Both Attention-Deficit/Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD) are associated with choice impulsivity, i.e. the tendency to prefer smaller immediate rewards over larger delayed rewards. However, the extent to which this impulsivity is mediated by shared or distinct underlying neural mechanisms is unclear. Twenty-six boys with ADHD, 20 boys with OCD and 20 matched controls (aged 12–18) completed an fMRI version of an individually adjusted temporal discounting (TD) task which requires choosing between a variable amount of money now or £100 in one week, one month or one year. Activations to immediate and delayed reward choices were compared between groups using a three-way ANCOVA. ADHD patients had steeper discounting rates on the task relative to controls. OCD patients did not differ from controls or patients with ADHD. Patients with ADHD and OCD showed predominantly shared activation deficits during TD in fronto-striato-insular-cerebellar regions responsible for self-control and temporal foresight, suggesting that choice impulsivity is mediated by overlapping neural dysfunctions in both disorders. OCD patients alone showed dysfunction relative to controls in right orbitofrontal and rostrolateral prefrontal cortex, extending previous findings of abnormalities in these regions in OCD to the domain of choice impulsiveness. •ADHD patients alone showed significantly steeper discounting relative to controls.•ADHD and OCD shared underactivation in fronto-striato-insular-cerebellar regions during delayed choices.•Only patients with OCD had dysfunction in right orbitofrontal and rostrolateral prefrontal cortex relative to controls. It has Impulsivity is a core feature of ADHD, which is particularly prevalent during childhood and adolescence . In OCD,To date, most neuroimaging studies of impulsivity in ADHD and OCD have focused on tasks involving motor impulsivity, i.e. the poor ability to inhibit inappropriate prepotent responses during response inhibition paradigms . Recent Choice impulsivity is typically measured in temporal discounting (TD) tasks , during Performance during TD tasks relies on two main brain networks . The firImpulsive decision making is also a feature of OCD , includiIt is not clear to what extent the underlying brain mechanisms of TD differ or are shared between disorders as no published studies have directly compared ADHD and OCD patients during TD using fMRI. Shared neural dysfunction would lend credence to the idea that impulsive decision making in ADHD and OCD is a shared transdiagnostic mechanism, whereas disorder-specific patterns of functional abnormalities would suggest that shared decision making impairments are similar phenocopies associated with distinct underlying mechanisms .The aim of this study was therefore to conduct the first direct comparison of the neurofunctional substrates of TD in ADHD and OCD patients using fMRI. Behaviourally, we anticipated that both patient groups would show steeper discounting relative to controls . In the 22.1Sixty-six  right handed  male adoEthical approval was obtained from the local Research Ethics Committee (05/Q0706/275), and the study was conducted in accordance with the Declaration of Helsinki. Study details were explained to both child and guardian. Written informed consent was obtained for all participants.2.2In each trial of the TD task  particip2.3kD), where V is the subjective value of a reward, A is size of the reward, D is the delay until reward receipt, and k is a constant which characterizes an individual's rate of discounting, and which is calculated by fitting a hyperbolic function to the indifference values for every delay  × 3  ANCOVA. We anticipated group differences in IQ, since ADHD is associated with low IQ . Details on scanning parameters are given in the 2.5Data were analysed using the non-parametric XBAM software package . XBAM's p<0.05 to give maximum sensitivity and to avoid type-II error . Follow-up analyses were performed between medicated and unmedicated patients with ADHD as well as between controls, unmedicated ADHD and unmedicated OCD using these extracted BOLD responses.In order to interpret the group differences in brain activation from the between-group ANCOVA, statistical measures of BOLD response (SSQ) for each participant were extracted from significant clusters, plotted, and subjected to pairwise  33.1There were no significant group differences in age, but IQ was significantly lower in ADHD .Table 1P3.2k =4.49, p=0.02) that was driven by steeper discounting in ADHD relative to control boys (p=0.003) but not relative to OCD boys (p=0.12) =7.36, p<0.001), which were smaller in ADHD relative to healthy controls (p=0.001) and patients with OCD (p=0.002), who did not differ from each other (p=0.89). This finding survived after covarying IQ =3.44, p=0.04). ANCOVA comparing groups for indifference points for one week =2.33, p=0.11) and one year =0.04, p=0.96) were not significant. There was a trend for participants to be slower when making delayed relative to immediate choices =3.56, p=0.06). However, the group by choice interaction was not significant =0.79, p=0.46). Reaction times did not differ between groups for either immediate =0.65, p=0.52) or delayed =0.23, p=0.8) decisions. Findings remained unchanged after controlling for IQ, except that the ANCOVA for group differences in k remained significant only at trend level =2.99, p=0.06) (ANCOVA showed a significant between-group difference in (p=0.12) . Signifi p=0.06) .3.33.3.1F=1.6, p=0.1).There were no group differences in median displacement of x, y, z rotation and translation parameters (3.3.2Within-group findings for delayed-immediate contrast are presented in the 3.3.3post-hoc t -tests (corrected for multiple comparisons for three groups using least significant differences method) revealed that patients shared underactivation relative to controls in right IFG/AI/caudate , right thalamus  and bilateral occipital lobe/cerebellum  during delayed relative to immediate trials, as well as left superior/middle temporal/supramarginal gyrus/fusiform gyrus  and right postcentral/superior temporal/supramarginal gyrus/posterior insula  to immediate relative to delayed trials. OCD patients alone showed significantly reduced activation in right OFC (p=0.006) and RLPFC/DLPFC (p=0.001) relative to controls , which was more active during immediate choices in medicated patients. In the unmedicated subgroup analysis on extracted BOLD activation, the thalamus cluster no longer differed between ADHD and controls (p=0.12) and the right AI/IFG/caudate cluster differed only at a non-significant trend (p=0.06), presumably reflecting reduced power. All other group difference clusters remained significant. There were no significant correlations between CY-BOCS scores and brain activation in the group difference clusters in the OCD patients, or between SDQ inattention/hyperactivity scale or CPRS-R scores and brain activation in ADHD patients. There was a significant positive correlation between thalamus activation to delayed choices and k (r(26)=0.389, p=0.049) in ADHD patients, although this correlation did not survive correction for multiple comparisons  with follow-up controls .. All grparisons . There w4This fMRI study investigated potentially shared and disorder-specific neurofunctional abnormalities in paediatric ADHD and OCD during TD. The findings show that patient groups relative to controls, shared underactivation in key regions of self-control and temporal foresight , includiDuring TD, IFG, DLPFC, AI, striatum and cerebellum are typically recruited more during the selection of larger delayed than immediate rewards . These rFindings of largely shared dysfunction in right IFG, DLPFC, AI, dorsal striatum and cerebellar regions during delayed choices in ADHD and OCD suggest that TD taps into a shared underlying transdiagnostic mechanism . A furthOnly OCD patients showed significantly reduced activation in right OFC during delayed choices relative to controls. The OFC is a key region for representing reward values , and recIn RLPFC, controls showed greater activation during delayed choices while OCD patients showed greater activation during immediate choices. RLPFC has been implicated in episodic prospection , plannink and brain activation and the fact that differences in brain activation remained after controlling for differences in k suggest that there is not a one-to-one relationship between brain activation and choice behaviour during TD. As noted above, lateral prefrontal, orbitofrontal, insular and striatal regions are associated with a number of cognitive processes which may be important for TD performance, and these regions have been found to be underactive in patients with OCD during reversal learning, attentional and inhibitory control, and reappraisal tasks (In line with previous research, we found evidence of steeper discounting in ADHD relative to controls  but unlial tasks . Findingal tasks .Limitations of the study include a lower IQ in the ADHD group, in light of evidence linking IQ to TD performance . HoweverTo summarise, the study provides the first comparison of functional abnormalities during TD between ADHD and OCD patients. Both disorders were associated with a common pattern of underactivation in fronto-striatal-insula-cerebellum regions implicated in self-control and temporal foresight during delayed choices, suggesting that choice impulsivity in both disorders may partially represent a shared transdiagnostic mechanism. In addition, we found that OFC and RLPFC were disorder-exclusively underactivated in OCD relative to controls, in line with existing orbito-striatal accounts of OCD, and providing initial evidence for its involvement in choice impulsivity in the disorder.K.R. has received funding from Lilly for another project and speaker's honoraria from Lilly, Shire, Novartis and Medice. C.M. has received funding from Lilly for another project and speaker's honoraria from Flynn Pharma. The other authors have no conflict of interests to declare.LJN, COC, KR devised the study. LJN & COC analysed the data. LJN prepared the manuscript. LJN, COC, AC, KC, CM collected data. Included authors provided intellectual input into the final draft of the manuscript.


Bartonella in 11 of 109 insectivorous bats from France and 1 of 26 bats from Spain. These genetic variants are closely related to bat-associated Bartonella described in Finland and the United Kingdom and to B. mayotimonensis, the agent of a human endocarditis case in the United States.We detected  Bartonella variants and potential arthropod vectors . Whenever possible, we identified bat species and sex. Methods were approved by the University of California, Davis , Institutional Animal Care and Use Committee (protocol 17669).We performed necropsies on 26 bats from Spain and 109 from France to collect heart tissue for gnostics Table 1. Pipistrellus spp. ; 15 Nyctalus noctula; 7 Eptesicus serotinus; 11 Myotis spp. ; 6 Plecotus spp. (4 P. austriacus and 2 P. auritus); 6 Tadarida teniotis; 2 Barbastella barbastellus; and 1 Vespertilio murinus.We used sampling records to determine the genus and species for 118 of the 135 bats; identification data were not available for 17 of 26 bats from Spain. The 118 identified bats belonged to 8 genera and at least 13 different species: 70 B. henselae as a positive control for DNA extraction. We screened samples by PCR targeting the citrate synthase gene (gltA). Primers CSH1f (GCGAATGAAGCGTGCCTAAA) and BhCS1137.n (AATGCAAAAAGAACAGTAAACA) amplified an ≈350-bp fragment suitable for distinguishing Bartonella species  to extract DNA from 25 mg of macerated heart tissue according to the manufacturer’s instructions. We used tissue spiked with http://www.openepi.com/) to calculate descriptive statistics and CIs for prevalence data. We constructed phylogenetic trees by using the MrBayes plugin in Geneious version 8.1.7 with a Markov Chain Monte Carlo value of 1,100,000 and 100,000 burn-in length (https://www.r-project.org/) to create spatial maps.We used OpenEpi version 3.01 (Bartonella DNA in 12 (8.9%) of 135 bat heart tissue samples , P. nathusii , M. daubentonii , and M. mystacinus .We detected  samples  Table 2;Bartonella variants (GenBank accession nos. KY041981–KY041992) clustered closely with zoonotic B. mayotimonensis (M. daubentonii bats sampled in Lorraine (GenBank accession no. KY041985) and Upper Normandy (GenBank accession no. KY041989), France, shared 100% nt identity with Bartonella strains previously isolated from bats of the same species in Finland and the United Kingdom (Bartonella variants were closely related to Candidatus Bartonella naantaliensis or Candidatus Bartonella hemsundetiensis, which were also described in bats sampled in Finland (Bartonella spp. across bat populations and selective adaptations to specific host reservoirs. All 12 monensis . Two seqBartonella species in western Europe and to determine if B. mayotimonensis, the agent of a US case of human endocarditis, is present across a broader range than currently documented. Future studies should consider specifically focusing on Nyctalus, Pipistrellus, and Myotis bat species, from which we most frequently detected variants similar to B. mayotimonensis.Further research is needed to better evaluate the prevalence of zoonotic Bartonella-positive bats.Geographic origins of bats samples in France and Spain and descriptive characteristics of


Bartonella prosthetic valve endocarditis were cured when treated for 2 weeks with gentamicin and 3 months with doxycycline. Clinical cure correlated with decreased Bartonella antibody titers. This report suggests a strategy to monitor, treat, and cure Bartonella prosthetic valve endocarditis.Two cases of  Bartonella, a causative agent of blood culture–negative endocarditis (BCNE) that usually requires valve surgery, was first attributed to endocarditis over 20 years ago ; results showed high IgG titers to both B. henselae and B. quintana , serum creatinine of 2.76 mg/dL (reference range 0.6–1.2 mg/dL), C-reactive protein of 48 mg/L (reference range 0.08–3.1 mg/L), rheumatoid factor of 742 U/mL (reference range 0–30 U/mL), and c-ANCA (cytoplasmic antineutrophil cytoplasmic antibody) positivity . Urine dipstick  revealed the presence of blood (4+), and renal biopsy demonstrated necrotizing crescentic glomerulonephritis. Five blood cultures were sterile. Transesophageal echocardiography showed no evidence of endocarditis. quintana , but theCase 2 involved a 29-year-old woman with inflammatory bowel disease and primary sclerosing cholangitis. Her symptoms began in 2011 with fever, rigors, night sweats, and anorexia for 2 weeks. She had no pets but recalled contact with a kitten 8 months previously. In 2002, BCNE developed, requiring mechanical aortic and mitral valve replacements. In 2003, BCNE was again diagnosed but was complicated by an ascending aorta to left atrial fistula, requiring an aortic root replacement, a homograft, and a repeat mechanical mitral valve replacement. B. henselae after a 19-day incubation . A serologic test for Bartonella was strongly positive , a high C-reactive protein concentration (26 mg/L), normal renal function, and positivity for rheumatoid factor (114 U/mL). Transesophageal echocardiograms revealed no evidence of endocarditis. One of 20 blood culture tests grew positive . Three dBartonella antibody titers dropped slowly over a period of 3 years in both patients (Bartonella IgG titer of >1:800 and a positive Western blot or PCR analysis when using valve or blood specimens should be considered major Duke criteria (.patients . Only caBartonella endocarditis involve native valves; the first prosthetic valve infection was reported in 2002 (Bartonella is not in itself a recognized indication for surgery. Because our patients responded to medication, we did not need to consider cardiac surgery. The optimal antimicrobial drug therapy and duration for Bartonella endocarditis is undetermined. The recommended regimen of gentamicin for 14 days and doxycycline for 4 weeks (,Bartonella prosthetic valve endocarditis cured without valve surgery; it was cured with a 30-month antimicrobial drug regimen (.Most reported cases of Bartonella endocarditis is unknown. In our cases, as in a previous report (Bartonella titers occurred over a 3-year period in those who were cured, suggesting follow-up serologic testing might be useful to assess Bartonella endocarditis clinical cure.The role for serial serologic testing in assessing cure of Bartonella endocarditis and that serial serologic testing can confirm adequate treatment and cure. Further research is needed to validate this approach to managing Bartonella endocarditis.Our findings suggest that a simple, inexpensive drug regimen is optimal therapy for


There is a global trend of large increases in the prevalence and incidence of Attention Deficit Hyperactivity Disorder (ADHD). This study aimed to address potential causes of these major changes.The authors used a large cohort to analyze data employing patients’ electronic medical records, with physicians’ diagnosis of ADHD, including records of medication purchases.p < 0.001), while the ratio of males to females with ADHD decreased from 2.94 in 2005 to 1.86 in 2014 (p < 0.001). The incidence increased, peaking in 2011 before declining in 2014. ADHD medication usage by children and adolescents was 3.57% in 2005 and 8.51% by 2014 (p < 0.001).The prevalence of ADHD diagnoses rose twofold from 6.8% to 14.4% between 2005 and 2014 (We report a dramatic increase in the rate of ADHD diagnoses. One of the leading factors to which we attribute this increase is the physicians’ and parents’ changed attitude towards diagnosing attention/hyperactivity problems, with more parents appear to consider ADHD diagnosis and treatment as a means to improve their child’s academic achievements, commonly with the aid of medications. This change in attitude may also be associated with the dramatic increase in female ADHD diagnosis prevalence. Attention Deficit Hyperactivity Disorder (ADHD) is one of the more common neurobehavioral disorders in the world, making its diagnosis and treatment an area of growing interest for physicians and parents alike. In the US, ADHD is the most common behavioral disorder among children and adolescents , with thAccording to Getahun et al. , relyingInformation on the ADHD incidence rate is published less frequently, but points to an increase that is similar to the published prevalence data. In a Danish nationwide sample of people aged 4-65 years for the period 1995-2010, the incidence rate increased from 7.3 to 91.2 per 100,000 people  while inFor some parents, treating ADHD with medication may be the preferred approach, and an increasingly common one. Data from parents’ reports in the US indicates that 69% of children diagnosed with ADHD aged 4-17 years currently receive medication . The preThe different methodologies utilized in various studies and nations make the comparison of rates and treatments of ADHD very challenging. Therefore, it is important to use the same inclusion criteria when evaluating ADHD annual trends.The aim of the present study was to investigate the prevalence, incidence, and pharmacological treatment of ADHD in children and adolescents between 2005 and 2014, in a large cohort, in an attempt to better understand the reasons behind any significant changes in the number of cases of ADHD being diagnosed and pharmacologically treated.We examined data of ADHD diagnosis from the computerized database of the second largest health maintenance organization (HMO) in Israel, Maccabi Healthcare Services, which provides services to 25% of Israel’s 8.4 million citizens.In Israel, the diagnosis of ADHD and the first recommendation for medication is expected to be given by a neurologist (adult or pediatric) or a psychiatrist (adult or pediatric) and, over the past 7 years, also by qualified pediatricians recognized by the Ministry of Health upon completion of a course on ADHD diagnosis and treatment . The necUsing Maccabi’s computerized database, the following key words were used for case identification – Attention Deficit Hyperactivity Disorder (ADHD) Combined Type, ADHD Predominantly Inattentive Type, ADHD Predominantly Hyperactive type, ADHD Not Otherwise Specified.A major challenge in defining incidence and prevalence is in case definition. A case of ADHD was defined as any child with an ADHD diagnosis aged 5-17 years (17 and 364 days) between the years 2005-2014, with a physician-recorded ADHD diagnosis and / or two purchases of ADHD medication. Children with additional diagnoses, such as autism, were not excluded.total cohort , while other records contained both an ADHD diagnosis and medication purchase (58.7%), and a few cases included only the purchase of ADHD medications 1.6%) without noting ADHD in the diagnosis section. All of these records comprised the .6% withoAt this stage, we aimed at estimating the number of children with a definitive ADHD diagnosis. Our basic premise when ascertaining a definitive diagnosis is that ADHD medication is highly targeted, and is therefore unlikely to be prescribed to treat anything other than ADHD. Thus, all children with two or more purchases of ADHD medication (with or without an ADHD diagnosis mentioned in their records) were considered as definitive. Of the cases that included medication purchase without a diagnosis (1.6%), we infer that the majority are a documentation error due to the computerized system not requiring physicians to enter a diagnosis in order to prescribe medication. The number of treated cases by itself does not necessarily reflect the true and full prevalence . Those westimated definitive diagnosis, 110,034,  was the sum of the children with two medication purchases , plus 6482 children with a primary physician’s definitive diagnosis and 19,852 children with an expert’s definitive diagnosis , in contrast to 160 out of 250 records (64%) made by an expert that had a definitive diagnosis. Using this percentage, one can extrapolate that from the total of 24,006 children with an ADHD diagnosis given by primary physicians, only 6482 children were designated to have a definitive diagnosis, whereas from a total of 31,019 children with an ADHD diagnosis given by an expert, 19,852 children were designated as definitive ADHD. Hence the total number of children with an For the first prevalence measure, we determined for each year the total number of children aged 5-17 years (17 and 364 days) who had an estimated definitive ADHD diagnosis in the years 2005-2014. We divided that figure by the total number of children in that age group who were registered with Maccabi Healthcare Services for the given year.For the second ADHD prevalence figure, we measured prevalence for each year among three age subgroups: 5-8, 9-12, and 13-17 years.ADHD prevalence was calculated in two ways.Subsequently, we calculated the annual estimated definitive diagnosis ADHD incidence rate as the total number of new cases of ADHD diagnosis in children aged 5-17 years (17 and 364 days) in each year from 2005 to 2014, divided by the total membership in that age group for the same year. We also measured the yearly incidence in the three age subgroups .The prevalence of children who received ADHD medications was calculated by dividing the number of children who received at least two purchases in a specific year by the number of children of the estimated definitive cohort. We also calculated the prevalence of children who received ADHD medication for the years 2005 and 2014 by dividing the number of children treated by the number of all children registered with Maccabi Healthcare Services in those specific years.We explored whether ADHD prevalence varied by socioeconomic status (SES) based on a social scale that divides geographic locations into different socioeconomic categories on a scale ranging from 1 to 20, where 1 is the lowest SES and 20 is the highest, based on residence area . We assiA sample size of 250 records from all study years and both genders from the group of children with expert ADHD diagnosis has 80% power to estimate rate of 0.6 of definitive ADHD from this subgroup with 95% Confidence Interval for this rate.A sample size of 200 records from all study years and both genders with ADHD from the group of children with only primary physician ADHD diagnosis have 80% power to estimate rate of 0.2 of definitive ADHD from this sub-group with 95% Confidence Interval for this rate.Descriptive statistics of patient data is expressed as numbers and percentages for dichotomous variables. The 99% Confidence Interval for proportions were provided for the rates of prevalence and incidence between years. The Chi-square test for categorical variables was performed to determine significant differences in SES between ADHD diagnosed and all Maccabi healthcare services members.All analyses were conducted using standard statistical software .p < 0.001) between 2005 and 2014 , the female prevalence rate tripled (3.5% to 10.4%) (Table p < 0.01)) for the youngest group of 5-8 years old . The prevalence among boys with ADHD changed dramatically for the group aged 13-17 years (from 11.41% in 2005 to 25.82% in 2014), and lesser  from 2005 to 2014, but there was significant change for the group aged 9-12 years (4.72% in 2005 to 11.4% in 2014) and an even more significant increase for the adolescent 13-17 years group (3.95% in 2005 to 15.69% in 2014)  before declining in 2014 in both sexes (Table p < 0.001) in 2014 . For 2014, the lowest usage of medication among those with an ADHD definitive diagnosis was seen for males and females in the 13-17 years’ category, at 55.1% and 57.1% respectively, while the highest medication usage was seen in the group aged 9-12 years, at 65.3% and 58.5% respectively  are responsible for the significant changes in the number of cases of ADHD being diagnosed and pharmacologically treated.However, a potential limitation has been in calculating the The large increase seen in the prevalence, incidence and drug therapy for ADHD diagnoses, highlight challenges in distinguishing between methods of collection and ascertainment of children with the condition, versus the possibilities of genuine, true increase rates of ADHD. However, while we acknowledge that over-diagnosis exists, one has to bear in mind that from that moment on, the children live with the diagnosis, along with their self and peers’ perception of it, and often with medication.We suggest stricter adherence to the diagnostic criteria. In addition, we suggest that physicians rigorously document the fulfilled criteria, as well as explain the functional ramifications they impose on the child, especially prior to prescribing medication.


Hernia of umbilical cord is a well-known entity which presents with herniation of small bowel into the proximal part of umbilical cord. It has very good prognosis after surgical repair. Occasionally, it can have distinct presentations and varied malformations at the umbilicus which have bearing on the course of treatment and final outcome. Herein, we describe various presentations and malformations associated with hernia of umbilical cord. Embryological extrapolation is attempted for the malformations at umbilicus.  Introduction:In past few years, we encountered various perplexing malformations at umbilicus associated with hernia of umbilical cord (HUC), few of these were already reported by us. [1-3] Given our experience of dealing with these different bowel malformations associated with HUC, an explication to the formation of these malformations during intrauterine life is presented here. We have also conducted a perusal of literature to support our assumptions. Various presentations are also summarized for better understanding (Table 1). Embryology:Normally, the bowel herniates physiologically into the developing umbilical cord during 5th-6th week of gestation and returns completely back to the abdominal cavity by 12th week of gestation. [4]During this period, the rotation and fixation of bowel takes place. This journey is safe in majority; however, a number of misadventures can occur during this period.[5] The most common malady encountered on account of disruption of normal return of bowel to the abdomen is HUC. Failed closure of umbilical ring or failure of complete return of physiologically herniated bowel is considered the possible mechanisms of formation of HUC.[5] Nevertheless, there are various other events during physiological herniation that result in various malformations at the umbilicus associated with HUC. These are described in the next sections.Simple HUC:It is the most common variety of HUC and presents with a small swelling at the base of umbilical cord in otherwise normal and asymptomatic neonate. Mainly a small loop of mid ileum is the usual content of HUC but rarely remnants of vitellointestinal tract can be found such as Meckel's diverticulum . [6] Other contents may be terminal ileum, cecum, , ascending colon, or entire small bowel even extending till transverse colon, though the size of HUC in that case would be much larger. Rarely entire liver or part of it or accessory lobe of liver, and gallbladder are also reported as contents of HUC.[7-10]The size of herniated contents may range from as small as 2cm, accommodating a small part of small bowel, to more than 10cms harboring many loops of small bowel which may often mimic as omphalocele .[1] Simple HUC can be treated surgically with a very good prognosis. A gentle squeeze during initial few hours of birth usually leads to reduction of the contents followed by umbilicoplasty . HUC with Intestinal Obstruction:As the name indicates, this type of HUC presents with features of intestinal obstruction which may be congenital or acquired/iatrogenic in etiology. The congenital intestinal obstruction associated with HUC is mainly due to intestinal atresia.In-utero vascular accidents in the form of volvulus or compression from the umbilical ring are considered the causes of intestinal atresia.A case of in-utero small bowel perforation proximal to ileal atresia, within the HUC, is also reported in literature.[11]HUC associated with intestinal atresia may occasionally have very short length bowel.[3] A vascular event secondary to volvulus of herniated midgut during physiological herniation or a narrow umbilical ring may occlude mesenteric blood supply resulting in complete resorption of the herniated midgut are the possible phenomenon behind it. We have reported a case of HUC associated with complete loss of mid gut. [3] On removing umbilical cord there were two blind loops of bowel being herniated from the umbilical ring. Further exploration revealed less than 10cm of proximal jejunum and almost same length of distal sigmoid colon; rest of the entire midgut has been lost in-utero . Occasionally a relatively dilated and meconium filled loop of small bowel may get entrapped in the umbilical cord while returning to the abdomen. Due to continued pressure of the closing umbilical ring, it may get sequestered from the rest of the bowel and presents as content of HUC. It is associated with entry and exit level atresias at the level of umbilical ring . Twist of the herniated loop could be the other plausible explanation of the event leading to isolation of the entrapped bowel segment.We have encountered few cases of HUC presented with intestinal obstruction without any atresia. We believe that presence of only small part of small bowel in HUC does not lead to intestinal obstruction. Occasionally, the presence of terminal ileum, cecum and ascending colon  in HUC may produce obstructive symptoms. The reasons may be speculated as compression on the herniated bowel, small size of umbilical ring, and kinking of the ileocecal valve. In such cases more adhesions of the herniated contents with the sac, are observed during surgery. This is not always true as Gajdhar et al [10] reported case of giant HUC where entire small bowel from proximal jejunum to the ascending colon was herniated to the HUC but patient did not develop intestinal obstruction. On the other hand, Ali et al[1] reported a case of giant HUC harboring many bowel loops, few of which were compromised thus mimicked as herniation of liver tissue. They initially thought it omphalocele but later on patient deteriorated clinically and exploration divulged it as HUC containing many loops of small bowel; few loops were compromised and needed resection-anastomosis of the bowel. Iatrogenic injury to the herniated contents makes handful number of cases of HUC with intestinal obstruction. It is usually caused by accidental ligation or clamping of the HUC .  Untrained birth attendants or lack of awareness about the entity is the main cause of application of ligature/clamp over the HUC resulting in intestinal obstruction. The ligature or clamp can cut through the intestinal contents leading to meconium discharge at the level of injury. All these cases need investigations in the form of abdominal radiograph, and ultrasound to see level and nature of intestinal obstruction although it is overt clinically. More extensive surgery is required needing resection of bowel and restoration of continuity of bowel or formation of temporary stoma. The outcome is good but occasionally patients may have a stormy outcome and may die especially those with complete loss of mid gut or who developed septicemia secondarily.[3] HUC with Mucosal Prolapse:This is a special variety of HUC which presents with mucosal prolapse from the sac of HUC. The prolapse in majority is secondary to the presence of patent vitellointestinal duct (PVID) . Occasionally, an in-utero perforation of herniated small or large bowel during physiological herniation phase may also lead to prolapse of mucosa from the sac of HUC.[14]Embryologically, developing intestines are communicated with yolk sac through a Vitellointestinal tract at the summit of mid gut. This connection is lost during 5-7th week of gestation when the midgut is physiologically herniated in the umbilical cord coelom. When there is failure of resorption of this tract completely, a PVID results. It can be speculated that the PVID, which has one free mucosal lined end, may get adhered to the umbilical cord and causes its localized rupture or resorption; the mucosa may then be prolapsed through the wall of HUC as a result of peristalsis as normally happens in case of enterostomy. Similar events might be presumed in case of in-utero bowel perforation within the HUC. Mucosal prolapse is not always part of this event.[14] The prolapsed mucosa hangs into the amniotic cavity and excretes meconium leading to meconium staining of the fetus and meconium aspiration syndrome.[11]These patients on antenatal scan may mimic as gastroschisis owing to direct floating of bowel mucosa in the amniotic cavity.[11] At birth, these patients present with HUC with a prolapsed mucosa from sac of HUC and pass meconium from the prolapsed mucosa. These patients may exclusively pass stool from prolapsed mucosa in case of distal obstruction such as associated distal atresia but can occasionally pass meconium per-anally in case of PVID associated prolapse. The surgical approach is by trans-umbilical or semilunar infra-umbilical incision. The prolapsed bowel is reduced back and PVID can be resected with restoration of the normal bowel continuity by anastomosis. In case of massive prolapse and edematous mucosa not able to be reduced back, a more extensive resection and anastomosis is performed to restore the continuity . HUC with Bowel Evisceration:This is extremely rare variety of HUC.[2]Although these patients present with typical features of neonatal intestinal obstruction, but owing to presence of bowel evisceration are grouped in this category. During physiological herniation of bowel, the umbilical coelom may get ruptured leading to evisceration of herniated bowel. The reason of rupture of umbilical cord is not known as yet. It may happen secondary to bowel dilatation with associated intestinal atresia or there might be some vascular accident such as rupture of umbilical vessels which may become fatal to the fetus. Haas et al [5] described such an occurrence in a fetus which was on follow-up for HUC and developed in-utero evisceration of bowel through the umbilical cord. This led to demise of the fetus. On autopsy, a wall of umbilical cord was ruptured along with rupture of umbilical vessels which caused to fatality. After evisceration, the bowel loops float freely in the amniotic cavity as happens in gastroschisis. If no further devastating events take place, these patients are born with eviscerated bowel from one side of umbilical cord. The bowel and mesentery look edematous and is covered by a thick peel of fibrin; the entity usually mimics as gastroschisis,[2] on initial inspection . Careful and detailed inspection will differentiate it from gastroschisis owing to lack of an abdominal wall defect to the right side of umbilical cord. It is usually associated with entry/exit level atresias.[2]Occasionally the eviscerated loops may mat together and present as a discoid mass of bowel over the umbilicus . It is likely that the freely floating eviscerated bowel in the amniotic cavity may get twisted leading to loss of entire mid gut. These patients present with a small bowel mass extruded out from one side of the umbilicus . On exploration, there is extremely short length of bowel; merely 5-10cms of proximal jejunum and 5-10cm of distal colon, rest of entire bowel is lost due to in-utero volvulus . Abdominal radiography shows 2-3 air fluid levels and ultrasound abdomen also depicts few dilated bowel loops. Exploration is mandatory to identify total length of bowel. In case where eviscerated bowel is healthy and not associated with volvulus or midgut loss, the outcome is good.[2] The associated entry/exit atresias are managed primarily. We have reported such a case where proximal atresia was primarily managed by end to end anastomosis and at the level of distal colonic stenosis, an enterostomy was formed which worked well in our case.[2] The outcome is very poor in case of complete loss of mid gut leaving few centimeters of proximal jejunum and distal rectosigmoid colon .These patients can be initially managed on TPN and later on gut transplantation may be an option for these children although not available In Pakistan as yet.Associated anomalies:Hernia of umbilical cord has been associated with very few malformations especially of alimentary tract. We have reviewed the literature regarding associated malformations and presented our findings in Table 2. Summary of Embryological Events:A summary of the possible embryological events and its correlation with the clinical presentation and the malformations at the umbilicus associated with HUC is presented as follows: physiological herniation of mid gut occurs into the developing umbilical cord during 5-12th week of gestation. Simple hernia of umbilical cord can result owing to failure of bowel to return back completely. The bowel during physiological herniation may get volvulus inside the umbilical coelom resulting in HUC with loss of entire midgut. Occasionally the bowel, during physiological herniation may get evisceration through a rupture of umbilical cord. The freely floating bowel may mimic gastroschisis at birth. If the freely floating bowel in the amniotic cavity gets a twist, it may lead to extensive bowel loss and extremely short length bowel. Lastly a meconium filled part of bowel may entrap in the umbilical cord and isolate owing to a very narrow umbilical defect.Source of Support: NilConflict of Interest: None


Adults with attention deficit hyperactivity disorder (ADHD) suffer from various impairments of cognitive, emotional and social functioning, which can have considerable consequences for many areas of daily living. One of those areas is driving a vehicle. Driving is an important activity of everyday life and requires an efficient interplay between multiple cognitive, perceptual, and motor skills. In the present study, a selective review of the literature on driving-related difficulties associated with ADHD is performed, seeking to answer whether individuals with ADHD show increased levels of unsafe driving behaviours, which cognitive (dys)functions of individuals with ADHD are related to driving difficulty, and whether pharmacological treatment significantly improves the driving behaviour of individuals with ADHD. The available research provides convincing evidence that individuals with ADHD have different and more adverse driving outcomes than individuals without the condition. However, it appears that not all individuals with ADHD are affected uniformly. Despite various cognitive functions being related with driving difficulties, these functions do not appear helpful in detecting high risk drivers with ADHD, nor in predicting driving outcomes in individuals with ADHD, since impairments in these functions are defining criteria for the diagnoses of ADHD . Pharmacological treatment of ADHD, in particular stimulant drug treatment, appears to be beneficial to the driving difficulties experienced by individuals with ADHD. However, additional research is needed, in particular further studies that address the numerous methodological weaknesses of many of the previous studies. Driving is an important activity of daily living, which can be crucial for independent living, social integration, quality of life, life-satisfaction, and even mental health, such as susceptibility to depression . This assumption is supported by a variety of studies showing that adults with ADHD display impairments of selective attention , may pay less attention to the road, and consequently miss important environmental cues or the behaviours of other road users. Individuals with ADHD may also be more easily distracted and, therefore, may not anticipate behaviour of others or show delayed reactions to, for example, other road users who might lose control over their vehicles. Beside their cognitive impairments, adults with ADHD might also be more prone to be involved in road traffic accidents because of their emotional-motivational dysfunctions and personality traits functions of individuals with ADHD are related to unsafe driving and whether pharmacological treatment improves the driving behaviour of adolescents and adults with ADHD significantly. The answers to these questions are of high relevance for patients, health specialists, and society alike.A selective literature review was carried out to identify studies on driving-related difficulties of adults with ADHD. A thorough literature search was performed using electronic data bases PsycINFO, PubMed, and Web of Science including available literature up until September 2015. Initial search terms that were used were ‘ADHD’, ‘ADD’, ‘attention deficit hyperactivity disorder’ or ‘attention deficit disorder’ in combination with ‘driving’, ‘driver’, ‘drive’, ‘car’, ‘road’, ‘traffic’, ‘speeding’, ‘accident’, or ‘collision’. The literature was considered for inclusion if the study addressed one of the research questions, i.e., (1) whether individuals with ADHD show increased levels of unsafe driving behaviours, (2) which cognitive (dys)functions of individuals with ADHD are related to driving difficulty, and (3) whether pharmacological treatment significantly improves the driving behaviour of individuals with ADHD. The reference lists of the initial studies were then used to locate other relevant studies. Furthermore, studies were only included if they were written in English, were peer reviewed, included a sample of adults formally diagnosed with ADHD, and investigated driving behaviour by means of either self-reports, informant reports, official reports, driving simulators or on-road driving tests.Different approaches were applied in the assessment of the driving performance and behaviour of individuals with ADHD. These approaches comprise self-, informant- and official reports, driving simulator studies, and on-road driving assessments. All these approaches have their strengths and weaknesses, which are important to consider when interpreting the study results. Therefore, the available findings will subsequently be presented for each of these methods separately and then summarised in a brief synopsis.A number of studies have collected data on driving performance and driving behaviour of adolescents and adults with ADHD by analysing patients’ self-reports, informants’ reports  and/or official driving records  as compared to informant reports or scores obtained by clinicians  number of road accidents in which samples of patients with ADHD are involved in represents a highly relevant measure for the driving risk related with ADHD. Several studies have provided clear evidence that the (mean) number of road accidents increases in individuals with ADHD  is possible across participants  were included but nevertheless it was found that in comparison to automatic transmission, manual transmission increases arousal and driving safety (as assessed by self-reports and simulated driving)  including samples of 30 or less participants. Moreover, a biased selection of participants often resulted in the recruitment of individuals with ADHD with a recent history of driving mishaps and a predominance of male young participants. These are relevant issues, since studies on older participants and larger samples found fewer and weaker positive effects of pharmacological treatment on driving performance  or 1.23 when controlled for mileage Vaa . However


Evidence shows altered somatosensory temporal discrimination threshold (STDT) in Parkinson’s disease in comparison to normal subjects. In healthy subjects, movement execution modulates STDT values through mechanisms of sensory gating. We investigated whether STDT modulation during movement execution in patients with Parkinson’s disease differs from that in healthy subjects. In 24 patients with Parkinson’s disease and 20 healthy subjects, we tested STDT at baseline and during index finger abductions . We also recorded kinematic features of index finger abductions. Fifteen out of the 24 patients were also tested ON medication. In healthy subjects, STDT increased significantly at 0, 100, and 200 ms after movement onset, whereas in patients with Parkinson’s disease in OFF therapy, it increased significantly at 0 and 100 ms but returned to baseline values at 200 ms. When patients were tested ON therapy, STDT during index finger abductions increased significantly, with a time course similar to that of healthy subjects. Differently from healthy subjects, in patients with Parkinson’s disease, the mean velocity of the finger abductions decreased according to the time lapse between movement onset and the delivery of the paired electrical stimuli for testing somatosensory temporal discrimination. In conclusion, patients with Parkinson’s disease show abnormalities in the temporal coupling between tactile information and motor outflow. Our study provides first evidence that altered temporal processing of sensory information play a role in the pathophysiology of motor symptoms in Parkinson’s disease. Sensorimotor integration is the process whereby incoming sensory information is continuously monitored so as to allow the current motor plan to be adjusted and voluntary movements to be executed accurately –5. SensoSeveral studies have consistently reported abnormally high STDT values in patients with Parkinson’s disease , 11–15. The aim of this study was to investigate whether STDT modulation during movement execution in PD patients differs from that in healthy subjects and to evaluate changes in the kinematic properties of movements during the sensorimotor integration task. We also investigated the effects of dopaminergic therapy on movement-induced STDT modulation. Finally, we investigated possible correlations between neurophysiological and clinical variables.We enrolled 24 patients with Parkinson’s disease  and 20 age-matched healthy subjects  at the Department of Neurology and Psychiatry of the University of Rome, Sapienza. All the participants gave their written informed consent. The experimental procedure was approved by the institutional review board at Sapienza University Rome and conducted in accordance with the Declaration of Helsinki. The diagnosis of PD was based on clinical criteria , 18. DisAll the PD patients were studied OFF therapy . Fifteen of the 24 PD patients were also tested in “ON” state after receiving levodopa; the two sessions in these patients were performed in a randomized order, at least 1 week apart.STDT was investigated on the volar surface of the index finger of the right hand and of the left hand in patients and of the right hand in healthy subjects, according to the experimental procedures previously used , 19, 20.EMG activity was recorded through surface electrodes placed over the FDI muscle, in a belly tendon configuration. EMG signals were recorded and filtered with a Digitimer D360  (bandwidth 20 Hz–1 kHz), then analyzed off-line with a personal computer through a 1401 plus A/D laboratory interface . Data were stored on a laboratory computer for on-line visual display and further off-line analysis .via a dedicated software that runs the automatic algorithm to compute the range of motion (ROM), which represents the displacement of the index finger around its metacarpophalangeal joint expressed as the degree of the angle and mean velocity (degrees per second) .The SMART analyzer motion system , equipped with three infrared cameras , was used to record index finger abductions. The arm was abducted at the shoulder by about 45–50°, and the elbow joint was flexed at about 90°. An optical marker was placed over the distal phalanx of the index finger. After a verbal “go” signal, subjects abducted the index finger, then returned the finger to the starting position upon being given a verbal “stop” signal shortly after –23. MarkExperimental procedures envisaged first the assessment of basal STDT values (without movement). Participants were then instructed to perform index finger movements. Subjects were asked to abduct the index finger as widely and as quickly as possible and were continuously encouraged to do so throughout the motor task. Participants performed 10 index finger abductions before starting the experiment to familiarize with the motor task required . The experimental tasks consisted of index finger abductions, with the STDT being tested on the volar surface of the same index finger. Paired stimuli for STDT were triggered by movement execution at various time lapses after movement onset. The threshold to identify movement onset of index finger abductions was set at 100 μV of EMG activity. To define the time course of movement-induced STDT changes, paired stimuli were delivered as soon as the EMG signals reached 100 μV in amplitude (defined as “0 ms” for simplicity), 100 and 200 ms after movement onset. The STDT values were thus calculated for each time lapse . At each index finger abduction, the ISI for STDT testing was progressively increased in 10-ms steps, until the subject recognized the two stimuli as sequential  and neurophysiological results. P < 0.05 indicated statistical significance.We first checked STDT and kinematic data for normal distribution using Shapiro–Wilk test. Having excluded any assumption violations, we then performed separate between-group ANOVA to compare baseline absolute values of STDT and kinematic values (ROM and mean velocity) in healthy subjects and patients with Parkinson’s disease. To evaluate any difference in the amount of STDT modulation and changes in kinematic variables during movement execution between patients and healthy subjects, we used separate between-group repeated measure ANOVA with factor GROUP and factor TIME LAPSE  entering percentage values. To evaluate changes in the STDT modulation and kinematic variables induced by dopaminergic therapy, we used separate repeated measure ANOVA with factor THERAPY (two levels: ON and OFF), SIDE (more and less affected hand), and TIME LAPSE . As a T test: P = 0.43) and sex (Mann–Whitney U test: P = 0.77).PD patients and healthy subjects did not differ in terms of age  = 26.4, P < 0.0001; less affected hand: F = 32.0, P < 0.001] as well as ON therapy  were higher than in healthy subjects. No significant difference was observed in the baseline STDT values of PD patients between the more affected and less affected hand   = 7.8, P = 0.008; less affected hand OFF therapy: F = 4.5, P = 0.03], factor TIME LAPSE , and a significant GROUP × TIME LAPSE interaction . Between-group ANOVA to compare changes in STDT values during index finger abductions in patients ON therapy and healthy subjects showed a significant factor TIME LAPSE  but not significant GROUP × TIME LAPSE interaction. Post hoc analysis showed that the increase in STDT values in healthy subjects was significant at 0 ms (P < 0.0001), 100 ms (P = 0.001), and 200 ms (P = 0.002). In PD patients in the OFF therapy condition, the STDT increased at 0 ms  and 100 ms  but returned to baseline values at 200 ms . In PD patients ON therapy, the STDT increased significantly at 0 ms , 100 ms , and 200 ms   = 9.8, P = 0.007], factor TIME LAPSE  and a significant THERAPY × TIME LAPSE interaction . STDT values in PD patients were significantly higher OFF therapy than ON therapy  = 7.7, P = 0.008; less affected hand OFF therapy: F = 14.0, P = 0.0001; more affected hand ON therapy: F = 14.3; P < 0.001; less affected hand ON therapy: F = 6.8, P = 0.01; mean velocity: more affected hand OFF therapy: F = 27.2, P < 0.001; less affected hand OFF therapy: F = 24.9, P < 0.0001; more affected hand ON therapy: F = 15.2, P = 0.001; less affected hand ON therapy: F = 14.4, P = 0.001]  = 4.7, P = 0.03], but no significant factor TIME LAPSE  or TIME LAPSE × GROUP interaction .Between-group repeated measure ANOVA to compare percentage changes in ROM during index finger abductions in PD patients and in healthy subjects across the various time lapses tested showed a significant factor GROUP , factor TIME LAPSE , and a significant GROUP × TIME LAPSE interaction . Index finger abductions were slower in both hands in PD patients OFF therapy than either in those ON therapy or in healthy subjects at all the time lapses tested . Post hoc analysis performed to evaluate percentage changes in the mean velocity of index finger abductions during STDT testing showed that the mean velocity in PD patients, unlike that in healthy subjects (in whom the mean velocity was not affected by STDT testing) (P > 0.05), significantly decreased across time lapses, with lower values being recorded at 200 ms  than at 0 ms interval  = 7.4, P = 0.001]. When PD patients were tested in OFF therapy condition ROM slightly decreased across ISIs, being smaller at 200 ms interval in comparison to 0 ms interval, whereas, when PD patients were tested in the ON therapy condition, similar to healthy subjects, ROM remained unchanged across time lapses.ANOVA performed to analyze changes in ROM induced by dopaminergic therapy in PD patients revealed a significant HAND × THERAPY × TIME LAPSE interaction , and a significant TIME LAPSE × HAND × THERAPY interaction . In PD patients, dopaminergic therapy increased the mean velocity in both the less affected and the more affected hand. The increase in mean velocity induced by dopaminergic medication was more evident at the 0 ms than at 200 ms interval, as well as in the less affected hand than in the more affected hand   .Changes in mean velocity in the more affected hand OFF therapy at 200 ms interval were inversely related to the UPDRS part III score OFF therapy  Figure . We did The results of this study first confirm that STDT values are higher in PD patients than in healthy subjects –16, 19. Since we randomized the order of the trials testing the different time lapses between movement onset and paired stimuli for STDT, we are confident that changes in the STDT values and in movement kinematics did not depend on different attention levels or fatigue. Similarly, we alternated the order of the OFF and ON medication conditions. Thus, since the time lapses and medication conditions were randomized, the changes we observed in movement kinematics at different time lapses suggest that they were due specifically to the time lapse between movement onset and paired electrical stimuli. We also rule out that the time course of the STDT changes during index finger abductions in the OFF therapy condition was due to the higher baseline STDT values in PD patients because the STDT increased significantly at 0 and 100 ms. Moreover, with the stepwise method, we used for STDT, a floor effect might occur in experimental protocols in which STDT values are expected to decrease below the threshold, whereas values may increase to a considerable extent above the threshold.l-DOPA likely improves the time-related interaction between corticosubcortical structures (The distinctive finding of our study is that temporal coupling of tactile sensory information processing and motor outflow is altered in PD patients, which extends our knowledge by bridging the gap between altered temporal processing of sensory information and motor symptoms. We show that sensory information processing related to STDT is abnormally gated during movement execution in PD patients OFF therapy if compared with healthy subjects and those ON therapy. Using our time-controlled experimental paradigm, we now provide evidence that tactile information gating is less efficient in PD patients than in healthy subjects, as indicated by the observation that STDT values of PD patients OFF therapy returned to those at baseline when STDT was tested 200 ms after movement onset, whereas the STDT was still gated in healthy subjects at this time interval. We therefore hypothesize that dopaminergic depletion in PD not only affects sensory processing in the temporal domain but also alters the temporal coupling between tactile information and motor outflow. Consistent with previous observations , 19, 24 ructures , 19 but ructures , 24–27. In keeping with previous studies –30, indeIn conclusion, altered tactile–motor integration, in addition to the previously reported proprioceptive–motor integration , 40–44, All the participants gave their written informed consent. The experimental procedure was approved by the institutional review board at Sapienza University Rome and conducted in accordance with the Declaration of Helsinki.AC and DB: conception/design/execution of the project/drafting the manuscript. MT, NC, VB, EB, and XZ: acquisition of data/data analysis. GF and AB: revising the work critically for important intellectual content. All authors: manuscript preparation.AC received funds from Sapienza University of Rome for a research project on movement disorders. DB, MT, NC, VB, EB, and XZ reported no disclosure. GF received funds from Sapienza University of Rome for research projects on movement disorders. AB received funds from the Benign Essential Blepharospasm Research Foundation for research on blepharospasm. He has received national grants from Italian Ministry of University and Sapienza University of Rome, Chiesi, Lundbeck, Merz, Allergan, Ipsen. He has received honoraria for lecturing from Boehringer Ingelheim, GSK Pharmaceutical, Novartis Pharmaceuticals, Lundbeck, Chiesi.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.


There have been no household surveys of adult attention deficit and hyperactivity disorder (ADHD) in Kenya, and only one in sub-Saharan Africa.Data on ADHD was used from a household survey of mental disorders and their associated risk factors conducted in Maseno area (population 70 805), near Lake Victoria in Kenya, using a demographic surveillance site as the sample frame, as part of a wider survey of mental health, malaria and immunity A total of 1190 households were selected, and 1158 adult participants consented to the study while 32 refused to participate in the study interviews, giving a response rate of 97.3%. ADHD symptoms were assessed with the WHO Adult ADHD Self-Report Scale (ASRS) Screener.p = 0.023), those with life events , and those with common mental disorders .This survey found that the overall prevalence of ADHD using the ASRS was 13.1%. This suggests a high level of ADHD in the Kenyan population which needs to be further investigated for its impact on adult mental health. In the adjusted analysis, increased odds ratios (ORs) were found in those with higher assets (OR 1.7, The study demonstrates the magnitude of ADHD symptoms as a public health issue, relevant for health worker training, and the importance of further research into its prevalence in adults and associated risk factors. Attention deficit hyperactivity disorder (ADHD) is a developmental disorder characterised by attentional problems, impulsive behaviour and hyperactivity, and symptoms starting in childhood  per capita rose from US$399 in 2000 to US$ 1040.55 in 2013, although poverty levels remain high at 45.9% UNDP,  with neaet al. Nyanza Province, where the study was conducted, has relatively high levels of unplanned pregnancies (53%), deaths of children under 5 (14.9%), spousal abuse (60%) , the Kenya Medical Research Institute (KEMRI),the Kenya Psychiatric Association and Great Lakes University) comprising situation appraisal , Kiswahili and English. The area is largely rural, with most residents living in villages, which are a loose conglomeration of family compounds near a garden plot and grazing land. The majority of the houses are mud-walled with either grass thatched or corrugated iron-sheet roofs. Water is sourced mainly from community wells (40%), local streams (43%) and the lake (5%) for those mostly living on the shores of Lake Victoria , on which the interview questions were programmed and responses were recorded. The research assistants received a 5 day training course, and were supervised in the field by a field manager.The participants received a structured epidemiological assessment of common mental disorders (CMD), ADHD, psychotic symptoms, alcohol and substance abuse, accompanied by additional sections on socio-demographic data, life events, social networks, social supports, disability/activities of daily living, quality of life, use of health services and service use, adapted from the adult psychiatric morbidity schedule . Socio-economic factors assessed included employment status, education attainment, economic assets and type of housing.et al. et al.  Screener  , loss of a loved one , relationship difficulties ; income instability  and legal problems . The list was developed for the British psychiatric morbidity survey  how many adults who live with you do you feel close to, (ii) how many relatives aged 16 or over who do not live with you do you feel close to, (iii) how many friends or acquaintances who do not live with you would you describe as close or good friends. Responses were added into a total social network score.Specific questions were also asked about caring responsibilities ; about growing up with one natural parent or two until age 16; and about spending time in an institution before the age of 16.et al. et al. We examined the prevalence of self-reported ADHD symptoms, CMD, individual diagnostic categories, individual non-psychotic symptoms and of alcohol consumption, hazardous drinking and substance abuse. The estimated prevalence of ADHD self-reported symptoms was examined by calculating the prevalence of ASRS scores of 14 and above  and KEMRI boards of research ethics respectively, and by the KEMRI/Walter Reed Project to conduct the study in households within Maseno area, which is part of the Kombewa HDSS.Informed written and witnessed consent was asked of heads of sampled households, and then of sampled participants to take part in the study.A total of 1190 households were selected, and 1158 participants consented to the study while 32 refused to participate in the study interviews, giving a response rate of 97.3%.p value.p = 0.003), those with more life events , and were significantly reduced in the self-employed , those living in larger households , and those living with a lack of social support , and those living with large social group size of 4–8  at the bivariate level of analysis.Odds of ADHD were significantly increased in those with higher assets  are household size, employment status, asset quintiles, life events, perceived lack of social support, total social group size and any CMD.The variables for which the outcomes have been adjusted (with p = 0.088), those with higher assets , those with life events , and those with CMD  are considered to be predictors/risk factors for ADHD.In the adjusted analysis , the self-employed  used the ASRS with O-6 scoring  found that 8.3% screened positive for ADHD, using the ASRS screener and the O-6 scoring method, with a cut off of 3/4.et al. et al. , those with higher assets , those with life events , and those with CMD .We did not find a gender difference in ADHD prevalence, similar to the lack of gender difference in other adult studies  with employment and financial stress, and the British mental health survey found an association of ADHD with unemployment and economic inactivity . Various studies nested on the DSS platform take advantage of the sampling frame inherent in the HDSS, whether at individual, household/compound or regional levels. This familiarity with survey procedures is likely to have been influential in the achievement of a high response rate. The ASRS proved reasonably straightforward to include in the overall research interview with questions specified on the PDA, and responses directly recorded to the PDA. The questions were available on the PDA in English, Kiswahili and Luo . Our research interviewers were trained health workers who lived locally and who were therefore familiar with the local languages. It was very important to ensure that the sample was properly random, and therefore we drew on the supervision of the demographic surveillance site staff as well as the project manager to ensure that the randomisation procedures were followed in the identification of households and the identification of one adult per householdOur study findings were limited by the fact that we did not validate the ASRS with a clinical diagnostic interview in this population. This is important to do as the wording of the ASRS may not always be understood in all populations and therefore accuracy of the screener is not clear until validated against diagnostic interview. If accurate estimates of ADHD are to be generated, it is essential to do a study with validation against the gold standard of diagnostic interview in a random subsample.et al. The validity of the ASRS screener has been examined in the USA  scores in Kenya indicate the importance of further research on this important condition both in Kenya and in other low and high-income countries, in order to have a better understanding of overall global mental health and illness. Since ADHD is essentially a clinical diagnosis, it is important in future studies in both high and low income countries to combine the ASRS screen with a clinical interview to obtain more information on the optimum cut off screening score in each population in which the screen is used, and the methodological challenges might inform the population measuring and surveillance of this condition in other settings, including high-income ones. The use of a demographic surveillance site as a sample frame where possible confers a number of advantages to the implementation of epidemiological surveys, particularly a relatively high response rate, which reduces the effects of non-response bias in the findings.The study demonstrates the magnitude of ADHD symptoms, as measured by ASRS screener scores of 14 and over, as a public health issue in Kenya, which is relevant for health worker training about detection and management. The study also indicates the importance of further research into measurement and surveillance of adult prevalence rates in both high and low income countries using a screening instrument to enable the coverage of large sample sizes together with a gold standard clinical assessment of a random subsample to assess validity of the screener in that population. It is also crucial to conduct further exploration of the complexity of associated risk factors, which may vary in different contexts, and between high and low income countries.


The SLY1 gene was needed for proper down-regulation of translation-associated genes in mature dry seeds, and for AR up-regulation of these genes in germinating seeds. Thus, sly1-2 seed dormancy may result partly from failure to properly regulate protein translation, and partly from observed differences in transcription factor mRNA levels. Two positive regulators of seed dormancy, DELLA GAI (GA-INSENSITIVE) and the histone deacetylase HDA6/SIL1 (SILENCING1MODIFIERS OF ) were strongly AR-down-regulated. These transcriptional changes appeared to be functionally relevant since loss of GAI function and application of a histone deacetylase inhibitor led to decreased sly1-2 seed dormancy. Thus, after-ripening may increase germination potential over time by reducing dormancy-promoting stored transcript levels. Differences in transcript accumulation with after-ripening correlated to differences in transcript stability, such that stable mRNAs appeared AR-up-regulated, and unstable transcripts AR-down-regulated. Thus, relative transcript levels may change with dry after-ripening partly as a consequence of differences in mRNA turnover.Plant embryos can survive years in a desiccated, quiescent state within seeds. In many species, seeds are dormant and unable to germinate at maturity. They acquire the capacity to germinate through a period of dry storage called after-ripening (AR), a biological process that occurs at 5–15% moisture when most metabolic processes cease. Because stored transcripts are among the first proteins translated upon water uptake, they likely impact germination potential. Transcriptome changes associated with the increased seed dormancy of the GA-insensitive  Phase III also includes post-germinative events such as completion of nutrient mobilization, cell division, and seedling growth. Living dormant seeds do not reach Phase III, but they do imbibe water and enter Phase II. This paper will refer to ungerminated seed in Phase I or II as “imbibing seeds” to distinguish them from seeds undergoing germination per se.The word “germination” refers both to a process and an event. The germination process has been divided into three phases  was associated with differential transcript levels, including 24 after-ripening-down-regulated mRNAs preferentially targeted for destruction by mRNA oxidation  and gibberellin (GA) act antagonistically to regulate seed dormancy and germination (reviewed in SLEEPY1 (SLY1) gene encodes the F-box subunit of an SCF  E3 ubiquitin ligase that directly binds to and ubiquitinates DELLA upon formation of the GID1-GA-DELLA complex. Thus, GA causes SCFSLY 1 to polyubiquitinate, and thereby, target DELLA for destruction by the 26S proteasome. Arabidopsis has five DELLA proteins, RGA (REPRESSOR OF GA1-3), GAI (GA-INSENSITIVE1), RGL1, RGL2, and RGL3 (RGA-LIKE). The failed seed germination of the GA biosynthesis mutant ga1-3 in the light was strongly rescued by loss of the DELLA RGL2  repressors of GA responses  or with 1–2 years of dry after-ripening (erecta (Ler) wild-type seeds fully after-ripen within 2 weeks. Neither after-ripening nor GID1-OE result in reduced accumulation of DELLA repressors of seed germination. Thus, GA signaling can occur without DELLA-proteolysis leading to increased germination potential. There are three GA receptor genes in Arabidopsis, GID1a, GID1b, and GID1c. GID1b protein has higher affinity for GA4 and for DELLA protein than GID1a and GID1c (GID1b-OE rescues sly1-2 seed germination and plant height phenotypes better than GID1a-OE and GID1c-OE (Loss of dormancy . The Araripening . In contnd GID1c . This isGID1c-OE .sly1-2 (sleepy1-2) mutant of Arabidopsis. Transcripts involved in protein translation were sly1-up-regulated in dry seeds, and sly1-down-regulated upon seed imbibition. Thus, it appears that SLY1 may be needed both to down-regulate protein translation during seed development, and to up-regulate translation during germination. The importance of protein translation during seed germination has been well characterized  wild-type and mutant lines used in this study including ga1-3, sly1-2, sly1-2 GID1b-OE, gai-1, gai-t6, sly1-2 gai-t6, and sil1 all in the Ler background were described previously (® growth chamber according to eviously . All linThe standard practice of harvesting seeds after the entire plant has turned brown (fully desiccated) was used in all cases, except where indicated that harvest occurred at “near maturity.” Since all parts of a plant do not turn brown simultaneously, harvesting fully brown plants means that some portion of the seeds collected have been after-ripening on the plant for up to a few weeks. In order to obtain dormant seeds for wild-type or when expecting germination rates higher than wild-type, seeds were harvested when the mother plants were partially brown and partially green. By collecting only seeds that fell freely from dry siliques and sifting seeds through a fine mesh, we ensured that only brown (desiccated) seeds were collected for use in assays.er wt, sly1-2(D), sly1-2(AR), and sly1-2 GID1b-OE , seeds for germination and RT-qPCR assays. Seeds from the same batch were collected for RT-qPCR and germination assays each day for 14 days.A single batch of Ler wt, gai-1, gai-t6, and sly1-2 gai-t6 were grown side-by-side and harvested at near maturity. Freshly harvested seeds were stored in open tubes overnight before collecting dormant 0wkAR seeds for germination assays.Seeds of Lhda6 loss of function mutant in the Ler background, sil1 was a kind gift from Dr. Jong-Myong Kim at the RIKEN Plant Science Center in Yokohama, JAPAN. Ler wt and sil1 seeds used for germination assays were grown side-by-side and harvested at near maturity to obtain dormant seeds. Freshly harvested seeds were stored in open tubes overnight before collecting dormant 0wkAR seeds for the germination assay. Seeds were stored for an additional 14 days in open tubes then collected for the 2wkAR germination assay.The er wt, ga1-3, and sly1-2 seeds were harvested from fully brown plants. Seeds were stored for 2 weeks with the exception of long after-ripened sly1-2, which was stored for more than 1 year.Seeds of LN-morpholino)ethanesulfonic acid], pH 5.5 (referred to as MS-agar plates). Germination was scored daily. Germination of the same batch of seeds used for microarray analysis was performed as in er after-ripening time course germination of at 0wkAR, 1wkAR, and 2wkAR was scored for three replicates of 100 seeds each after cold stratification for 4 days at 4°C in the dark. Ler after-ripening time course seeds were the seeds used for the RT-qPCR time course for AHb1 gene expression in Ler wt. For the comparison of GAI mutants, germination was scored for three replicates of 70–100 seeds each both with and without cold stratification for 4 days at 4°C in the dark. For sil1 mutants, because we expected higher germination efficiency than wild-type would be difficult to capture, each plate was divided into two halves with Ler wt plated on one side and sil1 plated on the other for side-by-side comparison. For the same reason, three replicates of 70 seeds each for each of three biologically independent batches of Ler wt and sil1 at 0 and 2 weeks of after-ripening were scored both with and without cold stratification for 4 days at 4°C in the dark. The tricostatin A (TSA) dose response experiments were performed for 2–4 replicates of about 30–90 seeds each. Tricostatin A (TSA) was added to plates at 0, 0.5, 1, 2, 4, and 6 μM concentrations and germination was recorded for 2–4 replicates of about 30–90 seeds.For all germination screens, seeds were sterilized with 70% ethanol and 0.01% SDS for 5 min followed by 10% bleach and 0.01% SDS for 10 min, washed, and plated on 0.8% agar plates containing 0.5× MS salts (Sigma–Aldrich) and 5 mM MES [2- = 9.0–9.3].RNA extractions for microarray and RT-qPCR were performed as in er wt (stored dry for 2 weeks), dormant sly1-2 (stored dry for 2 weeks), after-ripened sly1-2 (stored dry for 19 months), and sly1-2 GID1b-OE (stored dry for 2 weeks), 2 μg of RNA was processed by the Molecular Biology and Genomics Core Laboratory at Washington State University biotin-labeled cRNA synthesis, ATH1 chip hybridization, and chip scanning1. The LIMMA package as part of the Bioconductor suite of tools in the R was used for data analysis as described previously , control probesets removed, and significance determined by False Discovery Rate (FDR) with α = 0.05 . For each replicate of Leviously . Raw datously , whereas down in AvsB means down-regulated in A (or up-regulated in B).Reanalysis of published microarray datasets was conducted using the same methods as above to facilitate fair comparison. The raw dataset from 4  looking for global enrichment of genes in standard gene ontology (GO) categories, (2) looking for global enrichment of genes in specific gene families (GF), and (3) looking for enrichment of genes within a specific set of seed dormancy and germination related gene categories (TAGGIT). GO biological process and GF enrichment was performed using the BioMaps tool as part of the VirtualPlant 1.3 suite of online tools for analysis of genomic data4 . Enrichmp < 0.01 . For eacTAGGITontology and TAGGITplot R functions that we developed previously based on the 5. TAGGIT uses 26 categories defined for their involvement in seed dormancy and germination and matches genes to categories based on lists of AGI locus identifiers in combination with a gene description search for specific keywords. For simplicity, “more up-regulation” or “more down-regulation” in a category refers to a higher degree of enrichment in either the up-regulated gene fraction, or in the down-regulated gene fraction, respectively.For seed germination and dormancy specific GO classifications, the sly1-2 and Cvi dry seed datasets were non-random.One of the concerns about comparisons of dry seed gene datasets is that differential regulation may be random background due to differences in seed batches. To confirm that the differences in category enrichment identified by TAGGIT could not emerge from a random dataset due to unexpected bias in the computational algorithm, a non-overlapping random set of 330 up- and 430 down-regulated genes was analyzed by TAGGIT  in a given geneset a list of Arabidopsis transcription factors was compiled based on the combined databases of PlnTFDB10) with the Transcription Factor Targets (TFT) dataset was used to determine enrichment for known targets of transcription factors within differentially regulated genesets  correction for multiple testing adjustment with α = 0.05  was used for cDNA synthesis from 1 μg of total RNA and the LightCycler FastStart DNA Master SYBR Green I kit (Roche) was used for qPCR. The QuantPrime online tool11 was used for primer design with the exception of the previously published DOG1, GAI, and HSFA9  reference gene  wild-type Ler (WT) stored for 2 weeks, (b) dormant sly1-2 stored for 2 weeks [sly1-2(D)], (c) after-ripened sly1-2 stored for 19 months [sly1-2(AR)], and d) sly1-2 GID1b-overexpressed (sly1-2 GID1b-OE) stored for 2 weeks . Ler WT reached 96% germination after 1 day, whereas sly1-2(D) did not germinate even after 7 days of imbibition . sly1-2 germination was rescued by long after-ripening for 19 months (51% germination by 7 days), and by GID1b-OE (73% by 7 days). The same seed stocks were previously used in an imbibed seed microarray study, including a “0h” timepoint taken immediately after cold stratification for 4 days at 4°C in the dark, and a “12h” timepoint   to wild-type Ler (sly1-2 DvsWT) comparison identified 794 transcript differences associated with the sly1-2 seed dormancy phenotype . Since the comparison of another mutation affecting germination, ft-1 (flowering locus t-1), to Ler wt dry seeds detected no transcriptome differences  (517 sly1-down-regulated) than positive (277 sly1-up-regulated) , resulting in an adjusted Fisher-Pearson standardized moment coefficient skewed toward down-regulation  . Of the top 50 DELLA/sly1-regulated genes in dry seeds, 21 were similarly regulated at the previously published 0h and 12h imbibed timepoints  . Plots cetrical) . The slygulators . Thus, nmepoints .sly1-2 DvsWT comparison were characterized using BioMaps GO and gene family (GF) to look for biological process enrichment12 . There were 770 genes with different transcript abundances between D and AR sly1-2 dry seed, 330 up-regulated and 430 down-regulated with after-ripening of sly1-2 (sly1-2 ARvsD). In contrast, only 7 genes showed differential accumulation with GID1b-overexpression in sly1-2 (GIDvsD) dry seeds .The fact that ng seeds . We madeFigure 2C). For example, there were 20 up-regulated transcripts with logFCs from 2 to 4.3, whereas only 4 of the down-regulated transcripts had logFCs greater than 2. This is consistent with observations made during dry after-ripening of the dormant ecotype Cvi; where there were 777 up- and 1426 down-regulated transcripts in the Cvi ARvsD comparison . Since the plotted normalized intensities of sly1-2 ARvsD showed significant differences (red) over a wide range of intensities, the small number of transcripts highly up-regulated do not appear to be artifacts of comparing low intensity values . The most up-regulated gene was the AHb1 . This suggests that GAI plays a role in sly1-2 dormancy that is reversed with long after-ripening. BioMaps gene family analysis and GO analysis showed that many of the dry seed sly1-regulated terms (sly1-2 DvsWT) were oppositely AR-regulated , likely due to stronger up-regulation of fewer transcripts . The direct overlap of sly1-2 and Cvi AR-regulated transcriptome changes identified a list of genes associated with both Cvi wt and sly1-2 dormancy loss  family genes, MFT (MOTHER OF FT AND TFL), and HDA6 (HISTONE DEACETYLASE6) were all AR-down-regulated.The significant overlap between AR-regulated genes in Cvi and GID1b-OE rescue of sly1-2 germination was associated with only seven differentially abundant transcripts in dry seeds, 5 up- and 2 down-regulated (Table 1). Since GID1b is overexpressed on the 35S promoter, it was not surprising that the most up-regulated gene was GID1b itself. Among the remaining 6 genes, 3 were similarly regulated at 0h and 12h of imbibition, including: the up-regulated At1g21630 (EF hand family) gene, and down-regulated At2g46250 (myosin heavy-chain related) and BAG6 (BCL-2-Associated Anthogene6) genes. When the dataset was compared to the dry seed transcriptome changes with after-ripening of sly1-2, LTP4 and LEA5/SAG21 were GID1b-OE- and AR-up-regulated . LTP4 encodes a phospholipid transfer protein localized to the cell wall, while LEA5/SAG21 encodes a senescence-associated protein with a role in oxidative stress tolerance , and ecotype Cvi ARvsD dry seed comparisons  given that the translation category was among the most highly sly1-down-regulated at 0h and 12h of seed imbibition in our previous study . In contrast, the translation category showed strong up-regulation with after-ripening of imbibed Ler wt but not sly1-2 seeds . TAGGIT analysis of a randomly generated dataset confirmed that TAGGIT profiles similar to those observed for sly1-2 ARvsD and Cvi ARvsD were unlikely to happen by chance, suggesting that this agreement has functional relevance , revealed that transcription factor families strongly regulated with sly1-2 after-ripening included AP2-EREBP, ARF (Auxin Response Factors), C3H (Cys3His zinc fingers), GRAS, and MYB-related families  are among the AR-regulated genes in dry seeds using a combined list of Arabidopsis transcription factors compiled from the PlnTFDB, AtTFDB, and PlantTFDB databases . This aner but not in sly1-2 germination, we examined changes in TF-mRNA accumulation in the sly1-2 DvsWT dry seed comparison. Of the 794 sly1-regulated transcripts, 53 TF-mRNAs were sly1-down-regulated, while only 10 TF-mRNAs were up-regulated . The sly1-down-regulated TF-mRNAs families included AP2-EREBP (APETALA2 and ethylene-responsive element binding proteins), bHLHs (basic helix-loop-helix), C2H2 zinc fingers, and MYB-related family transcription factors  tool was used to look for enrichment of known transcription factor targets within the dataset of stored mRNA differences in the mparison . Targetser cell cultures were treated with the transcriptional inhibitor Actinomycin D . Although mRNA stability alone cannot account for all up- and down-regulation, shorter half-life mRNAs appeared more AR-down-regulated and longer half-life mRNAs appeared more AR-up-regulated. Similarly, when the AR-regulated transcripts were categorized by half-life range, a larger percentage of stable mRNAs  were up-regulated, whereas more unstable mRNAs  were down-regulated . This trend for high stability mRNAs to be up-regulated and lower stability mRNAs to be down-regulated was not seen at sly1-2 ARvsD 0h and 12h timepoints, indicating that mRNA stability is not the major determinant of transcript levels in imbibing seeds . For comparison, both RT-qPCR and microarray expression were plotted relative to the constitutively expressed control gene AKR2B   were AR-down-regulated, while GAI and MFT were sly1-up-regulated in dry seeds . As in imbibed seeds, the SLY1/sly1-2 transcript was AR-up-regulated and sly1-down-regulated in dry seeds (DOG1 (DELAY OF GERMINATION1) gene was AR-up-regulated in the sly1-2 microarray analysis, but just outside of statistical significance (p = 0.071) by RT-qPCR. Conversely, DOG1 was AR-down-regulated in Cvi wt (AHb1 transcript was highly AR-up-regulated based both on microarray and RT-qPCR (p = 8 × 10-4) analysis in sly1-2 .RT-qPCR analysis was used to validate transcript level differences identified by microarray in the 2g17390) . RT-qPCRry seeds . The dorn Cvi wt . FinallyAHb1 was not significantly up-regulated with ecotype Cvi dry after-ripening, it may be the case that AR-up-regulation of AHb1 is dependent on the Ler ecotype. Thus, an after-ripening time course examined if AHb1 was up-regulated with dry after-ripening of wild-type Ler. RNA was isolated from dry Ler seeds immediately after harvest at maturity , then after-ripened for 1 (1wkAR) and 2 weeks (2wkAR). AHb1 mRNA levels showed an increasing trend with AR, and a significant increase from 0wkAR to 2wkAR by RT-qPCR analysis , sly1-2(AR), and sly1-2 GID1b-OE seeds, the fact that only GAI and RGL3 transcript levels were high in dry seeds suggests that GAI may be more important in dry seed after-ripening . Cold stratification improved germination for all lines, but gai-t6 consistently germinated faster than wild-type, while gai-1 germinated slower. If elevated GAI mRNA levels in sly1-2 seeds stimulate dormancy, then we would expect gai-t6 to rescue sly1-2 seed germination. Indeed, while dormant sly1-2 seeds failed to germinate even with cold stratification, the sly1-2 gai-t6 double mutant germinated without cold stratification reaching 25% with 16 days of incubation . Taken together, these results suggest that GAI plays an early role in the negative regulation of seed germination.Based on double mutant studies with LLA RGL2 . While RHDA6 stimulates seed dormancy in wild-type Ler, then we would expect hda6 mutants to be less dormant than wild-type. The germination phenotype of the HDA6 allele in the Ler background called sil1 (silencing1modifiers of ) was examined in seeds harvested near maturity to maximize dormancy. Seeds of sil1 germinated more efficiently than wild-type Ler in three biologically independent batches of seeds at 0 and 2 weeks of after-ripening, both with and without cold stratification  . Interestingly, TSA also stimulated the germination of ga1-3 seeds, suggesting that GA functions in part by relieving transcriptional repression by histone deacetylases. TSA rescued germination most efficiently at 2 μM (76%), and showed decreasing germination at 4 and 6 μM TSA. It may be that histone deacetylation and TSA alter the expression of other positive or negative regulators of germination at different concentrations.If histone deacetylation stimulates the seed dormancy of GA mutants, then inhibition of histone deacetylation should rescue the germination of GA-insensitive  A (TSA) . TSA ressly1 mutant has increased dormancy due to overaccumulation of DELLA proteins, the negative regulators of GA responses and seed germination. Thus, comparing sly1-2 vs. WT (DvsWT) defined transcriptome differences associated with DELLA-imposed seed dormancy.There are many mechanisms contributing to seed dormancy. The sly1-2, suggesting that a major effect of sly1 loss/increased DELLA is decreased transcript abundance . DELLA proteins act in concert with DNA-binding proteins to regulate transcription  of these genes were down-regulated in cription . Thus, ioteasome . PIF1/PIoteasome . Thus, iper se. There were 5-times more sly1-down-regulated than sly1-up-regulated TF-mRNAs  and DELLA GAI are examples of major sly1-regulated TF-mRNAs  compared to WT arise entirely during development or maturation, these differences may also arise during 2 weeks of dry storage. For example, transcripts may be degraded at different rates in different genotypes, either faster or slower in the sly1-2 mutant than in WT. Since sly1-2 requires 1–2 years to reach a germination rate similar to WT after-ripened for 2 weeks, it is possible that some germination-inhibiting transcripts require more time to degrade or oxidize in sly1-2 than in WT. It could also be the case that germination-promoting transcripts are less protected in sly1-2. Investigation of DvsWT transcriptome differences during development and maturation might help to differentiate transcriptome differences arising during development from those arising during dry storage.While it is tempting to believe that dry seed transcriptional differences in While it may be argued that changes in the dry seed transcriptome are merely artifacts of mRNA oxidation/damage over time, the results of this study provide circumstantial evidence that some of these changes are of regulatory importance in dormancy loss. First, similar changes occurred with dry after-ripening in two different ecotypes. Second, transcription factors known to function in dormancy, dormancy loss, and GA signaling were among the AR-differentially regulated genes. And third, mutations in two of these differentially regulated genes resulted in altered seed dormancy and germination.sly1-2 and Cvi ARvsD comparisons suggested that dry seed transcriptome changes are not due to random degradation of transcripts as seeds age, but may represent dormancy-loss mechanisms. Of the 770 stored mRNAs that were differentially regulated with after-ripening in dry sly1-2 seeds, 12% of the AR-up-regulated and 23% of the AR-down-regulated were similarly regulated in Cvi wt . Since sly1-2 is a mutation in the Ler rather than the Cvi ecotype, differences between these two ARvsD comparisons may result either from ecotype differences or the sly1-2 mutation. Interestingly, the regulation of TAGGIT gene categories was similar in sly1-2 and Cvi wt dry seed after-ripening . The partial overlap in the sly1-2 and Cvi ARvsD comparisons may simply suggest that the seed dormancy of the two genotypes results from only partially overlapping mechanisms. In other words, there are multiple ways to acquire and to lose seed dormancy.The overlap in the sly1-2 but not Cvi may function in after-ripening of the Ler ecotype. For example, the AHb1 transcript was not AR-up-regulated in Cvi, but was strongly AR-up-regulated transcript in dry seeds of sly1-2 and Ler. AHb1  protects roots from severe oxidative stress . Of these, the AHb1 transcript was down-regulated at 12h of imbibition. Future research will need to examine if AHb1 is needed to stimulate sly1-2 germination in early Phase I, but not in Phase II of germination.Even transcripts that are AR-regulated in e stress . Thus, ie stress . Dormancper se. Thus, it is interesting that transcription factors known to control dormancy and dormancy loss were among the AR-regulated genes. ABA hormone establishes dormancy, ethylene can break dormancy in ga1-1, and auxin has been implicated in dormancy and dormancy release (HAB2 (HOMOLOGY TO ABI2), AHG3 (ABA-HYPERSENSITIVE GERMINATION3), and HAI3 (HIGHLY ABA-INDUCED PP2C GENE3) were among transcripts down-regulated with sly1-2 after-ripening . Moreover, the gai-t6 mutation was able to partly rescue sly1-2 germination without cold stratification, and strongly rescue sly1-2 germination with cold stratification . Thus, AR-down-regulation of GAI in dry sly1-2 seeds likely results in increased germination potential since GAI acts as a positive regulator of sly1-2 dormancy.The DELLA he light . DELLA Ggai-1 has reduced germination potential compared to wild-type Ler in cold-stratified seeds   . Thus, osly1-2 (DvsWT) were down-regulated, it was interesting that rescue of sly1-2 seed germination by long after-ripening was associated with down-regulation of the HDA6 histone deacetylase because histone deacetylases repress gene transcription. Histone deacetylation represses gene expression through heterochromatin formation, whereas histone acetylation promotes gene expression and has been implicated in seed dormancy release by stimulating gene expression needed for seed germination. Our hypothesis was that HDA6 down-regulation with after-ripening of sly1-2 and Cvi breaks dormancy through increased expression of germination-promoting transcripts. The notion that HDA6 stimulates seed dormancy was supported by the observation that loss of HDA6 in the sil1 mutant decreased seed dormancy in freshly harvested seeds . In addition to the hda6/sil1 mutant, the histone deacetylase mutants hda9 and hda19 also exhibited reduced seed dormancy . The increased seed dormancy in sly1-2 is rescued by long after-ripening, whereas the seed dormancy of the GA biosynthesis in ga1-3 is not. No GA signaling can occur in ga1-3, whereas some GA signaling can occur in sly1-2 mutants that cannot trigger DELLA destruction . Although not as much as in DvsWT, translation-associated mRNAs accounted for 12% of the up-regulated transcripts in the sly1-2 ARvsWT dry seed comparison . This indicates that SLY1 is not a requirement for this decrease with after-ripening, but that loss of SLY1 resulted in a higher starting-point during seed maturation. Thus, it appears that SLY1 is needed for down-regulation of translation-associated transcripts during seed maturation, since the translation-associated category accounted for 25% of the sly1-up-regulated genes in dry seeds . This suggests that SLY1 may serve as a kind of shutdown signal to down-regulate translation associated genes during seed maturation to prepare for the quiescent state. In this context, it is interesting to note that sly1-2 mutant seeds exhibit a mild decrease in survival of long-term storage  than the majority. Consistent with this notion, comparison of dry seed AR-regulation with Arabidopsis mRNA stability, showed a correlation between AR-up-regulation and higher mRNA stability, as well as AR-down-regulation and lower mRNA stability . This is consistent with a previous study showing RNA degradation during dry after-ripening of sunflower seeds and Arabidopsis . The AR-down-regulation of these two transcripts and of other transcription factors suggests that the control of gene transcription and of histone acetylation is one major mechanism controlling dormancy and after-ripening of dry seeds. The sly1 seed dormancy phenotype was strongly associated with decreased abundance of transcription factor mRNAs, and generally skewed toward transcriptome down-regulation. Thus, it appears that over-accumulation of DELLA repressors has the general effect of down-regulating dry seed transcript abundances. There is one major counterexample to this observation; genes associated with protein translation were strongly up-regulated in dry dormant sly1-2 seeds compared to wild type accounting for 25% of the sly1-up-regulated transcripts. Translation-associated genes are the major class of GA and SLY1-regulated transcripts in seeds (Figures 5A,B; SLY1 is needed to down-regulate protein translation-genes during seed maturation and to up-regulate protein translation-genes with after-ripening during seed imbibition. Future work will need to examine if the increased dormancy of sly1-2 and ga1-3 results largely from inability to efficiently up-regulate protein translation.How dormancy is lost in dry, metabolically inactive seeds is a fascinating question. This study took some first steps toward addressing this question by identifying transcriptional mechanisms underlying dormancy and dormancy loss in dry seeds of the GA-insensitive mutant, Figure 11. SN performed all remaining experiments and bioinformatics analyses. Both CS and SN contributed to the research and analysis design, and to the writing of this article.CS provided the initial research design and obtained funding. TA performed the TSA experiments 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.