Psychiatric classifications are understood in many different ways. For children with ADHD and their parents, psychoeducation is an important source of information for shaping their understanding. Moreover, psychoeducation is often taken by children and parents to represent how their story is understood by the therapist. As a result, the way psychoeducation is formulated may affect the therapeutic alliance, one of the most robust mediators of treatment outcome. In addition, psychoeducation may indirectly influence the way we understand psychological differences as a society.To better understand how the classification ADHD is given meaning through psychoeducation, we analyzed 41 written psychoeducational materials from four different countries; the USA, UK, Netherlands and Hungary.within a single thematic stance on ADHD as opposed to a conflict between parties with a different vision on ADHD. There were only few differences between countries in the way they constructed the discourse in the materials.We identified five patterns of how the materials construct the discourse on ADHD. Notably, tension between biomedical and psychosocial perspectives resulted in conflict These conflicts cause confusion, misrepresentation and decontextualization of ADHD. Ultimately, for those diagnosed with ADHD and their parents, conflicting information in psychoeducation materials may hamper their ability to understand themselves in the context of their difficulties.The online version contains supplementary material available at 10.1186/s12888-022-04327-x. Psychiatric classifications are terms that refer to clusters of symptoms , 2. SuchPsychoeducation on ADHD is a special case, as the ongoing debate on ADHD exemplifies tensions between biomedical and psychosocial perspectives on mental health –14. NotaStudies assessing biomedical and psychosocial perspectives in various texts on ADHD have mostly applied discursive analytic techniques. They start from the crucial assumption that information provided in psychoeducational materials mirrors the discourse around ADHD, while simultaneously constructing that same discourse –24. Prevexplanatory framework of ADHD is constructed through language use in these psychoeducational materials. We therefore carried out an exploratory study of patterns in how ADHD is framed and contextualized. In addition, we performed a cross-national analysis. Based on literature showing cross-cultural variation in the understanding and interpretation of ADHD [To better understand how the classification ADHD is given meaning through psychoeducation, we analyzed 41 written psychoeducational materials from four different countries; the USA, the UK, the Netherlands and Hungary. Our primary aim was to analyze how the  of ADHD , 31, we In this discourse analysis, we assessed American English, British English, Dutch and Hungarian psychoeducational materials on ADHD. We selected 8–12 materials in each language and assessed the commonalities and variation in how these materials constructed the discourse on ADHD.First, we performed an online scoping search to determine appropriate inclusion and exclusion criteria. Our psychoeducational materials reflect a broadly selected set of psychoeducational texts, including webpages, downloadable PDF-files with psychoeducational text and downloadable flyers. We performed a broad internet search using the following search terms or combinations thereof: ADHD, Attention Deficit Hyperactivity Disorder, psychoeducation, material, flyer, and diagnosis. Supplemented with a search term matching the appropriate language area: Great Britain, UK, United States, US, Netherlands, Dutch, Hungary, Hungarian. Search-terms were translated to search for Dutch and Hungarian materials.Standalone materials .Materials that were freely accessible onlineMaterials written in American English, British English, Dutch and Hungarian or translated into these languagesMaterials written for parents of children with an ADHD classificationWe used the following inclusion criteria:Materials written by the same author and/or published by the same organizationMaterials over 5000 words We used the following exclusion criteria:We subsequently selected the first 8–12 materials in each language. This selection resulted in a convenience sample adapted to online-searchability. This sample is not representative of all psychoeducational material on ADHD but rather roughly mirrors the likelihood that materials will be found online by parents.We collected and stored all psychoeducational materials in the original lay-out. We then transcribed materials into plain text files and entered them into a software package for qualitative data analysis Nvivo 12). Descriptive data was summarized for each of the selected materials . A detailed overview of our analysis plan is provided in Additional File To familiarize ourselves with the data, we read each of the materials four times. We kept notes and held discussion meetings about our findings. We then coded the data in three steps. First, we strictly coded the content of the material to gain insight into the information provided. Second, we carried out a critical interpretation of the data: we coded how the discourse on ADHD was constructed and how implicit ideas and understanding of ADHD were manifest in the text. Third, we coded for language use and phrasing in the text and selected relevant excerpts. After coding every two materials we discussed our findings. When coding was complete, we held a number of conclusive discussion sessions. We discussed our findings and settled on the interpretation of major themes, discursive patterns and associated text excerpts. We then analyzed the data again, coding for these predefined discursive patterns, to reassess our results and generate a comprehensive list of relevant text excerpts.In the sections below, we describe the results of our analysis of 41 psychoeducational materials from the United Kingdom (10), the Netherlands (10), Hungary (10) and the United States (11). Our results are presented in three sections: first, we discuss the content and major themes in the materials. Second, we discuss the five discursive patterns we found in the materials. Third, we present a cross-cultural comparison of the discursive patterns in the materials.In the first step of the analysis, we examined the content of the materials. We identified three themes: (1) Definition and Diagnosis, (2) Causes and Risk Factors, and (3) Treatment and Prognosis. Below we describe these themes to introduce the information provided in the materials.Definition and Diagnosis. Most materials started with a description and introduction of ADHD. ADHD was described as a chronic, neurobiological, neurodevelopmental, psychiatric, behavioral disorder or condition. It was described as a real disorder recognized internationally by professionals. Children were said to receive a diagnosis if they exhibited symptoms of ADHD. The materials discussed a wide variety of symptoms, many of which could be categorized as inattention, hyperactivity or impulsivity. Materials often mentioned that symptoms should occur in multiple environments for more than six months, should start at an early age and should cause impairment in everyday life. They also noted that a diagnosis is helpful and necessary for adequate and effective treatment. They stated that ADHD is very common among children and adolescents and it is diagnosed more often in boys than in girls. They also described that ADHD often co-occurs with comorbid disorders and additional problems.The first theme was Causes and Risk Factors. Most materials provided a thorough description of the etiology of ADHD. This etiological description usually discussed both neurobiological and environmental factors. Neurobiological factors mentioned included genetics and differences in brain regions, brain functioning, or neurotransmitter systems. Environmental factors mentioned included premature birth, pregnancy complications and substance abuse during pregnancy, as well as parenting styles and family stress. Neurobiological factors usually took precedence over environmental factors in the way they were described. Many materials explicitly mentioned that environmental factors may contribute to, but do not cause, ADHD. Materials often referred to neurobiological factors as causes and environmental factors as risk factors.The second theme was Treatment and Prognosis. Most materials mentioned that there is no cure for ADHD. However, most indicated that prognosis improves greatly with adequate treatment. Some materials mentioned that children can outgrow ADHD while other materials stated that affected children will have ADHD for life. Materials discussed a large variety of treatment options. These included behavioral treatments, parent training, environmental adaptations as well as a number of pharmacological options. Materials varied in how important they deemed behavioral treatment, environmental adaptations and pharmacological treatments to be. Most materials agreed that treatment prevents children from derailing and helps them to reach their full potential. Most argued that without adequate guidance, children would experience serious negative consequences of their ADHD.The third theme was within a single psychoeducational document, but this conflict was certainly present across materials with similar thematic stances on ADHD. These conflicts were usually not explicit in the materials, but rather implicit in the information provided. To illustrate the discursive patterns, we have added exemplary quotes for each of the discursive patterns. An extensive list of exemplary quotes is provided in Additional File In the second step of the analysis, we examined how the discourse on ADHD was constructed within these three themes. We identified five discursive patterns that are described below. In addition, we found that four out of five of these patterns contained an element of internal conflict. We defined internal conflict as a situation where different elements of the same explanatory framework are in (apparent) disagreement with each other. The term ‘internal’ therefore refers to a conflict that is present within an overarching explanatory framework. Sometimes this was even present Definition and Diagnosis, and Causes and Risk Factors. ADHD was described as a name given to a cluster of symptoms and simultaneously as the cause of those same symptoms. An example is given below, where ADHD is said to cause neurobiological differences, and to be caused by those same neurobiological differences.We found that ADHD was presented as both a cause and a consequence of the same phenomenon, sometimes even in the same material. This was particularly noticeable for the themes “Attention deficit hyperactivity disorder is a condition, which affects those parts of the brain which control attention, impulses and concentration .” - UK Material 11“ADHD is thought to be caused by an imbalance of two neurotransmitters, dopamine and noradrenaline, which are believed to play an important role in the ability to focus and pay attention to tasks.” - UK Material 11We noted that ADHD was often presented as a complex and multifactorial disorder that is not yet fully understood. Yet the information on causes and risk factors was simple, certain and clear, suggesting that ADHD is in fact well-understood. For example, materials mentioned that ADHD is complex, yet they would often go on to delineate simple categories that cause  or modulate (environment) ADHD. In a similar vein, materials often mentioned that the causes of ADHD are unknown, but just as often explained the causes of ADHD. The uncertainty and the intricacy of interplay between these factors were left out of the explanations. As such, materials constructed a simplified image of ADHD that contradicted the complexity they acknowledged elsewhere.“Scientists have not yet identified the specific causes of ADHD.” - US material 2“ADHD is a disorder in certain areas of the brain and is inherited in the majority of cases. It is not caused by poor parenting or a chaotic home environment” – US material 7Definition and Diagnosis and Treatment and Prognosis. In these themes, behavior related to ADHD was referred to as a common variation of normal childhood behavior. Materials noted that every child displays these behaviors to some extent during their development and these behaviors should be considered normal. Yet, at the same time, the psychoeducational materials stressed that ADHD is a real and serious disorder. It was described as a distinct category of behavior that has a major impact on a child’s life. These abnormal behaviors should be dealt with adequately. Both of these realities seem to exist simultaneously across materials, without their inconsistencies being acknowledged.We noted that materials both normalized and abnormalized ADHD. This pattern was particularly evident in the themes Its core symptoms are hyperactivity, impulsivity and inattention. These common childhood behaviours occur on a continuum from normal to abnormal. It can be very difficult to judge what ‘normal’ behaviour is in children; therefore when evaluating children for ADHD, many doctors try to assess the degree of impairment caused by these behaviors.” - UK Material 10““The recognition of ADHD as a serious medical condition continues to grow by physician groups and government health agencies around the world.” – UK Material 3Definition and Diagnosis where materials specifically defined what ADHD entails and simultaneously provided a general and extensive list of (associated) symptoms. The initial definition mostly adhered to DSM-5, mentioning three categories: inattention, hyperactivity and impulsivity. However, in a subsequent description of ADHD, materials included such a wide variety of symptoms, that this description broadened and blurred the definition. We have illustrated this pattern in Table We identified a pattern in the theme “ADHD is a well-defined clinical condition. All the major medical authorities recognise it, including the World Health Organisation and the American Psychiatric Organisation.” – UK Material 7Agency of Parents).Materials constructed ADHD as a very impactful, serious, negative and dangerous disorder that required proper treatment. It was described as a largely individual and usually biological problem: something in the child’s biology causes problematic behavior. In addition, materials described that the consequences of ADHD stretch well beyond the individual child. These consequences affect not only the child’s development, but also parents, siblings, peers, school and even society at large. In all, ADHD was explained as an individual problem that has far-reaching societal consequences. Due to this extensive impact, materials emphasized the necessity for children to receive proper care and treatment, for which expert knowledge is required in every step of the process. Expert status was assigned to professionals and clinicians. Materials paid limited attention to the experiences and knowledge of children and their parents. Children with ADHD were usually not mentioned as active agents in the process and were not mentioned in the communication about their experiences. Likewise, the child’s positive characteristics received little attention. In all, psychoeducation materials did not attribute a form of expert-status to parents or children  uncertain complexity versus certain simplicity, 3) normality versus abnormality and 4) specificity versus generality. In addition, there was a clear pattern of the materials emphasizing 5) the necessity of the expert view.We carried out a discourse analysis of 41 psychoeducational materials on ADHD from the US, the UK, the Netherlands and Hungary. We explored how the explanatory framework of ADHD is constructed through the use of language. The materials contained a number of internal conflicts in how ADHD was framed and contextualized. Notably, these conflicts remained unaddressed in the documents. Conflicts arose from tension between 1) By and large, we did not confirm our hypothesis of cross-cultural differences in how materials constructed the ADHD discourse. However, we did identify two differences between countries in the discourse on ADHD: we found differing etiological preferences and differing preferences for the agency of parents across countries. Here, American-English and British-English materials favored more straight-forward biomedical etiological explanations, while Dutch and Hungarian materials were more likely to include other, environmental explanations. Furthermore, American materials put greater emphasis on the agency of parents than materials from other countries. These differences are likely to reflect differences in national perspectives on mental health –33, suchWe found internal conflicts in the discourse on ADHD, across psychoeducational materials from four different countries. Such conflicts may have a number of consequences. One possible consequence is that children diagnosed with ADHD and their parents might be confused. One of the main aims of psychoeducation is to help children and parents better understand their problems and subsequently promote better coping –39. Yet,uncertain complexity and certain simplicity in psychoeducational materials. Materials often stated that the causes of ADHD were complex and unknown. Yet, in the simplified information they subsequently provided on causes and risk factors, they omitted details and nuance, nearly always in favor of biomedical causes. One example of such a misrepresentation is materials stating that neurobiological research has shown indisputable and consistent differences between children with and without a diagnosis [A second possible consequence stems from the conflict between iagnosis , 45. Howiagnosis , 47. As cause and consequence. We found a form of circular reasoning where ADHD was described as a term given to a cluster of symptoms and, simultaneously, as the cause of those symptoms. This finding is a replication of earlier studies describing this process [ADHD is part of the child’s make-up and doesn’t suddenly appear out of the blue – UK Material 7’ underline how we individualize ADHD.A third possible consequence stems from the conflict between  process , 48, 49. process , 45, 50.Three of the internal conflicts we have described, relate directly to tensions between the biomedical and psychosocial perspectives. In the biomedical framework, defining ADHD as a cause of behaviors is justified as a direct biological mechanism is believed to underlie the symptoms , 17. Sucwithin a single thematic stance on ADHD in psychoeducational materials, as opposed to conflict between parties with different visions on ADHD. We speculate that these unaddressed, internal conflicts arise from a covert tension within the biopsychosocial model. The biopsychosocial model is one of the most widely accepted approaches to mental health [primacy of biology. This primacy is illustrated in the notion, found in many materials, that ADHD is caused by neurobiological difficulties in the context of environmental risk factors. The opposite was never considered: could ADHD be caused by environmental difficulties in the context of biological risk factors? According to the biopsychosocial model, neurobiological and environmental factors should be considered equally. Yet the ordering and terminology in the materials prioritize biology. This covert primacy of biology may well lead to tension in the biopsychosocial model and in turn lead to inconsistent and incoherent information on ADHD.Notably, we found that tensions between biomedical and psychosocial perspectives have resulted in conflict l health . Accordil health , 51. Witl health , 26, 52.In sum, we found a number of internal conflicts in how ADHD is framed and contextualized in psychoeducational materials. Notably, these conflicts remained unaddressed in the materials themselves and may potentially lead to confusion, misrepresentation and decontextualization of ADHD. Ultimately, for those diagnosed with ADHD, and their parents, these conflicts may hamper their ability to understand themselves in the context of their attentional difficulties.A limitation of our study is that we did not involve children with ADHD and their parents. We therefore could not verify that our interpretation of the materials aligns with how parents and children understand and interpret the information. An important next step in this line of research would be to evaluate how psychoeducational materials are interpreted by lay readers.A second limitation in our study is the use of convenience sampling. We selected the first materials that we came across in our internet search (and that fitted our selection criteria). We chose to select the materials in this way, because we felt that parents of children with ADHD would be most likely to interact with those materials first presented by search engines. However, our sample is not representative of all psychoeducational materials on ADHD. We would have to carry out a much more extensive study to verify such claims. Moreover, we were unable to collect information on funding for psychoeducational materials, as information on websites was often missing or incomplete.Additional file 1. List of Psychoeducational Materials.Additional file 2. Data Analysis Plan.Additional file 3. Examples of internal conflicts in ADHD psychoeducation.


Attention Deficit / Hyperactivity Disorder (ADHD) is a highly prevalent neurodevelopmental condition characterized by inattention, motor hyperactivity and impulsivity. ADHD cognitive and behavioral presentation is characterized by a high heterogeneity . Indeed, a complex diagnostic process, that considers several validated tools, is, to date, necessary.The main aim is to develop supervised machine learning (ML) algorithms that could be used to support the diagnostic process for ADHD, by identifying the most relevant features in discriminating between the presence or absence of the ADHD diagnosis in children.We analyzed data from 342 children  referred for possible ADHD symptomatology. Assessments were performed by an expert clinician and through questionnaires: Social Responsiveness Scale (SRS), Child Behavior Checklist (CBCL), Conners Rating Scale for Parents (CPRS) and for Teachers (CTRS). Data were analyzed using a decision tree classifier and random forest algorithms.The decision tree model performed an accuracy of 0.71. The random forest model that was identified as the best tested, performed an accuracy of 0.77  and it identified as most informative parent- and teacher-rated DSM-oriented ADHD symptoms .Figure 1: Random forest confusion matrix and statistics.Figure 2: Ranking of variables importance.A random forest classifier could represent an effective algorithm to support the identification of ADHD children and to simplify the diagnostic process as an initial step. The use of supervised machine learning algorithms could be useful in helping the diagnostic process, highlighting the importance of a personalized medicine approach.No significant relationships.


We investigated the right Superior Frontal Gyrus (right-SFG) and Anterior Cingulate Cortex (ACC) in children with ADHD and their clinical relevance with Executive Function (EF) and ADHD symptom severity.About 26 children with ADHD and 24 typically developing children  underwent Magnetic Resonance Imaging (MRI) and completed an EF assessment battery.t (48) = 2.81, p = .007, Cohen’s d = 0.84). Linear regression models showed that 12.5% of inattention, 13.6% of hyperactivity, and 9.0% of EF variance was accounted for by the right-SFG thickness.Significantly thinner right-SFG in the ADHD group was found compared to the TDC group (Differences in the right-SFG thickness were found in our ADHD group and were associated with parent ratings of inattentive and hyperactive symptoms as well with EF ratings. These results replicate previous findings of thinner right-SFG and are consistent with the delayed cortical maturation theory of ADHD. ADHD is a prevalent neurodevelopmental disorder with estimates of 5% to 9% in Canadian school-aged children . TypicalSymptoms of ADHD affect development across multiple domains including academic , social Children with ADHD often exhibit significant Executive Function (EF) challenges, an umbrella term used to describe higher-order, goal-oriented processes. These EF skills typically include planning, inhibition, and working memory . EF skilDiagnosis of ADHD (and other disorders) are frequently made based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) symptom criteria . These sMage = 19.22 years) found lower surface areas in the frontal, cingulate, and temporal regions and lower cortical thickness in the fusiform gyrus and temporal pole , and neuropsychological endophenotypes  are someral pole .While neuroanatomical differences in ADHD have been commonly studied, a limited number of studies to date have investigated the dimensional relationship between EF, behavioral symptoms, and cortical thickness in the SFG and ACC to further support the clinical relevance of these anatomical regions . Given tWith recent criticisms surrounding the categorical understanding of different mental health disorders, there has been an increased interest and need to study symptoms along a continuum as suggested by the Research Domain Criteria RDoC; . AdditioThe purpose of the current study was two-fold: the primary goal was to investigate the neuroanatomical biomarkers of ADHD, in particular cortical thickness in the right-SFG and ACC regions in order to replicate previous findings  in a non. BehavioWe expected thinner cortical thickness in the SFG and ACC in children with ADHD compared to typically developing children (TDC). Even though previous research studies have reported abnormalities in both left and right frontal cortices, some studies have proposed that the right hemisphere is predominantly altered in children with ADHD , 2010. AChildren between the ages of 7 and 16 years old, with a confirmed diagnosis of ADHD and without a diagnosis of ADHD, were recruited from Calgary region pediatric clinics, the general community, and social media, including Facebook and Twitter. The study received research ethics approval from the Conjoint Health Research Ethics Board (CHREB) at the University of Calgary (REB19-0499). All parents provided consent for participation and the children provided assent.Participants in the ADHD group had to have (1) a confirmed ADHD diagnosis from a healthcare professional, verified by an experienced Developmental Pediatrician (author JFL), (2) a behavior rating score greater than 65 (T-score) on the Conners-3 parent rating scale, (3) confirmation of ADHD diagnosis on the Mini-International Neuropsychiatric Interview for Children and Adolescents  a diagnosis of Autism Spectrum Disorder (ASD), traumatic brain injury, seizure disorder, intellectual disability, or any other medical conditions that could impact their cognitive scores, (2) metal in their body that would prevent them from taking part in MRI, and (3) unable to complete a 48-hour medication washout period.Participants from both groups completed neuropsychological performance-based assessments related to inhibition and working memory. Specifically, for measuring both visual and verbal working memory, the Digit Span Backwards and Spatial Span Backwards subtests from the Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) and WISC-V Integrated  were use2, acquisition matrix size = 300 × 300, and voxels = 0.8 mm3 isotropic.All participants underwent a high-resolution MRI T1-weighted sequence using a 3 Tesla General Electric Discovery 750W MRI scan with a 32-channel head coil. Structural MRI parameters were as follows: TR = 8.2 ms, TE = 3.2 ms, flip angle = 10°, field of view (FOV) = 256 mmhttps://surfer.nmr.mgh. harvard.edu/fswiki/FreeSurferMethodsCitation; FreeSurfer 6.0 was used for cortical surface reconstruction . FreeSurt-tests were conducted to measure group differences between the right and left superior frontal gyrus and caudal and rostral anterior cingulate cortex. Multivariate analysis of variance (MANOVA) was used to investigate group differences in EF performance. Pearson Correlations were conducted to investigate the relationships between cortical thickness, EF performance, and ADHD symptomology. Lastly, linear regressions were conducted to investigate the relationships between cortical thickness, EF assessments, and behavioral symptoms of ADHD for the combined sample (both ADHD and TDC groups). Benjamini-Hochberg principle was used to correct for multiple comparisons  between June 2019 and November 2019. Participants first completed screening measures to ensure eligibility. Parents of children with ADHD and the TDC group completed questionnaires separately from their child to indicate their perception of their child’s Inattention and Hyperactivity ratings. After completing screening measures , participants completed additional neuropsychological measures . The study’s neuroimaging portion took about 75 minutes to complete, and participants could choose to have a caregiver sit beside them while in the scan. This scan time was chosen to ensure MRI sequences could be repeated if needed and to allow participants to take breaks. All participants were scanned by the same team of ACH diagnostic imaging staff on the same scanner with identical scanning parameters to ensure data acquisition consistency.http://enigma.ini.usc.edu/protocols/imaging-protocols/).A total of 55 participants consented to the study. Two participants were excluded because they did not meet study eligibility criteria: one ASD diagnosis, one failure to observe the 48-hour medication washout period. Also, one participant withdrew within 1 hour of joining due to extreme shyness and anxiety. Lastly, two additional participants were excluded due to being outliers, as indicated through quality control measures completed on cortical thickness outcomes according to Enigma Consortium protocols  and 24 typically developing children  completed the study. There were no age or biological sex differences between groups. As expected, there were significant group differences in ADHD symptoms, as reported by parents on the Conners-3 rating scale. Specifically, parents of children with ADHD endorsed higher levels of Inattentive (t (48) = 7.71, p < .001, Cohen’s d = 1.96) and hyperactive/impulsivity (t (48) = 8.86, p < .001, Cohen’s d = 2.48) symptoms compared to the TDC group. There was also significant difference in performance on the WISC-V Arithmetic subtest (t (48) = 2.26, p = .029, Cohen’s d = 0.65). No other significant group differences in the intellectual functioning screener were observed: WISC-V Integrated Vocabulary subtest (t (48) = 1.18, p = .24, Cohen’s d = 0.33) and WISC-V Integrated Block Design subtest (t (48) = 0.46, p = .65, Cohen’s d = 0.13). Parent ratings of EF indicated significant EF difficulties across all three primary indices on the BRIEF-2, Behavior Regulation Index ((t (48) = 7.72, p < .001, Cohen’s d = 2.16), Emotion Regulation Index (t (48) = 5.42, p < .001, Cohen’s d = 1.52), and Cognitive Regulation Index (t (48) = 9.14, p < .001, Cohen’s d = 2.57). Lastly, there were no other significant differences in demographic information between the two groups  = 2.81, p = .007, Cohen’s d = 0.84) and left SFG (t (48) = 1.93, p = .05, Cohen’s d = 0.52). No significant group differences in cortical thickness were observed in the right or left rostral and caudal ACC  = 1.99, p = .05, Cohen’s d = 0.57) and right rostral ACC (t (48) = 2.40, p = .02, Cohen’s d = 0.69). However, after correcting for multiple comparisons using the Benjamini-Hochberg principle  = 1.41, p = .24, Wilks Lambda = .14). However, univariate analysis of variance showed that children with ADHD made more perseverative errors than the TDC group on the CPT-3 task  = 5.29, p = .026, Partial Eta Squared = .10). No other significant differences in performance were observed. There was also no statistically significant biological sex difference in performance on the EF tasks  = 0.94, p = .49, Wilks Lambda = .09).EF assessment results are presented in No significant correlations were observed between right-SFG cortical thickness and performance on the different EF tasks.r = −.30, p = .04).Significant negative correlation was observed between right-SFG and BRIEF-2 CRI subscale  and right-SFG and Hyperactive subscale .Significant negative correlations were observed bet ween right-SFG and ADHD subscales from the Conners-3 parent rating scale: right-SFG and Inattention subscale  = 6.83, p = .012, R2 = .125) and Conners-3 Hyperactive  = 7.54, p = .008, R2 = .136) subscales were explained by right-SFG cortical thickness for the combined sample including both the ADHD and TDC groups  = 4.57, p = .038, R2 = .09). There were no significant regression models for different EF assessments or any of the other EF parent rating scales. Age, biological sex, and IQ measures were not included in the model as there were no correlations observed between these measures with right-SFG cortical thickness.Linear regression models indicated that a significant amount of the variance in the Conners-3 Inattentive , indicating possible clinical relevance of right-SFG in ADHD development and presentation.Consistent with our hypothesis and replicating previous study from our lab  this stuThe present study did not find any significant difference in cortical thickness in the ACC. Previous research within this domain has been inconsistent, with only one study finding significant differences in the ADHD group , while oExecutive Function challenges are commonly observed in children with ADHD . The curIt is also essential to acknowledge that some children with ADHD perform well in the lab setting, where they get one-on-one attention. Research studies often include rewards that may be motivating for individuals with ADHD. Other studies have reported differences between parent ratings of EF skills compared to performance in lab-based settings . Given tOne of the novel findings from this study is the significant negative correlations of ADHD symptoms (both inattention and hyperactivity) and parent ratings of EF with right-SFG cortical thickness. Regression models further showed that right-SFG cortical thickness predicted 12.5% of the variance in inattentive symptoms, 13.6% of the variance in hyperactive symptoms, and 9% of the Cognitive Regulation EF challenges. These results could suggest a possible brain-behavior link between cortical thickness and ADHD core symptomology. Previous studies have indicated that reduced cortical thickness can be associated with worse clinical outcomes in ADHD and other childhood disorders . FunctioThe present study did not find any correlations between right-SFG and EF task performances. While there were no a priori hypotheses about directional relationships, these findings are unexpected given the functionality of the frontal regions in EF tasks. It is possible that this study included a small sample size that was not able to detect EF differences. Moreover, we can also speculate that while there may be structural changes in specific regions, these structural changes do not necessarily indicate functional differences. The brain-behavior dichotomy has been a long-standing issue and one that requires further evaluation and replication by future studies.Overall, this study provides promising findings, but the results should be understood with limitations. The cross-sectional design of the current study limits the predictability of long-term outcomes associated with thinner right-SFG in our ADHD sample. Future longitudinal research is required to better understand the long-term impacts of delayed maturation of right-SFG in the ADHD population. The existent study sample size may be considered small as we were unable to study differences between the three ADHD presentation subtypes, gender or biological sex. As such, future studies with a larger sample size are needed to replicate the current findings. Additionally, ADHD participants were referred by clinicians and were not necessarily medication naïve. It is possible that early interventions including long-term medication use and behavioral strategies may have enabled the participants in the current study to perform somewhat better than what is generally expected.In summary, the study’s novelty is the expansion of previous findings showing thinner right-SFG in children with ADHD with clinical relevance using a dimensional approach to ADHD core symptoms of hyperactivity/impulsivity and inattention and parent ratings of EF. The second important finding from our results is that while brain-related challenges may be observed in the neuroimaging data, it does not often translate into cognitive and behavioral difficulties as measured through performance-based tasks. The study results emphasize the need for continued research using multimodal tools (both performance based EF tasks and informant ratings) to investigate biomarkers of ADHD. With the rising prevalence rates of ADHD and the need for early intervention, these biomarkers will allow for early detection and subsequently provide targeted interventions for pediatric ADHD patients.


Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that impairs the control of attention and behavioral inhibition in affected individuals. Recent genome-wide association findings have revealed an association between glutamate and GABA gene sets and ADHD symptoms. Consistently, people with ADHD show altered glutamate and GABA content in the brain circuitry that is important for attention control function. Yet, it remains unknown how glutamate and GABA content in the attention control circuitry change when people are controlling their attention, and whether these changes can predict impaired attention control in people with ADHD. To study these questions, we recruited 18 adults with ADHD (31–51 years) and 16 adults without ADHD (28–54 years). We studied glutamate + glutamine (Glx) and GABA content in the fronto-striatal circuitry while participants performed attention control tasks. We found that Glx and GABA concentrations at rest did not differ between participants with ADHD or without ADHD. However, while participants were performing the attention control tasks, participants with ADHD showed smaller Glx and GABA increases than participants without ADHD. Notably, smaller GABA increases in participants with ADHD significantly predicted their poor task performance. Together, these findings provide the first demonstration showing that attention control deficits in people with ADHD may be related to insufficient responses of the GABAergic system in the fronto-striatal circuitry. Relatedly, we found that Glx content at rest did not differ between ADHD and CONTROL groups  = 0.015, p = 0.904).A recent study by Taylor et al. (2015) has shown that glutamate content in the anterior cingulate cortex (ACC) increases when healthy human participants reported various font colors in the Stroop task . Here, wF = 4.651, p = 0.033, ηp2 = 0.036, H(1) = 0.04, p = 0.38).Next, we wanted to understand whether GABA content would show an increase during the tasks. There is evidence that GABA content shows rapid increases in the human anterior cingulate when people watch different visual stimuli ,30. HereH(1) = 4.062, p = 0.04; in the incongruent condition - CONTROL: mean ± SEM = 0.71 ± 0.35, ADHD: mean ± SEM = 2.12 ± 0.62; Kruskal–Wallis test: H(1) = 3.114, p = 0.070; Next, we wanted to understand whether differences in Glx and GABA increases could contribute to behavioral changes in the attention control tasks. We found that participants with ADHD committed more errors when they were monitoring arrow directions in the Flanker task  = 0.015, p = 0.904; for GABA: Kruskal–Wallis: H(1) = 0.04, p = 0.38). However, we found that the amount of Glx and GABA at rest significantly predicted how great an increase would be seen during the tasks . Participants with a lower Glx or GABA content at rest showed greater Glx or GABA increases , white matter (WM), or cerebrospinal fluid (CSF) to be different between the ADHD and CONTROL groups . Difficulties in inhibiting distractions and sustaining attention are hallmark symptoms of ADHD. Genome-wide association studies have revealed that glutamate and GABA gene sets are associated with ADHD symptoms. Consistently, brain imaging studies have provided evidence to show that glutamate + glutamine (Glx) and GABA content at rest in the fronto-striatal circuitry differ between people with or without ADHD. However, emerging evidence has suggested that glutamatergic and GABAergic systems are highly malleable to environmental changes or task demands. It remains unknown whether Glx and GABA content show changes when people are controlling their attention to conflicting presentations, and if so, whether these changes may explain the impaired control of attention in people with ADHD. To answer these questions, we studied Glx and GABA content when our participants performed attention control tasks. We found that participants with ADHD showed smaller Glx and GABA increases while performing the attention control tasks inside the MR scanner compared to participants without ADHD. Remarkably, participants with lower basal Glx or GABA content showed greater Glx or GABA increases during the tasks. Finally, we showed that participants’ performance in the task can be predicted by the GABA content during the task and by ADHD diagnosis. Together, our findings demonstrate that Glx and GABA content in the fronto-striatal circuitry exhibit increases when people direct their attention to conflicting visual presentations in tasks. These increases are smaller in people with ADHD, suggesting that impaired attention control may be attributed to insufficient GABA signaling in the fronto-striatal circuitry.The present study used MEGA-PRESS GABA-editing pulses to reveal dynamic changes in Glx and GABA content in the ACC and the caudate nucleus during attention control tasks. The existing literature has shown that glutamate + glutamine (Glx) and GABA content at rest are altered in children and adults with ADHD ,21. HereReduced Glx and GABA content during the tasks may reflect changes occurring in various steps in glutamate–GABA cycling, such as during synthesis, metabolism, and clearance. Increases in Glx and GABA content during the tasks  can reflGAD1) are associated with hyperactivity and impulsivity symptoms in ADHD [GAD1 polymorphisms can affect GABA concentrations during these tasks in people with ADHD.Intracellular glutamate–glutamine cycling increases when metabolism increases in neurons . Importa in ADHD ,45. The  in ADHD . There i in ADHD . In the GAT1) gene are associated with symptoms in people with ADHD [While altered metabolism in glutamate–GABA cycling may help explain decreased Glx and GABA concentrations in participants with ADHD, GABA and glutamate clearance in the synaptic clefts could also impact Glx and GABA quantification in the voxel. Once released from neurons, glutamate and GABA transporters uptake these metabolites from the synaptic clefts into astrocytes in order to maintain the homeostasis of excitatory and inhibitory neurotransmission in the local neural circuitry. Both GABA and glutamate transporters are strongly implicated in impaired cognition in neuropsychiatric disorders ,47,48,49ith ADHD . Thus, aGlutamatergic and GABAergic systems are highly malleable to changes in the environment. In the mouse visual cortex, increasing neural activity results in increases in both neural excitation and inhibition . EqualizNotably, we found that greater GABA increases during the tasks were predicted by a lower basal GABA content. Cai et al. (2012) reported a similar finding that increases in GABA content after gabapentin administration were negatively correlated with GABA content before gabapentin administration . This inOur participants with ADHD showed smaller Glx and GABA increases during the tasks in which they showed impaired performance compared to participants without ADHD. Our findings add to the growing body of the literature that task-related GABA content predicts task performance ,54,55,56Our group analysis revealed that participants with ADHD had significantly higher error rates in the Flanker task compared to participants without ADHD. It is worth noting that our participants with ADHD performed three attention control tasks with very minimal movements during the brain scan. Critically, they exhibited a significantly lower level of attention control, but not higher motion artifacts than the participants in the CONTROL group. These observations confirm the clinical view that adults with ADHD exhibit more inattentive or combined but less hyperactivity presentation. The trend of non-significantly higher rates in the Stroop task was unexpected given that behavioral studies have repeatedly shown that people with ADHD show impaired performance in this task ,58,59,60The study consisted of 18 participants in the ADHD group and 16 participants in the CONTROL group . ParticiF = 0.159, p = 0.692) groups. All experimental procedures were approved by the University of Washington Institutional Review Board and conformed to the ethical principles for research on human subjects from the Declaration of Helsinki, as revised in 2008. All participants gave written consent to participate in the study.All participants met the following criteria: no history of other mental disorders, neurological impairments, developmental disorders, or hearing loss, and right-handed. The average age did not differ between ADHD (31–51 years) and CONTROL  T1-weighted imaging and magnetic resonance spectroscopy (MRS) scans and remained still during the T1 scan. MRS scans consisted of four eight-minute blocks A. In theWe adopted an auditory task that we previously published to assess participants’ selective attention to auditory stimuli . We usedWe adopted the procedures for the Stroop task that we previously published , and useWe adopted the procedures for the Flanker task that we have previously published  and usedParticipants were instructed to respond as soon as a stimulus was presented. An invalid trial was marked if there was no button pressed two seconds after a presentation. E-Prime recorded the time when a presentation was shown and the time when a button was pressed in every trial. The latency represented the reaction time (RT) in a given trial.2, matrix size = 328 × 320 mm2, reconstructed voxel size = 0.68 × 0.68 × 0.70 mm3 and was used to place a voxel in each individual’s brain to perform partial volume tissue correction in the subsequent data analysis. The total scan time was four minutes and one second.MR measures were acquired on a Philips 3T Achieva scanner version 5.18 using a 32-channel head coil C. MPRAGE3 encompassed the anterior cingulate cortex and the head of the caudate nucleus  with an editing pulse applied either at 1.9 ppm (ON) or at 7.5 ppm (OFF) ,67. Wate nucleus D,E. The We used the Gannet3 toolbox to quantify Glx and GABA concentrations within the voxel . ProcessF = 0.042, p = 0.990; F = 0.516, p = 0.672: for GABA: repeated measures ANOVAs: F = 1.207, p = 0.310; We used the MEGA-PRESS OFF spectra and examined creatine (Cr), N-acetylaspartate (NAA), and N-acetylaspartylGlu (NAAG) signals using the LC Model (version 6.3-1L) . Only suR (version 3.6.2) for data analysis. We calculated the average, standard deviation, and 95% confidence interval of measurement precision of Glx and GABA content  and rstatix libraries in  content . To testp values by two to account for two conditions in the task.We calculated task error rates by dividing the number of incorrect responses by the total number of trials in the congruent and incongruent condition, respectively. We found that one participant without ADHD and one participant with ADHD showed an error rate three SDs higher than their group average. Thus, their data were removed from the Stroop analysis. We used the non-parametric Kruskal–Wallis test to understand behavioral measures in the tasks. We applied the Bonferroni correction and multiplied the resulting p values of each model was greater than would be expected by chance (p < 0.05).We used linear regression and entered Glx, GABA content, and group (ADHD vs. CONTROL) as predictors in a linear regression model. We used ANOVA to understand the model fit and the eta squared to determine the effect size of a predictor. We performed permutation tests with 500 iterations to confirm if the chance of obtaining the observed R-squared and p values. We used an alpha level of 0.05 to determine statistical significance in the study.We used the Pearson correlation test to assess the relationship between the basal Glx/GABA content in the non-task condition and Glx/GABA content during the task, as well as between GABA and Glx content in the non-task and task conditions; we applied Bonferroni corrections to the resulting We combined behavioral assessments of attention control with MRS imaging to demonstrate dynamic changes of Glx and GABA content in the ACC and caudate nucleus while participants performed three attention control tasks. We found that participants with ADHD showed smaller Glx and GABA increases during the tasks compared to participants without ADHD. We also found that basal Glx or GABA content predicted the extent of Glx or GABA increases during the tasks. Finally, GABA content during the task and ADHD diagnosis allowed us to predict the task performance. These findings demonstrate the dynamic role of glutamate–GABA cycling in the fronto-striatal circuitry and suggest that a smaller GABA content in the ACC and the caudate nucleus may contribute to impaired cognition in ADHD.


Rypticussubbifrenatus was incorrectly identified as that of its similarly colored congener R.carpenter. Hence the latter was deleted from the St. John-Thomas inventory. In addition, an image of the blenniid fish Hypsoblenniusexstochilus was obtained from St. Thomas, and it is now added to that inventory. These two changes did not substantially affect data on the ecological structure of the St. John-Thomas fauna.Review of the image plates shows that an image of  Prompt publication of corrections to faunal inventories helps ensure the accuracy of biogeographical data. Here we correct the erroneous occurrence of a misidentified serranid fish in the St. John-Thomas inventory. In addition, a newly available photograph of a blenniid taken at St. Thomas provides a voucher for its addition to that inventory.Rypticuscarpenteri” is incorrect and should read “Rypticussubbifrenatus”. The distributions of large dark spots on the interorbital areas and the colors of the fins of those two species differ  at St. Thomas. That species is easily recognized by its diagnostic pair of orbital cirri, each of which consists of a very large, branched stalk, and the color pattern of its head. This image represents the sole-source record for the addition of this species to the St. John-Thomas faunal inventory.Fig. R.carpenteri from and addition of H.exstochilus to the St. John-Thomas inventory had very little effect on data in Tables 3-6: In Table 3 the only change is the addition of one to the number of uncommon shallow species. The only changes in Table 5 are small increases (< 0.5%) in the percentages of Core Coral Reef Fishes. There are no changes to Tables 4, 6.The combination of the removal of


Adult patients with epilepsy (PWE) have an 18% prevalence of comorbid attention deficit hyperactivity disorder (ADHD) compared to a prevalence of 2%–5% in the general population. Recognition of this dual diagnosis is important since stimulant therapy is both safe and effective in this population.Here, we aim to determine if PWE have adequate documentation for comorbid ADHD when being admitted to the Epilepsy Monitoring Unit (EMU). A retrospective review was conducted at the Baylor St. Luke's Medical Center EMU for patients presenting between July 2017 and November 2020. Patients were divided into two groups: Group I—patients without a documented ADHD diagnosis or ADHD medications and Group II—patients with a documented ADHD diagnosis and/or taking medications indicated specifically for ADHD.p = .005) and a greater number of psychiatric medications prescribed (p < .001) in patients in Group II.Of 524 individual patients who presented to the EMU, only 25 patients (4.8%) had documentation of a diagnosis of ADHD and/or ADHD medications (Group II). The proportion of patients in Group II did not significantly differ based on the EMU diagnosis. However, there was a significantly greater number of other psychiatric diagnoses (Our study suggests that ADHD is underrecognized and underdiagnosed in patients presenting to the EMU, and screening tools may be useful to help clinicians address seizure comorbidities such as ADHD.  AlthougA Diagnostic and Statistical Manual of Mental Disorders (DSM‐V) diagnosis of ADHD requires that the symptoms begin before the age of 12, progress over at least six months, and affect at least two different environments   because the combination of diagnoses is associated with a decreased quality of life compared to patients with epilepsy alone  between January 2017 and December 2020. Our aim was to identify the degree to which ADHD is documented in patients with epilepsy and psychogenic nonepileptic seizures (PNES) in the EMU setting.2This retrospective study was approved by the Baylor College of Medicine Institutional Review Board (H‐32620). We reviewed all patients who presented to the Baylor St. Luke's Medical Center EMU in Houston, Texas, between July 2017 and November 2020. Patient information was extracted from the medical health record (Epic Systems Corporation), including demographic information, admission history, and physical, imaging, and EMU reports. A total of 524 patients who presented during this time were reviewed, ranging between the ages of 17 and 80 upon admission. All patients were evaluated by residents and faculty at Baylor College of Medicine using a standard template. No patients were excluded from this study.Patients were placed into two groups: Group I—patients without an ADHD diagnosis and not on ADHD medications, Group II—patients with a formal ADHD diagnosis and/or taking medications indicated specifically for ADHD. ADHD medications included generic and brand name derivations of methylphenidate, amphetamine, dextroamphetamine, lisdexamfetamine, and atomoxetine. For medications that may have served a purpose outside of ADHD, a review of the past medical history was performed to ensure that there were no other indications for its use. Factors such as age on admission, sex, handedness, magnetic resonance imaging (MRI) results, EMU assessment and diagnosis, lateralization, seizure/psychiatric medications, other psychiatric diagnoses, and seizure frequency per month were recorded. Handedness, psychiatric diagnoses, current outpatient seizure/psychiatric medications, and seizure frequency per month were reviewed in the medical record. Seizure frequency per month was recorded as an average if the patient presented with a range. EMU assessments and diagnoses were made based on the following: patient histories, MRI, and video electroencephalography results .A subset of the patients in this retrospective study participated in a prior prospective study screening for ADHD using the Adult ASRS, version 1.1  compared to 4.8% in Group II (documentation of comorbid ADHD present). In Group II, eight patients were found to have PNES, nine with epilepsy, seven ND, and one with multiple diagnoses. A greater proportion of PNES patients were in Group II than epilepsy patients, but this was not statistically significant  in the prior study expressed having had a diagnosis when specifically asked. These results indicate that documentation of ADHD is verified when asked, and many EMU patients with a diagnosis of ADHD can be missed if not specifically asked.4Out of the 524 patients in our study, 25 patients (4.8%) had documentation on admission supporting a diagnosis of ADHD in the EMU. Compared to an expected prevalence of 18%, this could indicate an underdiagnosis of ADHD in patients who present in an EMU setting. These findings are validated in a review of 97 of these patients who participated in a prior study from our group, showing that 11.2% of patients without ADHD documented on admission to the EMU expressed that they had been given a diagnosis of ADHD when specifically asked. Altogether, 18 of 97 patients (18.6%) admitted to the EMU in the prior study either had an admission diagnosis of ADHD and/or provided a diagnosis when specifically asked, consistent with the expected ∼18% rate of ADHD in this population  and GAD‐7 , inability to work due to disability, poorer physical health, and lower social functioning (Ettinger et al., There are several limitations to our study that should be considered. First, the data may be incomplete due to its retrospective nature, and since physicians were not specifically instructed to screen for or document ADHD on admission, a diagnosis could have been omitted from the patient history. In addition, the study only includes the specific population of patients seen in a single‐center tertiary medical center, which may limit the ability to translate findings to other populations. Finally, the diagnosis of ADHD was limited to patient reports, without validation from a formal diagnosis by a trained provider. However, despite the inclusion of ADHD diagnosis based only on patient reports, the prevalence of comorbid ADHD remained surprisingly low.Future research can be aimed at providing a more streamlined ability to screen, diagnose, and treat patients with seizures and comorbid ADHD. The Adult ASRS is useful in screening for ADHD in this population (Dunbar et al., The authors declare no conflict of interest.https://publons.com/publon/10.1002/brb3.2731The peer review history for this article is available at


Infant secondhand smoke exposure at one month was independently associated with shorter TL12 and also higher ADHD symptoms. Further work is needed to elucidate the mechanisms that influence TL attrition and early neurodevelopment.Environmental factors can accelerate telomere length (TL) attrition. Shortened TL is linked to attention deficit/hyperactivity disorder (ADHD) symptoms in school-aged children. The onset of ADHD occurs as early as preschool-age, but the TL-ADHD association in younger children is unknown. We investigated associations between infant TL and ADHD symptoms in children and assessed environmental factors as potential confounders and/or mediators of this association. Relative TL was measured by quantitative polymerase chain reaction in cord and 12-month blood in the birth cohort study, the Barwon Infant Study. Early life environmental factors collected antenatally to two years were used to measure confounding. ADHD symptoms at age two years were evaluated by the Child Behavior Checklist Attention Problems (AP) and the Attention Deficit/Hyperactivity Problems (ADHP). Associations between early life environmental factors on TL or ADHD symptoms were assessed using multivariable regression models adjusted for relevant factors. Telomere length at 12 months (TL12), but not at birth, was inversely associated with AP ( Telomeres are non-coding, repetitive nucleotide sequence structures located at the terminal ends of eukaryotic chromosomes and are essential for genomic stability . TelomerSeveral environmental and genetic factors are known to influence TL shortening. In adults, this includes social adversity, smoking and secondhand smoke (SHS) exposure, chronic stress, and alcohol consumption ,10,11,12ADHD is one of the most common neurodevelopmental disorders in childhood. The diagnosis is based on the persistent patterns of ADHD symptoms mainly characterized by two behavioral traits: inattention and/or hyperactivity-impulsivity  impactinEtiologically, ADHD is suggested to be a heterogeneous disorder due to both genetic and environmental factors. Despite known heritability among family studies, few candidate genes have been shown to contribute to the ADHD phenotypic variance ,34. EnviCharacteristics of the Barwon Infant Study (BIS) participants are presented in r = 0.85; p < 0.0001). Intra-domain correlations demonstrated that most of the sociodemographic factors were weakly to moderately correlated with each other . Similarly, some of the prenatal factors were moderately correlated (Perceived Stress Score (PSS) and Edinburgh Depression Scale (EDS), r = 0.55, p < 0.0001; tobacco smoking and SHS exposure, r = 0.42, p < 0.0001) or weakly correlated, i.e., PSS/EDS with antidepressant use, tobacco smoking, and SHS exposure; r ranged from 0.09–0.13, all p < 0.001; recreational drug use was weakly correlated with maternal smoking and SHS exposure . None of the perinatal factors were correlated (p > 0.05). As for the postnatal factors, paternal smoking and infant SHS exposure at one month were weakly correlated . Inter-domain correlations demonstrated that the majority of all early life environmental factors were correlated together. The Pearson correlations of all key early life environmental factors and TL in infancy, and ADHD symptoms at age two years, are shown in HBB)), DNA controls , and dilution concentrations  run in sets of quadruplicates. The intra-assay individual ICC was 0.99; 95% confidence interval (CI)  and the inter-assay individual ICC was 0.96; 95% CI  between 48 plates. TL0 (unit: relative amount of telomeric DNA (T) to a single copy gene ; T/S ratio) ranged from 0.004 to 3.75 and the TL12 (T/S ratio) ranged from 0.002 to 2.84. TL0 was not correlated with TL12  was 1.70% (standard deviation (SD) 2.20%; range 0.50% to 2.20%) for the quadruplicates, and the inter-assay %CV between plates was 3.60% . The intra-class correlation coefficient (ICC) was calculated for measurements of the same type (TL or human beta-globin gene (β) = −0.60; 95% CI ; p = 0.03) and ADHP ; p = 0.001). Longitudinal birth and 12-month TL measures were included in the same model ; the association with TL12 persisted for ADHP and attenuated for AP. There was less evidence of an association with TL0, so we focused on TL12 hereafter.Estimates of the univariable model of the associations between TL0 and TL12 with ADHD symptoms at age two years are shown in β = −0.08; 95% CI ; p = 0.05), and ADHP ; p = 0.05). Greater infant SHS exposure at one month was the only environmental factor that was independently associated with shorter TL12 ; p = 0.02) and also increased ADHD outcomes: AP ; p = 0.01) and ADHP ; p = 0.02). For an extension of associations between early life factors with either TL12 or ADHD symptoms, see Key sociodemographic and environmental factors that were independently associated with either TL12 or ADHD symptoms at age two are shown in Early life determinants of ADHD symptoms included maternal age, paternal age, household income, maternal prenatal perceived stress, maternal prenatal antidepressant use, maternal prenatal recreational drug use, prematurity, and paternal tobacco smoking at six months . Using tβ = −0.69; 95% CI ; p = 0.02), and ADHP ; p < 0.0001). In the mutually adjusted model with both time points in the same model, the inverse association increased in magnitude of effect between TL12 and both AP ; p = 0.05) and ADHP ; p < 0.0001). Multivariable models of the associations between TL0 and TL12 with ADHD symptoms at age two years are shown in p = 0.01 and ADHP: OR = 0.39; 95% CI ; p = 0.02) (p > 0.05).Shorter TL12 was associated with increased ADHD symptoms within the borderline to clinical range in the multivariable model ;  = 0.02) . TL in i = 0.02) . There w = 0.02) . Further = 0.02) . InverseThis longitudinal study prospectively investigated the association between two TL measures in infancy and ADHD symptoms in young children. Our findings indicate that shorter TL12 was associated with increased ADHD symptoms in children at age two years, whereas TL0 was not. This association persisted following further adjustments for potential confounding factors. In the mutual adjustment model where TL12 was additionally adjusted for the baseline TL0 time point, there was a stronger magnitude of effect with TL12 with ADHD symptoms at age two years. Together, these findings highlight that the sensitive window of neurodevelopment in the first year of life may be markedly influenced by the early life environment, which may also explain the differences in TL at birth and at 12 months. We also found that approximately half of the infants had longer TL at 12 months compared to the length at birth. This is consistent with a recent study that observed a similar pattern, with longer TL in children at four years compared to TL at birth , and thiTo date, few studies in the literature have reported on the association between TL and ADHD in both children  and younThe ‘developmental origins of health and disease (DOHaD)’ theory proposes that adverse environmental influences during in utero and the first few years of life have long-term programming effects, and this may be particularly true for the developing brain ,59,60. HTo advance understanding of the role of TL in health and disease risk, it is important to further explore underlying biological mechanisms that influence the rate of TL attrition. Both oxidative stress and inflammation have been implicated in this process ,71,72, aThis study is the first and largest of its kind to directly assess longitudinal measures of TL in infancy and subsequent ADHD symptoms in young children. The strengths of this study are the population-derived, prospective measures and the serial telomere measures in the first year of life. Furthermore, the depth of data assembled in the BIS enabled the investigation of a broad range of environmental factors. The CBCL-AP has good predictive validity of ADHD diagnosis  and has There are several limitations that should be noted. In the moderately sized cohort, some of the key exposures were relatively rare. For example, less than 3% of infants were subjected to SHS exposure postnatally, which may have contributed to inadequate statistical power, particularly for mediation analysis, whereby a larger sample size would have greater power . Using dThe BIS is a population-derived birth cohort study (n = 1074 infants); the objectives and methodologies of the study have been previously described . In brieUmbilical cord blood was collected by syringe and added to 10 mL of RPMI 1640  containing preservative-free sodium heparin  , while venous peripheral blood collected at 12 months of age was added to a 15 mL tube containing 100 μL preservative-free sodium heparin  . Samples were processed within 18 h of collection and a small aliquot (150 μL) of whole blood was cryopreserved at –80 °C until DNA extraction. Potential maternal-contaminated cord blood samples were identified using DNA methylation profiling as previously described by Morin and Gatev . ® dsDNA Broad-Range Assay Kit  following the manufacturer’s instructions and stored at −80 °C. The quantification and purity of genomic DNA were determined by the Qubit 2.0 Fluorometer  and Nanodrop 1000 Spectrophotometer . Relative TL was measured by the widely used qPCR method, originally described by Cawthon [® Green PCR Master Mix , and 0.5 μL of each forward and reverse primer at 2 μM, with a final volume of 10 μL for each reaction. The telomeric DNA primer sequences: CGGTTTGTTTGGGTTTGGGTTTGGGTTTGGGTTTGGGTT (forward) and GGCTTGCCTTACCCTTACCCTTACCCTTACCCTTACCCT (reverse), and the single-copy nuclear HBB gene primers sequences for GCAGGAGCCAGGGCTGGGCATAAAAGTCA (forward) and GGGCCTCACCACCAACTTCATCCACGTTC (reverse) were used for amplification.Genomic DNA was extracted from mononuclear cells isolated from cord blood and 12-month whole blood using the QIAamp DNA QIAcube HT Kit  and quantified using the Qubit Cawthon . Each saHBB qPCR reactions were performed on the same plate. The final plate layout included participant genomic DNA, three sets of genomic DNA controls, and a no-template control containing RNase-free water for each run. All assays were performed in quadruplicates using the Lightcycler® 480 Instrument II  . The cycling conditions were: pre-denaturation at 95 °C for 10 min, followed by 30 cycles of (i) 95 °C for 15 sec and (ii) 62 °C for 2 min. Standard curves were obtained by serially diluting genomic DNA controls  and then integrated into a composite standard curve to assess qPCR efficiency. In brief, after randomization, samples were transferred using a Sequenom MassARRAY Matrix Liquid Handler  to minimize pipetting error variability and systemic bias. Telomere and HBB) for each sample to a reference genomic DNA. Samples were omitted from the analysis if results were out of the acceptable range (>0.5 crossing point (Cp) from the median). Approximately 15 samples were removed from the analysis due to not meeting this threshold and were not re-assayed. A total of 48 assay plates were used for TL measurements. Samples matched from both birth and 12-month time points were sequentially measured on the same plate to minimize positional effects.The qPCR efficiency was defined by the gradient of each standard and incorporated to determine the T/S ratio. Relative TL was obtained by calculating the ratio, known as the T/S ratio, by comparing the relative amount of telomeric DNA (T) to a single copy gene   is a 99-Key factors included in the analyses were based on a priori knowledge of previously reported associations with childhood ADHD ,37,56 anSociodemographic factors including parental age at birth, parental education, and household income, and prenatal factors including maternal perceived stress, maternal depression, maternal smoking, and maternal SHS exposure, were collected by baseline questionnaires at around 28 weeks of gestational age. In brief, hardcopy self-assessed questionnaires were developed to facilitate the pooling of data with other Australian birth cohort studies, and the validity of the questionnaire items used have been examined and established, as previously described elsewhere . Househot test presented as the mean (SD) and Pearson’s χ2 test or Fisher’s exact test for categorical values, expressed as the count (percentage) for children in this study  were calculated for the quadruplicates, and inter-assay %CVs  were calculated for the standards, which were repeated on each plate ,108. Therelevant . As TL wUnivariable linear or logistic regression models were used to assess the associations between separate TL at each time point and ADHD symptoms. Mutually adjusted models were assessed to account for longitudinal measures of TL for one ‘distal’ outcome . DirecteFurthermore, additional analyses were conducted to evaluate the consistency in our findings. For ADHD symptoms, a dichotomized T score equal to or greater than 60 (T60) that indicated the borderline clinical range for both AP and ADHP outcomes were evaluated  Supplem. Categorp values of 0.05 or less, an arbitrary threshold [p-trend [In the tables, and in line with convention, we have refrained from asserting that an effect (difference) was found/not found on the basis of hreshold . Here, t[p-trend . We usedIn this study, we report on a prospective association between shorter TL at 12 months of age and increased ADHD symptoms in children at age two years. We also found that infant SHS exposure in the early postnatal period may impact the development of ADHD and may potentially influence TL shortening. A diverse range of early life factors, including parental education, child’s sex, and birth-related factors may play an important role in early TL dynamics, while other modifiable risk factors of childhood ADHD, such as parental age, household income, perceived stress, and parental lifestyle factors, together highlight the importance of environmental influences, and not genetic factors alone, in early life and subsequent development of ADHD in childhood. Our findings support and extend beyond work implicating that TL plays a role in the pathogenesis of childhood ADHD  and that


Triple-negative breast cancer (TNBC) is a highly malignant breast cancer subtype with a poor prognosis. Improved insight into the molecular biology basis of TNBC progression is urgently needed. Herein, we reported that POLD2 was highly expressed in TNBC and patients with high POLD2 expression in their tumors had poor clinical outcomes. In functional studies, knockdown of POLD2 inhibited the proliferation of TNBC. Mechanistically, we revealed that transcription factor E2F1 directly bound to the promoter of POLD2 and regulated its expression in TNBC cells, which in turn contributed to the proliferation of TNBC. Additionally, rescue experiments validated that E2F1-mediated cell proliferation in TNBC was dependent on POLD2. Taken together, our results elucidated a novel mechanism of the E2F1-POLD2 axis in TNBC proliferation, and POLD2 may be a potential therapeutic target for TNBC treatment. Breast cancer is the most prevalent cancer in women, among which triple-negative breast cancer (TNBC) accounts for approximately 15–20% (DNA polymerase delta (Polδ) is a major eukaryotic replicative polymerase, which is indispensable for efficient replication of the nuclear genome . Polδ coIn the present study, we aimed to investigate the expression of POLD2 in TNBC and explore the potential regulatory role of POLD2 in the progression of TNBC. Furthermore, we will elucidate the molecular mechanisms by which endogenous POLD2 expression is regulated in TNBC cells.The TCGA BRCA cohort data were downloaded through the UCSC Xena platform . The exp2.MCF-10A, MDA-MB-231, and 293T cell lines were obtained from the American Type Culture Collection, and the SUM-159 cell line was obtained from Asterand Bioscience. Each cell line was authenticated by STR analysis. MCF-10A cells were cultured with DMEM/F12 supplemented with 5% horse serum, 100 U/mL penicillin, 100 μg/mL streptomycin, 20 ng/mL EGF, 0.5 μg/mL hydrocortisone, and 100 ng/mL cholera toxin. MDA-MB-231 cells were cultured with RPMI-1640 supplemented with 10% fetal bovine serum. SUM-159 and 293T cells were cultured with DMEM supplemented with 10% fetal bovine serum. All cells were cultured in a humidified incubator at 37°C with 5% COLentiviral systems for knockdown or expression of POLD2 and knockdown of E2F1 were performed as described previously . The pri-(ΔΔCT) method. GAPDH was used as a housekeeping gene. The primer sequences of GAPDH, POLD2, and E2F1 are listed in Total RNA was extracted using TRIzol reagent (Invitrogen). RNA quantity and quality were determined by spectrophotometric measurements and agarose gel electrophoresis, respectively. Then, total RNA was reverse transcribed using Transcript First-Strand Synthesis Supermix (TransGen Biotech). qRT-PCR was conducted using the TransStart Green Q-PCR SuperMix kit (TransGen Biotech) on a CFX96 system (Biorad) and analysis was performed using the 2Western blotting was performed as described previously . Briefly3 per well) were plated in 96-well plates and cultured for 0, 24, 48, and 72 h at 37°C in 5% CO2. Then, 10 μl CCK-8 reagent (Dojindo) was added and incubated for 2 h at 37° C. Subsequently, absorbance at 450 nm was measured. And cell proliferation curves were assessed by two-way analysis of variance (ANOVA) after cell seeding 0, 24, 36, 48, 60, and 72 hours.Cells (3×103 per well) were plated in 6-well plates and cultured for 2 weeks at 37°C in 5% CO2. Then, the colonies were fixed in methanol and stained with 1% crystal violet for quantification.Cells (1×10EdU incorporation was performed using EdU Imaging Kits-Cy3 (APExBIO) according to the manufacturer’s protocols. Briefly, cells were incubated with 50 μM EdU for 2 h and then fixed in 4% paraformaldehyde for 15 min. Subsequently, cells were permeabilized with 0.5% Triton X-100 for 20 min, and stained with a click reaction cocktail for 30 min. Cell nuclei were stained with 5 μg/mL Hoechst 33342 for 5 min. The number of EdU-positive cells was counted and photographed under a microscope.via Lipofectamine 2000 reagent (Invitrogen). After 48 h, the luciferase activities were measured using the dual-luciferase reporter assay system (Promega) according to the manufacturer’s protocols.The human WT-POLD2 and MUT-POLD2 promoters were cloned into the pGL3−basic vector (Promega). Primer sequences are provided in ChIP-qPCR was performed as described previously , using aP value less than 0.05 was considered significant.Statistical analysis was performed using GraphPad Prism software. All the data are presented as the mean ± standard deviation. For correlation analyses of gene expression in tissue samples, the spearman correlation test was used. The survival of TNBC patients was analyzed with the Kaplan-Meier and log-rank tests. The statistical analysis involving two groups was performed by Student’s t-test. A ). Additionally, survival analysis revealed that high POLD2 expression was related to poor overall survival in TNBC patients, as shown in To explore the function of POLD2 in TNBC, we first investigated the expression of POLD2 in normal breast and different subtypes of breast cancer  from The Cancer Genome Atlas (TCGA) database. As shown in . Then, the CCK-8 assay revealed that inhibition of POLD2 reduced cell viability . Downregulation of POLD2 also inhibited colony formation in TNBC cells . Via EDU incorporation assay, proliferation abilities of cells were demonstrated to be significantly attenuated after POLD2 inhibition . Collectively, these results demonstrate that POLD2 is essential for TNBC proliferation.To investigate the roles of POLD2 in the malignant progression of TNBC, we firstly downregulated POLD2 expression by using shRNAs in MDA-MB-231 and SUM-159 cells . Then, t. Then, t. Then, tvia predicted EBSs, a dual-luciferase reporter assay was conducted to detect the luciferase activity of wild type POLD2 promoter (WT-POLD2 promoter) and mutant POLD2 promoter (MUT-POLD2 promoter) that respectively co-transfected with control or E2F1 overexpression vector in MDA-MB-231 cells . The results showed that overexpression of E2F1 could upregulate the luciferase activity of WT-POLD2-promoter, while mutated EBSs resulted in diminished luciferase activity . Of note, Chip-qPCR results showed that overexpression of E2F1 significantly increased its recruitment to the EBSs in the POLD2 promoter , demonstrating a predominant role for EBSs in the activation of POLD2 transcription by E2F1. In addition, the results of qRT-PCR and western blot showed that E2F1 knockdown significantly reduced the mRNA and protein expression of POLD2 in MDA-MB-231 and SUM-159 cells . Altogether, these results indicated that E2F1 activates POLD2 transcription and induces POLD2 expression in TNBC.To determine the regulatory mechanism of POLD2 expression in TNBC, we predicted the transcription factors (TFs) implicated in the transcription of POLD2 using the UCSC ENCODE, JASPAR, and PROMO public prediction websites. And three TFs were screened out, including E2F1, YY1, and SP1 . Thus, w31 cells . The res31 cells . The res31 cells . The resvia regulating POLD2 expression, POLD2 was overexpressed on the basis of E2F1 knockdown in MDA-MB-231 and SUM-159 cells . Then CCK-8 assay revealed that inhibition of E2F1 reduced cell viability; however, this effect was significantly weakened by the rescue of POLD2 expression . Downregulation of E2F1 also inhibited colony formation in TNBC cells, while overexpression of POLD2 attenuated this inhibitory effect . Via EDU incorporation assay, proliferation abilities of TNBC cells were demonstrated to be significantly attenuated after E2F1 inhibition, while rescued by POLD2 expression . Thus, E2F1 could promote cancer proliferation via upregulating POLD2 expression in TNBC, indicating that the E2F1-POLD2 signaling pathway is a driver of TNBC proliferation and could be a potential therapeutic target for the treatment of TNBC.To further determine whether E2F1 could mediate TNBC proliferation 59 cells . Then CC59 cells . Then CC59 cells . Then CCPOLD2, also referred to as DNA Polymerase Delta Subunit P50, is a subunit of the DNA polymerase delta complex, which serves as a scaffold for the proper formation of Polδ by interacting with POLD1/p125, POLD3/p66, and POLD4/p12 . The humPOLD2 expression is upregulated in various cancers, but little is known about how the expression of POLD2 is regulated. Using microarray, expression of POLD2 was found to be down-regulated by the exogenous overexpression of PTEN tumor suppressor . HoweverFurthermore, our findings established that the E2F1-POLD2 signaling pathway contributes to TNBC proliferation. Considering that E2F1 dysregulation is a common feature among different tumor types and can be a major cause of cell proliferation , our res.In this study, we demonstrated that POLD2 was overexpressed in TNBC and high expression of POLD2 predicted the poor clinical outcome of TNBC patients. And inhibition of POLD2 significantly reduced TNBC proliferation, indicating that POLD2 functioned as an oncogene in TNBC. At the molecular level, we identified that transcription factor E2F1 was directly bound to the promoter of POLD2 and regulated its expression, which consequently conferred TNBC proliferation. Collectively, our findings revealed that the E2F1-POLD2 axis played a key role in the proliferation of TNBC, which could be utilized as a novel therapeutic target for TNBC treatment The original contributions presented in the study are included in the article/ZZ conceived and designed the study, developed methodology, analyzed and interpreted the data  and wrote the paper. The author confirms being the sole contributor of this work and has approved it for publication.This work is supported by grants from the Science and Technology Research Project of Jiangxi Provincial Department of Education (No. GJJ218906).The authors declares 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. 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Balancing the immune system with immunosuppressive treatment is essential in kidney transplant recipients to avoid allograft rejection on the one hand and infectious complications on the other. BK polyomavirus nephropathy (BKPyVAN) is a viral complication that seriously threatens kidney allograft survival. Therefore, the main treatment strategy is to reduce immunosuppression, but this is associated with an increased rejection risk. Belatacept is an immunosuppressant that acts by blocking the CD80/86-CD28 co-stimulatory pathway of effector T-cells with marked effects on the humoral response. However, when compared with calcineurin-inhibitors (CNI), the cellular rejection rate is higher. With this in mind, we hypothesized that belatacept could be used as rescue therapy in severely BKPyV-affected patients with high immunological risk. We present three cases of patients with BKPyVAN-associated complications and donor-specific antibodies (DSA) and one patient who developed T-cell-mediated rejection after a reduction in immunosuppression in response to BKPyVAN. Patients were switched to a belatacept-based immunosuppressive regimen and showed significantly improved viral control and stabilized graft function. The cases presented here suggest that belatacept is a potential treatment option in the complicated situation of refractory BKPyV infection in patients with high immunological risk. BK virus (BKPyV) is a double-stranded DNA virus that belongs to the family Polyomaviridae ,2. In noUntil now, there has been no specific antiviral treatment for BKPyV. Hence, reduction in immunosuppression is the cornerstone of the treatment strategy used against severe BKPyV infection/reactivation . HoweverBelatacept is a CTLA-4-Ig chimeric fusion protein that was introduced in 2011. It inhibits a co-stimulatory pathway of effector T-cells by specifically binding to CD80/86, thereby blocking the interaction of CD80/86 with CD28, which activates effector T-cells .In a post hoc analysis of BENEFIT and BENEFIT-EXT studies, belatacept was found to be superior in preventing the formation of de novo donor-specific antibodies (dnDSA) at 3 and 7 years after KTx when compared with cyclosporine A (CsA) . In contAlmost nothing is known about the application of belatacept in the context of active viral complications after KTx, particularly BKPyVAN or significant DNAemia. In stable KTx patients, infectious complications have been found to be equally frequent in those receiving CNI when compared with those receiving belatacept . There iHere, we present three cases of refractory BKPyVAN and one case of refractory BKPyV DNAemia that were treated by converting their immunosuppressive therapy to a belatacept-based regimen as a rescue approach.Case 1:The first case was a 58-year-old male patient who received an ABO-incompatible living-donor transplant after desensitization with rituximab and immunoadsorption with semi-selective devices. Induction therapy was performed with anti-thymocyte globulins (ATG), and initial immunosuppression consisted of immediate-release tacrolimus (Tac) (trough level 6–8 ng/mL), mycophenolic acid (MPA), and prednisone.Four months after KTx, BKPyV viremia was initially diagnosed with 132,000 copies/mL. DSA-diagnostic was negative. A transplant biopsy showed BKPyVAN. Therefore, the immunosuppressive regimen was switched to CsA, EVR, and prednisone. Furthermore, intravenous immunoglobulins  were administered monthly nine times.2 to around 40–45 mL/min/1.73 m2 (CKD-EPI formula) —namely anti-HLA-A2 (mMFI~3.100FLU), anti-HLA-A68 (mMFI~700FLU), anti-HLA-DR7 (MFI~3.200FLU), and anti-HLA-DR53 (mMFI~3.100FLU)—were found. Based on the dnDSA, another renal biopsy was performed, which excluded anti-donor antibody-mediated rejection (ABMR) but again demonstrated BKPyVAN. Due to BKPyVAN, the estimated glomerular filtration rate (eGFR) had decreased from the initial baseline of 60–65 mL/min/1.73 m2 (CKD-EPI formula) , EVR (target trough 4–5 ng/mL), and prednisone. Furthermore, IVIG (at 0.5 g/kg of body weight) was administered monthly four times. BKPyV replication was controlled under this regimen with a reduction in BKPyV copies from 303,000/mL at the diagnosis of BKPyVAN to 100 copies/mL three months later. Nevertheless, allograft function deteriorated further. A second allograft biopsy at that time revealed acute TCMR 1A. Despite the use of steroid pulse therapy and the replacement of CsA with Tac (trough level 5–7 ng/mL), another biopsy three weeks later again showed ongoing TCMR 1A. Rejection was treated with another steroid pulse and with ATG (at a cumulative dose of 6 mg/kg of body weight).2 to an eGFR of 25–30 mL/min/1.71 m2, where it consolidated after a follow-up period of 3.5 years  was diagnosed. Two months later, co-replication of BKV (7400 Cop/mL) and CMV (750 copies/mL) occurred. Consequently, MPA was replaced with EVR. BKPyVAN was excluded by a kidney biopsy because the renal function had deteriorated from a baseline eGFR of 50–60 mL/min/1.73 m2  was infused monthly four times. One year after KTx, dnDSA anti-HLA-B8 (MFI~800FLU) and -DR14 (MFI~800FLU) were diagnosed. A transplant biopsy revealed BKPyVAN without signs of rejection. Approximately one year later, CsA was replaced by belatacept due to progressive loss of renal function from a baseline eGFR of ~60 mL/min/1.73 mThe most relevant demographic and clinical characteristics of the four presented patients are summarized in Because of the monthly belatacept administrations at our outpatient unit, follow-up periods for the four presented patients were similar. In Cases 1 and 4, which were ABO-incompatible living donor KTxs, induction therapy was performed with Rituximab and ATG. In Cases 2 and 3, basiliximab and ATG, respectively, were solely applied . Belatac® BKV-assay to quantify BKPyV DNA. The HLA-Antibody screening was performed three months after KTx and every 12 months after KTx as well as on indication. Biopsy specimens were examined histologically by a nephropathologist and discussed at the weekly pathology-nephrology conference.BKPyV diagnostics were performed monthly within the first 6 months after KTx, every second month during months 6–12, and on indication. EDTA-plasma was used for the kPCR 150 PLXThe four cases presented here demonstrate that belatacept can be successfully used in patients with concurrent BKPyV infection and immunological complications in the form of dnDSA or TCMR 1A and therefore might represent a valuable immunosuppressive option in this dilemma. However, we expressly point out that the immunosuppressive drug combinations used in the presented patients are off-label therapies.In all presented patients, we observed good control of BKPyVAN or DNAemia and stabilization or improvement of renal function with belatacept. None of the four patients experienced rejection episodes during follow-up, which ranged from 12 months to 3.5 years.It is postulated that the risk of antibody-mediated rejection is lower with belatacept when compared with a CNI-based regimen. Nevertheless, there is a concomitant increased risk of T-cell-mediated rejection ,15. In pIn contrast to the other three presented cases, Case 2 had experienced a recent steroid-refractory TCMR 1A. Because sufficiently strong immunosuppression was required without reactivation of BKPyVAN, we struggled to switch to belatacept and considered it as an ultima ratio therapy because of the increased risk of TCMR associated with belatacept. Nevertheless, we did not observe any recurrence of TCMR or BKPyVAN after switching to belatacept at a follow-up more than three years later.The available data on viral infections in patients on belatacept are somewhat contradictory. Chavarot et al. describe a sevenfold increase in the incidence of CMV disease and an atypical, aggressive disease phenotype in their patients . In respIn contrast to these observations, BENEFIT and BENEFIT-EXT studies report similar results with belatacept and CsA for BKPyV and CMV-associated complications in patients ,15. ThesThe T-cell co-stimulation modulator, abatacept, which shares the mode of action with belatacept and is used in patients with rheumatic diseases, does not appear to increase the risk of opportunistic infectious complications when compared with placebo or non-biologic disease-modifying drugs .It was evident that in addition to belatacept and steroids, which were 5 mg of prednisone in each of our four patients, a third immunosuppressive drug played an important role in both viral control and effective immunosuppression for preventing alloimmunity. In the patients presented herein, that drug was the mTOR-Inhibitor EVR with a target trough level of 3–5 ng/mL, rather than MPA, which is routinely used with belatacept. EVR was applied due to its antiviral potency, which has been proven to have comparable efficacy for BKPyVAN  and MPA/Immunosuppression with belatacept is associated with an increased risk of the EBV-related complication of post-transplant-lymphoproliferative disease (PTLD), particularly in patients who are seronegative for EBV-IgG , becauseWeakened BKPyV-specific cellular immunity is presupposed for high-replicative BKPyV infection or reactivation . SufficiTherefore, one possible explanation for our observations regarding the successful use of belatacept in our patients is that virus-specific memory T-cells, which were likely to be responsible for the control of BKPyV DNAemia in the cases presented, had already formed before the conversion to belatacept or that belatacept had less impact on the functionality of these T-cells than CNI did.We hypothesized that belatacept enhances the virus-specific immune response against BKPyV after conversion from the more unselective CNIs or MMF without significantly boosting allo-specific T-cell immunity. Simultaneously, humoral alloimmunity is known to be weaker under belatacept than under CNI therapy . This isA further step to elucidate the underlying mechanisms of BKPyV control under belatacept should be to test for BKPyV-specific T-cells before belatacept conversion and under ongoing therapy.In conclusion, three of the four cases presented here indicate that conversion of immunosuppression to belatacept and EVR in patients at high risk of ABMR and concomitant BKPyVAN might be a valuable therapeutical option to treat BKPyV infection without exposing the allograft to ABMR. In addition, the findings from Case 2 suggest that a high immunological risk based on recent TCMR is not a mandatory contraindication to the use of belatacept to simultaneously maintain virus and rejection control in certain cases.