clinical setting, as defined by the DSM-V . AlthougOur results demonstrated a much more observable and significant reduction in movement analysis through pixel subtraction. Thus, this new approach can provide better evaluation of the effects of therapy on patients with ADHD based on the fact that the average movement among children with ADHD who had received 1 month of treatment was significantly reduced. The advantage of this method is that it can detect every movement of the subject that has been captured using the video recorder . This suWe further compared the behavioral changes among the children who received 1 month of Ritalin or Concerta treatment through the traditional and movement analysis methods. We observed that a larger proportion of children exhibited improvement in terms of movement reduction of more than 25% through motion analysis. As mentioned earlier, regardless of the treatment prescribed, children with ADHD who had received 6–12 months of treatment reported a symptom reduction of 25% from baseline, as measured using the Vanderbilt ADHD Diagnostic Rating Scale . By contAnother issue is that in movement analysis, only hyperactivity or a combined ADHD subtype  can be analyzed. With its advantage of detecting movement changes, it provided consistent monitoring for hyperactive or combined subtypes of ADHD; this movement analysis can be viewed as being superior to the traditional method. Notably, ADHD-C and ADHD-H subtypes are predominant, with a combined prevalence of 78.0–81.7%, which is much higher than that of ADHD-I (18.3–22.0%) ,20,21. HIn our study, a few issues were noted when applying the movement analysis. First, the option of clothing color was our main concern. We could only choose participants who wore solid plain-colored clothes because clothing texture or color affected the pixel subtraction value. Striped or contrasting-color clothing increased the light field area, thus increasing the movement value. Second, our main focus in movement analysis was the children. It was imperative that the caretaker or parent should not block the view of the video recorder.n = 25) is a major limitation in this study. In Our study has some limitations. Our cohort primarily comprised patients with ADHD-C and with an unbalanced sex distribution; thus, our results may not be representative of all ADHD subtypes and both genders. The small sample size (In the present study, we demonstrated that pixel subtraction of video images is an objective and quantitative method of evaluating ADHD medication efficacy in the early stage. We suggest that the method could be clinically applicable for managing other behavior/movement disorders of children.


Very little research has prioritized girls with ADHD, despite accumulating evidence showing that girls with ADHD experience broader and more severe peer dysfunction relative to boys with ADHD. Attention to identifying the neural mechanisms underlying the peer difficulties of girls with ADHD is critical in order to develop targeted intervention strategies to improve peer functioning. New efforts to address the peer dysfunction of girls with ADHD are discussed. Girls with attention-deficit/hyperactivity disorder (ADHD) face profound peer relationship problems that likely play a key role in long-term mental health risks, including high rates of depression and self-harm –3. Yet, Self-report and behavioral observations are often used to make inferences about the encoding and interpretation of cues ,13,14; hn = 391, Mage = 12.64, 48.6% girls, including 17 girls meeting criteria for ADHD) completed a laboratory peer interaction task. In this ERP task, participants played a game with simulated peers, in which they exchanged personal information, voted to reject and accept co-players, and then received a combination of rejection and acceptance feedback from peers [We recently examined how youth with ADHD symptoms process peer rejection and acceptance cues at the neurophysiological level . Adolescom peers . This taom peers , has beeom peers . ADHD syom peers . These eom peers ,21.Although only a small portion of girls in this study were diagnosed with ADHD, and these effects may not be specific to girls with ADHD, these intriguing findings suggest potential mechanisms relevant to understanding social behavior in girls with ADHD , which is critical given that current evidence-based treatments have generally failed to meaningfully improve the peer difficulties of youth with ADHD .


Lipoptena fortisetosa is a hematophagous ectoparasite of game animals feeding accidentally on companion animals and humans. Since the presence of numerous pathogenic microorganisms has been described in this species, monitoring its geographic distribution is of great epidemiological importance. To the best of our knowledge, we present two new haplotypes of Bartonella sp. isolated from L. fortisetosa in south-eastern Poland and confirm the presence of this invasive species in Lublin Voivodeship since 2013.Lipoptena are parasitic arthropods with a broad host range. Due to the type of parasitism (hematophagy), their potential role as vectors of pathogens, i.e., Bartonella sp., Anaplasma phagocytophilum, Rickettsia spp., and Borrelia burgdorferi is considered. As the range of their occurrence has been changing dynamically in recent years and infestations of humans have increasingly been reported, these organisms are now the subject of numerous studies. Our research aimed to present the molecular characteristics of Bartonella sp. detected in Lipoptena fortisetosa parasitizing wild cervids in south-eastern Poland. Adults of Lipoptena spp. were collected from carcasses of roe deer and red deer between spring and autumn in 2013. The PCR method was used to detect Bartonella sp. in the insects. We report two new haplotypes of the rpoB gene of Bartonella sp. isolated from L. fortisetosa feeding on wild cervids in south-eastern Poland and the presence of this invasive ectoparasitic species in the studied area since 2013. Phylogenetic analyses of newly obtained Bartonella sp. haplotypes confirmed their unique position on the constructed tree and network topology. The rpoB gene sequences found belonging to lineage B support the view that this phylogenetic lineage represents a novel Bartonella species.Insects of the genus  Lipoptena deer keds (Diptera: Hippoboscidae) widespread in the world fauna occur in Europe [Lipoptena cervi  and Lipoptena fortisetosa Maa, 1965, inhabit the central and northern parts of the continent. In recent years, progressive expansion of L. cervi [L. fortisetosa [L. fortisetosa species in Europe was most likely caused by its natural dispersal outside Asia, overlapping the ranges of Siberian and European roe deer during periodic climate changes, or by introduction with alien mammal species, e.g., sika deer  [Five of the 32 species of n Europe ,2. Two sL. cervi ,5,6,7 antisetosa ,13,14,15k, 1838) ,17.L. fortisetosa was first found in Lower Silesia at the end of the 1980s [Cervus elaphus Linnaeus, 1758) and roe deer  in the north [In Poland, he 1980s . This dehe north , in envihe north ,22, and he north .L. cervi, it mainly depends on the host species [L. cervi parasitize domestic and wild animals, primarily representatives of Cervidae-red deer, roe deer, and moose  [L. fortisetosa host species have not been clearly defined, but they are probably the same animals as the hosts of L. cervi [Lipoptena adults in their habitats are increasingly being reported. Their bites cause dermatitis in humans [Depending on the geographical region as well as climate and ecological conditions, the level of prevalence and severity of invasion of specific ectoparasites varies significantly, e.g., in the case of  species ,24 and e species . L. cervs, 1758) ,26, own L. cervi ,16. Human humans ,27,28,29n humans ,31.Lipoptena spp., microorganisms causing human and animal diseases have been detected. These include, e.g., Anaplasma ovis [Anaplasma phagocytophilum [Bartonella sp. [Borrelia burgdorferi [Rickettsia spp. [Trypanosoma spp. [Coxiella-like bacteria, Theileria luwenshuni, and Theileria ovis endosymbionts [L. cervi sequences of Bartonella sp. with 99% similarity with B. schoenbuchensis [Bartonella sp. was also noted in L. fortisetosa sampled from cervids and from the environment in the northern and western parts of the country [In sma ovis , Anaplastophilum ,33, Bartella sp. ,38,39,40sia spp. ,32, Trypoma spp. ,42, Coxiymbionts ,43. Thisuchensis . The pre country .Bartonella sp. detected in L. fortisetosa parasitizing wild cervids in south-eastern Poland.Our study presents the molecular characteristics of Lipoptena were collected in spring and autumn 2013 from carcasses of C. capreolus and C. elaphus harvested by hunters in accordance with the Act of 13 October 1995  near Polesie National Park (51°23′39″ N 23°11′4″ E) (Specimens of 11′4″ E) . These aIdentification of the species and sex of the adult insects was carried out in the laboratory using an OLYMPUS SZX16  stereoscopic microscope and the key for identification of arthropod species compiled by Borowiec .Lipoptena spp., each blood-fed adult from a different animal host. The DNA from 15 L. cervi  and 9 L. fortisetosa  randomly selected for the pilot study was isolated with the ammonia method [rpoB gene were used to detect Bartonella sp. in the insects [The molecular analysis included 24 specimens of a method . Next, i insects . The amprpoB gene for RNA polymerase beta subunit were aligned and revised manually in BioEdit v7.0.4 [rpoB gene haplotypes and sequences downloaded from GenBank, we constructed a phylogenetic tree using a maximum-likelihood (ML) algorithm in Mega v5.05 [AIC test (Akaike Information Criterion) with jModelTest [rpoB gene haplotypes from GenBank by constructing a haplotype network using the median-joining method available in Network version 10.2.0.0 (http://www.fluxus-engineering.com (accessed on 10 February 2021).The resulting sequences of the t v7.0.4 . The obtga v5.05  with 100odelTest  for the L. cervi and L. fortisetosa, were identified among the Lipoptena adults collected from C. elaphus and C. capreolus. The preliminary analyses of the presence of Bartonella sp. in the deer keds involved 15 L. cervi specimens  and 9 L. fortisetosa specimens . In total, Bartonella sp. were detected in 3/24 (12.5%) of the studied insects. The presence of the bacteria was shown in only 3/9 (33.3%) L. fortisetosa adults . No Bartonella sp. were detected in the L. cervi adults. The derived sequences of Bartonella sp. were submitted to the GenBank database under the accession numbers: MZ061868, MZ061869. The sequences obtained in this study share from 96.6 to 98.3% similarity with Bartonella sp. Honshu isolated from sika deer blood in Japan (GenBank accession no. AB703145).Two species, i.e., rpoB gene fragment yielded two new haplotypes of Bartonella sp.: haplotype H1 (MZ061868) and haplotype H2 (MZ061869), as defined by three polymorphic sites, all being transitions. The maximum-likelihood phylogenetic reconstructions produced a strong topology  [Bartonella sp. isolated from Japanese sika deer in Wakayama Prefecture, Japan (GenBank accession no. AB703149) and with Bartonella sp. isolated from Japanese sika deer in Nara Prefecture, Japan (GenBank accession no. AB703146). The sequences obtained in this study showed high similarity with Bartonella sp. Honshu isolated from sika deer blood in Japan (GenBank accession no. AB703145) but did not show similarity with the sequences obtained by Szewczyk et al. from L. cervi [In this study, this bacterium was not detected in B703149) . In turnL. cervi .rpoB gene sequences, our two haplotypes formed a distinct branch with high bootstrap support within lineage B described by Sato et al. [Bartonella. Our newly discovered haplotypes differed by at least nine substitutions from haplotype 4  and by at least 10 mutations from haplotype 7 , both described by Sato et al. [Bartonella were isolated from Japanese sika deer in Japan. As shown by the network analysis, our two haplotypes and haplotypes 4 and 7 created a distinct group together, which additionally supports the view proposed by Sato et al. that lineage B represents a novel Bartonella species [Bartonella sp. haplotypes in L. fortisetosa and the haplotypes obtained by Szewczyk et al. in L. cervi may suggest that red deer in Poland seem to harbor the novel Bartonella species discovered in Japanese sika deer [Bartonella directly from red deer blood to resolve the relationships of Bartonella species in deer from Japan and Poland. In turn, the role of this deer ked species as a potential vector of this bacterium needs further study.In the maximum-likelihood (ML) algorithm based on the o et al. . The ML o et al. . Interes species . The preika deer ,51. More


The diagnosis of Attention deficit hyperactivity disorder (ADHD) is primarily dependent on parents’ and teachers’ reports, while children’s own perspectives on their difficulties and strengths are often overlooked.To further increase our insight into children’s ability to reliably report about their ADHD-related symptoms, the current study examined the associations between children’s self-reports, parents’ and teachers’ reports, and standardized continuous performance test (CPT) data. We also examined whether the addition of children’s perceptions of ADHD-symptoms to parents’ and teachers’ reports would be reflected by objective and standardized data.The study included 190 children with ADHD, aged 7–10 years, who were referred to a pediatric neurologic clinic. A retrospective analysis was conducted using records of a clinical database. Obtained data included children’s self-reports of their attention level and ADHD-related symptoms, parent, and teacher forms of the Conners ADHD rating scales, Child Behavior Checklist (CBCL), Teacher’s Report Form (TRF), and CPT scores.Children’s self-evaluations of their functioning were globally associated with their teachers’ and parents’ evaluations, but not uniquely. Children’s self-reports of ADHD symptoms were not uniquely linked to a specific CPT impairment index, but to a general likelihood of having an impaired CPT. The CPT performance successfully distinguished between the group of children who defined themselves as inattentive and those who did not.Primary school children with ADHD are able to identify their limitations and needs difficulties and that their perspectives should inform clinical practice and research. The clinical and ethical imperative of taking children’s perspectives into account during ADHD diagnosis and treatment is highlighted. Attention deficit hyperactivity disorder (ADHD) is currently one of the most prevalent childhood disorders , with anIncreasingly, research has recognized the importance of children’s and youth’s self-report of ADHD in the diagnosing and treating ADHD . HoweverThe current study aimed to examine whether and how children’s self-report of ADHD-related symptoms are associated with parents’ and teachers’ reports as well as with objective and standardized measures of ADHD . The study also examined whether the addition of children’s perceptions of ADHD symptoms to parents’ and teachers’ reports would be reflected by objective and standardized data.Historically, ADHD practice and research assumed that “children’s own descriptions of their problems are not a necessary or particularly useful part of the assessment procedure” , p. 217 Even today, research focusing on self-report measures of ADHD is greatly limited to adolescents and young adults. Most existing measurements assessing children’s self-report of ADHD, such as the youth self-report  whether gender differences exist between boys and girls in self-reports of ADHD symptoms (b) whether children’s self-reports of ADHD symptoms are in agreement with parents’ and teachers’ reports (b) the pattern of correlations between children’s self-reported ADHD symptoms and CPT performance (c) whether the addition of children’s perceptions of ADHD symptoms to parents’ and teachers’ reports would be reflected by their CPT performance.The current study included 190 children diagnosed with ADHD , referred to a private pediatric neurologic clinic. Families are entitled to partial reimbursement. Therefore, the clinic was accessible for patients from heterogenic socio-economic backgrounds. Children were referred to the clinic for ADHD evaluation between January 2018 and December 2020. Participating children and their families were all of Jewish background, living in rural and urban areas in the North of Israel.SD = 0.90). The diagnostic procedure of ADHD was conducted by a certified pediatric neurologist (the second author) and included an interview with the child and the parents, medical/neurological examination, CPT administration, and ADHD diagnostic questionnaires. Clinical interviews and examination screened for the existence of other conditions and disorders and excluded children who were found unsuitable for the study (see exclusion criteria).Children’s age ranged between 7 (0 month) and 10 (0 month) years , and psychosis.The protocol for the research project conforms to the provisions of the Declaration of Helsinki, approved by the Institutional Review of the Board of Maccabi healthcare services (0181-20-MHS).Background variables included the child’s age, gender, and grade level.ADHD-related symptoms were assessed by the parent and teacher forms of the Conners ADHD Index Rating scales, 3rd edition, short-form . The Conners 3 manual also reports high convergent/divergent validity through correlations with other related measures of childhood psychopathology and high utility in discriminating between relevant groups. In terms of the classification accuracy of the scores , the mean overall correct classification rate was 75.6% , and the Teacher’s Report Form TRF; , Hebrew Perceived level of attention—children were asked to report their level of attention during class, whereas “1” indicates the lowest attention level and “10” is the highest. To ensure consistency with teachers’ and parents’ scales, where higher scores indicate greater pathology, we reversed children’s scores during data analysis, so that “1” indicated the highest attention score and “10” the lowest. Since children’s self-reports of comorbid symptoms were rated on three levels of severity, we decided to categorize the perceived attention scale into three levels as well to present a more coherent picture of our findings. We have, therefore, coded the reported scores into three levels of attention: scores ranging from 1 to 3 were coded as “high attention level,” scores between 4 and 6 were coded as “medium attention level” and scores equal or higher than 7 as “poor attention level.”Children’s self-report of comorbid symptoms—Based on the Diagnostic and Statistical Manual of Mental Disorders DSM;  as well Given previous research indicating that school children have a preference for questions rather than statements , difficu1 version , conducted either during the stimulus presentation or during the void period that followed. This method allows the test to evaluate whether the participant was attentive to the target independently of his/her response time. The number of omission errors was also calculated .Timing: the number of correct responses (pressing the key in response to a target stimulus) conducted while the target stimulus was still presented on the screen. This index excluded responses that were performed during the void period (after the stimulus has disappeared). This method allowed the test to differentiate between the overall rate of correct responses (measured by the Attention index) and the rate of correct responses that were conducted on time (measured by the Timing index). These two aspects of timing correspond to two different deficits typical to ADHD: difficulty to provide an accurate response and difficulty to respond on time .Impulsivity: the number of commission errors conducted while a non-target stimulus was present on the screen. Other types of non-inhibited responses  were not considered as impulsive responses (as will describe in the next paragraph).Hyperactivity: the total number of commission responses that were not coded as impulsive responses . Differentiating between commission errors that were conducted due to impulsive behavior and commission errors that were conducted due to motor hyper-responsivity allowed the identification of multiple sources of response disinhibition.r = −0.274, p < 0.01) and the Hyperactivity  indices. The Impulsivity index was highly and positively correlated with the Hyperactivity index . The Timing index was not significantly correlated with the Attention , Impulsivity , or the Hyperactivity  indices.The children’s version of the MOXO-CPT showed high specificity and sensitivity rates (≥85%) in children aged 7–12 years . AUC valGender differences in children’s self-report of ADHD- related symptoms were examined with chi-square tests. To examine whether children’s self-reports of ADHD symptoms are in agreement with parents’ and teachers’ reports, we conducted a spearman correlation matrix between study variables. Further, to examine the pattern of correlations between children’s self-reported ADHD symptoms and CPT performance, we conducted a spearman correlation matrix between children’s self-report of attention and ADHD-comorbid symptoms and (a) each of the four MOXO-CPT indices , (b) the number of impaired CPT indices (ranging from 1 to 4), and (c) the presence of at least one impaired CPT index (yes/no). The child’s attention profile presents his or her performance level in relation to the norm group (reflecting the corresponding age and gender) for each index. A standard score is calculated for each index and categorized into one of four possible performance levels. The MOXO-CPT considers an index to be impaired if the child obtained a Z score ≥ 1.6.T-score ≥ 65. This cut-off score was chosen to include all the subjects with elevated and very elevated scores  The parent’s or the teacher’s scores on inattention and/or hyperactivity scales of the Conners were elevated (single informant). We considered children to be at risk of ADHD if they obtained a d scores .(2) Both parent and teacher reported elevated levels of ADHD symptoms (two informants). (3) Parent and/or teacher reported elevated levels of ADHD symptoms and the child reported poor attention . We assumed that children whose self-reports of inattention were in the upper third of the scale had the highest subjective severity of ADHD symptoms.post hoc analyses with Tukey correction for multiple comparisons. Analyses were conducted with SPSS software for Windows Version 25 .Group differences in MOXO-CPT performance were examined using ANOVA, followed by r = 0.179, p < 0.05) and hyperactivity . Also, children’s self-reports of inattention correlated with teachers’ reports of social problems . Children’s self-reports of social problems were positively associated with parents’ report of social problems  and anxiety , and with teachers’ reports of social problems  and depression . Children’s self-reports of learning difficulties were positively and significantly associated with teachers’ reports of inattention  and learning difficulties . Children’s self-reports of anxiety were correlated only with parental reports of anxiety . Finally, children’s self-reports of depression were associated with parental reports on child’s social problems , and anxiety  and with teachers’ reports on social problems , anxiety , and depression .r = 0.211, p < 0.01). Self-reports of learning difficulties were negatively associated with children’s ability to respond on accurate timing during the CPT , and positively with the number of impulsive responses . Self-reports of disliking school were negatively associated with children’s ability to respond on accurate timing during the CPT , but positively with the likelihood of obtaining at least one impaired CPT index .r = 0.155, p < 0.05). In all other analyses, the results for the continuous variable were very similar to that of the categorized one . Our results demonstrated that children’s self-reports of learning difficulties were linked only to teachers’ reports of inattention and learning difficulties, but not with any parental report measures. According to the literature on informant agreement in childhood ADHD, teachers and parents capture different aspects of a child’s behavior . TeacherCorrelation analysis between CPT performance indices and children’s self-reports indicated that children’s perceptions of their ADHD are mildly reflected by their CPT performance. Specifically, we found that children’s self-reports of inattention, and disliking school were associated with an increased likelihood of having at least one impaired CPT index. Additionally, self-reports of learning difficulties were associated with increased impulsivity and with decreased ability to respond at an accurate timing. The latter is valid also for self-reports of disliking school. Together, these results suggest that children’s self-reports of ADHD were not uniquely linked to a specific CPT index, but to the general likelihood of having an impaired CPT. Moreover, the fact that impairments in CPT performance were associated with children’s self-reports of their academic-related functioning and not with their emotional or social functioning provides additional support for primary school children’s ability to reliably perceive and report their difficulties.In line with previous findings in adolescents and adults, our results suggest that children’s self-report of their difficulties and strengths are only mildly and globally associated with their CPT performance. Recent findings of the association between the self-report of ADHD and CPT performance showed that adolescents’ and young adults’ reports of ADHD outcomes were only partly reflected by their CPT . To examAnalysis of differences between the groups showed that the three groups did not differ in the type of CPT impairment (impaired CPT index) nor the magnitude of such impairment (the number of impaired indices). However, we found that the risk of having at least one impaired CPT index was significantly higher in the group where both children and at least one informant reported elevated levels of ADHD symptoms. Our findings indicate that while ADHD children defined by one informant showed similar CPT profiles to ADHD children defined by two informants, the CPT performance successfully distinguished between these two groups and the group of children who also defined themselves as inattentive. These results suggest that adding children self -report to the diagnostic process of ADHD may improve the low-medium correspondence between informants’ reports and objective measures of ADHD documented in the literature .This study expanded prior research on the self-perception of children with ADHD in several ways. First, this study is one of the few to examine agreement between primary school children’s self-reports of their ADHD-related difficulties and a standardized objective measure of ADHD. Second, we included both girls and boys, making this one of the very few examinations of self-report in a large clinical sample.Several limitations of this study should be acknowledged. First, the current study did not allow the calculation of discrepancies between child and informant reports. Therefore, more information is needed about how children’s self-perceptions differ from those of parents and teachers and how these discrepancies are affected by age and gender. Furthermore, although we found that self-reports of ADHD symptoms were only mildly reflected by objective measures, self-reports may be better captured by other measures not included in our study. Second, the fact that we didn’t distinguish between different ADHD subtypes  limits our ability to examine whether they are differently related to children’s self-reports. Previous studies suggested that ADHD subtypes may be subject to different perception biases . For exaThird, the current study assessed children’s perceived attention level using a single item that asked them to report about their general ability to stay attentive and concentrated during class. Probably, children’s answers reflected attention problems, hyperactivity/impulsivity symptoms, and their distractibility level. Using a single item limits the psychometric accuracy of this measure and hinders our ability to examine specific associations between different children’s self-report of ADHD symptoms, parent/teacher reports, and CPT data. We, therefore, encourage future studies to identify how different self-report ADHD symptoms are reflected by other objective and subjective measures of ADHD.Finally, the generalizability of our results is limited, given the ethnic and geographic homogeneity of the sample, its limited size, and the fact that all children were recruited from a single neuro-pediatric clinic. Our ability to generalize our findings is also limited due to the restricted age range of participating children. The effects of the child’s age on the validity of self-report ADHD are currently understudied. However, there is evidence that children’s metacognitive abilities that allow them to identify and report about their performance and experiences can already be evident in toddlers and tend to increase with age . For exaAt a practical level, we found that primary school children are clinically informative as to what to focus our interventions on for each child  as well as providing some insight into the presence of ADHD symptomatology.Further investigations into self-reported impairment and its correlates would be beneficial to understand on what basis young individuals estimate their levels of impairment. Regardless of their predictive validity, taking children’s perspectives into account while diagnosing and treating ADHD may have significant clinical outcomes. Being curious about how children perceive and cope with their difficulties promotes productive, respectful, and empathic interactions between children, parents, and professionals, and may eventually contribute to their collaboration and treatment adherence . MoreoveFinally, questioning children about their ADHD-related difficulties may enhance their self-awareness and improve their ability to reflect upon their difficulties and strengths.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Maccabi Health Services Ethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MD collected clinical information. OS wrote the original draft. Both authors have equally contributed to the conceptualization, methodology, analysis, and interpretation.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.