Bartonella species. The infection manifests as asymptomatic bacteremia to potentially fatal disorders. Many species are pathogenic to humans, but three are responsible for most clinical symptoms: Bartonella bacilliformis, Bartonella quintana, and Bartonella henselae. Peruvian wart, caused by B. bacilliformis, may be indistinguishable from bacillary angiomatosis caused by the other two species. Other cutaneous manifestations include maculo-papular rash in trench fever, papules or nodules in cat scratch disease, and vasculitis (often associated with endocarditis). In addition, febrile morbilliform rash, purpura, urticaria, erythema nodosum, erythema multiforme, erythema marginatus, granuloma annularis, leukocytoclastic vasculitis, granulomatous reactions, and angioproliferative reactions may occur. Considering the broad spectrum of infection and the potential complications associated with Bartonella spp., the infection should be considered by physicians more frequently among the differential diagnoses of idiopathic conditions. Health professionals and researchers often neglected this diseases.Bartonellosis are diseases caused by any kind of  Bartonella species.3Bartonellosis are diseases caused by any Bartonella spp. are fastidious Gram-negative bacilli, well adapted to a variety of animal reservoirs, particularly mammals. These bacteria are capable of infecting and surviving inside erythrocytes. The intraerythrocytic phase allows for a protection niche for the agent, resulting in a prolonged and recurrent infection.Bartonella spp. is from infected humans or animals to new hosts through blood-sucking arthropod vectors. Transmission through animal scratches has been reported but it is not certain, since fleas are needed for transmission among cats.Bartonella sp. has already been detected in blood donors.18The main route of transmission of Bartonella spp. are responsible for a broad clinical spectrum, from asymptomatic bacteremia to potentially fatal presentations. Although the manifestations associated with bartonellosis have increased considerably over the past decades, physicians usually do not consider the possibility of infection with these bacteria among differential diagnoses, except in cases with localized lymph node enlargement or endocarditis with negative culture,Bartonella that are pathogenic to humans, three are responsible for the majority of clinical symptoms: Bartonella bacilliformis, Bartonella quintana, and Bartonella henselae.21Among the 16 species of B. bacilliformis was considered the only species of this genus. It is the etiologic agent of Carrion's disease, previously known as the only bartonellosis. B. bacilliformis is transmitted by the female Lutzomyia verrucarum, endemic in the Peruvian Andes and regions of Ecuador and Colombia.Until 1993, Aotus infulatus), are susceptible to B. bacilliformis infection. These data warn of the risk of expansion of Carrion's disease due to the possible adaptation of vectors in areas inhabited by these animals, which may serve as disease dispersal facilitators in neighboring endemic regions, including Brazil.Reports in recent decades of outbreaks in regions of atypical altitude strongly suggest epidemiological areas as potential for expansion. Current climate changes associated with human activities have contributed to the resurgence of infection and its expansion into new areas. Climate changes affect vector distribution and, additionally, phenomena such as El Niño have caused an increase in humidity levels, which favors the reproduction of vectors and the occurrence of outbreaks.The disease is biphasic, with an acute phase (Oroya fever) characterized by fever, hemolytic anemia, and transient immunodeficiency and a chronic phase (Peruvian wart) marked by cutaneous vasoproliferative lesions.25The acute phase of the disease lasts from one to four weeks and severity can range from mild to fatal. Absence of antibiotic treatment can lead to a mortality rate of up to 88%. This is caused by the massive invasion of erythrocytes and initially leads to non-specific symptoms such as malaise, drowsiness, headache, chills, fever, anorexia and myalgia, which make the patient increasingly more jaundiced and confused. As the disease progresses, a severe hemolytic condition, accompanied by lymphadenopathy and hepatosplenomegaly, is established. Disease worsening can lead to acute respiratory distress, pericardial effusion, myocarditis, endocarditis, delirium, seizures, coma and multiple organ failure.25After an average of two months in the acute febrile phase  the Peruvian wart appears, an eruptive cutaneous manifestation formed by angiomatous lesions, which is often clinically and histologically similar to lesions of bacillary angiomatosis (BA). These lesions may present as angiomatous lesions, papules, papule-tumors, or nodules. They appear in patches, predominantly on the face and extremities, and measure 0.2–4 cm in diameter. They may persist for months or even years, and can be accompanied by fever, bone, and/or joint pains. The severity of the eruption is variable and it appears not to be related to previous antibiotic treatment. This is the tissue phase of Carrion's disease and is self-limiting.29B. bacilliformis in the interstice and inside the endothelial cells is an important finding, even in non-ulcerated lesions. The lesions can have more differentiated and ectatic vessels that are clinically and histologically similar to pyogenic granuloma. Cellular atypia can be seen, particularly in more solid lesions, with imperceptible lumens and spindle cells that resemble Kaposi sarcoma.Histologically, Peruvian wart lesions show a proliferation of endothelial cells of the terminal vasculature in the dermis and subcutis. The acute and chronic inflammatory infiltrate that accompanies the presence of B. quintana was initially associated with trench fever (TF), characterized by recurrent febrile episodes. Currently reported in hikers, alcoholics, and AIDS patients in the United States and Europe, the disease has been considered as re-emergent and is the agent implicated in cases of chronic bacteremia, endocarditis, and BA. Humans are the only known reservoirs and the transmission among them is through body lice, the reason why this pathogen is strongly associated to unsanitary conditions and poor personal hygiene.B. henselae is a zoonotic agent whose main reservoir is domestic cats. Transmission between cats does not occur in the absence of fleas, although transmission to humans is often associated with cat scratches. Bartonella sp. was detected through conventional polymerase chain reaction (PCR) for the internal transcribed spacer (ITS) region from a blood sample.B. henselae infection.B. henselae seroprevalence (4%–81%).Bartonella sp. infection could be more prevalent in developing tropical countries. In Campinas, SP, Brazil, 90.2% of the cats involved in the study were positive for the test detecting the presence of B. henselae DNA in their blood.Contact with cats is a risk factor for Besides cats, other pets already described as reservoirs include guinea pigs, rabbits, and dogs.Bartonella sp. infection in blood donors from Hemocentro at Unicamp .Ticks have been proven to be vectorsB. henselae can develop cat scratch disease (CSD), characterized by a self-limited regional lymphadenitis associated with fever.Immunocompetent patients infected with Ctenocephalides felis, to warm and humid climates, related to geographical location and seasonality, reinforcing that the disease is more prevalent in tropical regions.For Bass et al.Lymphadenitis follows the primary lesion, from a few days to many weeks after the cat scratch or bite, apparently by the exposure of the dermis to bacteria found in the feces of feline fleas. It is characterized by an erythematous, non-pruritic papule on the area of the trauma or on its extremity, in case of a scratch. In 2–3 days it becomes vesicular and crusty, remaining for a few days and evolving to a patch that can last for up to 2–3 months. The lesion persists for 7–21 days or is sometimes present with lymph node enlargement. Rarely, the cutaneous lesion is the only clinical manifestation, even when there is history of a scratch or bite. The presence of the inoculation lesion should be thoroughly sought in the history and physical examination, since it can be found in over 90% of cases.The histopathology of cutaneous lesions mimics that of lymph nodes, with the formation of granulomas with a central necrotic area, surrounded by lymphocytes and histiocytes and with a neutrophilic infiltrate. The pus can be loculed, which is important during aspiration. It differs from other granulomatous diseases with the presence of concurrent microabscesses and granulomas.Although rare, purpura can be serious.B. henselae also causes a wide variety of clinical conditions, such as fever of unknown origin, splenic and hepatic manifestations, encephalopathies, ocular diseases, endocarditis, etc.B. quintana or B. henselae, particularly those who are immunodeficient, can develop BA, which is characterized by angioproliferative lesions.B. henselae infection, these injuries may also be associated with peliosis, a rare condition characterized by small blood-filled cystic spaces found in the liver, often diagnosed only through biopsy, which may cause liver failure or rupture and may even be fatal.Patients infected by Cutaneous lesions are the main manifestations of BA but the disease may not affect the skin in up to 45% of cases.Differential diagnosis with Kaposi sarcoma can be clinically impossible, particularly with early sarcomatous lesions. Both diseases can occur at the same time. Any other angiomatous lesions will be part of the differential diagnosis.30Regarding histology, there are three main features: (1) angioproliferation in lobules, with vessels formed by prominent endothelial cells, with atypia and mitoses being seen in areas with dense cellularity; (2) predominance of neutrophils in the inflammatory infiltrate and occasional leukocytoclasia; (3) presence of interstitial or intracellular bacterial clumps found with Warthin–Starry staining, immunohistochemistry, transmission electron microscopy, or confocal microscopy.50It has been suggested that the difference between the angiogenic and granulomatous response triggered by the organism observed in BA and CSD, respectively, appears to be determined by the degree of the host's immunocompetence.Bartonella spp. can cause asymptomatic cyclic bacteremia in humans and animals. This chronic infection can potentially result in endocarditis and be fatal.Bartonella spp.Bartonella have been associated with endocarditis, but 95% of endocarditis cases from these agents are caused by B. quintana or B. henselae.B. henselae was confirmed by serology, PCR and culture.B. henselae can cause chronic non-specific hepatic inflammation in adults and children. It can also be responsible for hepatic angiomatosis and bacillary peliosis, besides granulomatous hepatitis, with or without necrosis. Bartonella spp. are not included in guidelines for the screening of cryptogenic hepatitis and it is possible that part of the 40% of de novo hepatitis cases that occur after liver transplants are related to infection by these bacteria.B. henselae DNA was amplified in a fragment of a mediastinal lymph node and in the patient's blood.Often identified as the clinical expression of atypical CSD, non-classic forms of the disease should be considered separately, sch asmorbilliform exanthem, urticaria, erythema marginatum, granuloma annulare, leukocytoclastic vasculitis.Bartonella sp. infection.B. henselae DNA, which showed to be positive  and 16.2% (78/500) of the donors, respectively. The same study found 3.2% of blood donors with Bartonella spp. blood infection; in 1.2% of them, B. henselae bacteremia was documented inthe donated blood.Asymptomatic hosts with erythrocytic infection can donate blood. In a recent study with 500 blood donors in Campinas, SP, Brazil, antibodies to B. henselae and B. clarridgeiae through intravenous and intramuscular inoculation with the blood of cats known to be infected.B. henselae to survive in blood stored at 4 °C for 35 days.Blood transfusion represents a potential risk for the transmission of these bacteria. Cats were experimentally infected with Bartonella spp. It is increasingly clear that none of the diagnostic methods available currently will confirm Bartonella sp. infection in all infected immunocompetent patients, since this group has low bacteremia, which makes detection even more difficult.67There is no standard laboratory diagnosis for infections caused by Bartonella spp., the differences in analysis parameters among pathologists, and the subjectivity of reading the results with IFA. Many studies have demonstrated the lack of correlation between PCR and positive serology.Bartonella sp. Serologic testing should be used with other techniques such as culture and PCR to assure diagnostic accuracy.IIF is the most common method because of its simplicity. However, immunologic methods have some limitations such as cross-reaction among species and with multiple pathogens, which can lead to false-positive results. There is also the possibility of false-negative results since the antigens from commercial kits are limited to a few species.Bartonella spp. is not as efficient due to the fastidious nature of these bacteria, the low number of circulating bacteria in infected organisms, and the cyclical bacteremia. Isolation requires a long incubation period (six to eight weeks) and special growth conditions .Bartonella spp. increases detection sensitivity of infection by these bacteria via molecular methods.75The use of conventional microbiologic techniques to detect and isolate Bartonella DNA through PCR. Besides the primers that determine the region to be amplified and, therefore, the sensitivity of the reaction, the chosen PCR technique also influences the success of the diagnosis. Double amplification PCR can enhance detection sensitivity considerably, as well as real-time PCR.79There is no consensus about the best primers and conditions to be used for detection of Histology is not frequently used as a diagnostic method but can be very valuable for BA cases, Peruvian wart, and CSD, or when there is tissue involvement, even if not cutaneous. Cutaneous histologic findings were described above.Bartonella from the organism. This can be easily demonstrated by the appearance of Peruvian warts even in patients treated with antibiotics for Oroya fever. Futhermore, antibiotic treatment does not alter the cure rates in patients with lymph node enlargement caused by Bartonella spp.There is no therapeutic regimen that guarantees eradication of Bartonella spp. should be treated with gentamicin and doxycycline;chloramphenicol has been proposed for treatment in case of bacteremia by B. bacilliformis (Carrion's disease). Gentamicin associated with doxycycline is considered the best treatment for endocarditis and TF, and rifampicin or streptomycin can also be used to treat Peruvian warts.Since there are no systematic reviews on this topic, treatment decisions are based in case reports that test a limited number of patients. Patients with systemic disease caused by As mentioned previously, contact with cats is the main risk factor for transmission of CSD and other forms of bartonellosis. Flea infestations, free street access, and an environment with multiple cats are factors that increase the likelihood of feline infection. Therefore, cat owners should avoid flea infestation, keeping them indoors and away from stray cats. The European Advisory Board on Cat Diseases suggests that immunodeficient people adopt cats older than 1 year of age, with no fleas, in good general health, and that do not come from shelters or houses with multiple cats.Bartonella sp. infection to the medical community in general is necessary to avoid the occurrence of bartonellosis. Neglecting the disease certainly contributes to the dissemination of the infection and to inadequately treated cases all over the world.Besides these relevant preventive measures, dissemination of information on Bartonella sp. These diseases are frequently neglected by health care professionals and researchers. The infection can be asymptomatic and have a great impact on the morbidity of, for example, patients with Hansen's disease (as triggers for Type 2 leprosy reaction), or patients with sickle cell anemia (associated with painful crisis due to vaso-occlusion), and cryptogenic hepatitis or cirrhosis. Diagnosis is challenging because physicians do not consider the possibility of bartonellosis and, even when this occurs, there are technical and laboratory difficulties for a conclusive diagnosis. There should be incentives for more research related to Bartonella spp. infection. There are limited resources for the investigation of these agents since Bartonellosis are not even in the list of neglected diseases of the World Health Organization.Bartonellosis are associated with a broad spectrum of symptoms, debilitating conditions, and potentially fatal outcomes. Ectoparasites are involved in the transmission of CNPq 159717/2013-2 ; Productivity Grant from CNPq 301900/2015-9 .Doctoral Scholarship from Karina de Almeida Lins: Approval of final version of the manuscript; conceptualization and planning of the study; composition of the manuscript; critical review of the literature; critical review of the manuscript.Marina Rovani Drummond: Approval of final version of the manuscript; composition of the manuscript; critical review of the literature; critical review of the manuscript.Paulo Eduardo Neves Ferreira Velho: Approval of final version of the manuscript; conceptualization and planning of the study; composition of the manuscript; critical review of the literature; critical review of the manuscript.None declared.


Objective: To evaluate annual concomitant psychotropic medication use among stimulant-treated children/adolescents with ADHD. Method: Children/adolescents with ≥1 primary ADHD diagnosis who had received ≥30 days of stimulant medication were identified from insurance claims for each calendar year (2011-2014). Use of 15 psychotropic medications concomitantly with stimulants was evaluated and their prevalence in each year was calculated overall and by medication category for children (6-12 years) and adolescents (13-17 years). Results: Each year 133,354 to 157,303 children and 95,632 to 111,280 adolescents were included. Annual period prevalence of any concomitant psychotropic medication use was 22.9% to 25.0% for children and 25.2% to 28.2% for adolescents. The most common medication categories included selective serotonin reuptake inhibitors , atypical antipsychotics , and guanfacine extended release . Conclusion: Around a quarter of children/adolescents with ADHD were prescribed psychotropic medication concomitant to stimulant treatment, although only 2 of the 15 medication classes studied were Food and Drug Administration (FDA)-approved for adjunctive use. ADHD is one of the most commonly diagnosed neurobehavioral disorders of childhood and adolescence . The worStimulants are effective first-line pharmacological treatments for children and adolescents with ADHD ; howeverDespite guidance from the American Academy of Pediatrics against off-label adjunctive drug therapy for the treatment of ADHD , off-labSeveral studies have reported that ADHD is the leading diagnosis associated with prescriptions of atypical antipsychotics (AAPs) even though AAPs are not indicated for this condition . StudiesA previous study estimated that the 1-year prevalences of concomitant psychotropic medication use with stimulants (in 2009) among children and adolescents with ADHD were 20.3% and 23.4%, respectively . Since tThe current study examined trends in concomitant psychotropic medication use (including off-label use) among stimulant-treated children and adolescents with ADHD from 2011 to 2014. As rates of ADHD diagnosis and treatment are known to vary by age category , childre®) database from January 1, 2011 to December 31, 2014. These data include commercial health insurance claims  and enrollment information from large US employers and health insurance plans. Such plans provide private health care coverage for more than 50 million employees, their spouses, and dependents and reflect a variety of fee-for-service, preferred provider organization, and capitated health plans .This study was conducted using data from the Truven Health MarketScan Commercial Claims and Encounters ; this consisted of patients who did not have any primary diagnoses associated with a psychiatric or neurological condition, including bipolar disorder, dementia, mania, schizophrenia, tics, adjustment reaction, anxiety disorder, conduct disorder, depression, insomnia, learning disability, obsessive compulsive disorder, oppositional defiant disorder, substance abuse, pervasive developmental disorder, epilepsy, and other psychiatric and neurological disorders . When evaluating multiple concomitant-use events, the periods of overlap between the index stimulant and differing concomitantly used agents were not required to be mutually exclusive.The 1-year period prevalence of concomitant psychotropic medication use, overall and by medication category, was calculated for each calendar year (2011-2014). The overall 1-year prevalence was calculated as the percentage of patients experiencing at least one concomitant-use event with any of the 15 distinct medication classes. The 1-year period prevalence by medication category was calculated as the proportion of patients experiencing at least one concomitant-use event with the given medication category per calendar year. As a sensitivity analysis, the 1-year period prevalence of concomitant psychotropic medication use, overall and by medication category, was calculated among the subpopulation of patients with noncomorbid ADHD. Results are reported in the text as ranges for the four 1-year periods.Separate analyses were performed for the child and adolescent subpopulations, and all analyses were performed using SAS Version 9.3 .Overall, between 133,354 and 157,303 children met the inclusion criteria for each year of the analysis . The meaAmong the overall population of children, 22.9% to 25.0% added at least one other psychotropic medication to their stimulant medication during the study period, and 6.9% to 7.8% added two or more medications . The mosIn the subpopulation of children with noncomorbid ADHD, 14.7% to 16.7% were prescribed at least one other psychotropic medication in addition to their stimulant medication . The mosOverall, between 95,632 and 111,280 adolescents met the inclusion criteria for each year of the analysis . The meaOf the overall population of adolescents, approximately one quarter (25.2%-28.2%) added at least one other psychotropic medication to their stimulant medication during the study period and between 7.3% and 8.5% added two or more medications . The mosIn the subpopulation of adolescents with noncomorbid ADHD, 13.2% to 14.7% were using at least one augmenting drug . The mosIn this large health care claims database analysis, around a quarter of children and adolescents with ADHD were prescribed at least one other category of medication concomitant to their index stimulant treatment between 2011 and 2014. Furthermore, data showed that 6.9% to 7.8% of children and 7.3% to 8.5% of adolescents were prescribed two or more categories of concomitant medication during this period. Overall, the rates of children and adolescents with ADHD being prescribed concomitant drugs increased in each year from 2011 to 2014. Reasons for this increase were not investigated, but possible reasons include an increase in the number of ADHD treatment options available or changes in prescriber attitudes.The two most commonly used concomitant agents were SSRIs and AAPs, neither of which is approved by the FDA for the treatment of ADHD. This finding is noteworthy given the sparse clinical evidence regarding the treatment of ADHD with SSRIs and AAPs, and the potential risk of serious adverse events with AAPs . A notabConcomitant use of guanfacine XR increased annually from 2011 to 2014 in children (5.1%-6.6%) and adolescents (2.3%-3.6%). Furthermore, even after guanfacine XR was approved for use as adjunctive therapy to stimulants (in February 2011), concomitant use of guanfacine IR with stimulant medication increased annually from 2011 to 2014 in children (2.0%-3.8%) and adolescents (1.1%-1.8%). This was despite the lack of efficacy and safety data from well-controlled studies of guanfacine IR for ADHD, and the finding that guanfacine XR is a cost-effective alternative to stimulant monotherapy among children and adolescents with suboptimal response to stimulants .Although there was some variation over the entire period in both children and adolescents, an increase in use of clonidine IR was observed, and the off-label formulation clonidine IR was utilized more than the on-label formulation clonidine XR.Children and adolescents with ADHD commonly exhibit additional psychiatric and neurologic comorbidities . As suchAmong children with noncomorbid ADHD, guanfacine XR was the most used concomitant psychotropic medication every year, with a notable increase during 2012. In adolescents, although the overall percentage of adolescents using at least one drug to augment their stimulant regimen rose between 2011 and 2014, use by the subpopulation of adolescents with noncomorbid ADHD stayed relatively consistent. Among these adolescents, SSRIs remained the most used concomitant therapy despite decreasing prevalence for each year analyzed.It is possible that some of the children and adolescents, considered in this analysis to have noncomorbid ADHD, may have had mental health conditions that were not recorded in the MarketScan database, perhaps due to the stigma attached to a psychiatric diagnosis. Furthermore, results from this subpopulation of children and adolescents with noncomorbid ADHD will not be generalizable to the entire ADHD population, many of whom are characterized as having a heavy comorbidity burden . For theThis study was conducted using administrative claims data, which are inherently associated with certain limitations. Concomitant psychotropic medication use was defined based on a period of overlapping prescription fills rather than the clinician’s intention to treat adjunctively. This approach allowed real utilization to be captured  but did not provide insight into the specific reasons for prescribing or the intended frequency of adjunctive therapy in ADHD. In addition, these results are only generalizable to the commercially insured population in the United States, which may not be representative of all U.S. children and adolescents, particularly, those with public insurance.Concomitant use of psychotropic medication with stimulants was prescribed for around a quarter of children and adolescents in the United States between 2011 and 2014 despite the fact that most medication classes studied were not approved by the FDA for concomitant use with psychostimulants during that time. Such concomitant use of psychotropic medication with stimulants was observed in both children and adolescents in the overall population, and in the sensitivity analysis among a subpopulation that did not have any psychiatric or neurologic comorbidities. These results underscore the need for adjunctive options for use during stimulant treatment of ADHD. In the management of ADHD among children and adolescents, clinicians should evaluate patients on a case-by-case basis, taking into account their unique characteristics and the defined risk–benefit profile for the different treatment options. The risk–benefit profiles of many medications used in combination with stimulants in practice are not well described . However


This twin study examines the degree to which genetic and environmental risk factors for attention-deficit/hyperactivity disorder (ADHD) traits, across childhood and adolescence, are associated with adolescent hypomanic symptoms. Do symptoms of attention-deficit/hyperactivity disorder and hypomania share genetic and environmental risk factors in young people?In this twin study of 13 532 Swedish twin pairs aged 9 and 12 years at enrollment, up to 29% of the variance for hypomanic symptoms was associated with genetic risk factors shared with attention-deficit/hyperactivity disorder traits, with differing estimates detected for hyperactivity-impulsivity (up to 25%) compared with inattention (up to 16%) attention-deficit/hyperactivity disorder symptom domains.Attention-deficit/hyperactivity disorder and hypomanic symptoms appear to be associated with similar genetic factors. Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder are highly comorbid, with significantly associated symptoms. The mechanisms that account for their co-occurrence are not known.To examine the degree to which genetic and environmental risk factors for ADHD traits, across childhood and adolescence, are associated with adolescent hypomanic symptoms.This study used data on 13 532 twin pairs from the Child and Adolescent Twin Study in Sweden, a prospective, longitudinal twin study. Their parents provided ADHD data when children were 9 or 12 years of age. Of those who reached 15 years of age, 3784 participated. Of those who reached 18 years of age, 3013 participated. The study was performed from December 20, 2017, to December 5, 2018. Data analysis was performed at the Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Stockholm, Sweden, from March 1, 2018, to October 31, 2018.Attention-deficit/hyperactivity disorder traits and hypomanic symptoms were assessed using parent-rated instruments. Associations between ADHD and adolescent hypomanic symptoms across childhood and adolescence were investigated using generalized estimating equations. Multivariate twin models were used to examine the extent to which genetic and environmental risk factors for ADHD were associated with hypomania.P < .001; age 18 years: β = 0.19; 95% CI, 0.16-0.22; P < .001), especially for the hyperactivity-impulsivity ADHD symptom domain  compared with the inattention domain . Between 13% and 29% of the genetic risk factors for hypomania were also associated with ADHD, with higher estimates detected for symptoms of hyperactivity-impulsivity (10%-25%) compared with inattention (6%-16%). Environmental factors played a negligible role in the associations. Genetic factors unique to adolescent hypomania were associated with 25% to 42% of its variance, suggesting some etiologic distinction between these forms of psychopathology.Among 3784 15-year-old twin pairs and 3013 18-year-old twin pairs, ADHD and hypomanic symptoms were significantly associated (age 15 years: β = 0.30; 95% CI, 0.24-0.34; More than a quarter of the genetic risk factors for adolescent hypomanic traits were also associated with ADHD symptoms in childhood and adolescence, with hypomania-specific genetic risk factors detected. These findings suggest that ADHD and hypomanic symptoms are associated with shared genetic factors, which should be the focus of further research. Bipolar disorder is characterized by hypomanic or manic episodes. Hypomania is common in youths, with up to 10% identified as being at high risk of BD based on the clustering, duration, and impairment of symptoms.2 Subsyndromal hypomanic symptoms or traits have been linked to subsequent manic or hypomanic episodes and BD onset.3Early identification of individuals at high risk of bipolar disorder (BD) is essential for prevention and intervention4 found higher incidence rates of BD among those with a history of ADHD  compared with those without . The comorbidity rates of BD-ADHD are higher than expected by chance5; the weighted mean prevalence of ADHD in pediatric bipolar samples is 48%.6 A study7 that used modified BD diagnostic criteria characterized by nonepisodic irritability and ultrarapid cycling in pediatric samples reported high ADHD-BD comorbidity rates of 74% to 98%. The focus on nonepisodic irritability, which also covers temper outbursts and emotion dysregulation, may have increased these comorbidity rates because such symptoms are associated features of ADHD.8 After much debate, there is some consensus that nonepisodic irritability is more characteristic of severe mood dysregulation or disruptive dysregulation disorder rather than BD.8 Thus, care needs to be taken to differentiate between BD and these syndromes.There is evidence that BD is preceded by childhood ADHD; a population-based study9 The ADHD symptom domains of hyperactivity-impulsivity and inattention may be differentially associated with BD. One study10 found that BD was associated with inattentive and combined but not hyperactive-impulsive ADHD presentations. Others12 have reported similar levels of inattention and hyperactivity-impulsivity in patients with BD. These disparate findings need to be addressed with further research. The co-occurrence of ADHD and BD is associated with worse outcomes, including higher rates of comorbidity and suicide attempts, compared with BD or ADHD alone.13 It is crucial to determine the origins of the ADHD-BD overlap, distinguishing inattention from hyperactivity-impulsivity, to avoid such outcomes.Significant, modest correlations between adolescent hypomanic and hyperactivity symptoms have also been reported.14 That study14 focused on BD not hypomania and did not distinguish between the ADHD presentations. The sample had a broad age range; thus, it is unclear whether the results apply to different age groups. Research focused on childhood and adolescence would be useful because the initial emergence of psychopathologic symptoms occurs at these developmental stages. This was the first twin study, to our knowledge, to explore the extent to which genetic and environmental risk factors for hypomanic traits are associated with ADHD symptoms in youths, examining inattention and hyperactivity-impulsivity separately.Shared genetic risk factors are postulated to be partly responsible for the ADHD-BD association and their related symptoms. A moderate genetic correlation between ADHD and BD II using family data has been reported.15 Their parents provided ADHD data when children were 9 or 12 years of age . Of those who reached 15 years of age, 3784 participated . Of those who reached 18 years or older, 3013 participated . Pairs were excluded if either twin had a known brain injury or chromosomal disorder (n = 207). Data analysis was performed at the Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Stockholm, Sweden, from March 1, 2018, to October 31, 2018. Parents provided consent for themselves and their children to participate at 9 or 12 years of age, and the twins and their parents gave separate written informed consent at subsequent waves after receiving the study description. The study was approved by the Karolinska Institutet Ethical Review Board. All data were deidentified.This twin study used data from 13 532 twin pairs who participated in the Child and Adolescent Twin Study in Sweden, a longitudinal, prospective twin study performed from December 20, 2017, to December 5, 2018.16 which distinguishes children with BD from children with ADHD and healthy control individuals with high sensitivity  and specificity .16 The parent-rated Mood Disorders Questionnaire17 was used to assess hypomanic symptoms at 18 years of age, with high sensitivity  and specificity  in identifying adolescent BD.17 Both instruments cover symptoms that are more specific to mania  compared with other forms of psychopathology (ADHD).18 Further details of all measures are presented in eTable 1 in the Hypomania was assessed at 15 years of age using the parent-rated Child Mania Rating Scale (CMRS),19 a structured telephone interview completed by parents. The A-TAC ADHD domain consists of impulsivity and activity as well as concentration and attention modules, corresponding to the DSM-IV ADHD criteria.19 Parents rated ADHD symptoms when the twins were 15 years of age using the Strengths and Difficulties Questionnaire hyperactivity subscale,20 and the ADHD DSM-IV subscale of the Adult Behavior Checklist21 was used when twins were 18 years of age. The Adult Behavior Checklist was divided into hyperactivity-impulsivity (6 items) and inattention (7 items) domains based on similarity with DSM-5 criteria.The ADHD symptoms at 9 and 12 years of age were assessed using the Autism-Tics, ADHD, and Other Comorbidities Inventory (A-TAC),International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code, F90) and/or BD diagnosis  were identified using the Swedish National Patient Register,22 which records all specialist inpatient and outpatient care given to residents of Sweden. Cases of BD were also identified through lithium prescriptions using the Prescribed Drug Register,23 which covers all medications prescribed to residents of Sweden since 2005.Participants who had received an ADHD  and ADHD  instruments , nonadditive genetic risk factors (D), common or shared environmental risk factors , and nonshared or unique environmental risk factors .26Univariate models were used to assess the relative contribution of A, D, C, and E to each measure and to test assumptions of the twin design. We assessed whether genetic and environmental risk factors for ADHD traits are associated with hypomania by fitting a multivariate Cholesky decomposition to the data . The pro27 All analyses were repeated for both ADHD dimensions. The Strengths and Difficulties Questionnaire hyperactivity scale was omitted from these analyses because it only covers hyperactivity.Because univariate analysis implicated C for hypomania and not ADHD, we fitted a model in which A, D, and E were associated with ADHD and A, C, and E were associated with hypomania (C and D did not contribute to the covariance among phenotypes in this model), as well as the A, C, and E and A, D, and E models. Whenever D was estimated, sibling interaction paths were also included in the model because these factors can mimic that of D with twin correlations and are implicated when the assumption of equal variances across zygosity is not met. Each model was fitted with separate variance and covariance components by sex (quantitative sex limitation). The significance of these sex differences was tested by constraining all pathways to be equal by sex. We tested further nested models to assess the significance of individual groups of variance and covariance components. Model fit was assessed using Bayesian information criteria, which outperforms alternative fit statistics when fitting multivariate models to large samples. Lower Bayesian information criteria values indicate better fitting models.P < .001).A total of 13 532 twin pairs  participated in this study at 9 or 12 years of age, with 3784 followed up at 15 years of age and 3013 at 18 years or older. The descriptive statistics by sex and zygosity are presented in The continuous measures of ADHD and hypomanic symptoms were used for the remaining analyses. Twin correlations for ADHD and hypomanic traits are given in Phenotypic and cross-trait cross-twin correlations are presented in Hyperactivity-impulsivity was more strongly associated with hypomanic symptoms compared with inattention . Up to 2To our knowledge, this was the first twin study to explore the shared genetic and environmental factors associated with ADHD and hypomania symptoms in youths. Traits of ADHD across childhood and adolescence were associated with adolescent hypomania. More than a quarter of the variance for hypomania was associated with shared genetic risk factors for ADHD traits . Hypomania-specific genetic risk factors accounted for 27% to 46% of its variance. Environmental factors played a negligible role in the ADHD-hypomania symptom association. The genetic overlap with hypomania was larger with hyperactivity-impulsivity  compared with inattention .2 For example, 1 study28 found that among 98 adolescent patients with BD, 37.8% presented with ADHD, similar to the comorbidity rate of 37% in our study. Both ADHD dimensions were significantly associated with hypomania in this study, with a stronger association with hyperactivity-impulsivity. Previous research suggests that both ADHD domains are associated with BD to a similar degree12 or more strongly with inattention10 using data from adults10 and outpatients.12 We used a community sample of youths because the association between hypomania and the ADHD presentations may vary with age and from population to service level and assessment method.The associations between ADHD and hypomanic symptoms observed here are similar to those reported in other adolescent samples.14 on BD II and ADHD  and a molecular genetic study29 .This investigation provides a novel contribution by exploring the shared genetic and environmental factors associated with the ADHD-hypomania overlap in youths, examining hyperactivity-impulsivity and inattention separately. The percentage of variance in hypomania that could be associated with shared genetic factors with ADHD symptoms  concurs with genetic correlations reported by a family study30 This finding is consistent with results showing that the degree to which ADHD symptom domains share genetic risk factors with other psychopathological dimensions in youths varies.31Our other novel finding is that up to 25% of the variance in hypomania was associated with genetic factors related to hyperactivity-impulsivity compared with up to 16% for inattention.13 Future studies should follow up youths identified as high risk for BD and who exhibit ADHD symptoms to ascertain whether they develop specific forms of psychopathology. Second, significant genetic factors play a role in adolescent hypomania that are distinct from ADHD, suggesting that these phenotypes are not an extension of one another. Our results build on the ADHD and hypomania etiologic models, indicating shared genetic factors associated with these disorders. Uncovering the specific nature of the genetic overlap between these phenotypes should be the focus of further research.Our findings have important clinical and research implications. First, our results provide additional evidence of the ADHD-hypomania symptom overlap in youths, highlighting the need for early identification and recognition among practitioners, especially given the care needed to avoid the negative outcomes associated with ADHD-BD comorbidity  compared with when these conditions occur alone.32 The ADHD measures have good psychometric properties and are widely used.Strengths of this study include the use of a large, longitudinal, genetically informative sample; use of nationwide registries; and the distinction between the ADHD symptom domains in association with adolescent hypomanic traits; however, there are some limitations. First, hypomania was not measured in childhood; thus, the association between earlier hypomanic symptoms and ADHD traits across childhood and adolescence could not be assessed. Second, hypomanic and ADHD symptoms were measured using different instruments at each age, which may have affected the results. Both hypomania measures are considered among the best-validated and most discriminating adolescent BD instruments.7 particularly concerning their symptom similarity. In the current study, significant correlations between hypomania and ADHD symptoms were detected even when overlapping symptoms were removed from the hypomania scales, but various factors may still confound these associations. For instance, shared method variance may have inflated the associations because both phenotypes were measured using questionnaires.33Also, there has been much debate surrounding the overlap between ADHD and hypomania,7 These features were not accounted for here, which may have affected the ADHD-hypomania associations reported and should be considered in future research. Questionnaires are a practical data collection method for large samples needed to undertake twin research. However, they have various limitations, such as the reliance on a restricted number of items that sometimes lack context. Given that ADHD and hypomania were assessed using a restricted number of items, only 2 of 10 items for the CMRS and 5 of 13 for the Mood Disorders Questionnaire overlapped between these phenotypes and were removed to account for symptom similarity. It is possible that some overlapping symptoms were not measured.Several associated features of ADHD  not included in its diagnostic criteria overlap with hypomania.Whether the presentation of overlapping symptoms is chronic or episodic is crucial to determining whether the symptoms are characteristic of ADHD or hypomania but was not clarified in all instruments used in this study . Standardized diagnostic interviews are a more comprehensive approach to establish the specific nature of the symptom presentation and should be adopted by future studies.28 These shortcomings include low agreement with standardized diagnostic interviews34 and questionable interrater reliability, particularly for BD.36 When BD is misdiagnosed, it is frequently misdiagnosed as ADHD,37 which affects the accuracy of the ADHD-BD comorbidity rate detected.The ADHD-BD comorbidity was assessed using official diagnoses in the Swedish National Patient Register, but this method has several shortcomings that can inflate the comorbidity rate, although it was comparable to that in another study.To our knowledge, this was the first study to examine the shared genetic and environmental factors associated with ADHD traits across childhood and adolescence and adolescent hypomania in a representative, longitudinal twin cohort. The collective genetic risk factors for ADHD across childhood and adolescence may also be associated with hypomanic symptoms. The observed associations were stronger between hypomania and hyperactivity-impulsivity compared with inattention, but the association between inattention and hypomania was moderate and significant. This finding suggests that the overlap between ADHD and hypomania traits is likely to reflect a genetic link between these phenotypes. Nevertheless, a substantial amount of the variance for hypomania was associated with genetic risk factors that were not shared with ADHD.


Microtus, has not yet been precisely examined concerning tick-borne pathogens in Central Europe. Therefore, we examined small mammals from Germany and the Czech Republic for the following vector-borne pathogens: Babesia spp., Bartonella spp., Anaplasma phagocytophilum, “Candidatus Neoehrlichia mikurensis” (CNM) and Coxiella burnetii. Spleen DNA from 321 small mammals belonging to four genera, Myodes (n = 78), Apodemus (n = 56), Microtus (n = 149), Sorex (n = 38), collected during 2014 in Germany and the Czech Republic were available for this study. DNA samples were examined for the presence of Babesia and Bartonella DNA by conventional PCR targeting the 18S rRNA gene and the 16S–23S rRNA intergenic spacer region, respectively. For the detection of CNM, A. phagocytophilum and C. burnetii real-time PCR assays were performed.Rodents are important reservoirs for zoonotic vector-borne agents. Thus, the distribution of rodents and their vicinity to humans and companion animals may have an important impact on human and animal health. However, the reservoir potential of some rodent genera, e.g. Bartonella spp. DNA was detected in 216 specimens (67.3%) with 102/174 (58.6%) positive in Germany and 114/147 (77.6%) in the Czech Republic. The prevalence in each genus was 44.9% for Myodes, 63.2% for Sorex, 77.2% for Microtus and 75% for Apodemus. Four Bartonella species, i.e. Bartonella sp. N40, B. grahamii, B. taylorii and B. doshiae, as well as uncultured bartonellae, were detected. The Bartonella species diversity was higher in rodents than in shrews. In total, 27/321 (8.4%) small mammals were positive for CNM and 3/321 (0.9%) for A. phagocytophilum (S. coronatus and M. glareolus). All samples were negative for Babesia spp. and Coxiella spp.Bartonella in Apodemus and Myodes spp. is confirmatory with previous findings, the prevalence in Microtus spp. was unexpectedly high. This indicates that individuals belonging to this genus may be regarded as potential reservoirs. Interestingly, only Sorex spp. and M. glareolus were positive for A. phagocytophilum in the present study, suggesting a possible importance of the latter for the maintenance of certain A. phagocytophilum strains in nature.While the detected high prevalence for The online version of this article (10.1186/s13071-019-3576-7) contains supplementary material, which is available to authorized users. Bartonella henselae, is mainly harboured by wild and domestic cats  were collected for a previous study  was performed as described . In total, 21 samples showed 97–100% similarity to B. taylorii , 11 samples showed 100% identity with B. grahamii (GenBank: CP001562), and ten with a similarity of 99–100% to B. doshiae . Seven samples showed 99–100% similarity to Bartonella sp. N40   than in shrews (only B. taylorii). Interestingly, B. grahamii was detected exclusively in M. arvalis originating in Germany and B. doshiae exclusively in M. arvalis from the Czech Republic.A representative number of 84 out of 216 (41.2%) M. glareolus had a significantly higher probability for CNM infection compared to M. arvalis, but not compared to A. flavicollis. The two species belonging to the family Cricetidae showed an effect of weight on infection probability  small mammals tested positive for A. phagocytophilum  . Regarding co-infections, double infections of Bartonella spp. and CNM were most frequently detected . Co-infections with A. phagocytophilum and Bartonella spp. occurred less often .In total, 27 out of 321  small mammals were positive for CNM  as well as in Norway rats (Rattus norvegicus)  is observed to be low to moderate in Europe [Bartonella spp. were reported with high prevalences (16–70.6%) in Apodemus and Myodes from Sweden, Germany and Poland [M. glareolus is expected to be lower because bank voles are known to have an immune-mediated clearance of the infection within a few months [M. glareolus was significantly lower than in Apodemus and Microtus in the present study. Thus far, prevalences in Microtus voles from Poland and Austria have ranged between 14–18%; however, only a low number of individuals were tested [Microtus spp. which is line with recent studies from Poland and Spain (47–66.8%) [Microtus were thus far not examined for immunity or the ability to resolve Bartonella infections. However, regarding the prevalence from the present study it seems highly unlikely that they have the ability to resolve an infection with Bartonella or the duration of resolving the infections seems rather long. The Bartonella species found in this study were likewise present in small mammals from a former study on small mammals [Bartonella-positive samples yielded similarity to uncultured Bartonella spp. with unknown pathogenicity. This observation is in line with previous findings in other small mammals from Germany [Bartonella spp. was higher in rodents than in shrews. However, B. taylorii was found in all examined small mammal genera. This Bartonella species is known to be strongly associated with rodent hosts and fleas adapted to rodents such as Ctenophthalmus nobilis [B. taylorii-associated strains which form in a cluster were found earlier in Sorex shrews from Sweden [B. taylorii-associated strains was detected in S. araneus from the UK [B. taylorii-strains adapted to Sorex spp. as the collected specimens were solely positive for B. taylorii. Bartonella grahamii is the only Bartonella species of proven human-pathogenicity [Microtus spp. originated in Germany, B. doshiae could exclusively be detected in these individuals, hinting that B. doshiae may have a rather focal distribution pattern in comparison to all other Bartonella species which were detected likewise in voles of both examined countries. Sex and age could not be confirmed as significant demographic factors determining individual infection status with Bartonella sp., which is in contrast to previous studies [This study presents the examination of arthropod-borne pathogens such as  species . The pren Europe . In prevalences 1–70.6% ind Poland , 35. Thee tested . In the 7–66.8%) , 37. Indm Sweden . Additiom the UK . Our stu studies .M. glareolus and A. flavicollis from the Netherlands, Germany, France and Slovakia (1.8–52.7%) [Microtus were also previously analysed for the presence of CNM in Germany, Russia, Slovakia and Sweden [Microtus spp. with a more representative number of individuals (n = 149). Individuals belonging to the family Soricidae are assumed not to maintain CNM in the natural life-cycle [Sorex spp. in our study was positive, this suggestion may be confirmed. Previous studies have reported approximately equally high prevalences of CNM in both A. flavicollis and M. glareolus [M. glareolus and A. flavicollis and was explained by a higher chance of encountering CNM through a higher stress level in males as well as their higher activity radius and fights due to territorial behaviour [I. ricinus burdens than females, which was explained by higher levels of testosterone reducing the resistance to tick infestation [CNM was exclusively detected in rodents, and in none of the insectivores here or in previous studies. Earlier studies showed moderate to high prevalences in 8–52.7%) , 40, 41.d Sweden , 15, 42.uals n = 9. Indivilareolus . Moreoveehaviour . Howeverestation .Sorex spp. (5.3%) and M. glareolus (1.3%) were positive for A. phagocytophilum in the present study. High prevalences in Sorex spp. and M. glareolus have previously been reported in studies from Romania, the UK and Switzerland (9.09–19.2%) [S. araneus for the maintenance of certain A. phagocytophilum strains in nature. In this regard, future studies should focus on a more thorough investigation of Sorex spp. as potential reservoirs, as our study also found high prevalences in Sorex spp. In contrast, all other captured small mammal species from the present study presumably only play a minor or no role in the maintenance of A. phagocytophilum in its natural life-cycle in central Europe.Interestingly, only  9.09–19.% [2, 44,9–19.2%) . In part9–19.2%)  emphasizBabesia nor C. burnetii were found in the small mammals leading to the conclusion that the captured small mammal species may play only a subordinate role in their transmission life-cycle. Pluta et al. [C. burnetii in small mammals from endemic areas in southern Germany. Nonetheless, DNA of C. burnetii was detected by low prevalence rates in brown and in black rats at livestock farms from the Netherlands [C. burnetii was further found in a few small mammals collected from a sheep farm with reported Q fever outbreaks [via indirect contact with infected sheep rather than through tick bites. In earlier studies, Babesia was found in Microtus and other small mammal species with a low to moderately high prevalence in Switzerland, Germany and Poland (0.4–14.17%) [Babesia spp. has also been reported in A. flavicollis and M. glareolus from Poland [B. microti in Ixodes ricinus ticks from central and eastern Europe is also known to be rather low (0.5–13%) [In the present study, neither a et al.  also repherlands . In Spaiutbreaks . However–14.17%) –50. Stilm Poland  which is0.5–13%) .Bartonella in M. arvalis from the Czech Republic. The prevalence for flea-borne bartonellae was higher than for tick-borne pathogens in M. arvalis in contrast to other tested common rodent species such as M. glareolus. The reason may be that Microtus spp. are more likely to live in grassland and agricultural areas than in urban or sylvatic regions where ticks are more prevalent. The species diversity of Bartonella spp. was higher in rodents than in shrews. Sorex spp. seem to be only relevant for the maintenance of non-pathogenic B. taylorii. Interestingly, only Sorex spp. and M. glareolus were positive for A. phagocytophilum in the present study, suggesting their potential importance for the maintenance of certain A. phagocytophilum strains in nature.To our knowledge, this study shows for the first time a very high prevalence of Additional file 1: Table S1. Details on primers and PCR assays used for the detection of vector-borne pathogens in rodents from Germany and the Czech Republic. Abbreviations: C, conventional PCR; RT, real-time PCR; ITS, intergenic spacer.


Background: Maternal diabetes mellitus (DM) increases the risk of fetal, neonatal, and long-term complications in offspring. Although this has been widely known for decades, data are limited regarding the effect of maternal pregestational and gestational diabetes on the subsequent neurodevelopmental outcome of offspring. This study investigated whether infants of mothers with diabetes (IDMs) were associated with a risk of subsequent attention deficit hyperactivity disorder (ADHD).Objectives: We collected data from newborn infants born to mothers with gestational or pregestational diabetes at China Medical University Children's Hospital between January 1, 2006, and December 31, 2012. These patients were followed to evaluate their risk of ADHD (IDM group) compared with that for those born to mothers without DM (non-IDM group). Several assumed perinatal risk factors accompanying the IDMs were also analyzed.Results: Overall, 104 patients with average gestational ages of 36.5 weeks were included in the IDM group. Additionally, 110 patients with average gestational ages of 36.6 weeks were included in the non-IDM group. Compared with non-IDMs (reference), the overall risk of ADHD in IDMs was 2.6 . Furthermore, the risk of ADHD among male  and full-term infants  in the IDMs was higher than that in the non-IDM group. No significant differences were found among IDMs for the assumed perinatal risk factors that were analyzed.Conclusions: The study revealed a higher incidence rate of ADHD in IDMs, especially male and full-term infants. It is crucial for pediatricians to identify the early symptoms neurodevelopmental disorders, especially ADHD, in children of diabetic mothers to initiate proper assessment and treatment. Maternal diabetes mellitus (DM) increases the risk of fetal, neonatal, and long-term complications in offspring. Although this has been widely known for years , publicaADHD is a disease with multifactorial etiology, characterized by symptoms of hyperactivity, impulsivity, or inattention that can affect cognitive, academic, behavioral, emotional, and social functioning . In addiBased on the understanding of the neurodevelopmental influence of maternal DM and clinical observation of higher ADHD occurrence in IDMs, we conducted a retrospective cohort study to observe whether IDMs were associated with a risk of subsequent ADHD. Additionally, risk factors accompanying IDMs were investigated in this study. We hypothesized that IDMs have an increased risk of ADHD compared with infants of mothers without diabetes.The study protocol was approved by the Ethics Review Board of China Medical University . In this retrospective study, we collected hospitalization data on newborn infants born to mothers with gestational or pregestational diabetes at China Medical University Children's Hospital between January 1, 2006 and December 31, 2012. Assumed risk factors related to IDMs and for subsequent NDDs were as follows: prematurity, congenital anomalies or cardiomyopathy, perinatal insults , macrosomia, and neonatal hypoglycemia. Preterm birth in the present study was defined as any birth before 37 completed weeks of gestation. Macrosomia was defined as birth weight over 4,000 g irrespective of gestational age. Neonatal hypoglycemia in the first 24 h of life was defined as a blood glucose level of <40 mg/dL. Congenital anomalies or cardiomyopathies were screened using echocardiography, cranial sonography, and renal ultrasound for each IDM by a neonatologist and confirmed by an individual subspecialist. The exclusion criteria were as follows:Loss of contact with a patient during the follow-up period.Patients who developed NDDs or epilepsy with documented etiology or followed by a causative event; for example, central nervous system infections, copy number variations, or single gene mutations, which were related to epilepsy and NDDs.Patients who were born relatively preterm (<30 weeks).Patients who had a history of traumatic brain injury during the follow-up period.Maternal drug and alcohol use and smoking habit during pregnancy.The final study population comprised 104 patients (IDM group). In addition, we selected 110 children who were immediately hospitalized to the sick baby room at birth for reasons other than those related to being IDMs  as controls. The exclusion and follow-up protocols for the control group and the IDM group were the same. The last patient was enrolled in December 2012. All patients included in the study were followed-up from baseline until December 31, 2018. Therefore, for the purposes of this study, the youngest patient diagnosed with ADHD was 6 years old. Quarterly, we followed-up patients by reviewing their medical records and contacting their families through telephone or e-mail from the beginning of 2016. ADHD in both groups was confirmed in two ways: (1) A definite diagnosis made by a pediatric psychiatrist or pediatric neurologist through a scientific assessment, which was documented in their medical records; and (2) Other children and their parents were contacted to return to our pediatric neurology clinic for completion of ADHD-specific scales that focused on the core symptoms of ADHD . Once ADp-value of <0.05 to be statistically significant.All data were entered centrally. Categorical variables between groups were analyzed using χ2 tests. Furthermore, we calculated the incidence density rates of ADHD in both groups. The odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the associations between ADHD in the IDM group compared with the non-IDM group. In addition, univariate and multivariable analyses using logistic regression models were conducted to analyze the unadjusted and adjusted ORs and 95% CIs for the perinatal risk factors and maternal confounders for ADHD in the IDMs. All statistical analyses were performed using PASW Statistics version 18.0 . In addition, for all statistical analyses executed, we considered a two-tailed n = 13, 12.5%) and perinatal insults  were the second most frequently noticed complications in the IDM and non-IDM group, respectively. The incidences of macrosomia and neonatal hypoglycemia in the IDM group were statistically different from those in the non-IDM group (p < 0.05). The incidences of associated NDDs were higher in IDMs than in non-IDMs in terms of ADHD and other childhood cognitive outcomes . Furthermore, the risk of ADHD among male patients in the IDM group was even higher than that in the non-IDM group . In addition, full-term IDMs had a 4.5 times  higher risk of having ADHD compared with those in the non-IDM group.Although it is not a new concern that IDMs are subject to certain NDDs during childhood, relevant studies are limited , 15. TheCommon neonatal morbidity factors associated with IDMs that we also assumed to be risk factors for ADHD included prematurity, congenital anomalies, perinatal insults , macrosomia, neonatal hypoglycemia, and cardiomyopathy . HoweverStudies have showed that IDMs have an increased lifetime risk of diabetes. The risk of DM (either T1DM or T2DM) in an offspring of a DM mother arises from both genetic susceptibility –30 and iThis study had some limitations. First, although we detected a possible risk of ADHD in IDMs through this observational study, more in-depth investigations are expected in the future to determine associated risks and to identify their underlying mechanisms. As stated above, some confounding factors may have affected the results, such as the health and diabetes control status of the mother before and during pregnancy, socioeconomic status, pharmacological treatment of children before preschool age, malnutrition, and other environmental factors. Second, our sample size was not sufficiently large; thus, a population based cohort study should be designed to prove our findings. Third, we did not perform an analysis of ADHD subtype because of study design restrictions. Fourth, the sample was biased because it had a higher number of boys than girls, given that boys may actually have a higher occurrence of ADHD in the general population, and this may have influenced the outcome of risk calculations. Furthermore, there are some difficulties for our researchers to convince large enough families of healthy babies to return to the hospital for completion of ADHD-specific scales. On the contrary, babies who discharged from the sick baby room underwent a routine follow-up till school age based on hospital policy. Therefore, additional research that focuses on neuroimaging, genetic susceptibility, iron homeostasis, or proinflammatory cytokines, and a control group based on healthy babies may identify potential mechanisms.In summary, the results of this study revealed a higher incidence rate of ADHD in children who were IDMs, especially male and full-term infants. It is crucial for pediatricians to identify the early symptoms of NDDs, especially ADHD, in children who were IDMs to initiate proper assessment and treatment. Additional patient data and more detailed studies are warranted to elicit potential prenatal, perinatal, postnatal, and maternal confounders in order to clarify the influence of being born to a mother with diabetes and its association with ADHD.The datasets generated for this study are available on request to the corresponding author.After a full description of the study, written informed consent of participation was obtained from the legal guardians. The study protocol was approved by the Ethics Review Board of the China Medical University ethics committee .S-YH collected and analyzed the data and prepared the draft. C-HL and W-DL participated in the design of the study and wrote the manuscript. I-CL and I-CC compiled the statistics of this study and participated in the editing and revising the tables. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Iron is a cofactor in the production and breakdown of neurotransmitters like dopamine and is vital for normal brain function. Iron deficiency potentially contributes to the development of attention deficit hyperactivity disorder (ADHD) because dopamine imbalances can cause hyperactivity, restlessness and problems with concentration and attention. However, a direct association between iron deficiency and ADHD remains to be determined.The aim of this study was to investigate the possible correlation between iron deficiency and ADHD in children and adolescents seen at the child psychiatry outpatient service at Tygerberg Hospital, South Africa.A retrospective chart review was conducted to gather data of all outpatient children and adolescents who had their serum ferritin and/or iron levels tested between February 2011 and January 2016. Relevant demographic and clinical information was extracted from 255 records, and statistical methods were used to test for correlations between ADHD and certain variables, including iron deficiency.p = 0.150).Out of 255 patients, 88 (34.5%) had iron deficiency, 157 (61.6%) had ADHD and 54 (21.0%) had both iron deficiency and ADHD. Of those patients with ADHD, 11 (7.0%) had other psychiatric comorbidities, and more males (89.0%) had this dual diagnosis compared to females (11.0%). Variables found to be significantly associated with ADHD included gender, age, Ritalin treatment and psychiatric comorbidities, but there was no significant association between ADHD and iron deficiency (There was no relationship between ADHD and iron deficiency in this cohort of children and adolescents. Further studies using a treatment-naïve sample are required.


Bartonella infections are known to inflict a wide range of mammals and, within rodents alone, more than 20 Bartonella species have been detected. There is, however, a lack of studies on the presence of Bartonella spp. in rodents in the Baltic region. We analysed 580 individuals belonging to eight small rodent species trapped in coastal and continental areas of Lithuania during 2015–2016. The presence of Bartonella DNA was examined by real-time PCR targeting the ssrA gene. The molecular characterization of the bacteria strains was based on sequence analysis of two housekeeping genes  and the intergenic spacer region (ITS). For the rodents overall, the prevalence of Bartonella spp. was 54.8%, while the prevalence figures for each of the individual species were 8.3% in M. musculus, 15.8% in A. agrarius, 33.3% in M. arvalis, 42.4% in M. glareolus, 53.4% in M. oeconomus, 57.5% in M. minutus, 79.6% in A. flavicollis to 80% in M. agrestis. Sequence analysis revealed that the Bartonella strains belonged to the B. grahamii, B. taylorii, B. rochalimae, B. tribocorum, B. coopersplainsensis and B. doshiae genogroups. The highest Bartonella infection rates and the highest species diversity were both detected in rodents captured in the coastal area. To our knowledge, these are the first reports of the presence of B. coopersplainsensis, B. doshiae and B. tribocorum in Lithuania.Worldwide,  The most important vectors for the maintenance and transmission routes of the Bartonella species are fleas, that feed on mammalian hosts such as cats, dogs, rodents, insectivores and rabbits3. There are currently 35 Bartonella species and three subspecies with standing in the Taxonomy Database of the National Center for Biotechnology Information (http://www.bacterio.net/Bartonella.html). However, the number of species in genus Bartonella is growing, as not all Bartonella species have been validated. Currently, 45 official and candidate Bartonella species have been detected in vertebrates, and at least fifteen of them have been related to human diseases4. During their evolution, Bartonella spp. have adapted to a variety of reservoir hosts and have become pathogenic when introduced into an incidental host6. With more than 20 Bartonella species associated with rodents, this group of mammals represents an important group of potential reservoirs for many Bartonella infections that have been reported worldwide7. Human pathogenic Bartonella species such as B. elizabethae, B. tribocorum, B. grahamii, B. rochalimae, B. vinsonii and B. washoensis have been isolated from various rodent species7. More than one Bartonella species can circulate in rodent communities, and multiple Bartonella genotypes in the same rodent host have been reported9.Bartonellae are facultative intracellular, fastidious, gram-negative bacteria that are transmitted to humans and other mammals by bloodsucking arthropod vectors such as fleas, mites, sand fleas and ticksApodemus flavicollis), wood mouse (Apodemus sylvaticus), striped field mouse (Apodemus agrarius), bank vole (Myodes glareolus), common vole  field vole (Microtus agrestis) and root vole (Microtus oeconomus) are rodent species that play important roles in the maintenance and circulation of Bartonella infections in Europe8. Bartonella pathogens have been reported in several rodent populations in Poland, Germany, Denmark and Sweden . However, Bartonella epidemiology and host-pathogen associations in Europe, including in the Baltic region, are insufficiently characterized.The yellow-necked mouse  and the 16S-23S rRNA intergenic species region (ITS).The objectives of this study were to investigate the prevalence of Bartonella spp., and out of these, 127 samples had Ct value below 30.Based on real-time PCR analysis, a total of 318 of the rodent DNA samples  were found positive for Bartonella spp. was found in A. flavicollis and M. agrestis ; in M. minutus, M. glareolus and M. oeconomus the prevalence was in the range of 30–50%, while in other rodents, the prevalence was lower   were detected in those trapped on the Curonian Spit . Likewise, among all investigated areas, a significantly higher overall prevalence of Bartonella was observed on the Curonian Spit  with the highest prevalence of Bartonella detected in sampling site 2 .Comparing Bartonella-positive PCR products of partial rpoB, groEL genes and ITS region derived from 56 different rodent specimens of eight species were subjected to sequence analysis (Table rpoB (n = 43), groEL (n = 9) genes, and ITS region (n = 21) were obtained and analyzed.Eighty-seven is Table . A totalrpoB gene sequences showed that the Bartonella species circulating among the investigated rodents were heterogenic and belonged to B. grahamii, B. taylorii, B. tribocorum, B. coopersplainsensis and B. rochalimae genogroup , A. agrarius (n = 3), harvest mouse Micromys minutus (n = 3), common house mouse Mus musculus (n = 1), M. glareolus (n = 5) and M. arvalis (n = 1) were 95–100% similar to B. grahamii sequences deposited in the GenBank   were identified , M. glareolus (n = 11), M. agrestis (n = 4) and M. oeconomus (n = 1) were 97–100% identical (differing at 48 nucleotide positions) to B. taylorii sequences obtained in the GenBank  ; four in A. flavicollis (differing at 28 nucleotide positions) and two in M. agrestis (differing at 10 nucleotide positions). Two Bartonella rpoB sequences derived from A. agrarius  shared 99–100% identity to the B. tribocorum detected in A. agrarius from South Korea (GenBank: JN81812) (Table Bartonella sequences derived from M. glareolus (site 2), M. oeconomus (site 7) and A. agrarius (site 6) were 98–99% identical to B. rochalimae (GenBank: DQ676489), Candidatus Bartonella rudakovii (GenBank: EF682088) and B. coopersplainsensis  respectively , A. agrarius (n = 2), M. minutus (n = 3), M. arvalis (n = 1), M. oeconomus (n = 1) and M. glareolus (n = 1) were 97–100% identical (differing at 17 nucleotide positions) to B. grahamii sequences deposited in the GenBank . Four B. grahamii genotypes were identified , M. oeconomus (n = 2), M. agrestis (n = 1) and M. glareolus (n = 1) shared 97–99% similarity with B. taylorii sequences deposited in the GenBank . Obtained sequences were heterogenic (differing at 33 nucleotide positions), and eight B. taylorii genotypes were detected  was 99% identical (differing at nine nucleotide positions) to B. coopersplainsensis detected in rats from the Australia (GenBank: EU111770). Two sequences, one derived from A. agrarius and another from M. agrestis (site 6) were 98–99% identical to B. tribocorum (GenBank: JN810856) and B. doshiae (GenBank: AF442954) respectively  , M. minutus (n = 2), A. agrarius (n = 1), M. arvalis (n = 1) and M. agrestis (n = 1). One Bartonella groEL sequence derived from M. agrestis (site 6) was 100% identical to B. doshiae (GenBank: AF014832)  and A. flavicollis (79.6%) (Table A. flavicollis from the eastern Germany (84.4%10) but higher than those from Slovakia , Slovenia , Denmark , Poland . In M. agrestis, lower infection rates were found in Sweden , Denmark  and France . In Lithuania, a high Bartonella prevalence was also detected in M. minutus (57.5%), M. oeconomus (53.4%) and M. glareolus (42.4%). In other European countries, reported prevalence of Bartonella infection in M. glareolus include 69.0% (160/232) in Slovakia, 56.4% (252/447) in France, 52.8% (21/36) in Germany and 15.0% (9/60) in Sweden16. Bartonella-infected M. oeconomus have been found in Poland with an 11.1% (14/128) prevalence of infection14, a figure that s five times lower than that obtained in our study. The lowest overall prevalences of Bartonella spp. in the present study were found in A. agrarius (15.8%) and M. musculus (8.3%). In comparison, studies conducted in Slovenia and Slovakia detected 26.6% (8/30) and 9% (31/344) prevalence of Bartonella spp. in A. agrarius12, while Holmberg et al.15 reported a 5.6% (1/18) prevalence of infection in M. musculus from Sweden.Worldwide, the prevalence of %) Table . Our finBartonella spp. might be related to habitats and to the abundance of the rodent species16. In this study, extremely high Bartonella-infection rates (56.4–77.8%) were detected in rodent communities on the Curonian Spit   Tables .B. grahamii and B. taylorii have been detected in A. flavicollis, A. agrarius, A. sylvaticus, herb field mouse , steppe field mouse (Apodemus witherbyi), M. minutus, M. glareolus, M. arvalis, M. agrestis and M. musculus; while B. rochalimae has been detected in A. flavicollis, M. glareolus and M. arvalis , and B. doshiae, in A. flavicollis, A. agrarius, M. agrestis and M. glareolus .In Europe, B. taylorii. In general, B. taylorii strains demonstrate high diversity and are frequently found in mice, as well as in Myodes and Microtus voles, inhabiting boreal forests of the Eurasian continent . In line with this, the present study showed high diversity of B. taylorii strains in Lithuanian rodents. Phylogenetic analysis of rpoB gene revealed the presence of twelve B. taylorii genotypes associated with A. flavicollis mice (four out of twelve) and three species of voles M. glareolus, M. agrestis and M. oeconomus (eight out of twelve) .In this study, the 52.9% of sequences derived from small rodents were ascribable to ve) Fig. . The higB. grahamii strains were detected in 39.2% (20 out of 51) of rodent specimens and showed lower sequence diversity in comparison to B. taylorii. B. grahamii was detected in four species of mice , and four species of voles  , and Eremeeva et al.18 reported clinical case of bacteremia, fever, and splenomegaly in a patient who traveled to Peru. In Europe, Bartonella spp. related to B. rochalimae group have been detected in A. agrarius, A. flavicollis and M. arvalis from Slovakia19. We report Bartonella spp. from B. rochalimae group in M. oeconomus for the first time  and continental (site 8) areas with 100% similarity to the B. tribocorum isolate from South Korea  and approved by the Ministry of Environment of the Republic of Lithuania, licenses No. 22 (2015-04-10) and No. 12 (2016-03-30) in accordance with Lithuanian  and European legislation (Directive 2010/63/EU) on the protection of animals. Live traps were checked at least twice a day. Captured animals were anesthetized with COA. flavicollis, A. agrarius, M. minutus, M. musculus, M. glareolus, M. oeconomus, M. agrestis and M. arvalis were trapped with live-traps or snap traps in 12 locations situated in western  and eastern  parts of Lithuania during 2015–2016  and in the Nemunas River Delta (sites 6–7). The Curonian Spit is a narrow sand peninsula  in the southeastern coast of the Baltic Sea separating the Curonian Lagoon from the Baltic Sea. Rodent sampling on the Curonian Spit was conducted in coastal meadows and ecotone between meadow and mixed forest. In the Nemunas River Delta, trapping was conducted in two specific habitats: in a flood meadow in Rusnė  and in Žalgiriai forest  Table . Site 8 A. flavicollis (n = 173), while in the eastern part of Lithuania, it was M. glareolus (n = 99). The indoor rodent species M. musculus was captured only in one sampling location (site 9) in the mixed forest-meadow ecotone in the continental area   GenBank database sequences, NCBI BLAST® blastn suite applet for alignment and FastPCR online  java applet for primers test. The qPCR reactions were carried out with SensiMix™ II Probe Kit  in a total volume of 15 μL using 1 μL of the isolated DNA sample, primers at a concentration of 200 nM each and probe at a concentration of 100 nM. Real-time PCR assays were performed employing a real-time thermocycler Rotor-Gene Q 5plex model with software version 1.7  under the following conditions: denaturation at 95 °C for 10 min (1 cycle); followed by 50 cycles of denaturation at 95 °C for 20 s, annealing at 50 °C for 1 min and extension at 72 °C for 10 s. In each real-time PCR run, positive  and negative controls  were used. The results that satisfy amplification cutoffs below 40 Ct (cycle threshold) when threshold was 0.10101 indicated positive samples. Samples with Ct value below 30 were chosen for further molecular characterization of bacteria strains. For the amplifications of the 795 bp fragment of the RNA polymerase β-subunit (rpoB) gene and 336 bp of 60 kDa heat-shock protein (groEL), conventional PCR was used and for the amplification of 0.9–1.6 kb fragment of the 16S-23S rRNA gene intergenic species region (ITS), nested PCR was used  and the ITS region (from different rodent species and different regions) were chosen for sequencing . PCR products were extracted from agarose gel and purified using a GenJET PCR purification kit . The obtained partial rpoB, groEL genes and ITS region sequences were analyzed using the Mega software package, version 6.05, and compared with the sequence data available from the NCBI GenBank database using the NCBI BLAST® blastn suite applet. Phylogenetic trees were constructed using the maximum-likelihood (ML) method with Tamura-Nei model.DNA was extracted from each rodent spleen using a Genomic DNA Purification Kit, , according to the manufacturer’s instructions. Screening for the presence of be Table . The ssrrpoB, groEL genes and ITS region sequences for representative samples were submitted to the GenBank under the accession numbers MH547308 to MH547335 and MH687373 for the rpoB gene, MH547336 to MH547350 and MH687377-MH687379 for the ITS region, and MH547351 to MH547354 and MH687374-MH687376 for the groEL gene.Partial Bartonella spp. infection between different species of small rodents, sampling locations, regions were assessed by Fisher’s exact test, supplemented with the Mantel-Haenszel common odds ratio estimate and 95% confidence intervals using SPSS software version 22 . p < 0.05 was considered significant.Differences in the prevalence of


Polyunsaturated fatty acids (PUFAs) biostatus has been proposed as possible attention deficit hyperactivity disorder (ADHD) diagnosis biomarker. The present exploratory study aimed to investigate the association between PUFAs biostatus and cerebral cortex metabolism measured by functional Near Infrared Spectroscopy (fNIRS) in a sample of children with and without ADHD. 24 children with ADHD and 22 typically developing (TD) peers, aged 8–14, were recruited. Linoleic, arachidonic, docosahexaenoic and eicosapentaenoic acids levels were evaluated in whole blood. All children underwent fNIRS while performing an n-back working memory task. Between groups comparisons revealed lower levels of arachidonic acid in children with ADHD and stronger NIRS signal in TD participants, especially when completing more difficult tasks. Correlations conducted between fNIRS activation and PUFA biostatus revealed several associations between hemodynamic changes in the frontoparietal regions and fatty acids profile across participants. This result was also confirmed by the multiple hierarchical regression analyses that remarked an inverse effect of eicosapentaenoic acid levels on oxyhemoglobin values in right frontoparietal region. Such preliminary findings, if confirmed, would suggest that PUFAs could play a role in atypical neurodevelopment. Attention deficit hyperactivity disorder (ADHD), which affects approximately 7.2% of children worldwide, is the most common childhood neurodevelopmental disorder . ADHD isADHD manifestations are heterogeneous and impact cognition and behavior through a multifaceted aetiopathogenesis that involves biological, psychosocial, and environmental aspects.Given this complexity, an objective diagnosis biomarker has not been established. Conventionally, the ADHD diagnostic process relies on subjective criteria, such as clinical interviews, observations, and rating scales. Insight into the biological markers associated with typical and atypical development could offer clinicians more reliable tools for ADHD assessment and the opportunity to implement targeted treatment plans .Taking these premises into account, there has been growing interest in recent years in the role of nutrition in the development, treatment, and prevention of neurodevelopmental disorders. In particular, attention has been focused on the role of polyunsaturated fatty acids (PUFAs) as possible biological markers in ADHD , suPUFAs represent an indispensable component of lipids that cover a relevant role in human diet and biological functions such as provision of energy, functionality of cell membranes and tissue metabolism . The simCis-linoleic acid LA 18:2, n-6) and α-linoleic acid  are considered “essential” fatty acids because mammals cannot biosynthesize them. They are primarily plant-derived and exclusively available from diet. Mammals metabolize LA and ALA in long-chain PUFAs: n-6 PUFAs  derived from LA and n-3 PUFAs  derived from ALA ,11. PUFA:2, n-6 aEPA, DHA and their derived eicosanoids, on the other hand, are powerful regulators of biological process, with anti-inflammatory properties ,12. The DHA represents the 10–20% of the fatty acids in mammalian grey matter. It is important for neuronal cell membrane integrity and for the signaling system because it influences various neurotransmitter pathways, including the cholinergic system, which is known to play a key role in memory and learning ,15. TherOn the other hand, EPA-derived eicosanoids regulate the immune and endocrine systems and cardiovascular functions .N-3 deficiency and high n-6/n-3 ratios are indicators of inflammation and have been linked with various mental disorders, including ADHD ,16. In aWithin the last decade, an increasing number of studies has evaluated the association between PUFA intake or biostatus and human brain structure and function using various neuroimaging methods. To date, studies involving healthy subjects indicate that increased dietary fish intake and higher blood levels of DHA and EPA are usually associated with increased grey matter volume and greater activity-dependent cerebral blood flow . The relNear infrared spectroscopy (NIRS) is a viable approach with which to obtain information about cerebral cortex metabolism in a non-invasive manner and at relatively low cost. NIRS is an optical technique that uses light at specific wavelengths to detect changes in oxygenated and deoxygenated hemoglobin  concentrations over time . NIRS haHamazaki-Fujita and colleagues  used NIRA clinical trial conducted on healthy adult volunteers evaluated the effect of DHA and EPA supplementation on cortical hemodynamics measured using functional NIRS (fNIRS) during a cognitive task that elicited prefrontal cortex activation . The stuAlthough PUFA supplementation is one of the most popular non-pharmacological treatments for ADHD , few stuTo our knowledge, only Bos and colleagues  have invBased on previous considerations, the goal of the present study was to investigate the association between cerebral hemodynamic activation measured using fNIRS and blood PUFA levels in children with ADHD and typically developing (TD) peers. To elicit the cortical hemodynamic responses, we used an n-back working memory task with blocks of increasing difficulty . The samClinicalTrials.gov as NCT01796262 and was approved by our institute’s ethics committee in accordance with the Declaration of Helsinki (1967) and its later amendments. Written informed consent and assent were obtained from all caregivers and participants.The present study is a cross-sectional, observational study of children with and without ADHD that investigates the association between PUFA biostatus and brain hemodynamic responses to a cognitive task with differing workloads as measured with fNIRS. Our research is part of a placebo-controlled double-blind intervention trial (June 2012–October 2014) that explored the efficacy of DHA supplementation in children with ADHD (“The Effects of DHA on Attention Deficit and Hyperactivity Disorder - DADA Study”). The trial was registered at As a part of a larger project , 24 chilTwenty-one TD children living in the same areas as the children with ADHD were recruited as a control group. The research team excluded possible neuropsychiatric diagnoses in control subjects, using the DAWBA parent diagnostic interview. The genders and ages of TD children were matched to those of the clinical sample. Children in the control group completed the vocabulary and block design subtests of the Wechsler Intelligence Scale for Children-III (WISC-III)  to estimRegarding the whole research sample, only participants with FSIQ scores or estimated FSIQ scores higher than 80 were included. Moreover, all children were drug-naïve and did not consume omega-3 or omega-6 supplements during the 3 months prior to recruitment. Exclusion criteria included a history of seizures, other psychiatric or neurological disorders, and diagnosed genetic disorders. All participants were Caucasian and had normal or corrected-to-normal vision.Participants were assessed at our institute’s child psychopathology unit. Each child’s weight and the blood pressure were measured. Familial socioeconomic status was coded according to the Hollingshead scale for parental employment .Four subtests from the Amsterdam Neuropsychological Tasks (ANT)  were admAfter a minimum 1-hour fast, biological samples were obtained from all children by collecting drops of blood using an automatic lancing device that punctured the participant’s fingertip; a strip of paper was used to collect each sample. FAs profile was evaluated in whole blood, which is more easily obtainable than other blood components, such as red blood cells and plasma. Thus, we measured the status of long- and short-chain circulating FAs in relation to dietary habits . All bloDuring fNIRS recording, each participant completed a computerized protocol (approximately 15 min long) developed with the Presentation® software  developed by Cui and colleagues ,32. The fNIRS data acquisition, optode localization and data preprocessing. We acquired fNIRS data with a commercial continuous-wave NIRS device . An elastic cap of the proper head size with 32 channels was used. Specifically, 8 light sources and 24 light detectors were placed on the bilateral frontotemporal areas centered at F3 and F4, according to the International 10–20 system . The sou3s and s3s are the mean and the standard deviation of the 3 seconds before the block’s beginning [The preprocessed fNIRS time series and prior to fNIRS analysis, were standardized applying at each data point (p0) of the nine task blocks the following formula:eginning ,47. ThenStatistical analyses were conducted using the SPSS statistical software package .t test analyses (according to variables distribution) were conducted to examine between-group differences for demographic, clinical, cognitive, behavioral (n-back task performance) measures, and blood FAs levels.Data were visually and statistically inspected to check whether the variables were normally distributed and to address assumptions of linearity, independence of observations and homogeneity of error variance. Fisher’s exact test, Mann-Whitney, and independent-samples t test analyses  were computed to examine the between-groups difference of activation in each task condition for HbO and HbR in the four ROIs.Mann-Whitney or two-tailed independent-samples Total” measure from ADHD-RS). Since this study was exploratory, no correction was applied for family-wise error rate. However, confidence intervals (CIs) of 95% were calculated for Spearman’s Rho using the bootstrapping method (1000 bootstrap resamples) to indicate the likely size of the effect [To investigate possible associations between cortical hemodynamics and ADHD severity in the clinical sample, Spearman correlations were conducted between fNIRS activation significantly different between-groups and clinical scales for ADHD severity  and HbO and HbR activation in each task condition in the four ROIs were analyzed using Spearman correlations. After verifying the assumptions and controlling for the effects of age, socioeconomic status, and total IQ, we conducted multiple hierarchical regression analyses to estimate HbO or HbR changes to varying blood FAs biostatuses, with FA level as an independent variable and brain hemodynamic activation as a dependent variable .Sample demographic characteristics and FAs biostatus are reported in p > 0.05).Demographic characteristics were balanced between groups . Thus, the two participants’ data were excluded from all further analysis. We found similar performances across participants for the n-back task, except for slower responses to stimuli in the 0B condition in children with ADHD. No other significant differences were found in any task condition.The results of between-groups differences for mean HbO and HbR activation in each ROI and task condition are summarized in p < 0.05) between HbO values in right frontoparietal ROI in the 2-back condition and Conners’ ADHD index. No additional significant correlation was found between HbO or HbR signals and ADHD clinical scores.With respect to the association between hemodynamic activations that differentiate the clinical group from the TD group see  and ADHDRegarding HbR levels, significant correlation coefficients were found in the right frontoparietal ROI: positive associations were found between HbR in the 0-back condition and EPA biostatus and HbR in the 2-back condition and AA levels; a negative correlation was found between HbR in the 1-back condition and DHA value. Lastly, a significant negative correlation coefficient was found for left prefrontal HbR in the 1-back condition and DHA.2 = 0.268, F = 3.786, p = 0.008). Specifically, EPA blood levels had a significant negative effect on HbO concentration , and, as such, explained approximately 24.6% variance of HbO concentration in right frontoparietal ROI, in 0-back condition.Our regression model with AA and EPA fatty acids as independent variables and HbO concentration in right frontoparietal ROI, in 0-back condition, as dependent variable , was statistically significant. Our model explained 26.8% of variance (adjusted RIn the last decades, an increasing body of research has drawn considerable interest to the possible impact of dietetic factors on ADHD symptomatology as playing a potential role in the pathophysiology of the condition and, therefore, as a possible coadjutant non-pharmacological intervention to pharmacological and psychological treatment .Given these premises, our study was aimed at evaluating the association between blood PUFA biostatus and cerebral hemodynamics as measured by fNIRS in a sample of Italian children with and without ADHD. To the best of our knowledge, no studies have examined the association between PUFA biostatus and fNIRS data in a sample with the above-mentioned characteristics.To this end, we recruited two groups of school-aged children, one composed of children with a clinical diagnosis of ADHD and one composed of TD children; all were of average IQ.As a preliminary step, we compared individual PUFA biostatus and task-related cortical activations between the two groups of children, observing lower levels of AA in children with ADHD than in TD children. As expected, this result is consistent with our preliminary findings in children with ADHD in an Italian setting . The impIn regard to the changes in the oxygenated and deoxygenated hemoglobin concentrations measured by fNIRS during performance of n-back working memory tasks, we found different activation patterns in children with ADHD than in their TD peers see . The resWith respect to the main goal of this study—to investigate the association between blood PUFA biostatus and cortical hemodynamics—we found, regardless of diagnosis, a few puzzling findings when exploring PUFA percentages and changes in the concentration of oxygenated and deoxygenated hemoglobin see . Most coIn light of this consideration, we were surprised to find no significant association between DHA, which derives from EPA and cortical hemodynamic changes after having controlled for the participants’ demographics. As also described in the Introduction, DHA is the brain’s major lipid constituent and plays a critical role in maintaining membrane integrity and fluidity and influencing inter-cell communications. Even though several previous studies that used various imaging techniques suggested a direct effect of DHA on cortical blood flow with regard to the effect of DHA supplementation ,29,54 orThe present study has relevant limitations. The novelty of our approach did not allow us to contextualize the results in a broader research area; in fact, to the best of our knowledge, there is no previous study addressing PUFA and brain cortex metabolism in a developmental-aged sample of children with and without ADHD. Previous fNIRS studies conducted with healthy adults gave inconsistent results ,27, whicFor the first time in the literature, the present exploratory study suggests a possible association between blood FA composition and cerebral hemodynamics in a sample of children with ADHD and TD peers. Such preliminary findings should be now considered as a relevant area of research and addressed in samples with sufficient size to disentangle possible mediating effects of genetics, brain structure or volume, nutrition and ADHD subtypes, and allowing for family-wise error rate correction as appropriately required. If confirmed, these results would suggest that dietary components, such as FAs, could play a role in atypical neurobehavioral development.