This cross-sectional study assessed knowledge, attitudes, and practices regarding meningococcal disease and related vaccinations among healthcare workers (HCWs) who provided care to patients with underlying high-risk medical conditions. A total of 411 HCWs returned the survey. Only 35% of the respondents had a good knowledge about the incidence and lethality of meningococcal disease, the most frequent serogroups in Italy and the diseases or conditions that expose patients to a high-risk of severe complications caused by meningococcal disease. Vaccination against meningococcal disease was perceived to be highly effective by 38.4% of participants, very safe by 36.2%, and 82% agreed or strongly agreed that HCWs should promote adherence to recommended vaccinations even in hesitant patients. Moreover, 34.1% recommended meningococcal vaccinations to all eligible patients and the results of the multivariate analysis showed that older HCWs, who work in pediatric/neonatal wards, have good knowledge about meningococcal vaccinations, have a favourable attitude towards vaccinations, and do not need additional information about meningococcal vaccinations, were more likely to recommend meningococcal vaccinations to all eligible patients. Interventions aimed at the enhancement of knowledge and awareness of HCWs who provide care to these patients on the benefits of meningococcal vaccinations are warranted. Meningococcal disease, although rare, is recognized as a severe worldwide public health issue . In EuroNeisseria meningitidis, is attributable to serogroups A, B, C, W135, X and Y, and although mainly affecting early childhood, it often occurs also in children and young adults who live in overcrowded conditions [Most of the burden of the disease, caused by the bacterium nditions .The most effective strategy to prevent meningococcal disease is through vaccination, which is currently available against serogroups A, B, C, Y and W135 . In addiIt is crucial for these patients to be vaccinated because their immune system is weaker and they are more likely to develop complications in their condition, which may involve long-term illness, hospitalization, and even death, when they acquire certain vaccine-preventable diseases, such as meningococcal disease . NeverthMoreover, most studies evaluating knowledge, attitudes and behaviors about meningococcal disease and related vaccinations have been conducted in the general population ,18,19, oThus, the primary objective of this study was to explore the knowledge, attitudes, and practices about meningococcal disease and related vaccinations among HCWs who provide care to patients with underlying high-risk medical conditions in Italy.The cross-sectional survey lasted from June until July 2020, and a total of 4 public hospitals were randomly selected across all hospitals in Campania Region, Italy. Before the start of the data collection, the Directors of the selected hospitals were sent a letter requesting collaboration in the survey, once the approval to conduct the study was obtained, HCWs who were employed in the units of pediatrics, oncology, hematology, endocrinology, nephrology, internal medicine and neonatology were informed of the survey and were invited to participate. The research team distributed the questionnaire to all HCWs, including a cover letter explaining the purpose of the study, and participation was voluntary and full confidentiality was assured. Anonymization of any personal identifier or situation was granted and a written informed consent form was also included to process personal data. Follow-up visits were made to each hospital to ensure maximum recruitment of the sampled HCWs. There were no incentives offered to those who participated in the survey. A sample size of 361 HCWs was calculated by using single population proportion formula with the assumption that 17% of HCWs ,22 wouldThe structured questionnaire was self-administered and consenting participants were asked to answer questions on the following five themes: (1) socio-demographic and professional characteristics ; (2) knowledge regarding meningococcal disease and related vaccinations; (3) attitudes towards the effectiveness, usefulness and safety of meningococcal vaccines, as well as towards the role of HCWs in the promotion of anti-meningococcal vaccinations to eligible patients; (4) behaviors concerning the recommendation of meningococcal vaccines to patients at risk for severe complications of their underlying medical condition in the presence of meningococcal disease  infection, chronic liver disease, Human Papillomavirus (HPV) infection and asplenia) , and abot-tests were conducted to assess the association between each independent variable and the different outcomes of interest. Then, multivariate stepwise logistic models with backward elimination were constructed to identify factors associated with the following outcomes of interest: good knowledge about meningococcal disease and related vaccinations  (Model 1); belief that HCWs should promote adherence to recommended vaccination even in hesitant patients  (Model 2); and recommending the meningococcal vaccinations to all eligible patients with underlying high risk medical conditions  (Model 3). To assess the level of knowledge, an overall knowledge score was constructed by assigning 1 point for each correct answer to the questions in the knowledge section of the questionnaire. The total knowledge score ranged from 0 to 18. Then, the overall median knowledge score was calculated and a ≤50th percentile score was considered poor knowledge, whereas a >50th percentile score was good knowledge. The outcome investigating favorable attitudes was constructed by separating those who strongly agreed with the statement “HCWs should promote adherence to recommended vaccinations even in hesitant patients” versus all others. The variables that showed a p < 0.25 at the univariate analysis, as well as those that were considered potential determinants of the outcomes of interest were chosen to be included in the models by the stepwise procedure with backward elimination [p = 0.2 and p = 0.4 [p ≤ 0.05.All statistical analyses were performed with the Stata software, version 15 . FirstlyOf the 740 HCWs invited to participate in the study, 411 agreed and returned the survey for an overall response rate of 55.5%. The mean age was 47.4 years (range 25–70), 57.2% were females, the majority (70.6%) were nurses, 76.6% worked in medical wards, and the mean length of practice in the present unit was 10.9 (0–40) years . No subsThe majority (74.8%) were aware that the incidence of meningococcal disease is low in Italy, only 39.9% knew that the lethality rate ranges from 5% to 10%, whereas the remaining overestimated the severity of prognosis. Moreover, when asked to indicate the most frequent serogroups responsible for meningococcal disease in Italy, 60.8% and 57.9% correctly identified B and C, 49.9% both, while 26% reported they did not know. Furthermore, when asked about the diseases or conditions that expose patients to a high-risk of severe complications caused by meningococcal disease, respondents reported, in descending order, immune disorders (79.8%), congenital immunodeficiencies (52.1%), HIV infection (45%), asplenia (38.9%), type 1 diabetes (21.9%), chronic liver disease (20.4%), thalassemia (18.2%), sickle cell anemia (16.3%), and chronic kidney disease (15.1%). Overall, only 35% of the respondents had a good knowledge about the incidence and lethality rate of meningococcal disease, which are the most frequent serogroups in Italy and the diseases or conditions that expose patients to a high-risk of severe complications caused by meningococcal disease. Multiple logistic regression analyses showed that physicians , having fewer years of practice in the present unit , and having received information from scientific journals, scientific activities or professional associations , and who reported need of additional information about meningococcal vaccinations , were significantly more likely to have good knowledge about meningococcal disease and related vaccinations, whereas younger HCWs (<36 years)  had a significantly lower knowledge than those >55 years old , HIV infection (74.9%), congenital immunodeficiencies (73.7%), asplenia (65.9%), type 1 diabetes (65.4%), chronic liver disease (62.1%), chronic kidney disease (59.8%), sickle cell anemia (56.9%), and thalassemia (56.2%). Results of the multiple logistic regression showed that respondents who believed that HCWs should promote adherence to recommended vaccinations even in hesitant patients were significantly more likely to work in pediatric/neonatal wards , to have fewer years of practice in the present unit , to have been immunized against meningococcal disease , and to have no need of additional information about meningococcal vaccinations . Conversely, respondents aged 36–45 years  and 46–55 years  were less likely to have this favourable attitude than those in the age group over 55 years old  considered very high or high the acceptability of meningococcal vaccinations by their patients. Furthermore, HCWs declared they recommended, during their work activity, meningococcal vaccines to patients with immune disorders (63.5%), HIV infection (57.9%), congenital immunodeficiencies (55.5%), asplenia (54%), type 1 diabetes (48.7%), chronic liver disease (47.7%), chronic kidney disease (43.8%), sickle cell anemia (42.6%), and thalassemia (42.6%). A proportion ranging from 8% for HIV infection to 15.3% for sickle cell anemia, declared that the reason for not recommending meningococcal vaccinations was that they are not recommended for that specific condition. Overall, 97.1% had received at least one and 3.6% all the vaccinations recommended for HCWs. In particular, respondents’ self-reported adherence to recommended vaccinations was high for hepatitis B (91.5%), whereas it was lower for tetanus (67.1%), diphtheria (51.8%), pertussis (41.4%), measles (35.3%), rubella (34.5%), chickenpox (32.4%), mumps (31.6%), and meningococcal disease (21.2%). Finally, only 18.2% had received the influenza vaccination in the previous epidemic season. One third (34.1%) of respondents recommended meningococcal vaccinations to all eligible patients with underlying high-risk medical conditions, and the results of the multiple logistic regression showed that those who work in pediatric/neonatal wards , have a good knowledge about meningococcal disease and related vaccinations , believe that HCWs should promote adherence to recommended vaccinations even in hesitant patients , and do not need additional information about meningococcal vaccinations , were more likely to recommend the meningococcal vaccinations to all patients with underlying high-risk medical conditions, whereas those aged 36–45 years  were less likely than those >55 years old (Model 3 in The vast majority (75.4%) of the HCWs had obtained information about meningococcal vaccinations, 50.7% from internet, followed by scientific journals (37.1%), mass-media (35.5%), continuing medical education courses (33.2%), congresses (30.6%), colleagues (21%), and professional associations (13.2%). Moreover, 48.7% and 42.3% considered their knowledge about meningococcal disease and related vaccinations strategy to be very poor/unacceptable, respectively, only 29% believed that the information received about prevention of meningococcal disease was useful, and 79.3% reported the need for additional information on this topic.To our knowledge, this is the first study that has thoroughly investigated knowledge, attitudes, and practices about meningococcal disease and related vaccinations among HCWs who provide care to patients with underlying high-risk medical conditions for whom these vaccinations are recommended, whereas most of the studies have involved GPs ,20 and pSome interesting remarks should be underscored in the results, addressing HCWs’ knowledge about meningococcal diseases and related vaccinations. Respondents tended to overestimate the lethality of meningococcal disease, and to mainly consider immune disorders as the most high-risk conditions for severe complications related to meningococcal disease, underestimating the role of other disorders, such as chronic kidney or liver disease. These findings suggest that HCWs’ knowledge is focused on all vaccine-preventable diseases and not specifically to meningococcal disease and related vaccinations. This is not surprising since a considerably lower level of knowledge was observed in a study performed in Turkey among pediatric and adult specialists, wherein asplenia/splenectomy (9.7%) and immunodeficient patients (9.7%) were identified among the risk groups recommended for anti-meningococcal vaccination . NeverthAn encouraging finding is the positive attitude towards vaccinations demonstrated by a large proportion of respondents (82%), who agreed or strongly agreed that HCWs should promote adherence to recommended vaccinations even in hesitant patients, whereas it was worrying that only slightly more than one third of HCWs perceived vaccinations against meningococcal disease to be very effective (38.4%) and safe (36.2%), confirming the finding of a scarce attention devoted specifically to meningococcal vaccinations. Additionally, similar to the responses on knowledge, the role of meningococcal vaccinations was mostly perceived to be effective in patients with immune disorders, whilst for other conditions, there was poor awareness of the beneficial preventive effects of these vaccinations.In common with good knowledge, fewer years of practice were positively associated with a favorable attitude towards vaccinations, reassuring that positive attitudes are influenced by correct knowledge, whereas the finding that this positive attitude was significantly more frequent among HCWs working in pediatric/neonatal wards demonstrates that HCWs continue to have a misperception, to date, that vaccinations are mainly a prerogative of the pediatric age. As expected, and consistent with a previous study , those wOne of the main findings of this study is that only one fourth (26%) of HCWs verify the patients’ need for vaccinations and only one third recommends meningococcal vaccinations to all eligible patients with underlying high-risk medical conditions. It is well established that any clinical encounter with these patients should be taken as a new opportunity to promote and/or provide vaccinations, and therefore our study highlights that there is plenty of room for improvement in order to reduce these missed opportunities for meningococcal vaccinations. This result, although concerning, is not surprising, since it has already been explored in different contexts, mainly related to missed opportunities for seasonal influenza vaccinations in patients with underlying medical conditions ,30, urgiThere are some potential limitations in the study that are worthy of emphasis and should be considered when interpreting the results. First, the analyses were based on cross-sectional data, and therefore the nature of the associations limited us from drawing definitive causal conclusions about the observed relationships between determinants and outcomes. Second, self-reported behaviors can result in the overestimation of “desirable” responses. Indeed, respondents many have inflated compliance with recommendations of the meningococcal vaccinations. Moreover, the information about their vaccination status was also self-reported and not based on vaccination records. This might be prone to recall, declaration, or desirability biases; therefore, an over or underestimation of coverage could have occurred. However, we attempted to minimize these potential biases by ensuring complete respondent anonymity and confidentiality. Third, the collected responses might not be generalizable to other regions of the country since the sample was selected from a confined geographic area. Forth, we did not explore barriers to meningococcal vaccinations recommendations, and further research on this issue would be of interest.Despite these limitations, the study has added valid and valuable new knowledge on a poorly investigated topic and the results may have significant implications for the improvement of meningococcal vaccination coverage in a notably under vaccinated population. Research on the effective interventions aimed at the enhancement of knowledge and awareness of HCWs who provide care to patients with underlying high-risk medical conditions on the benefits of meningococcal vaccinations is warranted.


Three in-scanner tasks drawn from distinct EF domains  were collected from children with and without an ADHD diagnosis (N = 63). Whole-brain activity and 11 regions of interest were correlated with parent reports of inattention and hyperactivity symptoms. Across the three EF domains, brain activity related to ADHD symptom burden, but the direction and location of these associations differed across tasks. Overall, activity in sensory and default mode network regions related to ADHD, and these relations did not consistently overlap across EF domains. We observed both distinct and overlapping patterns for inattention and hyperactivity symptoms. By studying multiple EF tasks in the same sample, we identified a heterogenous neural profile related to attention symptom burden in children. Our results inform ADHD characterization and treatment and explain some of the variable brain results related to EF and ADHD reported in the literature.Attention-deficit/hyperactivity disorder (ADHD) is a prevalent childhood disorder marked by inattention and/or hyperactivity symptoms. ADHD may also relate to impaired executive function (EF), but is often studied in a single EF task per sample. The current study addresses the question of unique  PediatrThe unity of EF is reflected in the organization of neural systems that support these processes across domains. Tasks that tap EF reliably recruit particular frontal and parietal brain regions across ages . These rGiven the existence of a consistent neural system supporting EFs in childhood, along with evidence of EF impairments in pediatric ADHD , controlThere is immense breadth in the brain regions named in disrupted EFs among children with ADHD, but there is a surprising lack of depth; the same regions or networks are not consistently implicated across studies. Across the three-domain model of EF, inhibition tasks are most commonly used to look at brain function related to ADHD , with feThe current study used a pediatric dataset to look for consistency of ADHD symptom impact across three MRI tasks sampled from separate EF domains. Neural activity from each task was related to parent reports of child inattention and hyperactivity, as measured on a continuous scale. Analyzing ADHD symptom burden as a continuous phenotype, rather than with the presence or absence of a diagnostic label, has proven to be a strong approach to capturing variability within the disorder and in the general population . We exam22.1Participants were drawn from a broad community collection assessing EF development in brain and behavior. The current sample  was 68.3% white, 30.2% Hispanic , 4% African American, and 1.5% Native American. All data collection procedures followed the human subjects research regulations overseen by the University of Texas at Austin Institutional Review Board. Parents provided informed consent for children less than age 18 years, and children under 18 provided informed assent. Families participated in one behavioral visit and one MRI visit. Participants were compensated for their time, and parents/guardians were compensated for completing research forms.SD = 2.53) and children with an ADHD diagnosis, including ADHD comorbid with other neuropsychological disorders . See The sample was made up of typically developing children who had no diagnosed developmental or psychological disorders . The majority of the group  contributed data for all three tasks, leaving a fairly consistent group of participants across the three tasks.Participants were excluded from the study if they were reported to have head trauma, epilepsy, MRI scanner contraindications such as a non-removable metal implant, or vision that could not be corrected with MR-compatible glasses. Participants with an ADHD or comorbid diagnosis who were prescribed medication were instructed to follow their medication routine on the day of the scan. Thirteen individuals were on psychotropic medications during the scans; for details on medications, see 2.2Measures of symptom burden were collected from parents (parent child report: PCR) as part of the behavioral visit occurring 1–6 weeks before the MRI session. The Conners-3  was used2.3MRI data were collected at the Biomedical Imaging Center at the University of Texas at Austin. All data were collected on a 3 T Siemens Skyra with a 32-channel head coil T1-weighted structural images were collected with an MPRAGE sequence . T2-weighted structural images with a turbo spin echo sequence  were collected. All functional scans used a multi-band echo-planar sequence . Stimuli were presented via laptop with PsychoPy version 1.8  and projThree tasks from distinct EF domains were presented in the following order : cognitiCognitive flexibility task: Participants performed an event-related design cued-rule matching task, where the relevant rule switched by trial Cognitiveby trial . Trials N-back working memory task: Participants performed a block design n-back task to tax working memory N-back woStop-signal inhibition task: A visual event-related stop-signal task was used to tax inhibition Stop-sign2.4t-test adjustment for unequal variances and unequal sample sizes in R version 3.2.1 (Measures of task accuracy and response time (RT) were calculated for each task . Overallon 3.2.1 .t-test, and correlated with symptom burden using R version 3.2.1  version 5.9 (www.fmrib.ox.ac.uk/fsl). T1 images were skull-stripped with non-brain matter removed using Freesurfer version 5.3.0 . A double-gamma HRF time-series model was carried out using FILM with local autocorrelation correction  as well as two contrasts testing the cue (preparatory period) vs. baseline and target (task execution period) vs. baseline separately, as the two have been shown to differ in control engagement   . Higher-ractices .2.6To examine EF activity common across the three tasks, we first replicated a previous cross-task overlap analysis using these same tasks, but modeled across error and correct trials, instead of just correct trials . Our rep2.7Z > 3.1 threshold was used to define contiguous clusters with a cluster probability of p < .05 .In addition to our whole sample correlational models, we also took a more traditional approach of looking at ADHD effects in the brain by creating groups based on the presence or absence of ADHD diagnosis. Third-level models testing for group differences in mean activity between participants with an ADHD diagnosis and typically developing participants were carried out using FLAME stage 1. Mean-centered age was added to all models to control for any age-related effects. Group-level 2.9To examine potential effects of comorbid diagnoses and medication use, all of the same whole-brain symptom burden correlation models described above were run with all typically developing participants and a restricted subset of individuals who had an ADHD diagnosis but no comorbid diagnoses and were also not on any psychotropic medication at the time of scan. See 33.1t = 7.12, p < .001) and hyperactivity  symptom ratings, though there was notable overlap (p = .02), but not of inattention (p = .65). Parent ratings of inattention and hyperactivity symptom burden were correlated . There were no gender differences in parent reports of symptom burden .Parent ratings of ADHD symptom burden were higher for individuals with an ADHD diagnosis; this was true for both inattention . There was no relation between inattention and task accuracy or between either measure of symptom burden and RT or RT variability . There were no differences in any performance measures between diagnosis groups , controlling for age, there was a positive relation between inattention symptom burden and brain activity in right post-central gyrus and superior parietal lobe (cue vs. baseline) or target period (target vs. baseline) alone.tal lobe a. See TaWorking memory: During the n-back task (2back vs. baseline), controlling for age, there was a positive relation between inattention and activity in the medial prefrontal cortex, and a positive relation between hyperactivity and activity in the medial prefrontal cortex, ventral medial prefrontal cortex, and right orbitofrontal cortex , controlling for age, there was a negative correlation between hyperactivity and brain activity in the posterior cingulate gyrus  carrying those effects? We found brain activity primarily in the default mode network (DMN) as well as somatosensory and visual regions to vary with symptom burden and did not observe such patterns in control regions.4.1We present experimental evidence within the same pediatric sample that the relations between ADHD symptom burden and brain activity are EF task specific. We found unique associations between brain activity and symptom burden in tasks related to inhibition, cognitive flexibility, and working memory, with no overlap. Our results suggest that ADHD symptom burden does relate to EF brain function, but that distinct EF domains are impacted in different ways. This is supported by a meta-analysis that found different associations between ADHD and brain activity during inhibition versus attention tasks  and aggrvs. dimensional measures.The current work sheds some light on the variability in brain regions that are reported across the ADHD neuroimaging literature. This heterogeneity in the literature is exemplified by use of ‘Neurosynth’ , a meta 4.2Considering the reported relation between EF performance and ADHD in children , we expe4.3In our cognitive flexibility task, we saw increased activity in somatosensory regions related to inattention symptom burden. Previous work showing atypical activity in somatosensory systems suggests an over-reliance on these systems when task preparation isn’t properly initiated , symptom4.4The default mode network (DMN) results seen in both our inhibition and working memory tasks, in posterior cingulate cortex and medial pre-frontal cortex respectively, are consistent with a large literature indicating attention problems and ADHD impact DMN function . During 4.5This work highlights the diversity in relationships between dimensions of ADHD behavior and brain activity across domains of EF, highlighting the need for careful task selection and generalization of findings. While we see remarkably different results across the three domains in the location and nature of attention relations, our working memory domain results were consistent across types of symptom burden (hyperactivity and inattention) and were robust across subgroup analyses. Specific working memory deficits in ADHD have received notable attention in recent years . In beha4.6The current work has several notable limitations. In order to keep protocols consistent, all tasks were presented in the same order for each participant. This led to slightly less collection of the second run of the last task . Varying task order in future studies could mitigate this issue and result in more even coverage across tasks. Additionally, task performance thresholds were kept liberal to preserve broad individual differences. Lowering performance thresholds introduces more possibilities of including noisier data from when participants not engaged in the task. However, we found no relationship between inattention symptom burden and task performance, indicating we don’t have a systemic issue of including individuals with high inattentive burden by lowering performance thresholds. Given that individual differences in attention is a core construct of interest in this study, we decided lowering thresholds was important for retaining variability in participant sampling. Future studies of ADHD dimensions in larger samples could compare results from varying performance criteria and inclusiveness. Due to MRI bounding box limitations in this study, we had inadequate coverage of the cerebellum and were unable to include it in the current study. The cerebellum has been shown to vary anatomically and functionally with ADHD diagnosis and symptomology . Future We did not impose medication restrictions on our participants, thereby creating a heterogenous sample. We made this decision to avoid transient withdrawal effects and to increase the comfort and inclusion of participating families. To address this possible confound, we tested for effects in a smaller unmedicated, ADHD-only subsample, but at the expense of substantial loss of power. We believe our community-recruited sample reflects the high degree of ADHD medication use and comorbid diagnoses with ADHD in ‘real-world’ samples, and thus reflects many experiences with ADHD. We cannot definitively reject the possibility that our lack of consistent across-task results was driven by the effects of medication or comorbid diagnoses; similarly, these factors may have masked additional meaningful results from the current study. Future work with larger samples such as the National Institute of Health's Adolescent Brain Cognitive Development study drawn from cross-site collections , may she5Across tasks from three EF domains, we did not find a coherent pattern of associations between brain engagement and ADHD symptom burden. We also did not see consistent cross-task ADHD symptom relations in putative core EF regions that are active across the three tasks. We found task-specific correlations between symptom burden and brain activity in somatosensory, visual, and DMN regions. This work provides evidence of the neural heterogeneity of EF function related to attention difficulties within a single sample. Our results strongly support testing multiple EF domains and using both categorical and dimensional measures of ADHD in future brain and behavioral studies.The current study was supported by Jessica A. Church’s Brain & Behavior Research Foundation NARSAD Young Investigator Award, and University of Texas start-up funds. The content is solely the responsibility of the authors and does not necessarily reflect the views of the funders.Tehila Nugiel: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing - original draft. Mary Abbe Roe: Data curation, Methodology, Writing - review & editing. Laura E. Engelhardt: Methodology, Writing - review & editing. Mackenzie E. Mitchell: Data curation, Project administration, Writing - review & editing. Annie Zheng: Data curation, Project administration, Writing - review & editing. Jessica A. Church: Supervision, Funding acquisition, Writing - review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


For example, in a patient with a principal diagnosis of major depressive disorder, a clinician might inquire about the presence of panic attacks or excessive worry. In contrast, for polythetically defined disorders such as ADHD, there is no ‘gate-criterion’ because diagnosis is based on the presence of a minimum number of attributes from a longer list and no single attribute is required to be present.14 However, questionnaires may be lengthy , based on outdated diagnostic criteria or not validated for workers’ home language and thus impractical in workplace mental health surveillance contexts. Given the scarcity of resources for mental health services, amongst the other limited resources for large scale screening of workers, there is a need to consider brief screening tools to identify individuals who may benefit from referral for further assessment.Given the under-recognition of ADHD, as well as the risk of workplace accidents and injuries, screening as part of occupational mental health surveillance may be beneficial. Although ADHD is always a clinical diagnosis, informed by a comprehensive assessment, multiple scales are available for screening.10Previous analysis of data from the Rhode Island Methods to Improve Diagnostic Assessment and Services (RIMDAS) project in the USA (using psychiatric outpatients) indicated the usefulness of two features of ADHD to serve as ‘gate-criteria’ to screen for the presence of ADHD in adults. It identified a 2-item screen, namely difficulty sustaining attention  and fidgetiness (DSM-5 criterion A2a), with a reported sensitivity of > 0.90 and negative predictive value (NPV) of > 0.97, to screen for adult ADHD.10 using data from local South African (SA) workplace samples. This was to determine whether it would be possible to similarly identify one or two ADHD symptoms that could serve as ‘gate-criteria’ to screen for ADHD in workplace populations, to improve recognition within the SA occupational medicine context.This study aimed to replicate the analysis of Zimmerman et al.,3 Data were collected through occupational mental health surveillance initiatives.The dataset came from a previously reported survey of adult ADHD in SA workplace populations.M = 31.0 ± 6.4). As a result of the diagnostic requirement of onset of symptoms in childhood, the assessment was limited to respondents under the age of 45 because of concerns about the accuracy of retrospective recall amongst older respondents.7 Age by gender distribution is presented in 3The current sample consisted of 2048 workers (43.9% women) in full-time employment, with ages between 19 and 45 , time of onset (criterion B), presence in multiple settings (criterion C) and evidence of impact on functioning (criterion D). Collateral information was not sourced and outcomes were indicative of diagnostic likelihood, rather than final diagnosis. Data on comorbidities were not available for this analysis.For the present study, the 18 items reflecting DSM-5 symptoms were subjected to a receiver operating characteristics (ROC) curve analysis, using SPSS-25. Further, sensitivity and specificity, as well as positive predictive value (PPV) and NPV, were computed for each item.10Following the study by Zimmerman et al., the primary interest was in each symptom’s sensitivity (i.e. likelihood that a patient with ADHD has the criterion) and NPV (i.e. likelihood that a patient who does not have the criterion is not diagnosed with ADHD). A symptom or diagnostic criterion functions well as a screen if almost all patients with the disorder have the symptom (i.e. high sensitivity) and most patients who screen negative do not have the disorder (i.e. high NPV). Thus, for screening purposes, having high PPV (i.e. high likelihood of having the disorder if the criterion is present) is less critical because the quick screen is anticipated to be followed by a comprehensive diagnostic assessment.The data were collected after approval from Stellenbosch University Health Research Ethics Committee (#N18/03/039). Workers were invited to participate on a voluntary basis, provided informed consent and all data were anonymised prior to inclusion in this analysis.Frequency of likely DSM-5 adult ADHD was 3.2% (66 of the sample). Area under the curve (AUC), as well as sensitivity, specificity, PPV and NPV for the 18 symptoms are presented in Four symptoms were identified that met the requirements of high AUC, high sensitivity and high NPV . Of those, the two with the highest sensitivity were similar to the features reported from the RIMDAS sample, namely difficulty in sustaining attention and fidgetiness. Both had a sensitivity > 0.90 and a NPV > 0.95.2 This study also closely replicated previous analyses of North American data from a psychiatric cohort, with similar test-characteristics found for the two pertinent items. The 2-item screen identified from the South African data – difficulty in sustaining attention and fidgetiness – had a sensitivity of > 90% and NPV of > 95%. In this dataset from SA workplace populations, the presence of these two features appeared to capture most individuals with a likely diagnosis of adult ADHD, whereas its absence ruled out the disorder. The identification of these two symptoms are consistent with other studies, which described difficulty in sustaining attention as amongst the most frequent ADHD criteria and fidgetiness as the most frequent hyperactivity-impulsivity symptom.17The frequency of adult ADHD in this sample is consistent with the reports from other workplace samples.18 to mitigate the risk that such screening may be perceived as punitive, rather than therapeutically supportive. Workers may be reluctant to disclose symptoms if they perceive it to threaten their continued employment, whilst they may be reassured of its positive medical benefit if perceived as part of ongoing occupational health support and personal safety management.The two features thus appear to have potential as ‘gate-criteria’ to screen for adult ADHD as part of occupational mental health surveillance. This may enable up-scaling the screening of worker populations to include ADHD, to facilitate the referral of identified individuals for further assessment and management. It would be important to position such screening within the occupational medicine context,10 The PPV of the two items were very low, and the majority of workers who reported either of these symptoms did not receive a diagnosis of ADHD. In contrast to the low PPV, the NPV was > 95%, and in workplace contexts similar to the study setting, clinicians may be confident in ruling out a diagnosis of ADHD in patients who do not report either of these two criteria.Furthermore, it is important to distinguish between screening and case identification. These findings do not suggest that the diagnosis of ADHD can be abbreviated to an assessment of the presence or absence of difficulty sustaining attention and fidgetiness.14It is emphasised that adult ADHD is always a clinical diagnosis informed by a comprehensive assessment. Brief screens like these are never meant to replace longer scales or clinical examination and in the occupational health context serve only to screen workers in order to stream them to appropriate mental health services. Accurate identification facilitates appropriate referral for therapeutic management, for which established local guidelines are available.The data represented generally healthy and skilled worker samples and cannot necessarily be generalised to community samples, psychiatric outpatients or unskilled labour populations without further research. Further, diagnostic likelihood depended on self-report, and future studies may need to include collateral information to confirm diagnosis. As a result of a technical error, data on comorbidities were not available for this analysis, and will need to be included in future studies. Difficulties with sustaining attention or remaining still could also occur as expressions of other conditions, which again emphasises the need for a comprehensive assessment to establish a diagnosis of ADHD.Clinicians, in comparable workplace contexts, can now with some confidence use two questions to screen for the possible presence of adult ADHD, when conducting diagnostic assessments. This can be performed with a 2-item screen that probes difficulty in sustaining attention and fidgetiness, where at least one is present in most patients with the disorder and the absence of which effectively rules out the disorder. The psychometric properties of the 2-item screen for ADHD suggest that it can function as such a screen. Such screening would then allow for streaming to appropriate mental health support.


The development of the complex clinical picture of motor and vocal tics in children and adolescents with Tourette syndrome (TS) must be paralleled by changes in the underlying pathophysiology. Electrophysiological methods such as EEG and event-related potentials (ERPs) are non-invasive, safe and easy to apply and thus seem to provide an adequate means to investigate brain dynamics during this brain maturational period. Also, electrophysiology is characterized by a high time resolution and can reflect motor, sensory and cognitive aspects as well as sleep behavior. Hence, this narrative review focuses on how electrophysiology echoes brain dynamics during development of youngsters with TS and might be useful for the treatment of tics. A comprehensive picture of developmental brain dynamics could be revealed showing that electrophysiological parameters evolve concurrently with clinical characteristics of TS. Specifically, evidence for a maturational delay of motor inhibition related to cortico-spinal hyper-excitability and brain mechanisms for its cognitive compensation could be shown. Moreover, deviant sleep parameters and probably a stronger perception-action binding were reported. For neuromodulatory treatments  targeting neuronal deficits and/or strengthening compensatory brain mechanisms, pilot studies support the possibility of positive effects regarding tic reduction. Finally, attention-deficit/hyperactivity disorder (ADHD), as a highly frequent co-existing disorder with TS, has to be considered when using and interpreting electrophysiological measures in TS. In conclusion, application of electrophysiology seems to be promising regarding clinical and research aspects in youngsters with TS. Tourette syndrome (TS) is characterized by motor and vocal tics, which can become apparent as early as 2–3 years of age. Usually, tics increase with a peak at about 10–12 years, but they decrease spontaneously afterwards, so that only a minority of patients (20–30%) will continue to suffer from their tics still in adulthood. Besides this motor aspect, children may report a sensory-motor urge (around the age of 9–10 years) before a tic, which might be relieved after ticcing. Also, they are able to suppress this urge and their tics, at least to withhold them for a short amount of time. This voluntary suppressibility implies a better tic control, increases by later adolescence and may be related mainly to the frontal lobe maturational course  during childhood and adolescence  has to be considered, when investigating the developmental brain dynamics of TS , 3. AlsoElectrophysiological approaches are non-invasive, safe, can be applied continuously through child development in the same way and thus seem to be adequate in order to investigate the maturational brain dynamics of TS. As tools, electroencephalography (EEG), evoked potentials (EPs), event-related potentials (ERPs), transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are available. Moreover, EEG/ERPs can be used for neurofeedback and repetitive TMS and tDCS may present other possible treatment approaches , 5. ElecThis narrative review focuses on how electrophysiology echoes the brain dynamics during the development of youngsters with TS. In the nearer future, one may aspire to support the clinical expert in the use of neurobiological background information for a better personalized diagnostic and treatment. On the one hand, one should be cautious while drawing firm conclusions from a particular electrophysiological finding available, so far, since usually small samples have been investigated with unclear generalizability and lack of independent replications. On the other hand, there is converging evidence regarding maturational brain dynamics of TS particularly in the motor system and aspects of comorbidity (with ADHD) as will be described in this article.n = 36; HC: n = 21), Duan et al. described a decreased intrinsic long-range connectivity between the frontal and the temporal/occipital/parietal lobes for TS  in several cases abnormalities  .n = 23) and without TS (n = 17)  during cued voluntary eye blinks among children (8–12 years) with TS ((n = 17) . Upon prAlthough all these reports favor the good abilities of children with TS for early and long-term compensation of their motor hyper-excitability, the question arises as to whether this still holds, when TS is associated with ADHD, what is often the case.n = 14, TS-only: n = 10) (n = 16 in each group) (n = 46)  as seen in children with ADHD, might limit their ability to mobilize this inhibitory system, while children with TS seem to be better off in this respect , which w n = 10) . Hence,  n = 10) . Moll eth group) , 37. For(n = 46) .In children and adolescents, tics are sometimes (about 40%) preceded by premonitory sensory phenomena (PSP) such as an inner urge to move, or by bodily sensations such as feelings of mounting inner tensions or itching in certain areas of the body. Usually, they are transiently relieved by tic expression, which can be seen as a negative reinforcement of tics. In children, PSP is experienced rarely under the age of 10 years and is not a necessary prerequisite for a tic or its suppressibility, i.e., usually there is a de-coupling. In a sample of 254 outpatients with TS, 37% reported PSP while 64% were able to suppress their tics .Electrophysiological studies in children and adolescents related to the issue of early sensory processing in TS are lacking. In adults, already in the 1980's somatosensory, visual and auditory evoked potentials, reflecting the basic functions of the respective sensory pathways, showed normal amplitudes and latencies up to about 100 ms after stimulus n = 22, HC: n = 22), Buse et al. . They found sensorimotor dysregulation in only 35% of cases, mostly related to the different comorbidities  showed clearly that the factor ADHD was related to poor performance; there was no interaction between the two factors. This independency suggests an additive model for the association of TS and ADHD.The concept of non-voluntary neuronal disinhibition as the main pathophysiological background in TS along the lifetime is still a matter of debate . Specifin = 14–29; 1-year follow-up in  revealed that neurodynamic sufficiency in ADHD and ADHD plus TS seems to be similarly impaired with ADHD as the responsible factor  negative wave (Nd) and P300 in four groups of children  were tested in a 2 ×2 factorial design. Only ADHD was associated with poorer performance and reduced amplitude of all ERPs, while TS was only related to slowed RTs, interpreted as a compensatory slowing of motor output to facilitate tic control. There was no interaction between TS and ADHD factors for any behavioral or ERP measure. The same authors conducted a similar four-group experiment on reinforcement learning  (n = 13–20 per group)  . As in tSimilarly, favorable results for TS were reported in the long-term. For example, Roessner et al. found stable normal executive function performance in TS after 1-year follow-up . Eichelen = 35, HC: n = 39) in a Go/NoGo task. While testing for the inhibition of a motor response they manipulated the complexity of sensory/stimulus input . They concluded that the binding within the sequence of stimulus perception-motor impulse-inhibition is stronger in TS and thus may reflect a strengthened perception-action integration   suggests that motor and sensory processes seem to be less relevant but merely cognitive processes may be important for linking perception to action   and analo action .Tics can be observed also during sleep and different kind of sleep problems are well-known to be associated with TS. A still valid overview on sleep and TS is provided by Rothenberger et al. , who stan = 90; four groups: TD, ADHD, TD + ADHD, HC)  in their usual sleeping environments and routines . They deDHD, HC) .n = 18 in each of the four groups in  and lower sleep efficiency/elevated arousal (for TS) in an additive manner, without indicating any interaction effect . Thus, Deviations of electrophysiological measures, either as a sign of defective inhibition  or its compensation  reflect a clinical-physiological correlation that could be used for treatment approaches for TS intended to improve automatic and/or cognitive control of tics . Also, tThe importance of dysrhythmic brain oscillations in TS has already been clarified e.g., , 18] Hen Hen18)] Other, merely passive electrophysiological treatment options are rTMS and tDCS, which appear to be safe for children and adolescents, although there remain many unmet needs in pediatric patients. Further, NF, rTMS, and tDCS are not disorder specific but rather may help to modulate neuronal excitability within the regional network stimulated on the scale of minutes to hours and might have clinical effects that can last weeks to months .For example, Kwon et al. designed a pilot, open-label 12 weeks cohort study to assess efficacy of low-frequency rTMS  in 10 male children with TS (11.2 years) . Tic symn = 40) and ADHD  indicating some improved inhibitory control  in children and adolescents with mental disorders is limited but has been tested in autism spectrum disorder .The comorbidity of Tourette syndrome and ADHD has been considered systematically  in only part of the studies. Thus, it remains open for some of the findings whether they rather reflect the factor tic or ADHD. Generally, effects indicate an additive model, i.e., an independent contribution of each factor to the electrophysiological parameter in question. Only, in the context of (very) high cognitive demands, do the two associated disorders appear to interact functionally.Neuromodulation via electrophysiological means  aim at targeting neuronal deficits and/or strengthening compensatory mechanisms. Pilot studies have been conducted in children and adolescents with Tourette syndrome, some with a probable reduction in tic severity. Further, well-controlled studies with larger samples and longer-term outcomes are necessary before firm conclusions can be drawn regarding the clinical benefit but also risks of these approaches for the developing brain.Other challenges for the future are the prediction of the course of the disorder for an individual patient and, in times of “personalized medicine,” the identification of predictors for treatment outcome. In this respect, electrophysiological measures may represent promising markers as has already been reported for ERP components regarding neurofeedback in children and adolescents with ADHD or cognitive-behavioral therapy in adult patients with Tourette syndrome .In conclusion, application of electrophysiology in youngsters with TS seems to have been promising for recent clinical and research aspects and is expected to remain promising for the future.AR initiated this review and drafted the manuscript. HH contributed to the writing of the manuscript. All authors approved the final manuscript.HH is an employee of neuroCare Group. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To evaluate stereoacuity, fusional vergence amplitudes, and refractive errors in patients with attention-deficit hyperactivity disorder (ADHD).Twenty-three patients who were newly diagnosed as having ADHD and had not started medication, and 48 children without ADHD were included. Retrospective data analysis of comprehensive eye examination, stereoacuity, and fusional vergence amplitudes of the patients were performed.The mean age at ADHD diagnosis was 10.68±2.34 (7-16) years in the ADHD group  and 12.23±2.16 (7-15) years in the control group  patients (p=0.605). The mean stereoacuity was 142.14±152.65 (15-480) sec/arc in patients with ADHD and 46.3±44.11 (15-240) sec/arc in the control group (p<0.001). For ADHD patients, the mean convergence and divergence amplitudes at distance were 19.87±8.40 (6 to 38) prism diopter (PD) and -9.09±-4.34 (-4 to -25) PD, and 37.30±12.81 (14 to 70) PD and -13.13±-3.45 (-4 to -20) PD at near, respectively. The mean cycloplegic spherical equivalent was 1.06±1.13 (-1 to 4.63) diopter in ADHD patients, with 6 patients having significant refractive errors . There were no significant differences between groups in terms of spherical equivalents (p=0.358) or convergence and divergence amplitudes at distance  or near .Fusional vergence amplitudes did not present significant difference, while the mean value of stereoacuity was significantly lower in newly diagnosed ADHD patients prior to treatment. In the literature, despite the variable results in studies associating visual dysfunction with school performance, there is a possible relationship between the symptoms of visual problems and ADHD-related behaviors.5Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children and adolescents. The prevalence of ADHD in developed countries is reported to be 2-18% among children between the ages of 6 and 17 years.7 As the eyes are considered a continuation of central nervous system, the ocular system enables the evaluation of neurological changes and nervous system activation/inhibition.8 In patients with ADHD, binocular vision changes and oculomotor deficits such as convergence insufficiency10, accommodative dysfunction11, reduced stereoacuity12, and ametropia13 have been reported. Regarding underlying mechanisms, Poltavski et al.14 suggested a bidirectional relationship between attention and accommodation. However, the association between ADHD and oculomotor control changes such as accommodative dysfunction and convergence insufficiency is not clearly known yet. Additionally, there are several contradictory reports in terms of stereoacuity, refractive state, etc.13, and treatment status of the patients enrolled in those studies also varied. Therefore, this study aims to investigate stereoacuity, fusional vergence amplitudes, and cycloplegic refractive errors in newly diagnosed ADHD patients prior to medication.Brain imaging studies demonstrated delayed maturation in the brains of ADHD patients, with reduced striatal volume and differences in hippocampal, accumbens, and amygdala volumes compared to healthy controls. These findings along with dopamine and norepinephrine imbalance in the prefrontal cortex supported the deficits in emotional regulation, motivation, and memory in these patients.3 and had not yet received medication, and the data of 48 control patients of similar age and sex distribution who did not have ADHD and consecutively presented to the ophthalmology outpatient clinic for routine evaluation were retrospectively reviewed. The study was approved by the Institutional Ethics Review Board of Ege University and adhered to the precepts of the Declaration of Helsinki. Patients with congenital or acquired ophthalmic pathologies , ophthalmic surgery history, and systemic or neuropsychiatric diseases other than ADHD were excluded. Stereoacuity measured with TNO Random-dot Stereo test , fusional vergence amplitudes, presence of heterophoria with cover/uncover test, best corrected visual acuity (BCVA) according to Snellen scale, and spherical equivalent (SE) of refractive errors (Topcon KR-7000P)  after cycloplegia (with 1% cyclopentolate hydrochloride) were recorded for all patients. As described in the literature15, fusional convergence and divergence amplitudes at distance (6 m) and near (33 cm) were measured by the same two examiners  3 times at 15-minute intervals with placement of the fixed horizontal prism bar (1D-40D) in front of an eye in all patients, while they fixated on an accommodative target. The base-out prism power was gradually increased for convergence and the base-in prism bar was gradually increased for divergence, and the patient was asked to identify the point at which the target image appeared to be doubled; this prism power was designated as the breakpoint. Patients with spectacles were tested with habitual optical correction in glasses or contact lenses. The mean value of the fusional vergence measurements were taken into account for the statistical analysis. Significant refractive errors were defined as an SE of myopia ≥0.5 diopter (D) or hyperopia ≥1.0 D. Significant astigmatism was defined as a level of ≥1.0 D and anisometropia, ≥1.0 D SE.16The charts of 23 consecutive patients who were newly diagnosed with ADHD according to DSM-IV criteria17 Statistical analyses were performed by independent t-test and chi-square test. A p value <0.05 was accepted as statistically significant.The statistical analysis was performed using SPSS software for Windows version 15.0  and Microsoft Office Excel . For stereoacuity, all values were transformed to the logarithm of arc seconds.The mean age of the subjects was 10.68±2.34 (range=7 to 16) years in patients with ADHD  and 12.23±2.16 (range=7 to 15) years in the control group . Anterior segment and fundus examinations were unremarkable and BCVA was 20/20 in both eyes of all subjects. No patient presented with restriction of eye movements, heterotropia, or anisometropia. The 22 patients (95.5%) in the ADHD group who were able to perform TNO Random-dot Stereo test had stereoacuity (at least 480 sec/arc) with full refractive correction. The mean and median values for stereoacuity were 142.14±152.65 (range=15-480) sec/arc and 60 sec/arc, respectively. The mean of convergence and divergence amplitudes at distance were 19.87±8.40 (range=6 to 38) prism diopter (PD) and -9.09±-4.34 (-4 to -25) PD, and at near 37.30±12.81 (14 to 70) PD, and -13.13±-3.45 (-4 to -20) PD, respectively. The SE following cycloplegia was 1.06±1.13 (range=-1 to +4.63) D. Thirteen patients were found to have significant refractive errors . Two patients who had hyperopia higher than 3.5 D were prescribed spectacles due to asthenopia and low BCVA. In the control group, all subjects were able to perform TNO Random-dot Stereo test and had stereoacuity with a mean of 46.3±44.11 (range=15 to 240) and the median of 30 sec/arc. The mean of convergence and divergence amplitudes at distance were 23.54±6.24 (range=14 to 36) and -9.67±-3.71 (range=-4 to -16) PD, and at near 38.21±8.13 (range=25 to 64) and -15.76±-3.52 (range=-12 to -25) PD, respectively. Following cycloplegia, the mean SE was 0.53±1.76 (range=-2.75 to 2.12) D, while 13 subjects had significant refractive errors . There were no statistically significant differences between groups in terms of SE (p=0.358) or convergence and divergence amplitudes at distance  or near . Stereoacuity, fusional vergence amplitudes, and refractive status of the subjects are summarized in 19 Specifically, school performance, along with intellectual capacity, social abilities and occupational functions are impaired in patients with ADHD. In addition, ADHD is considered a major public health problem due to the considerable economic burden to families and community.21ADHD is thought to be associated with several negative outcomes, such as antisocial behaviors, social and peer problems, and psychiatric disorders later in life.5 In the literature, there are only a few studies revealing the relationship between ADHD and ocular abnormalities.23 Granet et al.8 retrospectively evaluated 266 children with convergence insufficiency and reported that 26  patients (9.8%) had ADHD either at the time of diagnosis or during the follow-up period. Among them, 20 (76.9%) patients were on medical treatment and 6 patients had never received treatment or had discontinued treatment. Additionally, a review of 176 ADHD patients who underwent ophthalmic evaluation revealed that 29 patients (15.9%) were diagnosed with convergence insufficiency based on their medical records. Thus, the authors suggested that convergence insufficiency should be investigated in patients with ADHD, despite the lack of causal relationship. Vergence is defined as simultaneous movements of eyes in opposite directions in order to have single binocular vision.24 Viewing through a range of prisms placed before the eyes in both a base-in and then base-out direction has long been used as a diagnostic measure of vergence and accommodation dysfunction.25 The capacity to see a single image via the base-out prisms without diplopia or blur is referred to as the fusional limit and determines the strength of convergence response, and vice versa.26 Therefore, fusional amplitudes have an important role in the maintenance of single binocular vision.15 For instance, low positive fusional limits, with the accompanying complaints of asthenopia, blur, or diplopia leading to frontal headaches following prolonged periods of near work, might be distracting and adversely affect school performance.29 Moreover, oculomotor dynamics are related to brain areas controlling attention and demonstrate sensitivity to alterations in attentional status.14 Animal models also indicated that the superior colliculus (SC), which constitutes the principal subcortical area involved in ocular control, participates in the regulation of near response, visual fixation, accommodation, and convergence.31 The SC is also linked to distractibility and proposed to be dysfunctional in ADHD.32Therefore, the evaluation of stereoacuity and fusional vergence amplitudes are of special importance in patients with ADHD. Gronlund et al.12 evaluated ADHD patients receiving medical treatment both before and 2 hours after stimulant use. They reported that the proportion of patients with stereoacuity ≥60 sec/arc was significantly higher in the ADHD population, independent of stimulant use. The rate of convergence near point <6 cm was significantly lower in ADHD patients before stimulant use, while there was no significant difference between the groups 2 hours after stimulant use. Fabian et al.23 compared 56 ADHD patients with 66 control subjects and did not find a statistically significant difference in terms of stereoacuity  or fusional vergence amplitudes. They also noted that 15 patients (27%) were currently taking methylphenidate treatment. On the other hand, Fabian et al.23 did not report convergence insufficiency in any of their patients. Despite the near point of convergence being significantly lower in patients with ADHD , this did not reveal any clinical importance, since these values were <6 cm. In the present study, although all patients with ADHD had stereoacuity of at least 480 sec/arc, the mean value of stereoacuity in these patients was significantly lower compared to the control group. In addition, there was no significant difference in terms of fusional vergence amplitudes. The limitation of the present study is the lack of data regarding near point of convergence. However, convergence insufficiency was not present in any of the patients in terms of symptoms or decreased positive fusional vergences (both at the near point). These findings are also consistent with the report of Fabian et al.23 In contrast, in the present study, all patients were newly diagnosed with ADHD and had not previously received any medication, which eliminates the confounding effect of medication on these parameters. On the other hand, Bennett et al.33 suggested that some of the medications used in the treatment of ADHD might worsen convergence insufficiency and certain drugs may lead to blurry vision due to difficulty in accommodation. Herein, convergence insufficiency was thought to be a comorbidity rather than a disease-related problem, since fusional vergence amplitudes were similar in both groups. Also, when the prevalence of convergence insufficiency is believed to be as low as 2.25-13% in school-age children35, the sample size of our study does not seem to be adequate to make a definite conclusion. Therefore, more precise results will be achieved with larger prospective studies which will also evaluate the follow-up of ADHD patients. Another potential bias might have occured in relation to the examiner, who was only partially blinded to which children were in which group.A possible association between ADHD and visual problems was reported.23 Larranaga-Fragoso et al.36 reported that in patients with ADHD, SE before and after cycloplegia did not differ significantly during 9 months of follow-up. As compared with the literature, they suggested that methylphenidate treatment does not affect refraction in children with ADHD. Besides, the relationship between hyperopia and learning difficulties has not yet been clarified. Although some studies reported that hyperopia is associated with different developmental problems and low school performance37, some studies did not reveal such an association.39 However, in most studies measurements were obtained without cycloplegia. In hyperopia, unlike myopia, diagnosis may be delayed due to clear visualization through excessive accommodation at near distances. Excessive accommodation may also result in asthenopia, distractibility, hyperactivity, and learning difficulties.40 Additionally, it is stated that hyperopia >3.5 D increases strabismus and visual acuity problems and is accepted as an amblyogenic risk factor.40 In the present study, SE did not show a significant difference between groups. However, the prevalence of hyperopia was higher in patients with ADHD, whereas myopia was more commonly observed in control subjects (Refractive changes in patients with ADHD were previously investigated and no statistically significant difference was determined as compared to controls .11,23 Lasubjects . This alIn conclusion, this study showed that fusional vergence amplitudes did not differ significantly, whereas the mean value of stereoacuity was significantly lower in newly diagnosed and unmedicated ADHD patients. Despite the similar fusional vergence amplitudes, it is possible that low stereoacuity in patients with ADHD may suggest the lack of adequate attention while performing TNO random-dot stereo test. Nevertheless, it could be beneficial for children with vision problems to be examined for signs and symptoms of ADHD and vice versa.


Bartonella spp. are transmitted by fleas and harbored by small mammals which serve as reservoirs. However, little is known about the composition of fleas and their Bartonella spp. from small mammals in Central Europe. Therefore, the aims of this study were to investigate flea communities on small mammals from three differently structured sites  in Germany as well as the prevalence of Bartonella spp. in small mammals and their parasitizing fleas. In total, 623 small mammals belonging to 10 different species (the majority were Myodes glareolus and Apodemus flavicollis) were available. Fleas were removed from the small mammals' fur, morphologically identified and DNA was extracted. To detect Bartonella spp., two conventional PCRs targeting the gltA gene and the 16S−23S rRNA intergenic spacer were carried out followed by sequencing. Obtained sequences were compared to those in GenBank. In total, 1,156 fleas were collected from 456 small mammals. Altogether, 12 different flea species  were detected. At the urban site mostly Leptopsylla segnis and N. fasciatus were collected which may be vectors of zoonotic pathogens to companion animals. The overall prevalence for Bartonella in small mammals was 43.3% and in fleas 49.1%. Five different Bartonella spp. were detected in small mammals namely B. grahamii, B. taylorii, B. doshiae, Bartonella sp. N40 and uncultured Bartonella sp. whereas in fleas four Bartonella spp. were found which were with the exception of B. doshiae identical to the Bartonella species detected in their small mammal hosts. While B. grahamii was the only zoonotic Bartonella sp. most Bartonella strains found in fleas and small mammals belonged to uncultured Bartonella spp. with unknown zoonotic potential. This study showed a high diversity of flea species on small mammals from Germany. Further, high prevalence rates of Bartonella species were detected both in fleas and in their mammalian hosts. Several different Bartonella species with a high genetic variability were discovered. Especially at the urban study sites, this may pose a risk for Bartonella transmission to companion animals and humans.Most  Bartonella spp.    and their associated fleas (54.1%) in Germany  detection of flea species parasitizing small mammals and (2) detection of Bartonella spp. in small mammals and their fleas and (3) detection of associations between small mammals, fleas and Bartonella species.Bartonellosis, which can result in severe clinical symptoms in humans and their companion animals, is caused by the facultative intracellular alpha-proteobacteria llaceae) . Bartoneandflies –5. Bartoandflies , 7. Amonustralis . Bartone tamiae) . In stud tamiae) , 11, Swe tamiae) , France  tamiae) , and the tamiae)  the prev rodents , 16. Prean hosts , 18. Morn nature –21. Stud mammals –22. The  species . In Germ species . Recentl Germany . FurtherTo collect small mammals, traps were placed at three sites of urban, sylvatic or recultivated character. These locations were previously selected for field studies by our group , 26. The2, then euthanized by cervical dislocation and stored at −80°C. Small mammals were morphologically identified using taxonomic keys  as well as all shrews  (by-catch found dead in traps) and least weasels  were identified by conventional PCR targeting the cytochrome b gene (354 bp)  were placed at each Bavarian site between July and October in 2012 and between April and September in 2013. In Saxony, 60 traps were placed between March and October in 2012 and between January and September in 2013 . Traps were placed for two consecutive nights per month and site and checked twice a day. Collected small mammals were anesthetized with COmic keys . Additio(354 bp) , 32. Det(354 bp) –28.My. glareolus, 172 A. flavicollis, 6 A. agrarius, 35 A. sylvaticus, 6 Mi. arvalis, 1 Mi. agrestis, 2 M. nivalis, 4 Sorex coronatus, one Sorex araneus, and one Talpa europaea) were captured  which were collected from the small mammals. The DNA extraction was carried out for each sample individually with the QIAamp DNA Mini Kit  as previously described  targeting the gltA gene with BhCS.1137n (5′-AATGCAAAAAGAACAGTAAACA-3′) as forward and BhCS.781p (5′-GGGGaCCaGCTCATGGTGG-3′) as reverse primer  according to the manufacturer's recommendations. Purified amplicons were sequenced by Eurofins MWG Operon  with both primers and sequences were analyzed with Chromas Lite®  as formerly described . Independence of compared small sample sizes (n < 30) was tested with Fisher's exact test, respectively with the chi-squared test for sample sizes n > 30. The t-test was used to test significant differences of flea infestation on My. glareolus and A. flavicollis. The significance threshold was set at p ≤ 0.05.Confidence intervals (95%CI) for the prevalence of Ctenophthalmus agyrtes, 3 Ctenophthalmus bisoctodentatus, 62 Ctenophthalmus congener, 98 Megabothris turbidus, 8 Megabothris walkeri, 9 Hystrichopsylla talpae talpae, 25 Peromyscopsylla silvatica, 3 Paleopsylla soricis, 44 Nosopsyllus fasciatus, 11 Typhloceras poppei, 17 Leptopsylla segnis) . Megabothris turbidus was significantly more often collected from My. glareolus than from all other small mammal species . Nosopsyllus fasciatus was significantly more frequently collected from specimens belonging to the family Muridae (Apodemus spp.) than from those belonging to the family Cricetidae  . Leptopsylla segnis was exclusively found on A. sylvaticus, which were trapped only in the urban habitat. Peromyscopsylla silvatica were significantly more often collected from My. glareolus compared to all other small mammal species .In total, 1,156 fleas were collected from 456 small mammals. Altogether, twelve different flea species were detected (873  segnis) . Except Bartonella spp. Though not infested with fleas, positive T. europaea  and Sorex spp.  were detected. The prevalences were quite high in all captured small mammal species (20–100%) with the exception of Microtus spp. which were all negative and thus significantly less often infected than other species (p = 0.007). Considering the two most frequently captured species, the prevalence was significantly higher in A. flavicollis compared to My. glareolus  of all small mammals were positive for Bartonella species via sequence analysis. Altogether five different Bartonella species were detected in rodents and Sorex araneus (n = 56) which was detected in small mammals were uncultured Bartonella species. Altogether 56 sequences obtained in this study showed 100% identity to altogether 16 different uncultured Bartonella spp. sequences deposited in GenBank (Bartonella grahamii was significantly more often detected in My. glareolus compared to A. flavicollis (p = 0.0370). Bartonella doshiae was mainly detected in My. glareolus. There were four very short sequences (below 430 base pairs) which were not considered as a positive sequencing result and therefore not taken into consideration for Bartonella species identification.A total of 88 out of 270 (33%) PCR products were selected by small mammal species and location to be further processed in order to determine the  araneus . The mos GenBank , and theBartonella spp. [49.1% (95%CI: 44.5–53.7)]. Every tested flea species was positive for Bartonella spp. with a prevalence ranging from 18.8 to 100% . Comparing small mammals and fleas, the prevalence with Bartonella spp. was almost identical and thus not significantly different (p = 0.9018). Positive fleas derived from 53 negative and 54 positive small mammals.Overall, 221 out of 450 fleas were tested positive for  to 100% . The preBartonella species in the examined fleas. All confirmed Bartonella species detected in fleas were the same Bartonella species as described for their small mammal hosts. However, most samples were positive for uncultured Bartonella spp. which showed 100% identity to 13 different sequences deposited in GenBank . Due to very small sample sizes of most flea species, statistical comparisons between the flea species were not carried out.In total, 74 positive samples (29%) were further determined to species level by sequencing which revealed four different  GenBank . Almost  GenBank . Even thBartonella species in small mammals (43.3%) and their fleas (49.1%) from Germany. The Bartonella species detected in the current study were the same as earlier described by our group in small mammals from one of the investigated study sites   . Of the detected Bartonella spp., only B. grahamii is yet known to be zoonotic. Bartonella grahamii was isolated from My. glareolus from the UK for the first time  . The pre11–72%) , 37, 38.2% , 37, rst time . Since, Apodemus spp. showed a significantly higher infection rate compared to My. glareolus providing evidence that My. glareolus is able to resolve Bartonella infection after a certain time, while resolving a Bartonella infection has not been observed in Apodemus spp. yet  were reported in Mi. arvalis and Mi. agrestis from Finland and Poland, respectively (Microtus spp. from the Czech Republic and Germany (Microtus species (n = 8) were the only rodent species found negative for Bartonella spp. However, the sample size tested was rather low. Although no fleas were found on the insectivores analyzed in this study, all insectivore species were positive for Bartonella spp. In Sweden, it has been reported that insectivores may serve as reservoirs for certain Bartonella species  can be found at: Bartonella spp. AO, NK, and CS performed the sequence analysis. AO, NK, CS, and MP drafted the manuscript and wrote the final version. All authors read and approved the final manuscript.CS and MP organized and planned the study. AO and MP organized and participated in the fieldwork for the collection of wildlife samples. MK and DK carried out the morphologic determination of fleas. AO prepared the samples in the laboratory. AO and NK tested the samples for The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cinnamomum osmophloeum (C. osmophloeum) in vitro and in vivo and the potential therapeutic use of natural agents prepared from this plant for the alleviation of oral mucositis (OM). Reported articles were collected using web search engine tools. The systematic review was organized according to the preferred reporting items for reviews and meta-analyses (PRISMA) statement. Additional sources were identified through cross-referencing to identify the potential use of C. osmophloeum in the alleviation of OM. The results disclosed that C. osmophloeum is comprised of bioactive ingredients that could act diversely as a reagent in anti-inflammation, antibacterial, antioxidant, anti-hyperglycemic, antidyslipidemia, anti-cancer, renal disease therapy and anti-hyperuricemia capacities. Recent studies revealed that the overall effects on anti-inflammation, wound repair, and the antibacterial and antioxidant activities of its constituents would act as a potential remedy for oral mucositis. Up-to-date in vitro and in vivo studies on the medical-biological activities of C. osmophloeum suggested that C. osmophloeum and its constituents could be promising remedies as adjuvants in OM therapy and warrant further investigation.The aim of this review was to provide an updated overview of studies on the medical-biological activities of  Cinnamomum spp.) are of the genus Lauraceae, native to South and Southeast Asia, and are generally used as food flavors and traditional medicinal plants. Cinnamomum osmophloeum, commonly known as indigenous cinnamon or pseudocinnamon, is endemic to Taiwan’s natural hardwood forests [C. osmophloeum leaves explored by high-performance liquid chromatography (HPLC) are as follows: α-pinene, camphene, benzaldehyde, β-pinene, 3-pheayl pionaldehyde, cis-cinnamaldehyde, trans-cinnamaldehyde, isobornylacetate, eugenol, and cinnamil acetate [C. osmophloeum leaves comprise 101 volatile compounds, as identified by GC/MS analysis, including monoterpenoids, sesquiterpenoids, alcohols, phenols, aldehydes, ketones, esters, acids, and other miscellaneous compounds. It was demonstrated that the linalool chemotypes present in C. osmophloeum were as follows: linalool, trans-cinnamyl acetate, camphor, cinnamaldehyde, 3-phenyl-2-propenal, caryophyllene, coumarin, bornyl acetate, limonene, α-(+)-pinene, estragole, and caryophyllene oxide [C. osmophloeum has been applied as an alternative natural therapy to treat certain compromised and uncompromised diseases [Cinnamon plants  is known as the inflammation of oral mucosa, usually occurring as an adverse side-effect of chemotherapy and/or radiation therapy (radiotherapy), and is manifested as atrophy, swelling, erythema, and ulceration . OM occuC. osmophloeum [C. osmophloeum and its principal ingredients, both in vitro and in vivo. The potential use of this natural component in oral mucositis therapy is also discussed.Previous studies on cinnamon have been limited to ophloeum . However®, Scopus, ScienceDirect, and Web of Science databases by using the key words “cinnamon osmophloeum”, “indigenous cinnamon”, and “pseudocinnamon”. A systematic review was conducted following PRISMA. In order to identify the potential use of C. osmophloeum in the alleviation of OM, additional sources were identified through cross-referencing.A computerized search for the reported works was performed through PubMedC. osmophloeum in the alleviation of OM induced by radiotherapy and/or chemotherapy, a second computerized search using PubMed®, Scopus, ScienceDirect, and Web of Science databases was carried out by utilizing keywords with C. osmophloeum constituents that possess anti-inflammation, antioxidant, and antibacterial activities with OM, including “cinnamaldehyde + oral mucositis”, “trans-cinnamaldehyde + oral mucositis”, “kaempferitin + oral mucositis”, “kaempferol + oral mucositis”, “cinnamic acid + oral mucositis”, “cinnamyl alcohol + oral mucositis”, “cinnamyl acetate + oral mucositis”, “alloaromadendrene + oral mucositis”, and “linalool + oral mucositis”.In addition, previously published review articles were searched to gain additional information. In order to identify the potential use of C. osmophloeum was identified, in which 18 articles were excluded because they were duplicate papers (n = 2), were not related to the beneficial biological activities (n = 2), or were irrelevant articles (n = 14). Irrelevant articles involved studies not related to medical uses, studies related to mushroom planting in C. osmophloeum, and review article(s)  . Specifipers n = , were noles n = 1. IrrelevC. osmophloeum comprised six chemotypes; cinnamaldehyde, cinnamaldehyde/cinnamyl acetate, cinnamyl acetate, linalool, camphor, and mixed types , followed by ameliorating subsequent chronic inflammation-related diabetes mellitus [C. osmophloeum, including trans-cinnamaldehyde, caryophyllene oxide, L-borneol, L-bornyl acetate, eugenol, β-caryophyllene, E-nerolidol, and cinnamyl, were demonstrated to be anti-inflammatory, which could suppress the synthesis of nitric oxide (NO) by LPS-stimulated macrophages through an identical mechanism [Numerous studies reported the anti-inflammatory effect of ophloeum ,29,30,40ophloeum , pancreaophloeum . Some ofy effect ,28,30,40mellitus . Severalechanism .C. osmophloeum exhibited a protective effect on the pancreas by ameliorating pancreatic levels of interleukin (IL)-1β and nitric oxide [Other constituents such as Kaempferol glycosides were associated with nitric oxide inhibitory activities . In certic oxide , which pic oxide .C. osmophloeum has been used as a tyrosinase suppressor, which exhibited a substantial effect on wound repair. This phenomenon occurred through the inhibition of tyrosinase activity and reduced melanin content. Lee et al. carried out an animal experiment and explored the role of C. osmophloeum in wound repair and as an anti-oxidative agent. They evaluated a wound size assay, which revealed a decrease in the wound area by day 5 [by day 5 .C. osmophloeum, it is noteworthy to mention that one specific and major constituent (flavanol glycosides) with outstanding properties was involved in inhibiting the production of NO and cytokines (TNF-a and IL-12), from LPS/IFNc-activated macrophages (inhibition of inflammatory activities) [C. osmophloeum (cell-mediated immune response) observed [C. osmophloeum have also been applied systemically in specific disease treatment [In light of the specific activities of the constituents of ivities) . An addiobserved . Anti-inreatment ,22,27,40reatment ,28,40,45Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, Staphylococcus aureus, Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, Salmonella sp., and Vibrio parahaemolyticus have been used to investigate the antibacterial activity of C. osmophloeum [osmophloeum, the order of antibacterial activities was in the following sequence: cinnamaldehyde > cinnamic acid > cinnamyl alcohol > cinnamyl acetate. Cinnamaldehyde has been used as a bactericidal agent of Legionella pneumophila in vitro [C. osmophloeum possesses antibacterial activities in both Gram-negative and Gram-positive bacteria [The literature survey indicated that several pathogenic bacteria, including ophloeum . For conin vitro . Two invbacteria ,32. HencC. osmophloeum also has antifungal properties in rot fungi, such as Coriolus versicolor, Lenzites betulina, Pycnoporus coccineus, Trichaptum abietinum, Oligoporus lowe, Laetiporus sulphureus, Antrodia taxa, Fomitopsis pinicola, and Phaeolus schweinitzii [einitzii ,34.C. osmophloeum has been reported to be antioxidative, and its properties encompassing other medical-biological effects have been assessed systematically and independently by researchers worldwide [As one of the biomaterials commonly used for traditional medical therapy, orldwide ,36,37,41C. osmophloeum comprising trans-cinnamaldehyde [For the analysis of anti-oxidant activities, both in vitro ,35,37,41aldehyde , alloaroC. osmophloeum twig ethanolic extract [cinnamomum has been widely used for its medicinal purpose and in nutritional food [DPPH and NBT Assays reported the antioxidant activities of kaempferol-7-O-rhamnoside . The con extract . These anal food .C. osmophloeum in lowering the cholesterol level was investigated by Lin et al. They showed that both Kaempferol and kaempferitrin from C. osmophloeum have antidyslipidemic activity [C. osmophloeum was also reported to have hypolipidemic activity by inhibiting the accumulation of body fat through downregulating adipocyte differentiation [The activity of activity . Furtherntiation . Two in ntiation ,39.C. osmophloeum is one of the promising candidates. Proanthocyanidin and tannin from C. osmophloeum may possess anti-hyperglycemic activity [C. osmophloeum twig extracts) showed protein tyrosine phosphatase 1B inhibitory (PTP1B) activity to improve the insulin or leptin resistance [C. Osmophloeum, might ameliorate the pancreatic values of thiobarbituric acid reactive substances. The activities of superoxide dismutase and glutathione reductase ameliorated pancreatic levels of IL-1β and NO in vivo in streptozotocin-diabetes mellitus (STZ-DM)) animals [Diabetes mellitus (DM) has become a serious medical problem. Numerous studies have been conducted by adapting natural materials as DM therapy. Among these bio-resource candidates, activity . CoTE . It was discussed that Cinnamomum cassia (C. cassia) would be a potential drug for cardiovascular disease [C. cassia or C. osmophloeum) used in the report would be a critical issue to clarify because the authors may have been inconsistent in discussing the species of cinnamon.Cinnamaldehyde was shown to be one of the protective ingredients for cerebral microvascular endothelial cells in mice induced by aortic banding (AB) by reducing IL-1β-induced cyclooxygenase-2 (COX-2) activity . In addi disease . UnreliaC. osmophloeum successfully inhibited the high glucose-induced hypertrophy of renal interstitial fibroblasts, as indicated by the decreased cell size; the falling cellular hypertrophy index; and the descending protein levels of collagen IV, fibronectin, and α-smooth muscle actin [C. osmophloeum leaf oil demonstrated anti-hyperuricemia effects through its xanthine oxidase inhibitory activity. Xanthine oxidase can catalyze the oxidation of hypoxanthine/xanthine to produce uric acid. Gout and hyperuricemia are caused by an excessive accumulation of uric acid [It was reported that cinnamaldehyde in le actin . In ordele actin ,5. The cric acid ,19.C. osmophloeum, showed an inhibition of tumor growth [2+ entry with subsequent cell membrane scrambling and cell shrinkage, hallmarks of eryptosis, and the suicidal death of erythrocytes [C. osmophloeum constituents, was shown to be a possible anticancer compound . The cytotoxicity had a significant effect on human liver cancer (HepG2 and Hep3B) and oral cancer (Ca9-22) cells [Trans-cinnamaldehyde, a bioactive content of r growth ,54,55. Ihrocytes . Trans-c2) cells .The current protocols of medicine for chemotherapy are associated with oral mucositis. Cytarabine, high-dose 5-fluororacil, alkylating agents, and platinum-based compounds are highly associated with the incidence of oral mucositis. Actinomycin D, amsacrin, bleomycin, busulfan, capecitabine, carboplatin, chlorambucil, cisplatin, cytarabine, docetaxel, doxorubicin, etoposide, floxuridine, ifofsamide, irinotecan, leucovorin, methotrexate, mitoxantron, oxaliplatin, paclitaxel, plicamycin, tioguanin, vinblastine, vincristine, vindecine, and vinorelbine (the protocol can be combined) are the medicines used for chemotherapy and are reported to lead to the development of oral mucositis ,57. In oC. osmophloeum and/or its constituents in OM are limited. In one study, the effect of cinnamaldehyde on oral mucositis and an evaluation of the salivary total antioxidant capacity of gamma-irradiated rats were carried out. The saliva samples were taken from the rats in triplicate [Candida albicans growth inhibition  and oral epithelial cells (barrier integrity and inflammatory response) [The study of iplicate . In ordeiplicate . The autiplicate . A recenesponse) . The antesponse) ,62. The esponse) .Aloe vera, Acacia catechu, Chamomile, Hangeshashinto, indigowood root (Isatis indigotica Fort.), honey, Traumeel S, water grass decoction, and Weleda Ratanhia, also showed similar effects on the alleviation of OM via anti-inflammation activities [Achillea mileofolium), honey, Callendula officinalis flowers, Hipophae rhamnoides L. plant, Chamomile, and Aloe vera were associated with antioxidant, anti-inflammatory, antibacterial, and wound healing effects of oral mucositis therapy  or interrupting the third phase in which pro-inflammatory cytokines could enhance and accelerate the process of wound healing (Previous studies investigated the potential of  concern ,94,95. I healing .C. osmophloeum encompassing anti-inflammatory, antibacterial, antioxidant, anti-tumor and anti-cancer, anti-hyperglycemic, anti-hyperuricemia, and antidyslipidemic activities and the effect on the cardiovascular system that have been used for renal disease therapy. Various chemical contents identified in C. osmophloeum contribute to its valuable medical bioactivities. Several medical-biological activities are attributed to the active ingredients of C. osmophloeum for OM therapy. The key to OM alleviation could be the anti-inflammatory effect of C. osmophloeum, as the activation of several transcription factors might release the inflammatory reaction in the second phase of OM. The antibacterial and antioxidant properties of CO might also alleviate OM. These effects might occur during the first phase of OM, preventing the generation of reactive oxygen species, or in the fourth phase, inhibiting colonized bacteria. It was suggested that bacterial cell wall products could be prevented from entering the oral submucosa.In conclusion, in vitro and animal studies have revealed the various medical-biological activities of