This paper shows the ways that tales of stoicism during surgery at the Battle of Waterloo came to be a significant part of the ideological framework of Romantic Militarism. Celebrating the killing of enemies clashed with ideals of politeness, but hailing a soldier’s powers of endurance in surgery was an acceptable way of extolling courage, framing lived experience of agony into narratives of exalted pain, masculine fortitude and quasi-religious patriotic feeling. In Britain, an extensive discourse emerged about the supposed Britishness of surgical sangfroid at Waterloo, providing a narrative of national superiority in the decades of imperial expansion that followed. The Red and the Black is often mentioned as a dissection of the impact of the memory of Napoleonic glory on ambitious young men in the more banal decades that followed Waterloo. The author , who had been on campaign with Napoleon, depicts his protagonist Julien Sorel trying to rise in society and living out his petty adulteries in an ironic sub-Napoleonic key. It is less well known, however, that Sorel’s dreams of martial destiny are derived not from a soldier but from ‘an old Surgeon-Major of Napoleon’s Italian Army’, who provided him with the early education in Latin and in ‘the battles of Lodi, Areola and Rivoli’ that allows Sorel to escape from provincial obscurity.Stendhal’s 1830 novel With this view of battlefield surgery, Julien Sorel was in many ways a representative figure. In the wake of the Napoleonic Wars, tales of stoicism during (unanaesthetised) surgery came to be a standard part of the developing cultural and ideological framework of what Nancy Rosenblum has called Romantic Militarism.In Britain this Romantic cult of heroic bravery in surgery often took an explicitly national and patriotic form, with a widespread debate on the supposed Britishness of surgical sangfroid.The most prominent battle in this discourse of heroic British surgical fortitude was Waterloo, an unusually sanguinary encounter that was quickly understood to mark the end of the long struggle with France. As the final cataclysm of the war, the battle was a vital obsession in nineteenth-century Romantic Militarism, a last hurrah of glory before the lacklustre years of peace. Strategic and tactical concerns meant that both the British (or rather Anglo-German-Dutch) forces and their French opponents remained on the field despite heavy losses. By the time the French army collapsed on the evening of 18 June, perhaps 50,000 men were left dead or wounded.In many ways, this ‘official’ discourse of heroic British stoicism in surgery might seem a bad joke, so hyperbolic as to make one think of it as pure ideology, a fantasy cut from whole cloth with no relation whatever to what went on in the real world. It is certainly the case that depictions of wounded men often showed, in Shaw’s words, a ‘disregard for the inner experience’.The Charterhouse of Parma, wounded by his own side at Waterloo, who were ‘liberated’ from ‘the romantic element’ of war by the experience of injury, eyewitness testimony of extraordinary bravery in surgery of the kind described in this article was so common that one has to take it seriously.Flying Sketches of the Battle of Waterloo, noted that, ‘the wounded men seem to vie with each other in bearing their agonies with fortitude; and we actually saw two British soldiers disputing the precedence of valour at some particular moment, one of whom had lost a leg, and the other was severely wounded in the arm!’Nonetheless, it seems that the actual experience of military surgery was sometimes also powerfully mediated by ideas of masculine self-control and patriotism that gave meaning to the subjective experience of agony and dismemberment. While there were clearly some, like Stendhal’s callow hero Fabrice in First-hand testimony on the reality of Waterloo surgery from the many British surgeons who went to Brussels in the wake of the battle also reflected both the horrors involved and admiration for soldiers’ fortitude, often expressing profound sympathy in a way that undermines the clichés of the surgeon of the period as callous.After the battle, the experience of surgery was further mediated into a widespread cultural memory of British fortitude in surgery at Waterloo that had a significant impact.This article considers the experience of surgery at Waterloo and the ways it was remembered as a field of manly heroic endeavour, sublime agony and national valour. First, it considers the notion that there was something particularly British about such heroism in in the context of the British National Romance, before turning to issues of how that related to the class divisions within British society. It is hoped that it represents a step towards a view of the history of nineteenth-century surgery that goes beyond progress narratives of great surgeons, to focus on the attitudes of patients and other observers. Likewise, previous historiography has arguably somewhat neglected military surgery in favour of its civilian counterpart, although the army and navy accounted for a significant percentage of all serious surgical operations.Victory at Waterloo, including stories the apparent fortitude of British men in surgery, was balm to elite anxieties about national character. Defeat in the American War of Independence and inept interventions on the continent in the 1790s had led to fears that British commercial success was leading to luxury and a weakening of exactly the sort of martial resolve necessary for composure during surgery.bottom or a happy union of strength of body and resolution, or firmness of mind, sufficient to have resisted attacks of the French at the Battle of Waterloo.the steadiness, valour, energy and discipline of the British army. It was remarked to me, that scarcely any other troops possessed that firmness and discipline, joined to what we would call ancien régime armies, in the wake of the French levée en masse, there was also an increasing sense of war as a conflict between peoples.The cult of fortitude in Waterloo surgery often focused on the role of national character, although, at this point in time, seldom of race in any ‘scientific’ sense. Eighteenth-century ‘cabinet wars’ were widely understood as rational acts of self-assertion by states, not necessarily as ‘patriotic’ struggles, even if national feelings played a part. Although the war against France was finally won by essentially Les Misérables, Victor Hugo  included a long section on Waterloo. Eager not to give too much credit to Wellington, he ascribed the victory to a fickle deity and to the national virtues, the ‘obstinate coolness … the ancient classic courage … the English firmness, the English resolution, the English blood’ of the British soldiers, contrasted with the ‘superhuman instinct, a flaming glance’, of the French. As he put it, ‘The iron soldier is worth as much as the Iron Duke’.The standard narrative of Waterloo, that it was the result of British endurance in the face of French attack, played to well-known clichés of national traits. In his 1862 novel One of the oldest tropes in the historiography of war is building up the strength of your enemies so as to magnify one’s achievement. It is thus no surprise to see many British sources praising the capacity of French troops to endure surgery.These fellows are brought from the field after lying many days on the ground, many dying, many in agony, many miserably racked with pain and spasms, and the fellow next to him mimics him and gives it a tune. ‘Ah, ha! vous chantez bien!’A number of stories about Frenchmen exhibiting bravery in surgery became standard anecdotes, reflecting supposed undying loyalty to Napoleon and French verve rather than the stolid virtues ascribed to their British counterparts. For instance, tales of one who ‘tossed his amputated arm in the air, with a feeble shout of “vive l’Empereur” and another wounded Frenchmen who cried out last words that he would ‘cheerfully shed the last drop in his veins for the great Napoleon!’ and a third who said ‘An inch deeper and you’ll find the Emperor’ as a bullet was removed from his chest, were often repeated.Ned Costello expressed a more sceptical view about the fortitude of French soldiers compared to their British opponents. Having seen a lot of ‘cutting off legs and arms’ in Brussels after Waterloo, he wrote about an ‘incident’ that ‘may in some measure show the difference of the two nations’. He described an ‘English soldier’ undergoing the amputation of an arm while holding ‘the injured limb with his other hand without betraying the slightest emotion, save occasionally helping out his pain by spitting forth the proceeds of a large plug of tobacco, which he chewed most unmercifully while under the operation’. In contrast, a nearby Frenchman whose shoulder was being probed by a surgeon looking for a ball was ‘bellowing lustily’. The noise caused by the French soldier so ‘annoyed’ the British soldier that ‘as soon as his arm was amputated, he struck the Frenchman a smart blow across the breech with the severed limb, holding it at the hand-wrist, saying, ‘Here take that, and stuff it down your throat, and stop your damned bellowing!’Over the past few years there has been a trend in historiography towards emphasising the range of the emotional repertoire of the nineteenth-century British soldier, what Holly Furneaux (writing primarily about the Crimean War) has called the British ‘military man of feeling’.The emotional world of Napoleonic-era surgery and its memory included intense ideas of blood sacrifice, one that reinforced British collective identity and that justified British power.After serving my country during the flower of my days, after spilling my blood in her cause, and losing a portion of my animal self to secure or defend her honors [sic], I have been discharged from the service with the remuneration of a lieutenant’s pension. I reproach not my country, however; I love, I venerate every spot of British ground. Her laws and constitution are unrivalled by any nation beneath the sun.Thanksgiving Ode, written for the first anniversary of Waterloo. Notoriously, it contains the line, ‘Yea, carnage is Thy daughter’, seeming to revel in the hurt done to human flesh at the battle.Childe Harold’s Pilgrimage. Other, less prominent, poets wrote about the blood ritual element at Waterloo in less critical terms. Victorian versifier Edmund White’s A Soldier at Waterloo depicted a soldier in despair over the moral crime of killing his fellow man, before he is redeemed by a divine vision of the battle as a blood sacrifice and he kisses his own blood-stained sword.Song of the Dead made this point very succinctly – ‘If blood be the price of admiralty,/Lord God, we ha’ bought it fair!’Marseillaise’s lines ‘Let an impure blood/Water our furrows’) meant that British observers generally avoided overt references of that kind, but at an implicit level, an almost Jacobin conception of blood, purity and nation was a vital element in the ideology of spiritualised warfare that underlay Romantic Militarism in Britain, too.This conception of the battle shocked many, but can often be seen in implicit terms, for instance in Wordsworth’s poem One of the principal themes in stories of composure in surgery at Waterloo was the sense that the increasingly respectable common soldier was capable, even enthusiastic, about enduring torments in his country’s cause.Evidence from first-hand testimony does suggest that some common soldiers did show remarkable composure in surgery. For instance, in his memoir written in the 1840s, Thomas Jackson, a sergeant from the Coldstream Guards, provided a detailed account of the loss of his leg in an amputation while a prisoner during the campaign a year before Waterloo. In it, he wrote:They had got me fixed upon the end of a long barrack-room table … a bason [sic] was brought for me to drink out of. I said, ‘Sir, let me have a good draught’. He poured out nearly a pint [of red wine], which I eagerly drank off. In an instant it raised up my spirits to an invincible courage. ‘Now, gentlemen’, said I, ‘go on, if you please’. The serjeant [sic] was preparing to blindfold me ‘Oh no,’ I said, ‘I shall sit still and see as well as the rest’. One of the surgeons sat on a stool, to hold the leg steady: the second ripped up my trousers and took down the stocking low enough, then he waited on the head surgeon … the tourniquet being placed painfully tight above the knee, he put his hand under the calf of the leg and setting the edge of the knife on the shin bone, at one heavy, quick stroke, drew it round till it met the shin bone again. All eyes were fixed on me, but I was too high spirited then to give way. The blood quickly following the knife, spread around and formed like a red fan, downwards, at the sight of which, the frightened, but sympathising Dutch lookers on, screamed as though they were being cut. They pitied me very much and said ‘poor sergean [sic] major’. … When the saw was applied, I found it extremely painful; it was worn out … it stuck as a bad saw would when sawing a green stick. I said, ‘Oh, Sir, have you not a better saw?’ He said he was sorry he had not, as they were all worn out. The bone got through, the next thing to be done was still more painful – that of tying up the ligatures: then followed the drawing down of the flesh to cover the end of the bone, and tightly strapped there with strips of sticking plaster; after this, strongly bandaged; thus ended the operation, which lasted about half an hour. It was curious enough. These gentlemen, finding me not squeamish, amused themselves by engaging my attention in a conversation.ancien régime in character, but a reflection of the development of modern conservativism, in which the masses were to be brought in to uphold the status quo. As Linda Colley noted, ‘Waterloo made the world safe for gentlemen again’.The way that the passage above combines a description of his terror (needing a stiff drink beforehand and the frank acknowledgement of the pain) and his bravado and fortitude (insisting on watching the operation and chatting away to the surgeons) fits with a broader pattern in eyewitness sources that suggests that masculine self-esteem generally played a greater role than any ideological considerations. Other common soldiers expressed outright scepticism about those ideological aspects. Having seen punishment floggings, Thomas Morris, a sergeant in the 73rd Regiment of Foot, felt ‘somewhat less disposed to hazard life and limb, in a service, with the probability of being repaid with such gross inhumanity and ingratitude’.While common soldiers were the object of increased interest, it was the composure and character of gentlemen officers that remained at the heart of the discourse of heroic fortitude under the knife. At a time when the officer corps remained socially exclusive and commissions were still purchased, the British officer was increasingly being portrayed as a ‘moral leader’ in terms of his manly stoicism.The Wellingtonian noted that he was unable to find a surgeon, so ‘he made a common soldier cut it off with his sabre’, which he bore ‘without flinching’, but also mentioning that he was ‘peculiarly sensitive, and could not bear the sight of blood’, and that he fainted at the sight of the hand the next day.Famous officers at Waterloo provided many of the most important anecdotes of surgical heroism, some of which became fixtures in myths of Romantic Militarism and the British National Romance. Indeed, the number of such cases gives one a sense of the scale of the surgical carnage involved. Thomas Picton, the most senior officer to die at Waterloo, had, it seems, sworn a surgeon to secrecy after being injured in the days before the battle in order to lead his troops, supposedly saying, ‘I give you my word of honour, both as a gentleman and an officer, that if you place my name in your report as unfit for duty, I will shoot you with my own hand’.Waterloo, these words are depicted in terms of pathos and brotherly feeling. Other commentators have seen Wellington’s response as deliberately cold and sarcastic since relations between the men were bad, after Paget, a married father of eight, had run off with Wellington’s brother’s wife in one of the era’s biggest scandals.The powers of endurance of Henry Paget  at Waterloo provided the most well-known instance of hyperbolic courage in surgery, becoming the centre of a cult with its own shrine and relics. The oft-repeated anecdote which suggested that he responded to a cannon ball taking his leg off by saying ‘By God, I’ve lost my leg’, only to hear the Duke of Wellington reply, ‘By God, Sir, so you have’, matched a need for exemplary tales of aristocratic phlegm.The best source we have for the events involved, the medical notes of the surgeon, John Hume, however, gives a rather different account of what happened.Flying Sketches of the Battle of Waterloo written ‘on the spot’ in 1815, reports being told ‘little anecdotes’ shortly afterwards, one of which involved being told that an observer ‘had seen Lord Uxbridge’s leg amputated, and that this nobleman not only bore the operation like a hero’.A Poem of the Battle of Waterloo included a note on ‘the heroic Earl of Uxbridge’ to the effect that, ‘During the amputation of his leg not a groan escaped from him, nor did a contortion of countenance indicate that he was undergoing the operation; but with a firmness equal to that which he displayed on the field, even while the instrument of the surgeon in this painful duty, he magnanimously exclaimed, “Who would not lose a leg for such a victory!”‘The Battle of Waterloo included a longer version of this anecdote, having Uxbridge follow that line with ‘It is true, I have a limb less; but I have a higher name in the eyes of my country’.The whole business of Uxbridge’s leg and his coolness in surgery soon became legendary, with the story evolving and gaining dubious additions. The author of The Poet’s Pilgrimage to Waterloo (1816) included a description of how Uxbridge’s leg had been made part of the sightseeing offering.The earl’s leg became arguably the most famous surgical relic of the whole Napoleonic Wars – part of the substantial material culture of the memory of the battle.Vanity Fair (1847) includes the most famous depiction of the aftermath of the battle, mocked the cult of Anglesea’s lost limb – ‘come, let us away and drop a tear over the Marquis[sic] of Anglesea’s leg!’ and expressed disgust at the fact that the British common soldiers’ names were not recorded on any memorial at the site.Not everyone was impressed by the adoration of aristocratic sacrifice at Waterloo. William Makepeace Thackeray, whose novel Along with Trafalgar, Waterloo remains arguably the most symbolically significant triumphs in the history of British arms, ‘the bedrock of Victorian self-confidence, pride and patriotism’.The reality of surgery at Waterloo does appear to have included stunning examples of composure, no doubt from complex motives related to ideas of masculine honour, regimental pride and national feeling. These were often exaggerated, simplified and channelled into familiar tropes and, joined by more or less invented stories, then turned into a key aspect of the British cultural memory of the wars. Shorn of the trauma of experience, stories of men enduring surgical agony, willing to literally sacrifice their blood and limbs in surgery as much as in combat, were a perfect fit for the developing culture of Romantic Militarism, new ideas of masculinity and to the British National Romance, giving a touch of steel and blood to the military man of feeling.Despite examples of actual heroic composure recorded by witnesses, the romantic blood sacrifice myth-making that dominated later discourse on the subject in many ways did therefore distort the true nature of what happened. Wellington, perhaps not a likely candidate for questioning the idea of the glory of war, had fewer illusions about the reality of the battle than some later anecdote-mongers. The rest of his career would be based on the victory at Waterloo, but his response to the battle was couched not in terms of romance but of trauma:My heart is broken by the terrible loss I have sustained in my old friends and companions, and my poor soldiers. Believe me, nothing excepting a battle lost, can be half so melancholy as a battle won … to win such a battle as this of Waterloo, at the expense of so many gallant friends, could only be termed a heavy misfortune, but for the result to the public.Any discussion of the dramatic or comical semi-mythological heroic discourse on Napoleonic-era surgery as a field of glory should keep one eye on its foundations in the actuality of killing and maiming in war.


Bartonella species in wild rabbit fleas from Colorado, USA: B. vinsonii subsp. berkhoffii (n = 16), B. alsatica (n = 5), and B. rochalimae (n = 1). Our results support the establishment of the zoonotic agent B. alsatica in North America.We detected 3  Francisella tularensis), plague (Yersinia pestis), pasteurellosis (Pasteurella multocida), ringworm (Trichophyton spp.), and cryptosporidiosis (Cryptosporidium cuniculus)  in eastern France  are known or potential reservoirs for a number of zoonotic agents, including tularemia  in June and July 2005 from 8 sites in Boulder County, Colorado, USA (https://www.mn-net.com), with aliquots of extracted DNA maintained at the University of Richmond , and secondary aliquots sent to the Laboratory of Veterinary Public Health, Nihon University College of Bioresource Sciences . Both laboratories screened samples for Bartonella infection by conventional PCR targeting part of the ssrA gene; primers used were ssrA-F (5′-GCTATGGTAATAAATGGACAATGAAATAA-3′) and ssrA-R (5′-GCTTCTGTTGCCAGGTG-3′). The targeted gene was selected because of the robustness of the PCR assay and the ability of the locus to segregate Bartonella at the species level –labeled probe ; primers were the same as for conventional PCR. Samples that tested positive for Bartonella DNA by real-time PCR and for which unambiguous sequence data were collected in both laboratories from the target locus (ssrA) were reported as Bartonella positive. We sequenced all amplicons (301 bp) from conventional PCR and aligned them with Bartonella type strains and then subjected them to phylogenetic analysis using MEGA 7.0 (https://www.megasoftware.net).We collected fleas from live-trapped desert cottontail rabbits  collected from 7 rabbits sampled at 4 sites  and were not available for Bartonella testing. We collected 141 fleas from 14 desert cottontail rabbits  in the summer of 2005. Of these fleas, 105 (81 Bartonella DNA in 2 (8.3%) C. inaequalis fleas collected from 1 rabbit (ID no. 522) and 21 (25.9%) E. glacialis fleas collected from 5 rabbits  , PS674-e5 (GenBank accession no. MN654366), and PS674-e6 (GenBank accession no. MN654366). All 3 rabbits  from which >1 flea was PCR-positive and available for sequencing produced multiple Bartonella species (We detected and 674) . All nucchalimae , and cluchalimae . The rep species .Bartonella species among the 105 rabbit fleas we tested for this study; overall Bartonella prevalence in fleas was 21.9% (23/105), which is comparable to previous prevalence estimates from rabbit fleas in Europe  in Spain (Spilopsyllus cuniculi and Xenopsylla cunicularis) collected in France  infesting cats and dogs in the United Kingdom  in Brazil  captured in Taiwan and in California, USA , a species associated with epizootic Y. pestis emergence, and flea exchange between desert cottontails and prairie dogs has been described (Bartonella species, including B. alsatica, which had not been previously recorded in North America, and that wild lagomorphs may contribute to the maintenance and transmission of several vectorborne zoonoses.rtonella  exchange


We showed that pomegranate juice (PomJ) can help to maintain memory in adults aged >50 y. The mechanism for this effect is unknown, but might involve Trp and its metabolites, which are important in brain function.We aimed to test the hypothesis that PomJ and its metabolites ellagic acid (EA) and urolithin A (UA) affect Trp metabolism.Stool and plasma from a cohort  of subjects enrolled in our double-blind, placebo-controlled trial (NCT02093130) were collected at baseline and after 1 y of PomJ or PL consumption. In a mouse study, cecum and serum were collected from DBA/2J mice receiving 8 wk of dietary 0.1% EA or UA supplementation. Trp metabolites and intestinal microbiota were analyzed by LC-MS and 16S rRNA gene sequencing, respectively.P = 0.03). In serum of experimental mice, we observed a 230% increase of IPA by EA but not UA, a 54% increase of indole sulfate by UA but not EA, and 43% and 34% decreases of kynurenine (KYN) by EA and UA, respectively. In cecum, there was a 32% decrease of Trp by UA but not EA, and an 86% decrease of KYN by EA but not UA (P < 0.05). The abundance of 2 genera, Shigella and Catenibacterium, was reduced by PomJ in humans as well as by UA in mice, and their abundance was negatively associated with blood IPA in humans and mice (P < 0.05).In the human study, the change in the plasma Trp metabolite indole propionate (IPA) over 1 y was significantly different between PomJ and PL groups (These results suggest a novel mechanism involving the regulation of host and microbial Trp metabolism that might contribute to the health benefits of ellagitannins and EA-enriched food, such as PomJ. Trp is an essential amino acid, and Trp metabolism has been involved in many aspects of host metabolism and physiology , 2. Bothn = 15) for 1 mo improved memory performance and altered brain neural activity in older subjects with mild memory complaints compared with daily intake of taste-matched placebo juice (PL) with high fructose content but no polyphenols (n = 13) (n = 98) experienced stabilization of performance of a memory score involving visual-spatial learning compared with subjects in the PL group (n = 102) who consumed the PL and showed a decline on that learning score  . In addiroup n = 2 who con 13) n = 8 experieng score . PomJ co . In addng score . After ong score . The benng score , 19–21.1) investigating the possible mechanism of PomJ on memory by evaluating the effect of PomJ intake on Trp metabolism; 2) investigating the individual effects of EA and UA on Trp metabolism by supplementing EA and UA individually in mice lacking the ability to produce UA; and 3) investigating the effect of PomJ, EA, and UA intake on gut microbiota and the association with Trp metabolism.PomJ intake was found to acutely regulate the concentrations of the Trp metabolite melatonin in both healthy and insulin-resistant (IR) subjects . EA suppFor this purpose, we first analyzed plasma Trp metabolites and fecal microbiota from a small cohort of subjects enrolled in our recent randomized controlled trial comparing memory performance of 1-y PomJ compared with PL consumption in healthy older adults . We recen = 98) or PL (n = 102) for 1 y in a randomized, double-blind, 2-arm, parallel-design study . Two hundred and thirty-seven millilitres PomJ provides ∼120mg EA when completely hydrolyzed  for 8 wk; they were then randomly assigned to 1 of 3 groups, and fed either an HFHS diet, or an HFHS diets supplemented with 0.1% EA , or 0.1% UA  (drolyzed . EA and drolyzed . Howeverdrolyzed . After Edrolyzed .g for 10 min at 4°C. Supernatant was dried using a SpeedVac evaporator (ThermoFisher Scientific) and then resuspended in 50% methanol for analysis. LC coupled to electrospray ionization triple quadrupole MS (LC-ESI-MS/MS) at positive mode was used to determine Trp, serotonin, tryptamine, kynurenic acid (KYNA), and KYN, and HPLC fluorescence was used to determine indole acetate (IAA), indole sulfate (IS), and IPA at excitation/emission 280nm/370nm. The LC-ESI-MS/MS was performed on a 2.1 × 150-mm Agilent Zorbax C18 column. The mobile phase for LC-ESI-MS/MS analysis consisted of 2 solutions: acetonitrile and 0.25% formic acid/H2O. Tandem MS spectra were automatically performed with argon as the collision gas . The HPLC was performed on an Inertsil ODS-4 4.6 × 150-mm column. The mobile phase for HPLC analysis consisted of 2 solutions: acetonitrile and 0.2% trifluoroacetic acid/H2O. Concentrations were calculated by comparing sample peak area with the commercial standard peak area. For every 10 samples, we randomly picked 1 and spiked that with known concentrations of mixed standards in duplicate to evaluate the accuracy and precision of the LC-ESI-MS/MS and HPLC methods. We used the following equation to calculate percentage recovery:Fifty microliters of human plasma or mouse serum samples were precipitated with 500 µL methanol and centrifuged at 10,000 × % recovery = 100 × /known value of mixed standardsSamples with the percentage of recovery between 80% and 120% were included in the results.g for 10 min at 4°C. Supernatant was dried by SpeedVac and reconstituted in 10 µL water. Seventy microliters AccQ Fluor Borate buffer and 20 µL reconstituted AccQ Fluor Reagent were added to the sample tubes following manufacturer's manual . Samples were vortexed for 1–2 min and incubated at 55°C for 10 min. Samples were then cooled at room temperature and centrifuged, and the supernatant was used for HPLC analysis as described above.Twenty-five microliters human plasma or mouse serum samples were mixed with 500 µL of methanol, vortexed for 1 min and then centrifuged at 10,000 × www.mrdnalab.com) on a MiSeq sequencer (Illumina). Sequence data were processed using the MR DNA analysis pipeline as previously described (http://rdp.cme.msu.edu), and the National Center for Biotechnology Information (www.ncbi.nlm.nih.gov) as previously described (DNA from stool or cecum content was extracted using the DNeasy PowerSoil Kit (Qiagen). Sequencing of the V4 variable region was performed at MR DNA .DESeq2 was used to identify abundance changes at the genus level that occurred differentially between PomJ and PL groups. Null and test models were constructed, and an interaction between “time ” and “intervention (PL or PomJ)” was the differentiating term between 2 models as previously described . A likeln = 12) . Summary statistics  were calculated. The sample size was determined based on a previous study showing that 200 mL PomJ intake for 4 wk effectively changed phenolic metabolites and gut bacteria (n = 12) . For theP = 0.03) from that in the PomJ group. In the PL group, IPA concentrations decreased, whereas in the PomJ group the IPA concentrations were stable over 1 y of PomJ consumption (P = 0.008), whereas IS concentrations remained stable over 1 y of PomJ consumption . The β-diversity measure Bray–Curtis dissimilarity was calculated and visualized via PCoA. No distinct separation between baseline and final visits in PL or PomJ groups was observed . Comparing final with baseline in the PL group, the fecal abundance of 3 genera  was increased, and in 2 genera (Fusobacterium and Barnesiella) it was decreased  were increased and 7 genera  were decreased , as well as decreased or reversed the increase of 7 genera   . Some asococcus) . For exaectively .Serum and cecum Trp and its metabolites were evaluated in experimental mice fed an HFHS diet or HFHS diets supplemented with 0.1% EA or UA for 8 wk , C. The Lactobacillus and Eubacterium were positively associated with serum and cecum IPA, whereas the abundance of Alistipes was negatively associated with serum and cecum IPA .Other amino acids in serum were not altered by dietary EA or UA supplementation (P = 0.058) as well as a significant difference between clusters when compared with the HFHS group (P = 0.01)  were increased and abundances of 4 genera  were decreased by EA  were increased and 11 genera  were decreased by UA  were higher, and 8 genera  were lower in the UA group  , C. Comped by EA . Compareed by UA . CompareUA group .This study investigated the effect of PomJ and its bioactive constituent EA and microbial metabolite UA on Trp metabolism. We first showed that plasma concentrations of the microbial Trp metabolite IPA were maintained in individuals who drank PomJ compared with a decrease observed in the PL group in a small cohort from our recent clinical trial . We furtUA is a microbial metabolite of ETs/EA, but its potential in regulating microbial composition and metabolic activity has not been documented , 27. In We also evaluated the effects of PomJ intake on fecal microbiota in the small cohort from our recent clinical trial . BecauseShigella and Catenibacterium, were found to be decreased by PomJ intake in humans as well as by UA supplementation in mice. Shigella is a well-known pathogenic Gram-negative bacterium that causes inflammatory destruction of the intestinal epithelial barrier and has been associated with IBD  drink or PomJ for 1 y . Changeswith IBD . The exapatients , 46. In Clostridium, Burkholderia, Streptomyces, Pseudomonas, and Bacillus . The second limitation is that PomJ contains a variety of bioactive compounds in addition to ETs and EA, but we only evaluated the impact of EA in the mouse experiment. It would be interesting to study whether other constituents in PomJ also affect Trp metabolism. The third limitation is that although we show the impact of PomJ, EA, and UA on Trp metabolism in human and mice, no analysis of the host and microbial genes or enzymes involved in Trp metabolism was performed. The fourth limitation is that it is unclear how the impact of PomJ, EA, and UA on Trp metabolism subsequently contributes to health benefits of their intake. Additional research is necessary to provide this link.There are several limitations of the present study. The most important limitation is the small sample size for this subset of the clinical cohort. Due to the small sample size, the between-group difference in the primary cognitive outcome did not reach significance (The present data include analyses of a small cohort of a double-blinded and placebo-controlled trial and mouse feeding study to analyze changes in Trp metabolites in response to consumption of PomJ and EA/UA, respectively. Our data show that dietary PomJ, EA, and/or UA supplementation not only affected the metabolism of the essential amino acid Trp but also altered the gut microbiota composition. In addition, to the best of our knowledge, our data show for the first time that UA is not only a postbiotic, generated from microbial EA metabolism, but also significantly affects microbial composition and metabolism. Manipulation of the complex interplay between diet, microbiota, and host represents a powerful strategy for altering the physiological status of the host.nzaa165_Supplemental_FileClick here for additional data file.


Subgaleal abscess is an extremely rare and unusual presentation of head and neck infections and has been reported to occur following scalp infections, head trauma, sinusitis, septicemia, scalp monitoring, and surgical interventions. We report a 10-month-old child who presented with cellulitis around a pustule on the right forehead of three days duration. It was initially treated with oral cloxacillin for five-days. However, the child went on to develop a high continued fever on the day of discharge and remained febrile and unwell for seven days until a subgaleal abscess was identified and surgical drainage was performed. Pus cultures grew Staphylococcus aureus, which was sensitive to flucloxacillin. Following drainage of the abscess and change of antibiotics to intravenous flucloxacillin, fever completely subsided and the child made a complete clinical recovery. This report highlights the importance of having a high clinical suspicion of this rare complication in children with continuing high spikes of temperature following skin infections in the head region. A subgaleal abscess is rare in healthy children and is reported as a potentially dangerous complication of untreated or partially treated infections in the scalp. It commonly occurs following infection of a subgaleal hematoma, which could be secondary to a skull fracture, incidental minor injuries to the scalp, birth trauma, and either hair pulling or vigorous hair combing -7. In thA 10-month-old, previously healthy child presented with cellulitis around a pustule on the right side of the forehead for a three-day duration. It was very painful, disturbing his sleep; in addition, cellulitis was extending over the same duration. The rash was not associated with fever and the child’s activity, and feeding had been satisfactory. As it was an obvious localized lesion (2.5 cm x 3 cm), oral cloxacillin was commenced for impetigo-associated cellulitis of the forehead, and investigations were not performed. On the following day, after having normal observations and good clinical response, he was planned for discharge. However, on the same day, he developed high-grade fever with chills and rigors and became irritable and unwell.Subsequently, the diagnosis was reviewed and the child was reassessed. The physical examination was normal apart from tenderness over the back of the scalp. The investigation revealed that high white blood cells (16x103/ cumm) with neutrophil leukocytosis (80% of white blood cells), elevated C-reactive protein , and erythrocyte sedimentation rate (40mm/first hour). Ultrasound of the scalp and brain was normal. Chest X-ray was normal. Since the diagnosis was not apparent, the child was commenced on broad-spectrum intravenous antibiotics as for sepsis. Despite being on intravenous antibiotics for three days, his fever continued and increased up to 39.2 °C. Subsequently, the antibiotic was changed to intravenous cefotaxime as increasing white blood cells  and CRP (24 mg/dl) were noticed. Cerebrospinal fluid (CSF) analysis and blood culture were negative. Although fever spikes started to decline following the change in antibiotics, the fever did not reach the baseline. The mother reported pain mainly over the right side of the head, as he was crying while handling his head. Tenderness was elicited over the same region. A repeated ultrasound scan of the scalp showed a subgaleal abscess on the right side of the nape (5 cm x 5 cm). The abscess was drained under ultrasound guidance, and the pus that was sent for culture grew Staphylococcal aureus. Based on antibiotic sensitivity, the antibiotic was changed to intravenous flucloxacillin and continued for five days. Following drainage of the abscess and change of antibiotics to intravenous flucloxacillin, fever completely subsided, and the child made a complete clinical recovery.The subgaleal space is a potential space between the skull periosteum and the scalp and formed by the epicranial aponeurosis, which extends from the supraorbital ridge to the zygomatic arches and auricular muscles laterally and to the cervical triangle muscles posteriorly. Increased laxity of the loose connective tissues of the subaponeurotic space in children has been thought to be allowing for greater mobility of the scalp relative to the cranium. Emissary veins connecting dural sinuses and superficial scalp veins reside in this space along with loose connective tissue. Infections can potentially seed through both hematogenous spread and direct bacterial invasion leading to abscess formation -10.A subgaleal abscess has been reported to be caused by multiple pathogens. A neonatal subgaleal abscess usually follows invasive fetal monitoring with the placement of scalp electrodes and the most common pathogen is Staphylococcus epidermidis . StaphylComputed tomography (CT) brain identifies hypodense collections and allows better visualization for the aspiration of subgaleal fluids. Operative debridement can be performed alternatively for extensive subgaleal abscesses -10. The In the reported child, infection of the subgaleal space could be secondary to direct extension rather than hematogenous spread since the child had been indicating scalp pain throughout the period, and later, the infection likely localized to form a subgaleal abscess. Identification of the subgaleal abscess was backed by the atypical course of the swelling. This atypical presentation was supported by persistently increased inflammatory markers and continuing high spikes of temperatures without any other focus of infection.The authors have reported on a child who developed a subgaleal abscess caused by Staphylococcus aureus following impetigo and cellulitis of the forehead. The mechanism of subgaleal abscess infection in this child is likely to be direct spread via the scalp. It is important to have a high clinical suspicion of this rare complication in children with continuing high spikes of temperature following skin infections in the head region.


Co-occurring psychiatric disorders in adults with Attention Deficit Hyperactivity Disorder (ADHD) and/or Autism Spectrum Disorder (ASD) contribute to the burden of the healthcare and possibly to the delay of diagnosis. Aim of the study was to clinically assess the prevalence and compare lifetime co-occurring psychopathology in a sample of newly diagnosed ADHD and/or ASD adults and discuss the diagnostic challenges they pose.n = 151), the ASD (n = 58), the ADHD+ASD (n = 28) and the nonADHD/nonASD (NN) (n = 88) group.The lifetime prevalence rates of ten of the most frequently co-occurring psychiatric diagnoses was registered in 336 adults of normal intelligence who underwent a thorough clinical evaluation for the diagnosis of ADHD and/or ASD for the first time in their lives. Four study groups were formed: the ADHD (p = 0.004). In all groups the most frequent psychiatric disorder was depressive disorder. The only significant difference regarding the patterns of psychiatric co-occurrence between the ADHD and the nonADHD groups (ASD and NN groups) was found for SUD (p = 0.001). Also, the proportion of subjects with Bipolar Disorder was significantly greater in the NN group as compared to those with ASD (p = 0.025).At least one co-occurring psychopathology was found in 72.8% of the ADHD group, in 50% of the ASD group, in 72.4% of the ADHD+ASD group and in 76.1% of the NN group (Our results support the high prevalence of co-occurring psychiatric disorders in adults with ADHD and/or ASD with the ASD group presenting the lowest rate. The most marked difference between the ADHD and the nonADHD groups was found for SUD. Moreover, our findings highlight the need for a thorough clinical assessment of all referred patients both in the presence and absence of ADHD and/or ASD. Attention deficit hyperactivity disorder (ADHD) and Autism Spectrum Disorder (ASD) are both neurodevelopmental disorders with a typical onset in childhood and symptoms that usually remain persistent over time. The growing awareness of ADHD and ASD in adulthood, the increasing number of adults being referred for or requesting an ADHD or ASD diagnosis for the first time in their lives and the DSM-5 changes in diagnostic approach for ASD/ADHD co-occurrence have increased the demand for diagnostic services able to provide evidence-based assessments for this age group , 2. The The prevalence of ADHD in adults is in the range of 2–5% . StudiesTraditionally autism has been regarded as a severe form of neurodevelopmental disorder which in many cases goes along with abnormal language, learning difficulties and low IQ. Current prevalence of ASD is estimated to be between 1 and 2% in developed countries, with recent increases primarily among those without comorbid intellectual disability , 16 wherThe previous diagnostic exclusionary criteria that prohibited a dual diagnosis ADHD+ASD have been amended in DSM-5  leading The above presented epidemiological and clinical research data show increased rates of co-occurring psychiatric disorders in ADHD and/or ASD patients. Of particular interest is the group of adult patients who are overlooked until adulthood. Despite the increasing awareness on the clinical presentation of the disorder, many people with ADHD are still underdiagnosed, misdiagnosed and undertreated which is partly explained by the high rates of comorbidity , 42, 43.Interview based clinical studies aiming to compare patterns of a wide range of lifetime psychiatric diagnoses in adults referred for a possible Attention Deficit Hyperactivity Disorder (ADHD) or/and Autism Spectrum Disorder diagnosis are lacking. Aim of the present study is to clinically assess the prevalence and compare lifetime co-occurring psychiatric diagnoses among adults of normal intelligence who seek to receive for the first time in their life an ADHD, ASD or ADHD+ASD diagnosis and discuss the diagnostic issues they pose .The study took place at the Adult Neurodevelopmental Outpatient clinic of the 1st Department of Psychiatry of the National and Kapodistrian University of Athens, Greece. It has been running since 2004 for the assessment of adults with ADHD and/or ASD and is accepting both self-referrals and referrals from other health services. Self-referrals were subjects willing to receive an ADHD and/or ASD diagnosis and were often directed to our department through patient’s associations. A waiting list based on the time of referral is formed. The assessment procedure is built on a standard diagnostic routine and is carried out by a multi-disciplinary team. During a three-year period (January 2015 – December 2017) we selected all referred adults of normal intelligence with fluent phrase speech who were assessed through the standard diagnostic routine for the first time in their life for a possible ADHD and/or ASD diagnosis. Exclusion criteria were a previous ADHD and/or ASD diagnosis, the presence of acute psychopathology requiring urgent psychiatric treatment, a current substance abuse disorder, IQ < 70 according to WAIS and a known genetic cause.n = 151, 44.8%), the ASD group n = 58, 17.2%), the ADHD+ASD group  and the no neurodevelopmental disorder (NN) group consisting of the referred subjects that did not meet the diagnostic criteria for an ADHD and/or ASD diagnosis . Table The sample consisted of 326 participants (217 men and 109 women) with mean age 31.7 years (SD = 10.4). Participants formed four groups: the ADHD group  –54. The Responses to the questionnaire are then discussed with the patient and a family member when possible. Patients undergo a thorough at least two-hour psychiatric examination exploring current psychopathology and the life time presence of psychiatric disorders with the aid of the semi-structured interview Mini International Psychiatric Interview (MINI) , 56. AccSubsequently, during a session lasting up to 3 hours a psychiatrist assesses the existence and pervasiveness of the suspected neurodevelopmental disorders and the impairment caused by them. The DIVA is administered to all patients while the ADOS is administered to selected cases considered to be more complicated.The final diagnosis regarding the presence of ADHD and/or ASD and co-occurring psychiatric disorders is given during a consensus meeting of the multidisciplinary team and is based on DSM-5 criteria while taking into consideration all available information. Finally, the diagnosis and possible treatment options are discussed with the patient and relatives.The study was approved by the scientific and ethics committee of our University Department. All subjects gave written informed consent.p values reported are two-tailed. Statistical significance was set at 0.05 and analyses were conducted using SPSS statistical software (version 22.0).Continuous variables are presented with mean and standard deviation (SD). Quantitative variables are presented with absolute and relative frequencies. For the comparison of proportions chi-square and Fisher’s exact tests were used. Analysis of variance (ANOVA) was used to compare mean values between the four groups. Bonferroni correction was used in case of multiple testing in order to control for type I error. All p = .004).The number of co-occurring lifetime psychiatric diagnoses of subjects in each study group is showed in Table Table Aim of the present clinical study was to examine the lifetime prevalence of co-occurrent psychiatric disorders in 326 adults of normal intelligence referred for an ADHD or ASD diagnosis for the first time in their lives. In the four study groups formed  lifetime prevalence rates of ten of the most frequently co-occurring psychiatric diagnoses were registered.Among the probands that received an ADHD and/or ASD diagnosis the ADHD only and the ADHD+ASD groups presented the highest rates of co-occurring disorders. In both groups approximately three quarter of the patients had at least one co-occurring psychiatric disorder and of those almost half received three or more diagnoses. Our findings are in line with the majority of data available in the literature for newly diagnosed  or previInterestingly, subjects in the NN group had equally high rates of psychiatric disorders. Although some differences in demographic parameters were found in this group, most importantly it is their psychopathological characteristics that pose diagnostic challenges. It might be that with the increased awareness of adult ADHD and ASD, some patients with resistant to treatment psychopathological conditions attribute their symptoms to a neurodevelopmental disorder.In the ADHD group the highest rates of co-occurring disorders were the ones related to Depressive Disorder (DD) and Substance Use Disorder SUD), in the ASD group to Depressive Disorder (DD) and Generalized Anxiety Disorder (GAD), in the ADHA+ASD group to Depressive Disorder (DD) and Obsessive Compulsive Disorder (OCD) and in the NN group to Depressive Disorder (DD) and Bipolar Disorder (BD). The only significant difference regarding the patterns of psychiatric co-occurrence between the ADHD and the nonADHD groups (ASD and NN groups) was found for SUD. The low prevalence rate of SUD in adults with ASD and the marked difference between ADHD and ASD are consistent with previous studies in adults , 41. A sBelow, we discuss our findings regarding the lifetime prevalence of each co-occurring psychiatric diagnosis in all groups in relation to data from clinical and epidemiological studies and we highlight some of the diagnostic challenges clinicians have to face with adults referred for a possible ADHD or ASD diagnosis.The most commonly reported psychiatric disorder in all groups was depressive disorder . Although being close to the lower rate, our findings on patients with ADHD are consistent with the 32–60% lifetime prevalence of co-occurring depression reported in previous studies . Also, the rate of depression in the ASD group lies in between the pooled estimates of 12%  and 37% It is of particular note that the NN group had a high ratio of DD. Overlapping symptoms such as decreased attention, memory and concentration have to be taken in consideration in the differential diagnosis among DD and ADHD. Also, diagnostic overshadowing together with difficulties in describing low mood are difficulties that a clinician has to overcome when conducting diagnostic interviews for co-occurring DD in ASD patients.The rate of lifetime co-occurring BD in the ADHD group was 9.3%., in the ASD group 3.5%, in the ADHD+ASD group 13.8% while almost one fifth of the NN group (19.3%) received a BD diagnosis.High rates of lifetime prevalence of co-occurring ADHD among BD have been consistently reported in adults ranging from 9.5 to 25% , 59–62. The diagnosis of ASD is also associated with an increased risk of BD . SystemaOur results are close to the lower rates of BD co-occurrence found in previous studies of ADHD patients and even lower compared to previous ASD adult samples while the ADHD+ASD group although more impaired still shows a lower to the Norwegian population study prevalence. Discrepancies might be attributed to the different study design and the fact that our sample consists of newly diagnosed adult patients, often self-referred, who are expected to be less impaired compared to those diagnosed earlier in life.The finding that the rate of BD in the NN group was so high is very interesting, supporting diagnostic overshadowing. Symptoms of a maniac or hypomaniac episode and emotional lability can be easily attributed by patients with BD or clinicians to ADHD symptomatology, leading them to ask for an ADHD assessment. Several of the diagnostic criteria for ADHD and bipolar disorder, such as increased activity, distractibility, irritable mood, talkativeness, are similar. A thorough clinical evaluation including past psychiatric and developmental history that would clarify features such as age of onset, persistent or episodic display of symptoms is necessary when examining adults referred for a neurodevelopmental disorder diagnosis .Our findings on the co-occurrence of PD (4.6%) and GAD (16.7%) in ADHD patients were consistent with those presented in previous studies –70. On tIn the ASD group the prevalence of PD (6.9%) and GAD (13.8%) was in-between the rates reported in other studies ranging from 1 to 18% for PD and 11.8–26% for GAD , 36, 72.There are some possible reasons explaining at least to some extend the low rate of SP in both our ASD and ADHD samples. First, it might be that either we were trapped in the diagnostic overshadowing between ASD and SP or that other researchers considered core symptoms of ASD as social anxiety. The lack of standardized tools measuring anxiety in ASD individuals makes more difficult for clinicians to disentangle symptoms of social phobia from ASD symptoms. Second, our ASD sample consisted of high functioning individuals, newly diagnosed and possibly less socially impaired. Finally, after the release of DSM-5, clinicians are allowed to give a dual diagnosis of ASD and ADHD and some patients with both ADHD and ASD symptoms who in the past would receive an ADHD+social phobia diagnosis can know receive an ADHD+ASD diagnosis. We suggest therefore that in previous reports there might be an overdiagnosis of SP in ADHD patients.In the ADHD+ASD group all three anxiety disorders presented a prevalence of approximately 10%. The increased rate of SP in our dual diagnosis group suggests that even if some formerly ADHD+SP cases are now classified as ADHD+ASD cases SP remains a true co-occurrent disorder in probands with ADHD+ASD. Regardless, the nature of social anxiety in ASD and/or ADHD is an issue that has to be further investigated .The NN group showed elevated rates of all three anxiety disorders. Restlessness-psychomotor agitation, concentration difficulties, decreased attention, increased distractibility, mood swings, and anger outbursts are symptoms that overlap between ADHD and anxiety disorders , 79. DifThe rate of lifetime co-occurring OCD was similar in the ADHD and the NN groups (approximately 10%), somewhat lower in the ASD group (8.6%), with a 2.5-fold increase in the ADHD+ASD group (24.1%).Our results on the ADHD group are in accordance with previous findings showing a 7–13% prevalence of OCD in adults with ADHD . In adulIn our study the highest rate was noted in the dual diagnosis group. Although the small sample did not allow a statistically significant difference among groups, a possible additive effect of the presence of both ADHD and ASD on the occurrence of OCD cannot be ruled out. To our knowledge there are no previous studies exploring the co-occurrence of OCD in ADHD+ASD adults.The elevated prevalence of OCD in the NN group underlines the need for a thorough clinical assessment of the referred individuals. The Executive Overload model  suggestsThe rate of lifetime co-occurring PsD in the ADHD group was 4.7% which is comparable to the previously reported co-occurrence of PsD and ADHD which can be up to 11%, especially when ADHD is of inattentive type  or assocThe rate of 6.9% co-occurrence of PsD in our ASD group is among the lowest reported in the literature. Rates of co morbid PsD in ASD population, possibly more with atypical affective disturbances , presentIn the dual diagnosed group we could hypothesize that the additive effect of the neurocognitive and developmental deficits of ADHD and ASD would increase the rate of a lifetime diagnosis of a psychotic disorder. The only study assessing Schizophrenia Spectrum Disorder (SSD) in adults with ADHD+ASD, is the Norwegian population study  which coThe rate of 5.7% in the NN group highlights the multiple phenotypic commonalities between ADHD, ASD and PsD and the risk for a misdiagnosis, especially in unidentified ASD and ADHD adults. The attentional deficits, hyperactivity features, emotional dysregulation, and disorganized behavior that might accompany psychosis may not be “true” ADHD. Also, impairments in social interaction and communication, lack of emotional response, poverty of speech, withdrawal from reality accompanied by extended fantasy and catatonic features are common features of ASD and PsD that can complicate the diagnosis of adults referred for an ASD diagnosis.In our study SUD was the only co-occurring psychiatric disorder whose prevalence significantly differed between ADHD, ASD and NN groups. The rate in the ADHD group was almost four times higher than in the ASD group (26.6% vs 3.5%) while in the ADHD+ASD group the rate was comparable to the rate of the ADHD group (20.7%). Rates of AD were much lower in all groups and in fact there were no reports of co-occurring ASD and AD cases. In the NN group rates of SUD were significantly lower to the ADHD group but still substantial (11.4%).Our ADHD findings are in line with previous reports of SUD prevalence in ADHD ranging from 12 to 58% , 88, 89.The low rates of AD and SUD in our ASD sample apart from the existence of a separate ADHD+ASD group can be also attributed to the exclusion of patients with a current co-occurring AD or SUD. It might also reflect cultural differences among various countries. The same reasons could explain the low rate of AD in our ADHD patients.In our sample the co-occurrence of ADHD+ASD increased the risk for a lifetime diagnosis of SUD in comparison to solely ASD which is in accordance with the rates of AD and SUD found in ASD samples including ADHD patients. In the Norwegian population based study  where ADThe above support the notion that SUD and alcohol related disorders are lifetime diagnoses that have to be taken in consideration when assessing individuals referred for an ADHD and/or an ASD diagnosis in adults. The personality trait novelty-seeking is strongly related to SUDs, alcohol related disorders and ADHD personality characteristics . They shThe rate of lifetime co-occurring ASPD in the ADHD group was 7.3%, in the ASD group 2.5%, in the ADHD+ASD group 13.8%, and in the NN group 11.4%.In previous studies 12–17% of ADHD adults , 64, 95 Our ASD findings are in line with previous reports showing low rates of ASPD in ASD individuals. In de novo diagnosed adults with ASD, 3% of ASD patients received an ASPD diagnosis with 43% of ASD patients having a co-occurring ADHD  while inIn the Norwegian population study the prevalence rates of ASPD were higher to the rates found in our study. Although, the sample is much smaller and differences do not reach a statistical significance our findings follow the same pattern, namely the highest rate is noted in the dual diagnosis group followed by the ADHD group while the ASD group presents a low rate.The elevated prevalence of ASPD in the NN group might reflect the confusion between ASD and ASPD that arises owing to the “lack of empathy”, although empathy profiles in the two disorders seem to be the opposite (reduced cognitive empathy in ASD vs reduced affective empathy in ASPD) , 99, 100Very few studies have assessed and compared co-occurring lifetime psychiatric disorders in newly diagnosed adults with ADHD, ASD and ADHD+ASD or nonADHD /ASD probands. The fact that the sample is homogeneous in many aspects namely in terms of functioning and intellectual ability, absence of a previous ADHD and ASD diagnosis and of acute psychopathology, can also be considered as a strength of the study. Moreover, the diagnosis was made in consensus by experienced psychiatrists in developmental disorders trained in structured interviews for ADHD and ASD, working in a university psychiatry clinic and supplemented with psychologists for the assessment of possible intellectual disability. On the other hand some of the strengths could also be considered as limitations of the study. We cannot generalize our findings to the entire ADHD and ASD populations. The exclusion of patients with current AD and SUD and patients requiring urgent psychiatric treatment might have biased all groups to present less co-occurring disorders and may account for some of the differences found in our study compared to others. Further, since it was a clinical study including all referred patients during a three-year period, sample sizes were disproportionate and males outnumbered females as expected according to already known clinical data , 16. TheIn diagnosing and treating adults with ADHD and ASD clinicians should be able to overcome difficulties related both to the high frequency of co-occurring psychiatric conditions and to the symptom overlap between the two disorders. The co-occurrence of ADHD in ASD patients seems to significantly increase the total rates of psychopathology while the most marked difference between the ADHD and the nonADHD groups was found for SUD. Interestingly, a significant proportion of adults referred for a possible ADHD or ASD do not meet criteria for any of those two neurodevelopmental disorders and meet criteria for other mental health problems. The detection of Bipolar Disorder seems to be of particular importance since almost one fifth of the nonASD and nonADHD patients suffered from it. Therefore, in order to assess for possible ADHD and/or ASD in adults there is a need for a thorough clinical assessment by an experienced in the neurodevelopmental disorders clinical team able to provide the correct diagnosis and treatment which are essential in changing the prognosis.


The development of the smart building concept and building automation field is based on the exponential evolution of monitoring and control technologies. Residents of the smart building must interact with the monitoring and control system. A widely used method is specific applications executed on smartphones, tablets, and PCs with Bluetooth connection to the building control system. At this time, smartphones are increasingly used in everyday life for payments, reading newspapers, monitoring activity, and interacting with smart homes. The devices used to build the control system are interconnected through a specific network, one of the most widespread being the Building Automation and Control Network (BACnet) network. Here, we propose the use of the BACnet Application Layer over Bluetooth. We present a proposal of a concept and a practical implementation that can be used to test and validate the operation of the BACnet Application Layer over Bluetooth. The smart buildings  concept In addition, BAS systems that are integrated into smart buildings can be used to provide the support needed for the remote monitoring and/or the self-monitoring of patients with various chronic diseases . At thisRecently, mobile devices represented by smartphones and tablets have experienced explosive development. They are optimized for more computing power at lower energy consumption and a lower price compared to desktop systems, in addition to their mobility function. Now, the number of these mobile devices has exceeded the number of personal computers ,16. MobiThe following sections are structured as follows: BACnet is a communication protocol  used in At the Application Layer, BACnet is object-oriented. A BACnet device is a collection of objects that contain device-specific features. At the moment, 60 types of objects are standardized , the mosThe BACnet Data Link Layer organizes/segments data into frames or packets called Network Protocol Data Unit (NPDU) packets that are transmitted to lower levels. The maximum size of a NPDU is determined by the communication technology used at the physical layer. The lower layers are the Data Link and Physical Layers. As can be seen from This section presents BACnet gateway solutions to other protocols and examples of using the BACnet network for smart buildings. We will focus on functionality and how to interact with human operators. We will also present some cases of using Bluetooth technology for the development of smart buildings. They are all on the same topic as the solution presented in this article.The automation field has developed considerably and uses new technologies such as intelligent equipment, advanced sensors and controllers, and low energy consumption technologies, all being integrated via communication interfaces and appropriate software in order to manage specific operations such as those from the automotive industry, healthcare, or modern buildings. Based on these premises, a research paper  proposedAnother research paper  proposedIn , a BACneIn , the autA compressive study related to the environmental monitoring technologies used in smart buildings is presented in . In termWe propose the implementation of the BACnet Application Layer over Bluetooth. The proposed concept allows us to define BACnet objects over Bluetooth, taking advantage of standardizing definitions of the data format that is transmitted over Bluetooth. This concept allows BACnet networks to be available via Bluetooth, and smart BACnet devices with Bluetooth connectivity can also be designed and developed. Software applications that are connected by this device and can monitor and control the device can be used on smartphones/tablets. It does not require a Wi-Fi network or an Internet connection; it requires only a smartphone/tablet with a Bluetooth interface . There may also be a similar PC application that can run on PCs, laptops, or tablets with the Windows operating system and Bluetooth connection. Additionally, for the integration of traditional wired BACnet devices, a gateway that connects to the BACnet network and translates data over a Bluetooth connection can be designed and developed. This allows monitoring and controlling the classic BACnet devices via the application on smartphones/tablets/PCs and Bluetooth. One advantage of the proposed solution is that we can use smartphones or tablets to connect to the BACnet network. This allows us to monitor and graphically display the parameters and send commands to the BACnet network by taking advantage of the mobility capabilities provided by smartphones and tablets. Another advantage is the convenience of using smartphones and tablets. The main disadvantage is that Bluetooth communication can be used over short distances   debugging and tracing environment. With the help of this toolset, a virtual BACnet device is created that contains three virtual objects: an object of the Device type and two objects of the Analog Input type. This application also takes into account the fact that the data will be transmitted using a serial port. For this reason, in the application, a software module is used that allows the selection of data according to the request received throughout the Universal Asynchronous Receiver/Transmitter (UART) port via the HC-05 Bluetooth module, the request that is transmitted from the graphics application. The second part of the test system is a graphical application developed to run on PCs with the Windows operating system. The main window of this application is shown in As can be seen in Once we obtain the window shown in At the same time, by selecting the “BACnet Objects” option, the board will indicate that this option was chosen by turning on the red and green LED, as can be seen in In order to view the properties of an object, the object to be analyzed must be selected from the selection list from the bottom left, according to After selecting the object type and the specific option, a new window will appear showing the properties of the selected object as shown in Furthermore, segmentation takes place at the Network Layer , which has at least 2 bytes given by the segment header and the Identification (ID) from which the segment numbering starts. After entering this data, we can proceed to calculate the number of segments. Thus, for the Point-to-Point (Bluetooth) technology previously selected, and for an NPDU of 3000 bytes that has the ID of the first segment equal to one, a number of six segments were obtained see . As can The security vulnerabilities of the proposed solution are generated by Bluetooth communication. A detailed analysis of these security vulnerabilities is presented in . To addrHerein, we proposed and tried to present the use and the utility of the BACnet Application Layer over Bluetooth. This can be performed by designing and developing a BACnet device with a Bluetooth connection or by implementing a gateway that connects to a classic BACnet network via Bluetooth. We proposed and validated a concept by implementing a BACnet device on the STM32F4DISCOVERY development board, which contains an HC-05 module for Bluetooth connection and a PC application that communicates with this module via Bluetooth, all being implemented at the BACnet Application Layer over Bluetooth. The proposed solution is convenient because most modern smartphones and tablets support Bluetooth communication, the main disadvantage being that Bluetooth allows point-to-point connection only. In fact, the purpose of the proposed solution is to allow access to the BACnet network for the visualization of the measured parameters  and to transmit simple commands such as turning on/off the light and not to perform real-time control of the smart building.


Scanning electron microscopy indicates that the compactness of the sample can be easily adjusted by changing the contents of S and Mo sources in the solution. The results of ultraviolet–visible (UV–vis) diffuse reflectance spectra, photoluminescence, transient photocurrent response, and electrochemical impedance spectra indicate that the formation of heterojunctions contributes to enhancing visible-light utilization and promoting photogenerated carrier separation and transfer. The composite material is used as a catalyst for the visible light photocatalytic reduction of Cr(VI). Remarkably, the optimal Bi2WO6/Bi2S3/MoS2 n-p heterojunction achieves the greatest Cr(VI) reduction rate of 100% within 75 min ; this rate is considerably better than the Cr(VI) reduction rate of pure Bi2WO6. The recycling experiment also reveals that the photocatalytic performance of the n-p heterojunction toward Cr(VI) is still maintained at 80% after three cycles, indicating that the n-p heterojunction has excellent structural stability. The capture experiment proves that the main active species in the system are electrons. The reasonable mechanism of Bi2WO6/Bi2S3/MoS2 photocatalytic reduction Cr(VI) is proposed. Our work provides new research ideas for the design of ternary heterojunction composites and new strategies for the development of photocatalysts for wastewater treatment.Exploiting excellent photocatalytic activity and stable heterostructure composites are of critical importance for environmental sustainability. The spherical Bi However, the concentration of Cr(VI) in sewage is usually higher than 100 mg L−1 [With the rapid development of industrial production, the pollution of water and land resources by heavy metals is becoming increasingly serious ,2,3. Wat0 mg L−1 . Therefo0 mg L−1 ,12,13,140 mg L−1 ,16,17.2WO6) has been widely studied for its safety, cheap, proper band gap (~2.8 eV), high stability, and excellent photocatalytic activity [2WO6 has the disadvantages of high photo-generated electron-holes recombination efficiency, narrow light absorption range, small specific surface area, and weak surface adsorption capacity, which makes it exhibit poor photocatalytic performance [Bismuth-based photocatalysts have always been a research hotspot in the field of photocatalysis. Bismuth tungstate  under visible light (vis-light) irradiation [2WO6–MoS2 heterojunction photocatalysts, which exhibited excellent vis-light photocatalytic activity in Cr(VI) and tetracycline hydrochloride degradation [3N4/Bi2WO6/AgI catalyst by a hierarchical assembly method. Compared with bare Bi2WO6, the ternary heterojunction composite has stronger redox capacity and exhibits better catalytic activity during the photodegradation of organic pollutants such as TC [2/Bi2S3 heterostructures with excellent photocatalytic activity toward the photodegradation of low concentrations of organic pollutants [2WO6-based photocatalysts still have disadvantages, including a complex preparation method, narrow light response range, and rapid photogenerated charge carrier recombination. In recent years, the use of MoS2 and Bi2S3 coupled with other semiconductors for boosted photocatalytic performance has been widely investigated. To our knowledge, the preparation and application in photocatalysis of the Bi2WO6/Bi2S3/MoS2 ternary heterojunction has not been reported. Hence, seeking a facile and controllable preparation method to fabricate ternary heterojunctions containing Bi2WO6, Bi2S3, and MoS2 is of great importance for improving the photocatalytic performance of Bi2WO6 in environmental purification.At present, the methods used to improve the photocatalytic activity of semiconductors are as follows: nanostructure modification , surfaceWO6/MoS2 , Bi2WO6/O6/Fe2O3 , Bi2WO6/O6/Bi2S3 , CdS/Bi/S3 [2WO6 , meso-teO6 [2WO6 , and Co3g/Bi2WO6 , have beadiation . Wan et radation . Xue et ch as TC . Long etllutants . The abo2WO6/Bi2S3/MoS2 heterojunction ternary composite materials are prepared via hydrothermal method using the synthesized Bi2WO6 microspheres as substrate  and thiourea (CH4N2S) in the solution during the hydrothermal process. To the best of our knowledge, the Bi2WO6/Bi2S3/MoS2 heterojunction for Cr(VI) photocatalytic reduction under vis-light irradiation is investigated for the first time. The composites have higher adsorption capacity and photocatalytic activity than pure Bi2WO6 in terms of Cr(VI) reduction due to the successful construction of heterojunction structure. The synergistic effect among the three components enhances light absorption and realizes the effective separation and transmission of photogenerated carriers. The Cr(VI) reduction rate of Bi2WO6/Bi2S3/MoS2 reaches 100% within 75 min  and is considerably better than that of the pure Bi2WO6. These results provide new research ideas for the design of ternary heterojunctions to develop highly efficient vis-light-driven photocatalysts for wastewater treatment.Based on the above considerations, in the present work, Biubstrate  and whic2WO4·2H2O, AR, 99.5%), Na2MoO4·2H2O , bismuth(III) nitrate pentahydrate (Bi(NO3)3·5H2O, AR, 99.0%), and CH4N2S  were acquired from Sigma-Aldrich . Absolute ethanol , glacial acetic acid , polyvinyl pyrrolidone K30 , and other chemicals used in the experiments were bought from Shanghai Chemical Reagent Co., Ltd. . Ultrapure water (18.2 MΩ cm−1) was served throughout the study and acquired from the Milli-Q water purifying system .All chemicals and materials in this work were of analytical grade and purchased from commercial suppliers, which could be directly utilized without any further purification. Sodium tungstate dihydrate 3·5H2O and 4 g PVP K30 were added to a mixed solution of 50 mL ultrapure water, absolute ethanol, and glacial acetic acid with a 3:1:1 volume ratio and then stirred at room temperature for 60 min. In solution B, 1 mmol Na2WO4·2H2O was added to 20 mL H2O for 30 min of ultrasonication. After the solutions were clarified, solution B was dropped to solution A under agitation and stirred continuously for 60 min to obtain a white uniform suspension. The suspension was transferred to a Teflon-sealed autoclave (100 mL) for a solvothermal reaction at 180 °C for 18 h. After cooling, the light-yellow product was collected, washed thrice with absolute ethanol and ultrapure water in sequence, and finally dried overnight and ground for reserves.Solutions A and B were prepared in the synthesis of Bi2WO6/Bi2S3/MoS2 n-p heterojunction nanocomposites were prepared by a simple hydrothermal reaction. First, 200 mg Bi2WO6 was dispersed in 40 mL water with ultrasonic treatment for 10 min. Further 1 h stirring treatment was needed after the addition of 200 mg Na2MoO4·2H2O and 400 mg CH4N2S as an ion source. Second, the dispersion was transferred to 100 mL Teflon-sealed autoclave for hydrothermal reaction at 200 °C for 24 h. Wait for cooling, the obtained sample (named as product BBM-3) was rinsed with ultrapure water and anhydrous ethanol for thrice and then dried overnight at 60 °C in a vacuum oven. As a control, the addition amount of Na2MoO4·2H2O:CH4N2S was adjusted , and the corresponding products with BBM-1, BBM-2, and BBM-4 were expressed. In addition, the preparation method of pure MoS2 nanosheets was similar to the above process except that Bi2WO6 was not added.Biλ = 1.5046 Å) radiation. Raman spectra were measured using a Renishaw in Via9 Raman microscope system  with a 50× objective and a 532 nm laser irradiation to focal point the laser beam into a spot with a diameter of approximately 1 µm. The morphology and energy-dispersive spectra (EDS) of the samples were tested and characterized by a field-emission scanning electron microscope . The microstructure and lattice fringe of the samples were examined by a transmission electron microscope  and high-resolution TEM . The elemental composition and chemical state of the samples were determined by X-ray photoelectron spectroscopy (XPS) . The specific surface areas of the samples were obtained based on the N2 adsorption–desorption isotherm tested on a Micromeritics ASAP 2460 system . The ultraviolet–visible (UV–vis) diffuse reflectance spectra (DRS) were tested within a 200 nm to 800 nm wavelength range using a spectrometer  with BaSO4 as a reference. A Hitachi F4500 fluorescence spectrophotometer  was used to test the photoluminescence (PL) measurements (λexcitation = 300 nm). The Mott–Schottky curves, electrochemical impedance spectra (EIS), and photocurrent response experiments were carried out using the electrochemical workstation  with a conventional three-electrode configuration  and Na2SO4 aqueous solution as the electrolyte (0.1 mol L−1).Powder X-ray diffraction (XRD) patterns were obtained on a SmartLab SE X-ray diffractometer  with Cu Kα (2Cr2O7) were as follows: Cr(VI) solution with concentration of 40 mg L−1 was prepared using ultrapure water as solvent. Then, 50 mL of this initial solution was accurately measured and placed in the reaction vessel. Next, the initial solution pH to 2 was adjusted with HCl solution (1 mol L−1). Afterward, the 20 mg as-synthesized catalysts were evenly dispersed in the solution by ultrasonication. Before vis-light irradiation, the suspension was stored in the dark place and stirred for 60 min to reach equilibrium of adsorption and desorption. Under the irradiation by Xe lamp , 3 mL suspension was taken out in the reaction container every 15 min and centrifuged . Then, the supernatant was collected with microporous (0.22 μm) membrane filter syringe to eliminate residual particles. NaOH (1 mol L−1) or HCl (1 mol L−1) solution was used to adjust the pH of Cr(VI) solution to investigate the effect of solution pH on photocatalysis. Finally, the Cr(VI) concentration was obtained by measuring the absorbance of the supernatant at 540 nm  with diphenylcarbazide approach  (Cr(VI) source: K2WO6, the diffraction peaks at 2θ = 28.3°, 32.8°, 47.1°, 56.0°, 58.5°, 68.8°, 76.1°, and 78.5° correspond to the (131), (200), (202), (133), (262), (400), (2102), and (204) crystal faces of the Bi2WO6 orthorhombic phase (JCPDS Card No.39-0256), respectively [2 at 9.0°, 32.0°, and 58.0° correspond to the (002), (100), and (110) crystal faces of 2H-MoS2, respectively. The peaks at 9.0° and 17.0° indicate the formation of a layered structure with enlarged interlayer spacing [2S3 [3+ and S2−, Bi2S3 will be formed at relatively high temperatures [2WO6/Bi2S3/MoS2 samples show a discernible peak at approximately 32.0°, which is attributed to the (100) crystal plane of MoS2, indicating that the composite material contains MoS2 component. However, the absence of the highest MoS2 intensity peak (~9.0°) from the heterostructure samples indicates that MoS2 nanosheets may contain only a few layers that are too thin to be detected by XRD [ectively ,39. The , (262), 0, (2102)ing [2S3 . Given teratures . The Bi2d by XRD .−1, and the results are shown in 2WO6, Bi2S3, and MoS2, respectively. The peaks of 308, 723, 798, and 829 cm−1 in the Raman spectra are characteristic Raman shifts of Bi2WO6 [2S3 are located at 234.8, 260, 590, and 970 cm−1, of which the peaks at 234.8 and 260 cm−1 matched the Ag1 and B1g vibration mode, respectively [−1 are ascribed to the E12g and A1g vibrations of MoS2, respectively [2WO6/Bi2S3/MoS2 ternary composites are successfully prepared.Raman measurements of the as-synthesized samples were performed in the range of 200–1200 cmf Bi2WO6 . The Ramectively . Meanwhiectively ,45. Base2WO6 microspheres with diameters of 2.6–3.0 μm are self-assembled from nanosheets. The SEM images in 2WO6/Bi2S3/MoS2 microsphere increases accordingly with the increase in Mo and S sources concentration during the hydrothermal process. Nevertheless, with the further increase in concentration, MoS2 agglomerates are formed on the Bi2WO6/Bi2S3/MoS2 surface, and the corresponding results are shown in 3+ and S2−, which reacts under high temperature and pressure to form Bi2S3 (Bi2WO6 + 3S2− → Bi2S3 + WO66−) [2WO6 is consumed during this process, and Bi2S3 and MoS2 are generated. As the consumption of Bi2WO6 increases, the structure becomes looser. III. The formation of MoS2 agglomerates is mainly caused by the excessively high concentration of Mo and S sources, which promotes the nucleation speed to extreme degrees [2WO6, Bi2S3, and MoS2 in the BBM-3. The measured interplanar distances of 0.315, 0.360, and 0.620 nm belong to the (131) crystal plane of orthorhombic Bi2WO6, the (130) plane of Bi2S3, and the (002) lattice plane of MoS2, respectively [2WO6, Bi2S3, and MoS2, confirms the successful construction of the Bi2WO6/Bi2S3/MoS2 heterojunction [2WO6/Bi2S3/MoS2 n-p heterojunction with spherical structure can be synthesized by a simple in-situ hydrothermal method.As shown in the scanning electron microscope (SEM) images a, Bi2WO6+ WO66−) ,45. II.  degrees . Soon afectively ,48,49. Tjunction . Meanwhi5/2 and Mo 3d3/2 of Mo4+, respectively [6+ [7/2 at 157.4 eV, Bi 4f5/2 at 162.7 eV, and S 2p at 160.6 eV [7/2 and Bi 4f5/2 is 5.3 eV, indicating that Bi exists in BBM-3 as Bi3+. 7/2 and W 4f5/2, respectively [2WO6, Bi2S3, and MoS2, the Mo 3d and Bi 4f peaks of BBM-3 display a shift ~1.0 eV to the lower binding energy direction. Conversely, the W 4f peak of BBM-3 shows a shift ~1.0 eV to the higher binding energy direction. These results are primarily due to strong interactions and charge transfer among Bi2WO6, Bi2S3, and MoS2 in BBM-3 . The BET surface areas of BBM-1, BBM-2, BBM-3, and BBM-4 are 16.6, 19.7, 22.7, and 19.4 m2 g−1, respectively. Compared with pure Bi2WO6, Bi2WO6/Bi2S3/MoS2 composites have high BET surface areas and rich mesoporous structures, which facilitate the adsorption and reduction of Cr(VI).As shown in ructures ,22. The 2WO6, pristine MoS2, and ternary composites are recorded to investigate the light absorption of the samples. As shown in 2WO6, its intrinsic light absorption edge is at 450 nm, which means that the material has light absorption only in the UV and partially visible regions. By contrast, pure MoS2 shows a strong absorption in the UV–vis region. As expected, Bi2WO6/Bi2S3/MoS2 ternary heterojunction photocatalyst extends the vis-light absorption range compared with the Bi2WO6. Thus, the good photocatalysis performance of the composite is predicted. Furthermore, the bandgap energy (Eg) of as-fabricated materials is obtained in accordance with Tauc’s equation (Equation (1)) [α: absorption coefficient, h: Planck’s constant, ν: light frequency, and A: a constant.The DRS of the pristine Biion (1)) ,55:(1). According to the previous reports, the n of Bi2WO6 and MoS2 is 1, and their Eg are determined by the extrapolation of Tauc linear region [Eg of pure Bi2WO6 and MoS2 are ~2.74 and 1.30 eV, respectively  on the hydrogen scale. 2WO6 is classified as an n-type semiconductor due to its positive slope, whereas Bi2S3 and MoS2 are confirmed as p-type semiconductors due to their negative slopes. When they are coupled to each other to form a n-p heterojunction (Bi2WO6/Bi2S3/MoS2), the Mott–Schottky curve shows an inverted ‘V-shape’ characteristic ), 1.06 (1.26 eV vs. NHE), and 1.14 (1.34 eV vs. NHE), respectively. Therefore, ECB of pure Bi2WO6 and EVB of Bi2S3 and MoS2 can be estimated to be 0.33, 1.37, and 1.47 eV. On the basis of Equation (3), the corresponding EVB of Bi2WO6 and ECB of Bi2S3 and MoS2 can occur at approximately 3.07, 0.18, and 0.17 eV. These results are in agreement with the result calculated in accordance with Mulliken atomic electronegativity theory.On the above basis, the valence band (VB) and conduction band (CB) edge potentials of the samples are calculated in accordance with the Mulliken atomic electronegativity theory (Equations (2) and (3), respectively) ,51:(2)ECteristic . Generalotential . The flathan EVB . Figure 2WO6 and Bi2WO6/Bi2S3/MoS2 composites are obtained under the condition of λexcitation = 300 nm. The emission intensities of all Bi2WO6/Bi2S3/MoS2 composites are significantly lower than that of bare Bi2WO6. Based on the intensity, the composites can be sorted as Bi2WO6 > BBM-1 > BBM-2 > BBM-4 > BBM-3. This result shows that the successful recombination of MoS2, Bi2S3, and Bi2WO6 improves the efficiency of charge separation. The photocurrent response , which is highly consistent with the PL and photocurrent test analysis results. Therefore, the following conclusions can be drawn. First, the construction of Bi2WO6, Bi2S3, and MoS2 heterostructures can significantly improve the charge separation efficiency. Second, only when Bi2WO6 is compounded with suitable amount of Bi2S3 and MoS2 can n-p heterojunction photocatalysts be formed effectively. Thus, extremely high and extremely low compounding ratios are not conducive to the formation of heterostructures and the separation and transfer of photogenerated carriers. Third, BBM-3 is expected to have the best vis-light catalytic activity because it enables the effective separation of photo-generated carriers.The catalyst is further characterized by PL spectroscopy and photocurrent response to explore its charge separation efficiency. High PL intensity indicates low charge separation efficiency and easy electron-hole recombination, whereas the photocurrent response shows the opposite ,59,60. Tresponse  confirms4− and Cr2O72− in acidic environments and CrO42− in alkaline environments [2+), which in turn enhances the electrostatic adsorption on Cr(VI) [In this working system, the catalytic reduction of Cr(VI) under vis-light irradiation is used as the evaluation standard to evaluate the performance of the prefabricated materials. Previous reports have shown that the initial solution pH strongly influences the photocatalytic Cr(VI) reduction. Therefore, the pH of the initial solution is adjusted to show a linear gradient change, which is used to investigate the effect of pH on the catalytic activity of BBM-3. The photocatalytic reduction efficiency of BBM-3 is the highest under acidic conditions a. Under ronments . When thn Cr(VI) . Second,n Cr(VI) ,61,63:) ,61,63:(63+ will be converted into Cr(OH)3 and deposited on the catalyst surface under alkaline conditions, blocking the active sites that can be used for adsorption and photocatalytic reactions. In summary, acidic conditions are more conducive to the reduction of Cr(VI) than alkaline conditions.Equation (6) shows that Cr2WO6 and different Bi2WO6/Bi2S3/MoS2 composites are evaluated at the initial solution pH = 2.00, and the results are shown in 2WO6, which benefits from the high surface area and abundant mesoporous structure of the composite. After 75 min of irradiation, the reduction rate of Bi2WO6 to Cr(VI) is 5%. By contrast, all the Bi2WO6/Bi2S3/MoS2 composites manifest remarkably high photocatalytic reduction activity under the same conditions. In particular, BBM-3 shows the best photocatalytic performance with a corresponding Cr(VI) reduction rate of up to 100%. It is not difficult to find that there is an optimal compounding ratio between Bi2S3, MoS2, and Bi2WO6 occurs in the removal of Cr(VI). Extremely low or extremely high compounding ratio is not conducive to enhancing the photoreduction activity of Bi2WO6/Bi2S3/MoS2. When the actual ratio is lower than the optimal ratio, the number of active sites used to capture carriers increases with the increase in recombination ratio, thus prolonging the carrier lifetime and then increasing the photocatalytic activity. However, when the compounding ratio is higher than the optimum, excess MoS2 will agglomerate to disrupt the effective construction of n-p heterojunction, as confirmed by the SEM result  and the apparent reaction rate constant “k”  solution, and Ct is the concentration of Cr(VI) solution at “t” irradiation time. The “k” values calculated by the linear fit of ln(C0/Ct) and irradiation time (min) plots are 0.037, 0.223, 0.628, 3.612, and 1.379 × 10−2 min−1 for Bi2WO6, BBM-1, BBM-2, BBM-3, and BBM-4, respectively. BBM-3 obtains the highest k value. Immediately afterwards, an active species capture experiment is carried out to further explore the mechanism involved in the reaction system (hole/electron trapping agent: citric acid/KBrO3). The obtained results are shown in 3 significantly inhibited the photoreduction of Cr(VI) by BBM-3 with a final reduction rate of 75%. This finding indicates that the main active material in the catalytic reduction of Cr(VI) process is photogenerated electrons, which is consistent with previous reports [4− or Cr2O72− ions [2WO6/Bi2S3/MoS2 heterojunction composites show relatively satisfactory photocatalytic activity.tant “k” c. The ps reports . By cont72− ions . Second,72− ions . The abo2WO6, Bi2S3, and MoS2; this interaction is beneficial to improving structural stability [3/2, which highly matches Cr(III) in Cr(OH)3 [2WO6/Bi2S3/MoS2 heterojunction composite has high structural stability, good reusability, and can effectively reduce the toxicity of Cr(VI) to reduce it to Cr(III).Issues such as photocatalysts separation, recovery, reuse, and stability, are important in practical applications. The stability and reusability of BBM-3 after the reaction is proven by recycling and reusing the same catalyst for three cycles. The photoreduction rate of Cr(VI) after three cycle tests is 80% a, which tability ,52. Figu Cr(OH)3 . To sum 2WO6 is coupled with p-type Bi2S3 and MoS2, the n-p heterojunction is formed among semiconductors. The formation of the n-p heterojunction results in the equalization of their Fermi levels. This effect, in turn, induces band bending and a strong electric field at their interface. In this case, electrons and holes are prevented from coming into contact with each other due to the built-in electric field [2 and Bi2S3, whereas a traditional type-II staggered heterojunction forms on the interface of Bi2S3 and Bi2WO6. MoS2 and Bi2S3 are excited when type-I MoS2/Bi2S3 are exposed to vis-light. The electrons on the CB of MoS2 will quickly transfer onto that of Bi2S3, and the holes on the VB of the MoS2 simultaneously hop onto that of Bi2S3. If no measures are taken, the electrons and holes accumulate in the Bi2S3 semiconductor and recombine rapidly. Interestingly, the existence of type-II Bi2S3/Bi2WO6 enables the electrons on the CB of the p-type Bi2S3 semiconductor to transfer directly onto the CB of n-type Bi2WO6, and the holes on the VB of Bi2WO6 can be spontaneously injected into the VB of Bi2S3. This phenomenon realizes the effective separation and transfer of photogenerated electron-hole pairs. The strong electric field generated by the n-p heterojunction further promotes this process. Compared with a single heterostructure, this system can better realize the separation and transfer of photogenerated electron–hole pairs under the joint action of multiple heterostructures. Given the above analysis, the proposed photocatalytic reduction mechanism of Cr(VI) by Bi2WO6/Bi2S3/MoS2 photocatalysis under vis-light is obtained –(10)). Electrons on the CB of type-p Bi2S3 and MoS2 are transferred to CB of type-n Bi2WO6, which is finally used for Cr(VI) reduction, whereas the holes remain in the VB of Bi2S3 (Equation (11)). Moreover, the CB edges of Bi2WO6, Bi2S3, and MoS2 are more negative than the reduction potential of E(Cr(VI)/Cr(III)) (0.51 eV) [2O72− to Cr(III), and the holes will oxidize H2O to produce O2 (Equations (12) and (13), respectively).We can now tentatively explain the mechanism underlying heterojunctions in photocatalytic reactions. When n-type Biic field . Meanwhiobtained . When vi0.51 eV) ,67. Theo2WO6/Bi2S3/MoS2 n-p heterojunction ternary composites with vis-light response are prepared by a hydrothermal method. The HRTEM and Mott–Schottky curves confirm the formation of the n-p heterojunction. The XPS spectra show the existence of strong interaction and charge transfer among Bi2WO6, Bi2S3, and MoS2 in the n-p heterojunction. The effects of various factors on the catalytic activity of Bi2WO6/Bi2S3/MoS2 photocatalysts are investigated. For vis-light photocatalytic reduction of Cr(VI), the composites show higher photocatalytic reduction capacity than pure Bi2WO6, where BBM-3 exhibits the highest photocatalytic activity with a corresponding Cr(VI) reduction rate of up to 100% within 75 min. After three cycles of experiments, XRD and XPS analyses verify that the heterojunction possesses structural stability and can effectively reduce Cr(VI) into Cr(III). The improvement of photocatalytic activity of composite materials mainly benefits from the following points: First, the successful construction of a heterojunction structure forms a good interface contact, which promotes the effective separation of photogenerated electrons and holes. Second, the effective assembly and interfacial synergy between the three components enhance the vis-light absorption capacity of the samples and expand their light absorption range. Third, the increased surface area and abundant mesoporous structure endow the composites with more reactive sites and strong adsorption capacity of pollutants. The successful construction and application of Bi2WO6/Bi2S3/MoS2 n-p heterojunction in this work provide new ideas and strategies for the development of photocatalysts for wastewater treatment.In summary, spherical Bi