Bartonella is a genus of Gram-negative facultative intracellular Alphaproteobacteria of public health importance. Although they are known to mainly infect mammalian hosts with some blood-feeding arthropods having been confirmed as vectors, there is some evidence of Bartonella association with non-mammalian hosts including birds.16S rRNA and Sanger sequencing of the citrate synthase (gltA) genes to test for the presence of Bartonellaceae in the blood of three migratory cavity nesting bird species, purple martins (Progne subis), tree swallows (Tachycineta bicolor) and eastern bluebirds  and their most prevalent and abundant nest ectoparasites, Dermanyssus prognephilus (mite), Ceratophyllus idius (flea) and Protocalliphora sialia (bird blow fly larva). We constructed maximum likelihood phylogenetic trees to verify the placement of the resulting sequences in the Bartonellaceae.Here we used high-throughput sequencing of Bartonella in all three bird species and all three arthropod species tested. We report multiple instances of identical Bartonella sequences in both birds and parasites, leading to the likely hypothesis that these ectoparasites are potential vectors of Bartonella. Our phylogenetic analysis suggests that ‘avian Bartonella’ may form its own sub-clade within the genus Bartonella.We found evidence of Bartonella strains among bird hosts and various species of nest-associated ectoparasites from the same system, suggesting a possible Bartonella host–vector relationship between these arthropods and a non-mammalian host. Our study adds to the growing appreciation of the Bartonellaceae as a phylogenetically diverse group with a wide range of hosts.To the best of our knowledge, we provide the first confirmation of overlapping  Bartonella is a genus of Gram-negative facultative intracellular Alphaproteobacteria whose niche is traditionally described as within the red-blood cells of mammalian hosts, from which it is transferred between hosts by blood-feeding arthropods   for editing.We used MEGA7  to find 16S rRNA gene is an appropriate target for metagenomics studies, it does not always provide high resolution for Bartonella sequences [Bartonella, we therefore performed PCRs for the Bartonella citrate synthase gene (gltA) for a representative subset of our samples, which contained 16S rRNA Bartonella sequences. Two samples from eastern bluebird blood, 2 samples from tree swallow blood, 9 samples from purple martin blood, 7 samples from C. idius and 13 samples of D. prognephilus were selected for analysis.While the equences . To supp4 and 13.8 μl of PCR grade water. We used BhCS781.p (5′-GGG GAC CAG CTC ATG GTG G-3′) and BhCS1137.n (5′-AAT GCA AAA AGA ACA GTA AAC A-3′) primers to generate a 379-bp amplicon of the Bartonella gltA gene [http://www.tacgen.com). PCR-positive bands were obtained in all D. prognephilus samples (n = 13), all but 2 of the C. idius samples (n = 8) and all but 2 of the avian blood samples (n = 13). Paired-end sequences were merged, and the quality of the resulting consensus sequences was assessed from chromatograms in Geneious v.8.0.5 (https://www.geneious.com). However, sequence quality was very poor for all blood and C. idius samples and three of the D. prognephilus samples and these samples conservatively recorded as negative for Bartonella and excluded from further analysis. All of the 10 mite samples with high quality consensus gltA sequences were identified to Bartonella sequences using a BLASTn search  for eastern bluebirds, 39% (19/49) and 83% (5/6) for tree swallows. Ectoparasite samples were comprised of multiple individuals  which complicates the calculation of prevalence. At the sample level, a quarter of the P. sialia samples (3/12) and 36% of the C. idius samples (27/76) were Bartonella-positive. Only one D. prognephilus sample out of 57 did not contain Bartonella, but as that sample had a low total number of reads compared with other samples, we consider prevalence to approach 100%. Considering the limits of individual prevalence, these ranged between 13–25% in P. sialia, 9–36% in C. idius and 13–100% in D. prognephilus. The mites had a very high relative abundance of Bartonella sequences in their microbiome compared with the other arthropod and avian species  both  being apparently closer to Bartonella tamiae and sequences from mites parasitizing tree swallows and eastern bluebirds (Group A) as a sister clade to the other Bartonella sequences. Mesorhizobium and Brucella both formed their own well-supported clades  shared Bartonella ASVs with nestling birds and all three species were found in nests continuously throughout the nesting period , implying that any or all of these species could be vectoring Bartonella to the birds. Of the three, D. prognephilus may be the most likely vector candidate for two reasons. First, D. prognephilus is the most abundant and prevalent nest-associated ectoparasite of all three bird species at our field location, with prevalence approaching 100% for all three species and abundance estimates ranging from means of 300 mites per nest for eastern bluebirds, 600 for tree swallows and almost 2000 for purple martins . Given a positive correlation between vector abundance and transmission in other host–parasite systems [D. prognephilus may have a significant role in transmission in this system, simply due to the higher encounter rate between birds and mites compared to with the other ectoparasites. Secondly, our microbiome study of D. prognephilus suggests a much higher relative abundance of Bartonella than in either of the other two ectoparasites considered, or than observed in the birds themselves.Our finding of multiple identical  systems –30, D. pBartonellaceae, our study does not specifically address transmission modes for the bartonellae. Vector transmission of the Bartonellaceae by arthropods has been recorded both directly via blood-feeding [Pediculus humanus [While vector-transmission appears to be a parsimonious explanation of our finding of identical ASVs in birds and ectoparasites, especially given most of the previous evidence that has been gathered for the -feeding , 31 and  humanus , or when humanus . In our Bartonella vectors in this system. Other hematophagous arthropods such as chewing lice and biting midges are known to inhabit or visit nests of all three bird species at low abundance and may equally transmit Bartonella horizontally to the nestlings. Alternatively, given that Bartonella has been recorded as being transmitted maternally in mammals [Bartonella vertically. In either of these scenarios, the bacteria could then have been acquired by D. prognephilus, C. idius and P. sialia during blood-feeding. Experimental studies documenting vector competence would be needed to distinguish between these scenarios and to definitively designate vectors and transmission mechanisms in this system. Furthermore, given the relatively short duration of the breeding period in the migratory birds in this study, our study does not capture potential seasonal variation in the prevalence and relative abundance of Bartonella in the microbiomes. As previous work has shown a variety of seasonal patterns in Bartonella infection status in different systems [Bartonella prevalence and relative abundance observed fluctuate through the seasons.It is also possible that the three nest-associated ectoparasites studied here are not the only potential  mammals , it is a systems –37, furtBartonella. However, the sequences do appear to form their own sub-clade within the genus, supported by the close phylogenetic relationship between the 16S rRNA sequences from this study and those found in the poultry mite, Dermanyssus gallinae [Bartonella and will lead to a further expansion in our view of the group in the coming years [Our phylogenetic analysis of two genomic regions, supports placement of our sequences within the genus gallinae . It is png years .Bartonella species has been associated with human disease [Bartonella, some authors have suggested that any species of Bartonella may be capable of human infection [Dermanyssus mites, in particular, are proven to be a vector of Bartonella, there may be consequences of this from a public-health perspective. The Bartonella sequences in our samples of D. prognephilus group with the sequences obtained in a recent study of the microbiome of the poultry mite D. gallinae [D. gallinae and associated dermatological lesions are increasing in the medical literature [Dermanyssus genus which were found to be carrying B. quintana [Bartonella in their microbiomes, further work should examine whether Dermanyssus have the potential to vector Bartonella to humans and/or wildlife and whether avian-derived Bartonella species are pathogenic to humans.A growing subset of  disease . Althougnfection . In thisgallinae . Cases oterature , 40 bothterature . Furtherquintana . Given tBartonella and their most likely arthropod vectors. We also presented evidence of expanded diversity within the Bartonella genus. Future research may continue to expand our view of the diversity within the Bartonellaceae and may seek to confirm the vector relationships suggested here and the potential for avian strains of Bartonella to be pathogenic to humans.We have uncovered additional non-mammalian reservoir host species of Additional file 1: Table S1. BLASTn analysis of ASVs identified as Bartonella spp. in this study.Additional file 2: Table S2. Sequences obtained from GenBank and used in phylogenetic trees.Additional file 3: Table S3. BICc ranking of nucleotide substitution models for the 16S rRNA tree.Additional file 4: Table S4. BICc ranking of nucleotide substitution models for the gltA tree.Additional file 5: Table S5. Showing prevalence of sequences identified to the Bartonella genus in 16S rRNA sequences via naïve Bayesian taxonomic classification against the Greengenes database.


Brain-derived neurotrophic factor (BDNF) facilitates neuronal growth and plasticity, and is crucial for learning and memory. Contactin-1 (CNTN1) is a member of the subfamily of neural immunoglobulin and is involved in the formation of axon connections in the developing nervous system. This cross-sectional study investigates whether BDNF and CNTN1 affect susceptibility to attention deficit/hyperactivity disorder (ADHD). A total of 136 drug-naïve patients with ADHD (108 boys and 28 girls) and 71 healthy controls (45 boys and 26 girls) were recruited. Blood samples were obtained to measure the plasma levels of BDNF and CNTN1 in each child. We found that BDNF levels in the ADHD boys exceeded those in the control boys, but BDNF levels in the ADHD girls were lower than those in the control girls. Boys who had higher BDNF levels performed worse on the Wechsler Intelligence Scale for Children—Fourth Edition, but girls who had higher BDNF levels made fewer omission errors in the Conners’ Continuous Performance Test. However, CNTN1 level did not differ significantly between patients and controls, and were not correlated to ADHD characteristics, regardless of gender. The findings suggest BDNF may influence sex-specific susceptibility to ADHD, but CNTN1 was not associated with ADHD pathophysiology. Attention deficit/hyperactivity disorder (ADHD) is characterized by inattention, impulsivity, and hyperactivity . It is nBrain-derived neurotrophic factor (BDNF) has an important role in neuronal survival and growth, serving a neurotransmitter modulator . BDNF isContactin-1, also known as CNTN1, is a protein that is encoded by the CNTN1 gene. The CNTN1 gene is a member of the subfamily of neural immunoglobulin (Ig) and is involved in the formation of axon connections in the developing nervous system . CNTN1 iWe hypothesize that BDNF and CNTN1 are involved in ADHD susceptibility, and patients with ADHD may exhibit lower BDNF/CNTN1 levels than control subjects. Furthermore, we have reasoned that the relationship of BDNF/CNTN1 levels and ADHD characteristics may differ between boys and girls. To elucidate the role of BDNF and CNTN1 in susceptibility to ADHD, a cross-sectional study was carried out to examine whether levels of BDNF and CNTN1 differ between ADHD patients and healthy controls. Additionally, whether the relationships among BDNF, CNTN1, and ADHD characteristics differ between genders.The Institutional Review Board at Chang Gung Hospital in Taiwan approved the research protocol. Patients with ADHD being treated in the outpatient Department of Child Psychiatry at Chang Gung Children’s Hospital in Taiwan were recruited for this cross-sectional study and informed consent was obtained in writing from all participants or their guardians. The inclusion criteria were as follows; (a) clinical diagnosis of ADHD by a senior child psychiatrist based on the DSM-IV-TR through structured interviews using the Chinese epidemiologic version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-E) ; (b) betThe healthy control subjects were recruited from the school in the same catchment areas through advertising or were the healthy classmates of ADHD patients. The control group included children without ADHD or other psychiatric disorders  from the same catchment area as the non-control patients to serve as healthy controls. Overall, a total of 136 patients with ADHD (108 boys and 28 girls) and 71 healthy controls (45 boys and 26 girls) were recruited for this investigation.Blood samples were collected at 8:00 a.m. from participants who had fasted overnight. The BDNF and CNTN1 levels in plasma samples were obtained using the Human Magnetic Luminex Assay . The assays were conducted according to the protocol that was provided by R&D Systems. Briefly, a 96-well filter-bottom microplate  was blocked for 10 min with assay buffer (R&D Systems). To generate standard curves, four-fold serial dilutions of standards were prepared in serum diluent (R&D Systems). 50 μL of standards and plasma samples (1:2 dilution) were added to the wells, which contained 50 μL of the immunobead mixture. The microplate was incubated for 40 min at room temperature in the dark and then washed three times with washing buffer (R&D Systems) using a vacuum manifold. A mixture of biotin-conjugated secondary antibodies (R&D Systems) was added. After 40 min of incubation and three washes, streptavidin-phycoerythrin (R&D Systems) was added. After 10 min, the immunobeads were washed three times, resuspended in 50 μL assay buffer, and analyzed using the Bio-Plex 200 system .A senior psychiatrist interviewed the ADHD patients and healthy control subjects using the K-SADS-E diagnostic tool. An experienced child psychologist conducted a neurocognitive assessment using the Wechsler Intelligence Scale for Children–Fourth Edition (WISC-IV). The Swanson, Nolan, and Pelham Version IV Scale (SNAP-IV) parent form and SNAP-IV teacher form were completed by each patient’s parents and teacher of both ADHD patients and controls, respectively.The WISC-IV is an individually administered and norm-referenced tool for determining the intelligence of children from 6 to 16 years old . The WISThe SNAP-IV is a 26-item questionnaire that is completed by parents or teachers and used to evaluate ADHD symptoms and severity . The 26 The CPT is a 14-minute computerized test that primarily assesses attention and impulse control . Brieflyp values of < 0.05 were considered to indicate statistical significance. We used Bonferroni correction to adjust for multiple testing in the correlation matrix.Data were analyzed using the statistical software package SPSS, version 21.0  and variables are presented as either mean (with standard deviation) or frequency. Categorical variables were compared between ADHD patients and healthy controls using either the chi-square test or Fisher’s exact test, depending on the number of cases. Continuous variables were shown as mean (standard deviation), median, and first- and third-quartiles. Mann–Whitney U test was used to determine the differences in BDNF and CNTN1 levels. The Spearman’s correlation was used to analyze the relationships between BDNF and CNTN1 levels, clinical symptoms and neuropsychological functions. Two-tailed The study sample comprised 136 patients with ADHD  and 71 healthy controls . In the sex-stratified analysis , the girp = 0.027, Standardized Test Statistic = 2.210) and the girls with ADHD had lower BDNF levels than the healthy control girls . The gender-stratified analysis revealed no significant differences in CNTN1 levels  and girls (n = 54), separately. In boys, BDNF levels were negatively correlated with FSIQ  and VCI , and positively correlated with ODD symptoms as rated by parents  and teachers . In girls, BDNF levels negatively correlated with inattention symptoms rated by parents  and omission score in the CPT . Among both boys and girls, levels of CNTN1 were not significantly related with either ADHD clinical symptoms or neuropsychological functions. However, if we used Bonferroni correction to adjust for multiple testing in the correlation matrix, none of the results maintained their significance.The main finding in this study is that BDNF levels in ADHD boys exceeded those in control boys, but BDNF levels in ADHD girls were lower than those in control girls. CNTN1 levels did not significantly differ between patients and controls, whether they were boys or girls. BDNF levels were negatively correlated with intelligence in boys, but negatively correlated with the omission errors of girls in the CPT.Several case-control studies have indicated that the peripheral BDNF levels in both serum and plasma do not differ significantly between patients with ADHD and controls ,15,16. AThe data herein reveal that BDNF levels in girls with ADHD were lower than in healthy controls. Among girls, BDNF levels were negatively correlated with omission errors associated with neuropsychological performance and showed a negative correlation between inattention symptoms. This finding demonstrates that BDNF may serve as a protective factor against ADHD among girls whereas the opposite is true for boys. The reasons for the contrary effects of BDNF on the risks of ADHD in boys and girls remain unclear. Sex-related hormonal, genetic, and epigenetic factors interact with BDNF signaling at various levels and in complex ways between genders . The resCNTN1 is involved in the formation of axon connections in the developing nervous system , and enhThis study has limitations. First, it is a cross-sectional study. Although a relationship was found between peripheral BDNF levels and ADHD, causality cannot be determined. Second, our sample size was small, particularly with respect to females. As a result, the negative findings with regard to the female group may be related to low statistical power. In general, girls with ADHD are diagnosed slightly later than boys . HoweverThe results herein suggest that BDNF may be involved in sex-specific susceptibility to ADHD. However, CNTN1 was not associated with ADHD pathophysiology. Whether peripheral BDNF levels serve as a potential biomarker for ADHD warrants further investigation in the future. A longitudinal study with a larger sample or an experimental study is required to elucidate the mechanism of the sex-specific relationship between BDNF and ADHD.


Many children with attention deficit hyperactivity disorder (ADHD) display motor deficiencies during their daily routine, which may have impact on their developmental course. Children with ADHD who experience motor deficiencies often display deficits in tasks requiring movements, such as handwriting.This study investigated deficiencies in fine motor skills in primary school children with ADHD. The study further sought to establish whether ADHD subtypes differ in deficiencies of fine motor performance, recorded for both the dominant and non-dominant hands.The Disruptive Behavior Disorders Rating Scale, completed by educators and parents, was used to screen for ADHD symptoms. Researchers confirmed the diagnosis of ADHD. Motor functioning was assessed using the Grooved Pegboard and Maze Coordination. The children diagnosed with ADHD were matched for age and gender with controls without ADHD. The sample consisted of an ADHD group (160) and control group (160) of primary school children from the Moletjie area.p < 0.05) with both the dominant and non-dominant hand. No significant difference between the hyperactivity and impulsiveness subtype and the controls were found. There was no difference on the Maze Coordination Task (p > 0.05) between the ADHD subtypes and the controls.Children with ADHD (predominantly inattentive subtype) and ADHD (combined subtype) performed significantly more poorly than the control group on the Grooved Pegboard (Difficulties in fine motor skills are prevalent in children with ADHD, particularly in the ADHD-PI and ADHD-C. Problems are encountered in distal, complex, speeded tasks. The effect may lead to poor handwriting and academic performance. Such children often appear clumsy and uncoordinated.5 Motor coordination problems have previously been labelled ‘clumsy child syndrome’, ‘non-cerebral-palsy motor-perception dysfunction’, ‘minor neurological dysfunction’ or ‘dyspraxia of childhood’.6Attention deficit hyperactivity disorder (ADHD) is a common, long-lasting, manageable childhood psychiatric disorder, characterised by a pattern of developmentally inappropriate inattention, motor restlessness and impulsiveness.7 Fine motor skills are required in smaller movements that occur in the wrists, hands, fingers, feet and toes and include more precise actions such as picking up objects between the thumb and finger and writing carefully.8 Poor fine motor skills can make cognitive learning and performance more difficult because of the involvement of fine motor skills in cognitive activities.8Motor skills are actions carried out when the brain, nervous system and muscles work together. It is a function that involves the precise movement of muscles with the intent to perform a specific act. They are categorised into two groups: gross motor skills and fine motor skills. Gross motor skills are involved in movement and coordination of the arms and legs and actions such as running, crawling and swimming.10 Recently it was suggested that the name ‘DAMP’ be changed to ‘DCD plus’.11 Developmental coordination disorder is diagnosed if the impairment in motor skills significantly interferes with the performance of, or participation in, daily activities in family, social, school or community life.2 Developmental coordination disorder does not have separate classifications; however, individuals may be impaired predominantly in either gross or fine motor skills, including handwriting skills. The core characteristic of DCD involves a marked impairment in the performance of motor skills. This impairment has a negative impact on activities of daily life such as dressing, feeding and riding a bicycle or academic achievement through poor handwriting skills. DCD is found in up to 50% of the children with ADHD.12Since 1994, the use of the term ‘developmental coordination disorder’ (DCD) has predominated in the literature. In the Scandinavian countries, the combination of ADHD and motor coordination problems is known as ‘deficits of attention and motor perception’ (DAMP).14 Kaiser et al.15 argue that individuals with DCD and ADHD may fall, bump into things or knock things over; this may not be because of distractibility and impulsiveness but rather because of motor impairment. Children with ADHD tend to show persistent motor skill impairment, which might meet the diagnostic criteria of DCD as a comorbid disorder.15Many of the differences found in the neural systems between ADHD and neurotypical comparisons are present in the areas responsible for motor control.17 A study by Pitcher et al.18 found that 58% of children with ADHD , 49% with ADHD combined (ADHD-C) and 47% with ADHD hyperactivity and impulsiveness (ADHD-HI) had motor problems. In clinical practice, less attention is paid to motor problems in children with ADHD.19The prevalence of motor problems in children with ADHD ranges from 30% to 52%, depending on the method of measurement.20 Kadesjö and Gillberg9 and Piek et al.21 affirm that inattentive symptoms relate mostly to motor coordination problems, though a relationship between hyperactive and impulsive symptoms and motor coordination problems has also been reported. Motor problems lead to difficulties in everyday living, including academic performance, sport, play and self-esteem.23 Motor problems severely affect children’s daily lives and are an active predictor of a child’s popularity and self-esteem.24 These deficits may have an intense effect on children’s development, leading to difficulty with written communication, inhibited social interaction and poor performance in sports activities.Most studies show a strong association between ADHD and fine motor problems.27 The nigrostriatal dopaminergic pathway is involved in the coordination of movement. Sagvolden et al.26 assert that a hypofunctioning nigrostriatal dopamine branch causes impaired modulation of motor functions and deficient non-declarative habit learning and memory. The altered dopaminergic function and hypofunctioning nigrostriatal dopamine will give rise to clumsiness and problems with gait, balance and laterality, as well as gross and fine motor control.26 Difficulties with motor inhibition may be associated with disturbances in the orbital prefrontal circuit system, which also plays a central role in executive functions.28 This view is further supported by Berquin et al.,29 who suggest that cerebellar-prefrontal circuit dysfunction may underlie the motor control, inhibition and executive function deficits encountered in ADHD.Several studies have identified dopamine as the key neurotransmitter in the brain in ADHD. Three pathways, namely the mesocortical, mesolimbic and nigrostriatal, have been shown to be dysfunctional and consequently cause deficiencies in the cortical areas, resulting in symptoms typical to ADHD: inattention, hyperactivity and impulsiveness.30 despite the estimate that 30% – 50% of children with ADHD exhibit motor problems.3 This study aimed to investigate fine motor difficulties in a sample of primary school children diagnosed with ADHD in Limpopo Province, South Africa. The study further sought to establish whether ADHD subtypes or presentations differ in motor performance deficiencies, whether this is true for both the dominant and non-dominant hand, and whether gender and age influence performance. Understanding the defects in fine motor skills and how the ADHD subtypes are affected will enable clinicians, educators and parents to devise appropriate intervention methods in the treatment of children with ADHD. The results will also help them to better understand the nature of fine motor deficits in children with ADHD to inform and guide future treatment and therapy for these children.Motor problems are not usually part of assessments for ADHD and are not included in intervention programmesThe study was conducted in primary schools in the Moletjie area, Limpopo, in 2016. A quantitative, case-control experimental design was used. In order to establish whether children with ADHD are deficient in fine motor skills, the sample was divided into participants diagnosed with ADHD and those without ADHD.The study was conducted with primary school children in the Moletjie area in Limpopo Province, South Africa. The selected regions were in a rural area in which assessment of this nature is very rare. The areas were selected based on the remoteness of the regions so that the community could benefit from such research.32 Learners who met the criteria for ADHD were assigned by the researcher as follows: Participants with scores ≥ 17 on the hyperactivity and impulsiveness scale were classified as ADHD-HI subtype and those having a score ≥ 20 on the inattention scale were classified as ADHD-PI subtype, based on the epidemiological study by Meyer and colleagues.33 Participants who met the criteria on both scales were categorised as ADHD-C subtype. The cut-off point for the neurotypical control group (non-ADHD) was set at the 85th percentile or below to decrease the risk for false positives in this group.33 Thus, children with scores of less than 15 on the hyperactivity and impulsiveness scale and the inattention scale, matched for gender and age, were selected as controls.Four thousand two hundred children completed the Disruptive Behavior Disorders (DBD) Rating Scale. A total of 320 primary school children were screened; 160 with ADHD (80 boys and 80 girls) were matched for gender and age with 160 children without ADHD symptomatology (80 boys and 80 girls), who formed the control group. They were all Sepedi speaking, Grade 1 to Grade 7 learners, between the ages of 6 and 14 years, and were recruited from six schools in the Moletjie area, Limpopo Province, South Africa. The DBD, completed by educators and parents, was used to screen the children for ADHD.Children with a history of neurological problems  or severe psychiatric disorders, as reported by the parents on the demographic questionnaire, were excluded from the study. None of the children were on psychostimulant medication at the time of testing.The principals of the schools were approached prior to commencing with the assessment. Following consent from parents, the study was explained to all participating children, and their assent was obtained. The return rate of the questionnaires was 100%. The data was collected from primary school children within the Moletjie area in Limpopo Province during 2016. The assessment was done during school hours at the participants’ respective schools. The testing procedure for each child lasted 30 min and was conducted by a clinical psychologist and five research assistants (who held bachelor degrees in psychology), who were fluent in the child’s home language.32 was used to screen for ADHD symptoms. The scale is standardised and normed for all language and population groups in Limpopo Province, South Africa.33 The DBD assesses the presence and the degree of ADHD-related symptoms (inattention and hyperactivity/impulsiveness), oppositional defiant disorder and conduct disorder.34 The DBD consists of 42 items based on the diagnostic statistical manual of mental disorder (DSM-IV) diagnostic criteria,35 of which 18 measure ADHD. All 42 items were administered. Respondents were asked to rate the behaviour on a four-point scale: not at all (0); just a little (1), pretty much (2) and very much (3). The scores were summed to produce a total score, and a 95th-percentile cut-off score is considered clinically significant.28 Those participants scoring below the 85th percentile formed the control group. The Cronbach’s alpha for the DBD for the targeted population was calculated at 0.90 for the hyperactivity and impulsiveness scale and 0.92 for the inattention scale.33The DBD Rating Scale36The Grooved Pegboard, measuring distal, complex fine motor coordination and psychomotor speed, was administered first, followed by the Maze Coordination Task, which evaluates tactual motor coordination skills and motor planning.36 This task consists of a small (10 cm × 10 cm) metal board that contains a 5 × 5 set of holes, each with a groove, oriented randomly in different directions. Twenty-five round metal pegs with a ridge running lengthwise have to be rotated to the correct position for insertion into the holes. The participants are instructed to insert the pegs as quickly as possible into the slots in sequence, first with the dominant hand and then with the non-dominant hand. The hand that they use to write was recognised as the dominant hand; the one not being used was recognised as the non-dominant. Pegs are inserted from left to right with the right hand and vice versa for the left. The score is the time it takes the participant to complete the task with each hand. The task duration is approximately 5 min.37 The Grooved Pegboard has good test reliability . The Grooved Pegboard correlates with the Bruininks-Oseretsky Test at −0.50 to −0.63 and with the Purdue Pegboard at −0.73 to −0.78.38 Studies40 have shown that the Grooved Pegboard could efficiently be used to detect problems with fine motor skills in children with symptoms of ADHD.The Grooved Pegboard is a manual dexterity test measuring complex fine motor skills.39 The Maze is placed at a ~60° angle to the table. The child is required to go through the maze with an electric stylus, trying not to touch the sides. The stylus is connected to an electronic clock and a counter, which record the number of contacts the stylus is making with the sides (counter) and the cumulative duration of these contacts (timer). The aim is to move the stylus through the maze without touching the sides. There is no speed requirement, and the test is performed twice with each hand. The total sum of touches and cumulative time of contact of two trials with the same-side hand are the final scores. According to Tichá et al.41 and Torgesen et al.,42 reliabilities range from 0.27 to 0.91.The Maze Coordination Task measures fine motor coordination.43 was used to analyse data from the tests mentioned above. Multivariate analysis of variance (MANOVA) models were used to determine differences in performance. A 4 × 2 × 3 (ADHD presentation × gender × age group) analysis of variance for independent samples for both the dominant and the non-dominant hand were computed to establish between-group differences. Post-hoc tests (Bonferroni) were used to establish within-group differences. The significance value was set at p < 0.05.Statistica (version 10)South African Journal of Psychiatry. The manuscript is the original and was never presented to any other journal and my institution, the University of KwaZulu-Natal, is fully aware of this submission. Ethical approval to conduct the study was obtained  from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal. The Department of Education provided permission for the study to be conducted at the participating schools, and consent was obtained from the relevant school principals. Written consent was obtained from the parents of the children, and children signed assent forms. Participation in the study was voluntary, and participants were informed that they could withdraw at any stage.I am enclosing a submission to the n = 160) and were matched for age and gender with a control group (n = 160) without ADHD symptomatology. The equal numbers in gender was coincidental. There was no statistically significant difference in ages of the ADHD group  and control group .A total of 4200 children completed the DBD, of which 320 children were screened in the study: 160 (50%) males and 160 (50%) females. One hundred sixty children (80 boys and 80 girls) met the criteria for ADHD , ADHD-PI  and ADHD-C .The participants were classified according to subtype: ADHD-HI (Hand dominance: Of the ADHD group 146 (91%) were right-handed, while 14 (9%) were left-handed. The control group consisted of 149 (93%) children who were right-handed and 11 (7%) who were left-handed. The effect of hand dominance could not be included in the analysis because there were too few left-handers, resulting in empty cells when subtype, age and gender were taken into account. Therefore the results of each hand were analysed separately.p < 0.05.F = 8.48, p < 0.001. Post-hoc analysis revealed a statistically significant difference between the ADHD-PI (p = 0.001) and ADHD-C (p = 0.002) and the control group only. These groups took longer to complete the task with their dominant hand. There was no statistical difference between ADHD-HI and the control group when using the dominant hand. There were also statistically significant differences in the performance of the non-dominant hand among the ADHD subtypes, F = 5.93, (p < 0.001). Post-hoc analysis (Bonferroni) further showed that the ADHD-PI (p = 0.011) and ADHD-C (p = 0.004) subtypes differed significantly from the control group in that the two ADHD groups took significantly longer to complete the task. There was no statistical difference when the ADHD-HI subtype was compared with the control group.On the Grooved Pegboard test, the MANOVA showed no main significant differences or interaction effects for gender and age for either the dominant or the non-dominant hand. Therefore, only the ADHD subtypes were further analysed. There were significant differences between ADHD subtypes in the performance of the dominant hand, p = 0.004). There were no effects for gender. The MANOVA indicated significant differences in performance for dominant hand, F = 6.05, p < 0.001; post-hoc analysis, however, revealed that this was because of the interacting effect of age, with the performance of the younger group significantly poorer than that of the older group. The difference was between the age groups only and not between the subtypes. The difference between the ADHD groups and the controls was not statistically significant, and there was no statistically significant difference between the subtypes in performance of the non-dominant hand, F = 2.15, p = 0.093.On the Maze Coordination Task, age had an effect on performance with both the dominant and non-dominant hands (44 The poorer performance on the Grooved Pegboard of the ADHD-PI and ADHD-C subtypes suggest that their eye-hand coordination is impaired when motor speed is required,45 possibly because of problems with attention as the underlying manifestation of the motor skills deficit.46 This finding is consistent with most other studies,47 which found that the most pronounced impairment of motor functioning was in children with symptoms of ADHD-PI and ADHD-C subtypes and that inattention may affect motor skills.49 These studies compared motor problems in children with ADHD with neurotypical controls, and the conclusion reached was that difficulties in gross and fine motor skills were all related to symptoms of intention, not hyperactivity or impulsiveness.The results of the study show that children with ADHD, especially the ADHD-PI and ADHD-C subtypes, were more impaired on the Grooved Pegboard Task, which measures distal, complex fine motor coordination and psychomotor speed, than on the Maze Coordination Task, which measures tactual coordination skills and motor planning.50 implied that fine motor skills of writing were predicted by the severity of symptoms of inattention. Motor responses require attention to a target and attention during the response. If the target is not properly attended to, it will affect the subsequent motor planning and consequent performance. Additionally, when the target is not noticed in time, it can reduce the time remaining for motor preparation and accordingly affect the performance.13 This may explain why the Grooved Pegboard, a timed task, discriminated better between children with ADHD and the neurotypical controls than the Maze Coordination Task, which was not timed and measured only motor planning and executions.The studies conducted by Ghanizadeh51 reported that all children with ADHD performed fine motor tasks more slowly than children without ADHD. Most studies, however, found that the ADHD-HI subtype was least affected.52 The conclusion drawn by these authors was that, unlike inattention, hyperactivity and impulsiveness was not a good predictor of deficiencies in fine motor performance in children with ADHD.Not all studies on motor deficiencies in ADHD have found fine motor impairment to be limited to inattention. Scharoun et al.39 who found that age had the most pronounced effect on the Maze Coordination Task, likely because of the maturation effect. Younger children with and without ADHD have poorer motor skills, visual planning and visual perceptual abilities than their older counterparts. Therefore, the task might have been too complicated for the younger participants.39 Meyer and her colleagues in a similar study conducted in 2006 among different cultures in Limpopo had comparable findings to our study. One can debate that a replication was necessary after a decade in an area where technology and educational facilities have improved. However, the similar results indicate that deficiency in fine motor skills is linked to ADHD symptomatology and is not affected by education and technology that has progressed over the past 10 years.Our study also showed that age influenced Maze Coordination Task performance with both the dominant and non-dominant hands. These results are similar to the findings of Meyer and Sagvolden,53 Therefore, it is evident that the underlying brain mechanisms are interrelated and that ADHD can be regarded as a multisystem developmental disorder with expressions in the cognitive, emotional and motor areas.53 Houwen et al.54 confirmed the relationship between motor performance and executive functions, finding that children who had motor coordination problems also performed poorly on tests of working memory and planning. Therefore, interventions for improving motor deficiencies may lead to improvement in cognitive and emotional functions.13The cortical-striatal and cortical-cerebellar network is considered to consist of parallel circuits that underlie motor, cognitive and emotional behaviours.23 and severely impact children’s daily lives. Fine motor problems are a strong predictor of a child’s popularity and self-esteem.24 Thus, poor motor performance may have an adverse effect on children’s self-esteem, anxiety and social functioning.24 Children with fine motor problems and ADHD are at risk for learning difficulties and deficient psychological adjustment.56Problems with attention are the underlying manifestation of the motor skills deficit. Motor problems lead to difficulties in everyday living, including academic performance, sports, play and self-esteem,10 and Sergeant et al.,30 motor problems are not usually part of assessments for ADHD or incorporated into intervention programmes. It is vital that fine motor functions be part of evaluations for ADHD and included in general intervention methods for the treatment of children with ADHD and fine motor problems. Early detection of fine motor problems and identification of ADHD subtypes will help clinicians to recognise children at risk, who then can be referred to appropriate mental health workers for pharmacological treatment and/or behavioural modification intervention.As noted by Gillberg et al.2 More research is needed to establish whether deficiencies in motor skills are usually comorbid with ADHD, or even can be regarded as diagnostic criteria for the disorder, or be considered as co-occurring pure DCD as stipulated in the DSM-5.The DSM-5 focuses mainly on DCD as a separate neurodevelopmental disorder, while the fine motor skill deficiencies related to ADHD are not documented in the DSM-5.The sample does not represent the general population of primary school children in Limpopo Province as it was limited to Sepedi-speaking children in a particular municipal area. Owing to the homogeneity of the sample, socio-cultural differences could not be indicated. Future studies should include Sepedi along with other language groups. Another limitation was the small size of the ADHD-HI group, which may not represent all individuals with ADHD-HI. It may also be a limiting factor to compare 6-year-olds with 14-year-olds, who may already have entered puberty. Future studies should examine groups of children of the same age in regard to fine motor deficits and ADHD subtypes.Our study showed that children with ADHD have poorer fine motor skills than typically neuro-developing children. The performance of the children with ADHD showed deficiencies in distal, complex, fine motor coordination and psychomotor speed, as measured by the Grooved Pegboard Task. The results suggest that fine motor difficulties affect mainly the predominantly inattentive and combined ADHD presentations. Given the relationship between motor problems, especially handwriting, and academic performance, assessment of fine motor skills should be part of the ADHD diagnostic process. The result of this and other studies show that the Grooved Pegboard Task can be used as a valid instrument to detect motor deficiencies in children with ADHD.


Researchers have suggested that the link between personality traits and Attention-Deficit/Hyperactivity Disorder (ADHD) could be a crucial factor in understanding the disorder’s diatheses. The aim of our study was to contribute to research on personality differences (based on fine motor precision – a novel approach) in children with and without ADHD symptoms. The Children Sustained Attention Task (CSAT) and Proprioceptive Diagnostics of Temperament and Character (DP-TC) were administered to children with an ADHD diagnosis and age-matched controls. Correlational and ANOVA analyses were performed to see the association between the results of both tests and the groups’ performance. Correlational analysis suggests significant relationships between some personality dimensions (DP-TC) and correct detection in a sustained attention task (CSAT). Statistically significant differences were found between the groups on the personality dimensions (DP-TC), with the following characteristics for ADHD children: (a) temperamental tendency to pessimism; (b) high temperamental excitability; (c) high Emotionality, and (d) Behavioral Rigidity . Correct detection in the sustained attention test was significantly correlated with reaction time and the personality variables Style of Attention and Irritability. The results also showed high proprioceptive Emotionality and lack of emotional control in children with ADHD. This is an exploratory study, investigating for the first time the differences in personality (based on fine motor precision) and the relation of personality traits to scores in sustained attention for children with and without ADHD. Theory and research state that both temperament and personality systems can be useful to describe endogenous basic tendencies of thoughts, emotions, and behaviors in children  and adulStudies based on the Since ADHD diagnosis is not accurate before the age of four , researcMost researchers agree on the importance of studies of the relationships between personality, temperament, and ADHD. Our research aim is to study the relationship between proprioceptive individual differences in personality (temperament and character) in children with ADHD and age-matched control groups and to explore the relationship of these personality indicators to variables of the sustained attention test . As One hundred and five children (37% girls), aged 7-14 years (9.5 ± 1.5) participated in the case-control study with the permission of their parents .1, a foundation which is deeply involved in ADHD and invests much effort and interest in supporting research about this disorder.Most of the experimental group sample data was collected thanks to the collaboration of the ADANA FundacióThe data were treated anonymously and confidentially, following the accepted institutional ethical committees of the participating centers for carrying out the study with consent of the children’s parents.The participants took two types of tests: (a) the CSAT (Children Sustained Attention Task)  and (b) To measure and assess sustained attention, we administered the Children Sustained Attention Task (CSAT), which is a version of the CPTs (continuous performance tests) that measures sustained attention capacity in childhood through a monitoring task. The performance of a subject is evaluated by direct scoring of successes (correct identifications/omissions), errors , and reaction time (latent period to response in msecs). The CSAT has been shown to have good psychometric indices (with test–retest reliability ranging from 0.59 to 0.88) and is recommended for application to clinical studies . As to iLas correlaciones somáticas del trabajo mental  (myokinetic psychodiagnosis (MKP) (We used the proprioceptive (myokinetic) indicators of individual differences in personality . This method goes back to Mira y López’s initial work, al work) , some inal work) , as wellal work) . This alis (MKP) . The tesis (MKP) . DP-TC iis (MKP) .The diagnostic meaning of the MKP results has also been explained by other researchers e.g.,  and the 2 similar to what is observed due to aging processes Irritability – line length (LL): Change in line length (compared to the 40-mm-long model), with the corresponding indexes: LLd and LLnd, for dominant hands (character) and non-dominant hands (temperament), respectively;(2)Behavioral Variability/rigidity - Line Length Variability (LLV): The variability of line length in parallels, with the corresponding indexes: LVd and LVnd, for dominant and non-dominant hands, respectively;(3)Mood – directional bias  in frontal movement type, with the corresponding indexes: DFd and DFnd for dominant and non-dominant hands, respectively;(4)Decision Making – directional bias in sagittal movement type, with the corresponding indexes: DSd and DSnd;(5)Style of Attention – directional bias in transversal movement type, with the corresponding indexes: DTd and DTnd;(6)Emotionality – formal bias (perpendicular to the model line), with the corresponding indexes: FFd and FFnd.The descriptive statistics, ANOVA, and correlation analyses were calculated to represent the results of this study and were performed with the use of SPSS v.19.p = 0.019), with a medium effect size (Cohen’s d = -0.47), and with worse indicators for the children with ADHD, but not in errors  or reaction time (Table The results of the CSAT (Children Sustained Attention Task) performance between the ADHD and control group revealed statistically significant differences in mean values for success (correct detection) p = 0.09, with aAs for the results in the fine motor precision test linked to individual Behavioral Variability (DP-TC), based on representing lines  in the proprioceptive condition , we observed the following most significant differences between the two groups:(1)In the directional bias, frontal movement in the non-dominant hand (temperament): a tendency toward the pessimism pole (Mood dimension) in the ADHD group;(2)3): a tendency toward being “warmer” in affective and dependent behavior with a need to be “affiliated” in the ADHD group, or “colder” or more distant in relations with others and more independent in the control group;In the formal bias, frontal movement for both hands (temperament and character(3)In Line Length Variability , both hands (temperament and character): a tendency toward more rigid behavior in the children with ADHD Table .p = 0.052)  performance was observed in the non-dominant hand , however, this difference did not reach statistical significance Within the CSAT test variables, a negative relationship exists between the frequency of committing errors  and correct identifications, as well as between reaction time and correct identification (indicator of good sustained attention);(2)Style of Attention (in using the dominant hand), a dimension of the DP-TC test, had a weak but statistically significant relationship with correct detection (good sustained attention) of the CSAT test; and(3)The Irritability dimension of the DP-TC was related to the correct identification (good sustained attention) of the CSAT test for both hands, statistically significant, with a negative sign Table .In order for the correlations to be distributed normally, we also performed the Fisher r-to-z transformation of Pearson’s r, according to the formula:r = (1/2)[loge(1+r) – loge(1–r)] and standard error: SEzr = 1/sqrt[N-3] online calculator, available at: http://vassarstats.net/tabs_rz.html)zThe results are given in Table r) are the following: per each group (ADHD and control), both are rounded to 0.14, and in general (both together), 0.099.The corresponding standard errors  and reaction time (CSAT), Irritability dimension , and Decision-Making ; whereas the children from the control group showed a significant relationship with a positive sign for Style of Attention  Tables , 4.SDs, which may be considered controversial and a study limitation. However, this provides information that the children with ADHD are much more variable in their behavior than the control group, whose members are more similar in their fine motor behavior and corresponding personality dimensions (the basis of the DP-TC).While the relationships between temperament and character or personality and the severity of ADHD symptoms have been studied mainly in adult populations , our stuHigher variability within the ADHD group was also observed in the performance of the CSAT test. If we compare just mean values for errors  in the CSAT, there is a difference between the average values for each group’s performance: 61 (ADHD) vs. 29 (control). However, the variance was greater within the ADHD group, showing that this group included participants whose CSAT points ranged from very low (compared with controls) to very high, meaning that some responders from the ADHD group could have results comparable to or even better than the control group. This concerned only a very limited number of children, since the average results for the ADHD group were worse than the average results of the control group.A similar situation for intra-group variability (in ADHD only) was observed for reaction time (CSAT), which is congruent with many other studies’ results for reaction time and attention e.g.,  and otheOur results obtained from the DP-TC test confirm the idea of other authors about personality differences in children with and without ADHD . In termThe tendency for pessimism on the Mood dimension of the DP-TC was shown in the children from the ADHD group only with the non-dominant hand (-15.48 ± 23.66 mm) if comparing both the dominant one and average values of the control group in both hands). This suggests a more temperamental, endogenous, or biological tendency to pessimism, confirming the idea of A similar tendency was also observed for Irritability (inhibition-excitability), which was higher in the non-dominant hand (temperament). In raw average values: Line Length performance was 48.90 ± 15.52 mm in the ADHD group in the non-dominant hand vs. 42.12 ± 15.30 mm in the dominant hand, which was closer to the control group’s performance (42.34 ± 11.73 mm in the dominant hand vs. 43.3 ± 13.33 mm in the non-dominant hand), and model Line Length itself (40 mm). Here the tendency to higher endogenous excitability in ADHD children was also somehow adapted, as per the results of the “reactive” hand performance. In both cases we can speak of adaptive, favorable processes that occurred due to education, therapy, and/or medication. Moreover, high excitability does not always have a negative interpretation: People with a high IQ were also found with it .Nevertheless, two other differences, most significant since they were big and statistically significant, observed between the groups did not have such adaptive changes, since similar results persisted in both hands on the DP-TC dimensions of Emotionality and Behavioral Variability. Greater emotional lability was shown in the ADHD group, indicating congruence with the observations and results mentioned by other authors who mentioned emotional lability and low maturity (compared with a control group of similar ages) in persons with ADHD . On the p < 0.001) to the number of correct answers on the CSAT test in the ADHD group only. However, reaction time had no significant relationship in the control group for correct answers, and thus was not so important. This suggests that only the ADHD children, when they respond more quickly, give more correct responses due to a negative sign relationship, and vice versa – the longer they take to respond, the less correct are their responses. Possibly in this context, the longer time spent by the children from the ADHD group on answering (longer latent period to reply) could be related to greater distraction or loss of motivation, with resulting worse scores on the CSAT test. Alternatively, sustained attention and better concentration might be maintained for a short time, while getting worse as the time increased. No similar studies have been performed in this context (showing the relationship between latent response time and correct answers in the children with ADHD), so our results could be considered as the first step in this direction.With regard to correlation analysis, although reaction time (latent period to reply) was almost identical in the two groups, it had a significant relationship  and correct responses (CSAT), meaning that the more attention was paid to the external world, the larger the number of correct responses on the sustained attention test. This tendency was not as pronounced in the children with ADHD.p = 0.052, r = -0.26).Another important tendency that can be considered as an indicator of more pronounced temperamental submission  in the ADHD group might be related to an increase in correct detection (an indicator of good sustained attention) in the CSAT test  had a weak, but statistically significant relationship (with a negative sign in both groups) with correct detection on the CSAT, it would be a considerable general feature, however, with more weight  in the adaptive behavior (dominant hand) of the children with ADHD. Thus, less excitability/more inhibition would be reflected in a higher percentage of correct answers on the CSAT.No statistically significant relationship was observed between the dimension of Variability in Behavior (DP-TC) and the indicators of good sustained attention, showing that this feature is just an indicator of individual differences between the ADHD and control groups, but this does not greatly influence the results of the sustained attention test in this study.We analyzed data in the full subgroups, otherwise the sample size would have been reduced significantly, and for this first exploratory study, the aim was to observe the general situation in children. But this approach has several limitations that should be considered when interpreting or generalizing the results. The first is that the range age is quite big and children in the preadolescent period can differ from those who are younger. The second limitation is that we did not have an opportunity to split the groups into other, smaller subgroups, such as different subtypes of ADHD or those children taking medication, although we controlled for the time of medication uptake and the tests were performed when the least effects of medication were seen (before the next uptake). Finally, the control group consisted of children selected by teachers as “without visible ADHD symptoms or tendencies”; they generally also had better academic performance and motor coordination than the children with ADHD. Some of the participants in the control group were attending musical or dance classes, which could have been a reason for better proprioceptive motor precision compared to those with ADHD. Thus, further studies are needed with a more homogenous control group, or split by design into those who had better and worse academic and motor performance. Also it would be appropriate to see whether the music or dance classes could be beneficial as an alternative therapy for children with ADHD.Significant individual differences in behavior were observed between the ADHD children and the control group, based on the Proprioceptive Diagnosis of Temperament and Character (DP-TC). Two variables – Mood  and Irritability  in the performance of the group with ADHD were shown to be more adaptive, since these tendencies were not pronounced in the subject’s character (dominant hand) and were similar to the control group’s average results. On the other hand, two DP-TC dimensions, Emotionality  and Variability in Behavior  were non-adaptive, since the performance persisted at the same level in both hands (non-dominant and dominant) and with a statistically significant difference from the control group. The correlational analysis of the individual differences revealed that not all differences were important for the quality of performance of the sustained attention task, supporting mainly a significant relationship with Irritability  among all of them.This is an exploratory study and requires more research along these lines and exploration of the Emotionality dimension in children with ADHD. High Emotionality can induce more physical movement among children, which could compensate or be a part of therapy instead. This study is a pioneer in the context of proprioceptive indicators  of children with ADHD and the control group of children who have not been so diagnosed, and have better academic as well as motor performance. The results could provide an orientation in work with children who are diagnosed with ADHD. Moreover, physical activity and music or art therapy for children with ADHD could be considered means of “emotional discharge,” to help them cope with their emotions, however, more studies with this focus are needed.This study was carried out in accordance with the recommendations of Ethical committee of the University of Barcelona with written informed consent from all subjects (parents of the childrens involved in the study) in accordance with the Declaration of Helsinki. The protocol was approved by the Ethical committee of the University of Barcelona and the educational centers .LL and JR made substantial contributions to the conception or design of the work or the acquisition. JR proved the study at the Ethics Committee of the University of Barcelona. TI recruited volunteers, performed all the testings, contributed to the literature review and writing the Introduction part, and reviewed and proved the manuscripts’ drafts. LL analyzed and interpreted the data for the study, and drafted the work. AV revised the draft critically for important intellectual content, approved the final version to be published,œ and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.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.


Single-dose cardioplegia is preferred in minimal invasive mitral valve surgery to maintain the adjustment of the operative site without change of preset visualization. The aim of our study was to compare two widely used crystalloid cardioplegias Bretschneider (Custodiol®) versus St. Thomas 2 in patients who underwent mitral valve repair via small anterolateral right thoracotomy. n = 123) or St. Thomas (n = 61). Primary efficacy endpoint was peak postoperative high-sensitivity cardiac troponin (hs-cTnT) during hospitalization. Secondary endpoints were peak creatine kinase-muscle brain type (CK-MB) and creatine kinase (CK) as well as safety outcomes. We used inverse probability of treatment weighting (IPTW) in order to adjust for confounding by indication.  From May 2012 until February 2019, 184 isolated mitral valve procedures for mitral valve repair via anterolateral right thoracotomy were performed using Bretschneider (Custodiol®) cardioplegia (p = 0.047). Peak CK-MB (geometric mean after Bretschneider (Custodiol®): 40 μg/L, CI 35-46, St. Thomas 2: 33 μg/L, CI 27-41, p = 0.295) and CK (geometric mean after Bretschneider (Custodiol®): 1370 U/L, CI 1222-1536, St. Thomas 2: 1152 U/L, CI 972-1366, p = 0.037) showed the same pattern. We did not see any difference with respect to postoperative complications between treatment groups after IPTW.  Peak hs-cTnT was higher after use of Bretschneider (Custodiol®)  605-847 mg/L) vs. St. Thomas 2  in propensity-weighted treatment groups. Mitral regurgitation is the second most common valve disease and a common indication for valve surgery in Europe. Therefore, mitral valve repair is the gold standard for the correction of severe mitral regurgitation and recommended (class I) by current ESC/EACTS guidelines for the management of valvular heart disease . MinimalThe aim of our study was to investigate whether St. Thomas 2 provides superior myocardial protection and decreases myocardial damage compared to Bretschneider (Custodiol®) in patients undergoing full endoscopic minimal invasive anterolateral right minithoracotomy.The local ethical committee (EKNZ BASEC Req-2019-00070) approved the study protocol, which is in accordance with the principles of the declaration of Helsinki. The ethical committee has waived the need to obtain informed consent.NCT03818113). The authors designed the study, gathered and analyzed the data, vouched for the data and analysis, wrote the paper, and decided to publish.The trial was registered at the ClinicalTrials.gov  in the department of cardiac surgery at the University Hospital Basel from May 2012 until February 2019. Patients received either St. Thomas 2 or Bretschneider (Custodiol®) cardioplegia as a single dose. Standard protocol for Bretschneider (Custodiol®) included antegrade delivery of 20 mL/kg and for St. Thomas 2 30 mL/kg within 6 minutes at 4°C perfusion temperature. We excluded patients who had known coronary artery disease, mitral valve replacement, second cross-clamping, and combined cardiac procedures.A group of 123 patients, who received Bretschneider (Custodiol©) cardioplegia, was compared to 61 patients with St. Thomas 2 cardioplegia. Given the observational origin of the data, we used IPTW to adjust for confounding by indication, including age, female gender, logistic EuroSCORE, and hypertension as covariates into the propensity model. We trimmed the tails of the propensity score, as the corresponding records are suspicious of residual confounding, and calculated standardized differences to assess comparability of treatment groups after IPTW.In brief, minimally invasive mitral valve repair is performed through a right anterolateral thoracotomy with a periareolar incision, usually entering the thoracic cavity through the fourth intercostal space. Usually, the left groin is used for venous and arterial femoral cannulation for the cardiopulmonary bypass. For the first two years, we used the Chitwood clamp; later, we switched to the Glauber clamp for aortic cross-clamping. Either St. Thomas 2 or Bretschneider (Custodiol®) cardioplegia as a single dose is administered. In all our cases, mitral valve repair with leaflet resection and/or implantation of artificial chordae in combination with ring annuloplasty is exclusively performed. Every patient is monitored by transesophageal echocardiography, which is used perioperatively to evaluate the surgical results.Primary efficacy outcome was the highest postoperative hs-cTnT level measured before discharge; secondary outcomes were peak CK-MB and CK and the first postoperative hs-cTnT, CK-MB, and CK, which have been measured at the first day after surgery at 6 am. Safety outcomes were postoperative complications such as myocardial infarction, MACCE, and need for defibrillation at the end of surgery. Operative mortality was defined as death during surgery. Postoperative stroke was defined as a new, permanent neurological disability or deficit. Atrial fibrillation was defined as a new and permanent postoperative atrial fibrillation during hospitalization. Length of hospital stay was defined as one day prior to the procedure until discharge.We conducted an IPTW analysis and included age, female gender, EuroSCORE 2, hypertension, last preoperative creatinine, ejection fraction (EF), prior myocardial infarction (MI), and preoperative stroke as covariates into the propensity model. We trimmed the tails of the propensity score distribution. Differences between the treatment groups (Bretschneider (Custodiol®) and St. Thomas cardioplegia 2) after IPTW were expressed as standardized differences to assess the difference independent of the number of observations. We considered an absolute standardized difference above 0.1 to be indicative for a possibly meaningful difference. Given the skewed distribution of hs-cTnT, CK-MB, and CK, these variables were analyzed as geometric mean with confidence interval which was back transformed from the logarithmic scale. To investigate the impact of cardioplegic solution on these cardiac markers, we used IPT-weighted Poisson regression with robust standard errors. We included size of ring for annuloplasty as covariate into the model as a first sensitivity analysis. As a second sensitivity analysis, we included year of surgery as fractional polynomial covariate into the model to adjust for the impact of changes in surgical details that might have happened within 7 years of patients' enrolment.p values are two-sided; a p value below 0.05 is considered significant. All analyses were done by a biostatistician (BG) using Stata 15 .Normally distributed continuous data were reported as mean ± standard deviation, and comparisons were made using linear regression. Nonnormally distributed continuous variables were analyzed the same way as cardiac markers. Categorical data are reported as numbers with percentage and compared using logistic regression. Confidence intervals and From January 2009 to February 2019, 871 patients underwent 904 mitral valve operations at our hospital. In 695 patients who received mitral valve repair, anterolateral thoracotomy was chosen as surgical access in 269 patients. 184 of which met the inclusion criteria of this study.p = 0.48). Male gender was predominant in both groups (Bretschneider (Custodiol®) n = 64% vs. St. Thomas 2 n = 66%). Before IPTW, groups were comparable with respect to hemodynamic profiles and all other baseline characteristics except hypertension which was more frequent in patients treated with Bretschneider (Custodiol®). After IPTW, treatment groups were similar with respect to patient characteristics and mitral valve pathology (Tables The median age of the patients in the group of Bretschneider (Custodiol®) was 63 years SD = ±11.8) and in the group of St. Thomas 2 64 years (SD = ±10.2), respectively . There was no statistical difference in perfusion time. Defibrillation was more frequently used in patients receiving Bretschneider (Custodiol®) cardioplegia (50%) vs. St. Thomas 2 (36%). Both cardioplegias were given as a single-shot antegrade. Neither of the two groups received a second injection of Bretschneider (Custodiol®) or St. Thomas 2 cardioplegia. The hemodynamic profiles of the matched patients were comparable in both groups. Both groups had predominantly a valve annuloplasty.n = 1 (0.7%) vs. St. Thomas 2 n = 0 (0%); p = 0.484). Although there were three cases (n = 2.4%) of myocardial infarction in the group of Bretschneider (Custodiol®), these were without statistical significance in comparison with the group of St. Thomas 2 . Moreover, we did not find any statistically significant difference in the stay of the hospital length in days and for atrial fibrillation at discharge (Bretschneider (Custodiol®) n = 32 (28.5%) vs. St. Thomas n = 15 (27.7%); p = 0.918).The in-hospital outcomes and complications are summarized in Postoperative biomarkers including creatine, CRP, GFR, potassium, hemoglobin, leucocytes, sodium, hs-cTnT, CK, and CK-MB are shown in p = 0.0047). The first hs-cTnT and CK showed the same pattern.After IPTW, our primary outcome peak hs-cTnT was higher after use of Bretschneider (median = 716 ng/L) as compared to St. Thomas 2 . Additionally, the first potassium was significantly lower in the group of Bretschneider (Custodiol®) (p = 0.017) but in the normal range of lab analysis. All cardiac markers measured in blood were higher in the group of Bretschneider (Custodiol®). These results were robust after further adjustment for size of ring (p = 0.027) but less pronounced after adjustment for year of enrolment (p = 0.054).There was a statically significant difference in the first CRP (Bretschneider (Custodiol®) mean = 51.1 mg/L vs. St. Thomas 2 mean = 64.2 mg/L; This study has shown the benefit of St. Thomas 2 cardioplegia regarding the postoperative cardiac markers in minimally invasive mitral valve repair.The purpose of cardioplegia is to cause myocardial arrest, to support normal physiology during ischemia, and to decrease the metabolism. Bretschneider (Custodiol®) and St. Thomas 2 are appealing cardioplegic agents for minimal invasive cardiac surgery. Both are given as a single dose and offer myocardial protection for up to 2 hours. On the one hand, Bretschneider (Custodiol®) cardioplegia is an intracellular crystalloid cardioplegic solution with low concentration of calcium and sodium. On the other hand, St. Thomas 2 cardioplegia is an extracellular cardioplegic solution, which is based on potassium and magnesium. Few studies compare the effect of either Bretschneider (Custodiol®) or St. Thomas 2 with other established cardioplegic solutions, but they have never been compared directly –13.This retrospective analysis focused on patients with a minimally invasive mitral valve repair via an anterolateral right thoracotomy. Patients receiving a single dose of Bretschneider (Custodiol®) were compared with patients receiving St. Thomas 2 cardioplegia regarding the postoperative cardiac markers such as hs-cTnT, CK, and CK-MB. Our primary endpoint was the hs-cTnT postoperatively, and the secondary endpoints were the CK, CK-MB, and safety outcomes. The patients' characteristics were similar in both groups.n = 20 (37%) as compared to Bretschneider (Custodiol®) n = 56 (50%); p = 0.130). There were no statistically significant differences in the postoperative outcomes. However, all postoperative cardiac markers were elevated in the group of Bretschneider (Custodiol®). In particular, the maximum values of hs-cTnT and CK were significantly increased compared to the group with St. Thomas 2 cardioplegia .We measured significantly lower cardiac markers postoperatively in patients receiving St. Thomas 2 cardioplegia in mitral valve repair via an anterolateral thoracotomy. Since the surgeons had the same experience, the duration of the operation, the cross-clamping time, and the perfusion time were statistically not significant. The number of perioperative defibrillation was statistically not significant, but there is a tendency in the group of St. Thomas 2, which needed fewer defibrillations  as cardioplegic solution versus 55 patients who were given St. Thomas 2 cardioplegic solution for myocardial protection during cardiac surgery. Second, measurement of the postoperative biomarkers was not according to a specific time. Time frame for the first postoperative hs-cTnT, CK, and CK-MB was within the first 36 hours after the cardiac surgery. The maximum values of high-sensitive troponin, creatine kinase, and creatine kinase-myocardial type were defined/measured as maximum during hospitalization. Additionally, in comparison to hs-cTnT and CK-MB, CK has a low specificity as a biomarker for myocardial damage. Concerning St. Thomas 2, it seems unusual to use it as a single shot, but we never had to reperfuse St. Thomas 2 cardioplegia due to cardiac activity while performing mitral valve repair.It is important to understand that such a complex operation like mitral valve repair with Bretschneider (Custodiol®) or St. Thomas 2 cardioplegia should be done without having interruption or complex changes in the position of the heart. Single-dose antegrade cold Bretschneider (Custodiol®) and St. Thomas 2 in elective valve surgery are both effective in protecting the myocardium. Both cardioplegia strategies had a similar cross-clamp time. All postoperative cardiac markers were higher in the group of Bretschneider (Custodiol®) cardioplegia. In addition to that, there was a statistically significant difference in the maximum values of hs-cTnT and CK.In summary, St. Thomas 2 cardioplegic solution was associated with significant lower levels of postoperative cardiac biomarkers compared to Bretschneider (Custodiol®) cardioplegic solution and therefore should be recommended in patients undergoing minimal invasive mitral valve repair.


The association between obstructive sleep apnea (OSA) and attention deficit hyperactivity disorder (ADHD) is well-established in children. However, there is a paucity of literature regarding this association in adults. The aim of this study was to determine if ADHD is more common in adult patients with OSA. All patients referred to a sleep center for sleep evaluation were administered the Adult ADHD Self-Report Scale and diagnostic polysomnogram. The ADHD screen is considered positive if 4 of 6 questions in part A of the screening questionnaire were answered abnormally. The study population consisted of 194 participants, predominantly male (62%), Caucasian (54%), and Hispanic (44%). OSA was identified in 160 (83%) of participants, with 116 (60%) having moderate to severe OSA. The ADHD screen was positive in 37 (19%) of participants. There was no significant association between the severity of OSA and presence of ADHD symptoms. Patients with OSA who screened positive for ADHD had higher Epworth Sleepiness Scale scores than those that did not. These data suggest that ADHD is more prevalent in patients with OSA, but do not demonstrate a relationship between OSA severity and ADHD symptoms. Interestingly, sleepiness is more prominent in patients with ADHD. Obstructive sleep apnea (OSA) is a common disease with prevalence ranging between 2-7% in the middle age population with apnea hypopnea index (AHI) >5, and is even higher among the elderly and in patients with cardiovascular complications and metabolic syndrome -4. OSA iAttention deficit hyperactivity disorder (ADHD) is thought to be one of the most common psychiatric disorders in adults, with an estimated prevalence of 4.4% . Adult AThe primary aim of this study was to determine if ADHD is more common in adult patients with OSA. Secondary objectives were to determine associations between OSA and ADHD in subgroups of adults, including gender, ethnicity, and age groups, and to determine any associations between ADHD and excessive daytime sleepiness (EDS).Consecutive patients undergoing polysomnography (PSG) at the Baylor College of Medicine Sleep Center in Houston, Texas in 2009 were provided with the ASRS to complete, in addition to standard pre-sleep study paperwork. Inclusion criteria were completion of a diagnostic or split-night sleep study and the ADHD questionnaire, and age >18 years. All records meeting inclusion criteria were selected for review; records were excluded if the patient failed to complete either the ASRS or PSG. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.QuestionnairesAt the time of PSG testing, each patient was provided questionnaires to complete, including demographic questions , the Epworth Sleepiness Scale (ESS), and the Adult ADHD Self-Report Scale (ASRS) , 11. ThePolysomnographySleep studies were performed using attended comprehensive PSG, including recordings of electroencephalogram, electrooculogram, submentalis electromyogram, airflow, respiratory effort, oxygen saturation, anterior tibialis electromyogram, and heart rhythm. Recordings were scored by a technologist manually according to the American Academy of Sleep Medicine Scoring Guidelines and interpreted by a board-certified sleep physician .Statistics2; ethnicity was broken down into Caucasian and Hispanic groups only, as the others had insufficient numbers to justify subgroup analysis; age was divided at age 50 and 65, which resulted in 3 approximately equal groups ; additionally, OSA has been shown to be more severe above age 50 [Comparisons between the means of 2 normally distributed groups were performed with the unpaired t-test. Comparisons between 2 non-normally distributed groups were done with the Mann-Whitney U test. The normality of a group distribution was determined using D’Agostino-Pearson omnibus normality test. Two groups of dichotomous variables were compared with the Fisher’s exact test. In defining subgroups for analysis, obesity was defined as a body mass index ≥30 kg/me age 50 . A P-valDemographic and clinical characteristicsA total of 194 unique patients were included in the analyses; 1 patient did not complete the ESS. The mean (± standard deviation) age was 55.6 ±13.9 years; 62% were male. The self-reported ethnicities were: 54% Caucasian, 44% Hispanic, 2% other. OSA of any severity (AHI ≥5) was identified in 160 (82.5%) of the patients, with moderate to severe OSA (AHI ≥15) seen in 116 (59.8%).Association between OSA and ADHDA positive result on the ADHD questionnaire  was obtained from 37 19.1%) of the patients. As shown in Table 9.1% of tAssociation of ADHD symptoms with sleepinessScores on the ESS were higher in patients that screened positive for ADHD than those that did not , as seen in Figure Our data shows that in patients with OSA there is a high prevalence of patients screening positive for ADHD (19.1%) - this is substantially higher than the reported prevalence of ADHD in the general population (4.4%). Given the previously reported characteristics of the ASRS, a positive result would be expected in approximately 7.3% of respondents from the general population. Our data did not demonstrate a significant relationship between the severity of OSA and the presence of ADHD symptoms.The data did show that patients OSA who had ADHD symptoms were, on average, sleepier than those without ADHD symptoms and a greater percentage of ADHD patients had abnormal ESS scores. Previous trials have shown that adults with ADHD tend to have greater subjective sleepiness and our data are consistent with these findings . While nPrevious reports have commented on the overlap between ADHD symptoms and those attributed to OSA, though these have primarily been in children and adolescents , 21. OurWe saw a high prevalence of ADHD in a population of OSA patients referred for sleep study testing. Despite no relationship to OSA severity, patients with positive ADHD symptoms were generally sleepier than those without ADHD, suggesting a shared common pathophysiologic neurobehavioral influence. The exact mechanisms underlying this shared vulnerability to sleep disruption may need to be further elucidated.


Rehmannia glutinosa with anti-inflammatory and anti-immune effects, can improve urinary protein excretion and immune disorder. Th22 cell is involved in IgA nephropathy progression. This study was determined to explore the effect of acteoside on mesangial injury underlying Th22 cell disorder in IgA nephropathy. Serum Th22 cells and urine total protein of patients with IgA nephropathy were measured before and after six months treatment of Rehmannia glutinosa acteoside or valsartan. Chemotactic assay and co-culture assay were performed to investigate the effect of acteoside on Th22 cell chemotaxis and differentiation. The expression of CCL20, CCL22 and CCL27 were analyzed. To explore the effect of acteoside on mesangial cell injury induced by inflammation, IL-1, IL-6, TNF-α and TGF-β1 were tested. Results showed that the proteinuria and Th22 lymphocytosis of patients with IgA nephropathy significantly improved after combination treatment of Rehmannia glutinosa acteoside and valsartan, compared with valsartan monotherapy. In vitro study further demonstrated that acteoside inhibit Th22 cell chemotaxis by suppressing the production of Th22 cell attractive chemokines, i.e., CCL20, CCL22 and CCL27. In addition, acteoside inhibited the Th22 cell proliferation. Co-culture assay proved that acteoside could relieve the overexpression of pro-inflammatory cytokines, and prevent the synthesis of TGF-β1. TGF-β1 level in mesangial cells was positively correlated with the Th22 cell. This research demonstrated that acteoside can alleviate mesangial cell inflammatory injury by modulating Th22 lymphocytes chemotaxis and proliferation.The existing therapies of IgA nephropathy are unsatisfying. Acteoside, the main component of  About 30–40% of patients with IgAN may develop into ESRD in 20–30 years . RecentlRehmannia glutinosa is a traditional medicine, which is widely used in Chinese, Russian and Japanese medicine for its anti-infection, anti-inflammation and immune-regulation abilities. Acteoside (ACT), the main component of Rehmannia glutinosa, has a wide range of effects, including regulation of immune and inflammatory responses [esponses . Previouesponses ,5. This + T helper (Th) lymphocyte subset characterized by the expression of CCR4, CCR6 and CCR10. Th22 cell disorder is involved in the immunopathologic and inflammatory processes in IgAN [T helper type 22 (Th22) lymphocyte is a newly identified CD4 in IgAN . The adv in IgAN . Thus, t2.2.1.This study protocol was approved by the medical ethics committee of the Xiangya Hospital of Central South University for Human Studies , and all subjects signed informed consents.2.2.Sixteen healthy controls and 31 adults from Xiangya Hospital during 2015–2016, aged between 18–64 years with biopsy confirmed IgAN, were included. Patients were excluded if they had acute infection, glucocorticoid or immunosuppressant treatments, or other complications. Demographic, clinical and biochemical characteristics of patients with IgAN were shown in 2.3.Rehmannia glutinosa acteoside  combined with valsartan . Twenty-four hour urinary protein were quantitatively analyzed. Peripheral blood Th22 lymphocytes were analyzed by flow cytometry as CD3+CD4+IL-17−INF-γ−IL-22+ lymphocytes. CD3 , CD4 , CCR4 , CCR6 , and CCR10  on T-cells isolated from the blood of patients with IgAN, and IFN-γ , IL-22 , IL-17 A , and Ki67  were stained using the fixation/permeabilization concentrate kit (BD Biosciences) according to the manufacturer’s instructions and analyzed by flow cytometry.Eleven patients with IgAN were treated with valsartan . Twenty-one IgAN patients were treated with 2.4.+ T lymphocytes from patients with IgAN were isolated and purified using a CD4+ T cell isolation kit according to the manufacturer’s instructions . Purified CD4+ T lymphocytes from each IgAN patient were separated into three groups, i.e., control group, HMC group and acteoside group. These CD4+ T lymphocytes were added into the upper chambers of a 24-well transwell plate  in RPMI-1640 medium with 0.5% FBS in a final volume of 100 μL. The lower chambers of transwell plate were filled with 600 μL of supernatant of cultured human mesangial cells (HMCs) . Acteoside  was used to interfere the Th22 cell chemotaxis. The transwell chambers were placed at 37 °C in 5% CO2 for 5 h. Th22 cells migrated into the lower chamber were analyzed by flow cytometry, and assigned a chemotaxis index . The concentrations of CCL20, CCL22 and CCL27 were quantified by using enzyme-linked immunosorbent assay (ELISA) kits  according to the manufacturer’s instructions.CD42.5.+ T lymphocytes were treated with 20 mM to 100 mM acteoside in dose-dependent effect assay. CD4+ T lymphocytes were treated with 40 mM acteoside for 24 h to 168 h in time-dependent effect assay. IL-2 (2 ng/mL), anti-CD3 and anti-CD28 mAbs (1 μg/mL each) were used to ensure the survival of T lymphocyte. The exogenous cytokines used to modulate cell differentiation were IL-1β (20 ng/mL), IL-6 (100 mg/mL), TNF-α (50 ng/mL), as well as acteoside (40 mM) alone or in combination. All the reagents used for cell differentiation assays were purchased from PeroTech, Rocky Hill, CT, USA.CD42.6.+ T lymphocytes of patients with IgAN were not pooled. CD4+ T lymphocytes drawn from one patient with IgAN at a single time point were divided into different treatment groups in one repeat experiment. Purified CD4+ T lymphocytes from IgAN patient were separated, co-cultured with HMCs in T + HMC group and acteoside group at a ratio of 5:1 with RPMI-1640 supplemented and 12% fetal bovine serum (FBS) for 5 days. Acteoside (40 mM) were applied into acteoside group. Th22 cells were harvested and analyzed by flow cytometry. IL-1, TNF-α and IL-6 levels in the supernatant were quantified by using ELISA kits  according to the manufacturer’s instructions. The immunoreactivity was determined by using an ELISA reader at 450 nm.Experiments were independent biological repeats. CD42.7.g for 15 min). Lysate samples (50 g) were boiled in sample buffer for 5 min and separated on 10% SDS-PAGE, followed by transfer onto a nitrocellulose membrane . The membrane was incubated with a monoclonal rabbit anti-human TGF-β1 antibody  and reacted with an anti-mouse IgG-HRP antibody (Proteintech). TGF-β1 levels were normalized to β-actin levels and quantified using ECL chemiluminescence system . Films were scanned and images were analyzed using Quantity One 4.62 software .Transforming growth factor beta 1 (TGF-β1) in HK2 cells and HMCs was analyzed by Western blot. Adherent cells in the co-culture system were harvested, lysed for 10 min on ice with 80 μL of RIPA buffer , and centrifuged .Data were expressed as mean ± standard deviation (SD) or median with minimum and maximum value. Data comparisons were performed using Kruskal–Wallis one-way analysis or Mann–Whitney 3.3.1.p < .001). After 6 months combination therapy of Rehmannia glutinosa acteoside and valsartan , Th22 cell proportion decreased , along with a remission in urinary protein excretion (1.64 ± 0.62 g/d vs. 0.10 ± 0.09 g/d) (As illustrated in .09 g/d) .+ valsartan group before therapy did not show any significant difference . However, urinary protein excretion of acteoside + valsartan group (0.11 ± 0.09 g/d) significant decreased after 6 months treatment, compared with valsartan group .Comparison of urinary protein excretion between valsartan group and acteoside 3.2.p < .001). By contrast, Th22 cells chemotactic index of acteoside group decreased .Th22 cells lymphocytosis is closely correlated with the aggravation of IgAN . The accp < .001, respectively), while acteoside significantly inhibited the secretion of CCL20, CCL22 and CCL27 .The Th22 cell chemotaxis response is regulation by the activities of Th22 cell attractive chemokines, i.e., CCL20, CCL22 and CCL27. We further testified the effect of acteoside on the production of CCL20, CCL22 and CCL27. As expected, an overexpression of CCL20 (96.70 ± 4.20 pg/mL), CCL22 (907.19 ± 8.04 pg/mL) and CCL27 (404.70 ± 12.59 pg/mL) were observed in T + HMC co-culture group compared with HMC group .Consisted with the reducing production of CCL22, CCL20 and CCL27, the expression of chemokine receptors, i.e., CCR4, CCR6 and CCR10, on recruited Th22 cells decreased in acteoside group, compared with HMC group . Moreover, acteoside inhibited the Th22 cell proliferation in a dose and time-depend manner  or a combination of IL-1, IL-6, TNF-α and acteoside (3.51 ± 1.03%) decreased.IL-1, IL-6 and TNF-α are well-known accelerators of Th22 cell differentiation. As shown in 3.4.p < .001).The Th22 cell percentage decreased in co-culture systems of acteoside group (2.51 ± 4.54%) compared with T + HMC group . The Th22 cell amount was positively correlated with the IL-1, IL-6 and TNF-α levels .Accordingly, the levels of pro-inflammatory cytokines, i.e., IL-1, IL-6 and TNF-α, were up-regulated in T + HMC group, while acteoside treatment inhibited their synthesis , while TGF-β1 in HMCs of acteoside group decreased significantly . This mesangial cell protective effect of acteoside was positively correlated with the changes of Th22 cells, IL-1, IL-6 and TNF-α .Though the up-regulation of pro-inflammatory cytokines indicates the exaggeration of inflammatory response , a chang4.Rehmannia glutinosa with anti-bacterial, antioxidant, anti-inflammation, and immunoregulation activities. These make acteoside a possible therapy for IgAN. Hong et al. have proved that urinary protein levels were more effectively controlled in patients with chronic nephritis treated with Rehmannia glutinosa acteoside and irbesartan compared with irbesartan [IgAN is the most common primary glomerulonephritis. Patient with IgAN, even if treated with standard therapy, still face an irreversible exacerbation of disease and a loss of renal function over time ,12. Therbesartan , but theRehmannia glutinosa acteoside could significantly improve the proteinuria and Th22 cell overexpression of patients with IgAN. This result was consistent with Sadakane’s research of nephritis mice, which included an IgAN subgroup and showed that the administration of acteoside improved renal function [We found that function ,15. But function . It is pTh22 lymphocytosis participates to IgAN progression . Xiao C The accumulation of Th22 cell may attribute to either cell infiltration or cell proliferation. In this research, we demonstrated that acteoside could directly inhibit the Th22 cell chemotaxis, which may induce an accumulation of Th22 cells in kidney. Grigore et al. demonstrated that acteoside could inhibit leukocytes infiltration and improve renal inflammation ,19, but Chemokines is essential to lymphocyte migration. Th22 cell chemotaxis is in response to the effects of CCL22, CCL20 and CCL27, which are the members of CC chemokines. The collaboration between these chemokines and their corresponding receptors expressed on Th22 cells may contribute to lymphocyte disorder in IgAN . ResearcThe effectiveness of acteoside also relies on regulating lymphocyte proliferation. We demonstrated that acteoside could suppress Th22 cell differentiation in a time and dose-dependent manner. Yoou MS et al. declared that acteoside attenuates inflammatory mast cell proliferation via down-regulating MDM2 .In view of the adverse effect of Th22 cell in IgAN, the activities of acteoside to alleviate Th22 cells chemotaxis and proliferation make it possible to improve kidney damage. Saegusa Y et al. suggested that acteoside had a mesangial protection activity . Our resSince chronic inflammation is a common hallmark of renal fibrosis in IgAN ,11, we f5.This study demonstrated that Th22 cell disorder and the relevant inflammatory response attributed to the progress of IgAN. Acteoside could serve as an alternative therapeutic for IgAN by remitting Th22 cell related-inflammatory injury and immune disorder.