For the pharmacists not participating in the workshops, they indicated to a much greater extent possible barriers affecting the readiness to provide vaccinations in pharmacies. They most often pointed out that vaccination services would result in a significant workload increase (p = 0.0001), that pharmacies were not adapted to immunization, and that there were not enough training courses for pharmacists (p = 0.0001). Conclusion: The pharmacists working in community pharmacies indicated many advantages of vaccinations in pharmacies. This study identified barriers to the introduction of vaccinations and factors necessary to implement these services in pharmacies. The pharmacists trained during the immunization programme of the Pharmacists Without Borders project showed a greater readiness to provide immunization services.Background: Immunization rates among the adult population in Poland are below desired targets, urging the need to expand this service in the community. During the COVID-19 pandemic, the ultimate goals for limiting the spread of the infection are vaccines against SARS-CoV-2. Pharmaceutical companies are in a race for the fastest possible way to deliver vaccines. Community pharmacists in Poland are recognised as an accessible yet underutilised group of medical professionals. Therefore, involving pharmacists in vaccinations may have beneficial results for the healthcare system. Objectives: The objectives of this study were to assess the readiness and willingness of community pharmacists following the Pharmacist Without Borders project who had either been trained or not in providing immunization services, and to identify the factors that may support the implementation of such services in Poland. Methods: This study was conducted among pharmacists between February and August 2020 in Poland. A survey was developed to determine their readiness to provide vaccination services in their pharmacies, to recognise any barriers to vaccinations, as well as the factors necessary to implement vaccination services in Polish pharmacies. Results: A total of 1777 pharmacists participated in the study, comprising 127 (7.1%) pharmacists trained in vaccinations during the Pharmacists Without Borders project and 1650 (92.9%) pharmacists not participating in the workshops. Pharmacists participating in the workshops more often indicated that providing vaccinations in community pharmacies would improve the overall vaccination rate ( The development of vaccinations has contributed to a significant decrease in infectious diseases worldwide . Not onlVaccinations are particularly important when the consequences are considered not only individually but also locally and globally, where common use of vaccinations in just some groups of people can result in general herd immunity to infectious diseases, lowering the incidence and exacerbating eradication. However, overall herd immunity depends on a high vaccination coverage rate .Despite the recommendations in favour of vaccinations, the burden of diseases that can be prevented by vaccinations remains high in many countries. This situation is especially important among senior citizens, leading to high mortality rates as well as the necessity to use resources and bear costs that could be avoided by vaccinations . For exaOne of the most recommended vaccinations is for the flu. Costs of treating the flu increase with patient age and comorbidities . DespiteFollowing European trends, educational workshops were organised for pharmacists in Poland—“Pharmacists Without Borders” . PharmacThe objective of the workshop was to update and deepen knowledge in vaccinology, with particular emphasis on the types of vaccination, their safety, routes of administration, and storage. The issues covered in the workshops included safe and correct administration of intramuscular injections, as well as diagnosing and treating patients with symptoms of anaphylaxis and cardiac arrest.After completing the course and particular modules, the participants of the “Pharmacists Without Borders” workshop received European certification certifying their knowledge in the field of vaccination and injections in pharmacies , accredited by the Royal Pharmaceutical Society of Great Britain and Collegium Medicum at the Ludwik Rydygier Medical College in Bydgoszcz.The proposal of including vaccination in the tasks of pharmaceutical care had been indicated in the Polish State Medicine Policy for the period 2018–2022 , yet theThe study was anonymous and was conducted among pharmacists working in community pharmacies in Poland between February and August 2020. The readiness and willingness of pharmacists to provide vaccination services were assessed by means of a questionnaire specifically designed for this study on the basis of a study conducted in the Saudi Arabia , and in The data collected included data on the pharmacists  and the pharmacies (type of pharmacy), as well as data relevant for the purposes of the survey . Each item of the questionnaire was assessed using a 5-point Likert compliance scale .p = 0.05.All statistical calculations were performed using the data analysis software STATISTICA version 12.0  and MS Excel. Qualitative variables were presented by the number and percentage values and Chi-square independence tests . To assess the impact of basic characteristics on vaccination readiness, barriers, and pharmacists’ vaccination needs in pharmacies, the univariate and multivariate regression (multiple linear regression) analysis were used. In all calculations the level of statistical significance was taken at The study involved 1777 pharmacists, comprising 127 (7.1%) pharmacists who had participated in the Pharmacists Without Borders workshops, and 1650 (92.9%) pharmacists who had not participated. Most respondents held an MPharm degree, were mainly aged 31–40 (39.6%), and most often with less than 10 years’ job seniority (40.7%). The pharmacists worked in both independent pharmacies (51.7%) and pharmacy chains (48.3%). Despite no significant differences in age, job seniority and type of pharmacy of the pharmacists participating and not participating in the Pharmacists Without Borders workshops, a higher percentage of pharmacists with a PhD(Pharm) attended the workshops than did not .p = 0.8704). Among the statements on the justification of their readiness to provide vaccination services in community pharmacies, the following were most frequently indicated in the entire study group: pharmacists from community pharmacies are easily accessible to patients, and pharmacists from community pharmacies can play an important role in advertising and promoting vaccinations. The pharmacists participating in the Pharmacists Without Borders workshops indicated more often than not that vaccinations administered in community pharmacies would improve the overall vaccination coverage rate (p = 0.0001), including the vaccination coverage rate in particular groups, e.g., seniors (p = 0.0001). The pharmacists participating in the workshops more often indicated that a vaccination project could be cost effective (p = 0.0001) and that pharmacists could play an important role in advertising and promoting vaccinations (p = 0.0001)  .p = 0.0021), with less than ten years of work experience (p = 0.0272) and completed Pharmacists Without Borders workshop (p = 0.0001). In the multivariate regression model, significantly greater readiness for vaccination was demonstrated for pharmacists up to 30 years of age (p = 0.0273) and completed the Pharmacists Without Borders workshop (p = 0.0001) (Table 5).Justification of readiness to provide vaccination services in pharmacies in relation to participants’ basic characteristics was analysed using univariate and multivariate regression analysis. Both models were statistically significant. In the univariate regression model, significantly greater readiness for vaccination was demonstrated for pharmacists up to 30 years of age (p = 0.0001)  .Barriers affecting the pharmacists’ readiness to provide vaccination services in relation to basic characteristics of participants were analyzed using univariate and multivariate regression analysis. Both models were statistically significant.p = 0.0376), with the title of Ph.D. in pharmacy (p = 0.0242), working in independent pharmacies (p = 0.0165), and completed workshops Pharmacists without Borders (p = 0.0001). On the other hand, significantly greater barriers to vaccination were demonstrated for pharmacists with a master’s degree in pharmacy (p = 0.0285), working in chain pharmacies (p = 0.0165), and with the lack of completion of the Pharmacists without Borders workshop (p = 0.0001).In the univariate regression model, significantly lower barriers to vaccination were demonstrated for pharmacists up to 30 years of age (p = 0.0158), working in independent pharmacies (p = 0.0095), and with completed Pharmacists without Borders workshops (p = 0.0001). On the other hand, significantly greater barriers to vaccination were shown for pharmacists who did not complete the Pharmacists Without Borders workshop (p = 0.0001) (Table 5).In the multivariate regression model, significantly lower vaccination barriers were shown for pharmacists up to 30 years of age , and that patients expect the implementation of vaccinations administered by pharmacists (p = 0.0001).The pharmacists participating in the Pharmacists Without Borders workshops indicated much more often that there was a need for more university education and training courses for pharmacists in the administration of vaccinations (p = 0.0002) and to employ more pharmacists in pharmacies (p = 0.0002).On the other hand, those pharmacists who had not participated in the workshops more often stressed that in order to implement vaccination services, it was necessary to be able to designate special rooms for administering vaccinations in pharmacies (p = 0.0001), with the title of MSc in pharmacy (p = 0.0250), working in chain pharmacies (p = 0.0001), and less than ten years of work experience (p = 0.0001). On the other hand, significantly lower needs were indicated by pharmacists aged 41–50 (p = 0.0020) and over 50 (p = 0.0001), working in independent pharmacies (p = 0.0001) and with over ten years of work experience. The multivariate regression model showed significantly lower needs indicated by pharmacists aged over 50 (p = 0.0459) and working in independent pharmacies (p = 0.0049)  .To the best of our knowledge, this study is the first aimed at assessing the readiness of pharmacists to administer vaccinations in community pharmacies in Poland. Our research shows that pharmacists up to 30 years of age, with less than 10 years of experience in the profession and participating in Pharmacists Without Boarders workshops indicate the greatest readiness to perform vaccinations. According to the pharmacists, the most important elements influencing the readiness to administer vaccinations in pharmacies included the ease of access for patients and the role that they can play in advertising and promoting vaccinations. The pharmacists participating in the Pharmacists Without Borders workshops were much more likely to point out that providing vaccinations in community pharmacies would improve the overall vaccination coverage rate. This may be due to the higher level of knowledge and skills acquired during the workshops. Similar results were shown by other studies, e.g., those conducted in the United States  and SaudMany studies indicate the positive effects of implementing vaccinations in community pharmacies. The results of these studies prove that pharmacists increase the availability of vaccinations, accelerate immunization, effectively educate patients, affect the vaccination coverage rate, prevent new cases of diseases, and by reducing the number of diseases or complications, they bring savings to the healthcare system ,20,21,22Experiences in such countries as England, Portugal, and the United States prove the benefits of vaccinations for both patients and the healthcare system . SimilarInternational organisations such as the American Public Health Association (APHA) and the International Pharmaceutical Federation (FIP) encourage pharmacists to get involved in administering vaccinations ,26. The Many countries have permitted pharmacists to administer vaccinations. Vaccinations administered by pharmacists are common in community pharmacies in 13 European countries, including the United Kingdom, Norway, Greece, Portugal, Estonia, and other countries want to join in these activities .This study identified potential barriers to the implementation of vaccinations in Polish pharmacies. The pharmacists mainly pointed out the increased workload, insufficient training for pharmacists, and the fact that pharmacies were not adjusted to provide vaccinations. Much fewer barriers were indicated by pharmacists under 30, with the Ph.D. title, working in independent pharmacies. What is more, the pharmacists not participating in the Pharmacists Without Borders workshops pointed out various barriers to a much greater extent. The lack of relevant training courses as a barrier to providing vaccinations in pharmacies was also pointed out by researchers in Saudi Arabia .Other studies on patients’ attitudes and beliefs about vaccinations in community pharmacies indicate that patients express the need to use such services and accept that pharmacists may administer vaccinations. Patient concerns about these services relate to uncertainty about the skills of the pharmacist or the lack of a place for administering vaccinations in pharmacies where patient privacy can be maintained .A Canadian study suggests that pharmacists’ main concerns about vaccinations in pharmacies are logistical issues, while public concerns relate to uncertainties about the safety of vaccinations administered in pharmacies, keeping of medical records by pharmacists, and the cost of such vaccinations. Patients in Canada expressed the opinion that the cost of vaccination administered in pharmacies should not be higher than the cost of vaccinations administered in another facility .When implementing vaccinations in pharmacies, patient-related barriers influencing the overall low vaccination coverage rate should also be considered. Literature highlights low patient knowledge, uncertainty about vaccination safety, the need to travel to facilities at inconvenient times to get vaccinated, or the need to wait a long time for vaccination ,31,32.Taking into account the above, it seems that the implementation of vaccinations in pharmacies will minimise many barriers for patients. Convenient locations and open hours, the possibility of educating patients and explaining any disturbing information, may effectively increase the patient vaccination coverage rate.This situation is particularly important given the fact that flu vaccination rates in those over 65 years of age in Poland are under 10%. By comparison, this level is 72% in the United Kingdom and 68.7% in the United States .Among the factors necessary for the implementation of vaccination services in community pharmacies, pharmacists from the entire study group indicated above all that the possibility to designate rooms for administering vaccinations in pharmacies, relevant remuneration or reimbursement for vaccination services, and cooperation between pharmacists and healthcare centres were necessary. Pharmacists aged up to 30, with the MSc title in pharmacy, working in chain pharmacies, and with less than 10 years’ work experience, indicated much greater needs.Barriers on the part of the healthcare system, e.g., no relevant vaccination regulations, no extensive opportunities for education related to vaccinations, and a lack of access to patient medical data by pharmacists, should also be taken into account ,32. In PApart from thorough legal and organisational changes, a broad education of patients on vaccinations is necessary in Poland. In many countries, patients are satisfied with the availability of vaccinations in pharmacies. In Poland, patients’ opinions on providing vaccinations by pharmacists should be investigated.If vaccinations are implemented in pharmacies, campaigns will be needed to inform patients of this possibility. The implementation of vaccinations as a pharmaceutical service will also require small-scale pilot programmes to assess the results and identify areas that can be improved when preparing larger-scale activities. Results of this study should be used while planning the immunization legislation in Poland.In Poland, in mid-June 2020, a Coalition for Vaccination in Pharmacies was established, associating 3 organisations of doctors and pharmacists—the National Influenza Control Programme, the Supreme Pharmaceutical Chamber and the Trade Union of Pharmacy Workers. This idea is supported by the Supreme Pharmaceutical Chamber, which recognises that pharmacists can greatly increase patient knowledge of vaccinations and increase the level of vaccination against infectious diseases, especially the flu . The impIn the prevention of infectious diseases, especially in the case of the flu, the Polish healthcare system requires the relief from burden that can be achieved by using pharmacists in the provision of preventive services. At the same time, these activities require relevant preparation of pharmacies in terms of sanitation and logistics. Pharmacists wishing to administer vaccinations must obtain appropriate qualifications, which many of them do not currently have. For this reason, as part of the Pharmacists Without Borders initiative, workshops have been organised to prepare pharmacists for administering vaccinations in pharmacies. Studies on the effects of vaccination education for pharmacists in Italy showed that pharmacists with greater knowledge of vaccinations were more willing to engage in this type of services . SimilarLimitations of the studyThe various data sources enabled to reach nearly 1800 responses from pharmacists among 28,000 registered pharmacists in Poland, strengthening the exploration of the research topic. The response rates in normal conditions are low.Voluntary self-administered questionnaire distributed to pharmacists who will be willing to provide pharmacist immunization services and interviews with flu vaccination trained pharmacists with the Pharmacist Without Boarders project could have caused participant bias as the response of trained pharmacist was lower than pharmacist who were not trained.This study was conducted in the whole regions of Poland, but the most active region in response was the Mazovian region, where pharmacy chamber is most innovative and open for new projects. Findings might differ in the other areas and local pharmacy jurisdictions due to differences in vaccination service opinions in pharmacies.Protective vaccinations are one of the most effective methods of combating infectious diseases. The widespread use of vaccinations makes it possible to significantly reduce the spread of many diseases that contribute to serious health consequences, and often death. In this context, the significant reduction in social and economic costs of diseases from vaccinations should also be highlighted. However, the reduction in vaccination coverage rates observed in recent years may lead to the re-emergence of many diseases even if the disease in question has already been eradicated in a given area. Thus, ensuring the provision of vaccinations for the most important population groups, from the point of view of the entire community, should be one of the most important activities of institutions dealing with public health.Community pharmacies in Poland are facilities where vaccinations can be administered. This study shows that pharmacists are, to a large extent, prepared to administer vaccinations, although they indicate the need to increase their immunization knowledge. Educational programmes such as Pharmacists Without Borders, can to a significant extent prepare pharmacists to administer vaccinations in community pharmacies. In addition to providing pharmacists with the relevant education, it is necessary to prepare standards as well as a legal framework for the provision of such services. These actions are particularly important during the COVID-19 pandemic as pharmacists can have a significant impact on the vaccination coverage rate of patients, and thus take an active part in combating infectious diseases.


Emotional dysregulation (ED) is a core diagnostic symptom in borderline personality disorder (BPD) and an associated feature of attention-deficit/hyperactivity disorder (ADHD). We aimed to investigate differences in dynamical indices of ED in daily life in ADHD and BPD.We used experience sampling method (ESM) and multilevel modelling to assess momentary changes in reports of affective symptoms, and retrospective questionnaire measures of ED in a sample of 98 adult females with ADHD, BPD, comorbid ADHD+BPD and healthy controls.angry and irritable, and the instability of feeling sad, irritable and angry, findings paralleled by data from retrospective questionnaires. The heightened intensity in negative emotions in the clinical groups compared to controls was only partially explained by bad events at the time of reporting negative emotions, suggesting both reactive and endogenous influences on ED in both ADHD and BPD.We found marked differences between the clinical groups and healthy controls. However, the ESM assessments did not show differences in the intensity of feeling This study supports the view that ED is a valuable trans-diagnostic aspect of psychopathology in both ADHD and BPD, with similar levels of intensity and instability. These findings suggest that the presence or severity of ED should not be used in clinical practice to distinguish between the two disorders.The online version contains supplementary material available at 10.1186/s40479-021-00144-y. Differentiating attention-deficit/hyperactivity disorder (ADHD) from borderline personality disorder (BPD) is clinically important to facilitate the correct management of both conditions. Yet, some overlapping symptoms, notably emotional dysregulation (ED), can make differentiation of the conditions challenging , 2. AccoResearch shows that ED, characterised by problems with temper control, emotional over-reactivity, and mood lability, is present in 72–90% of adults with ADHD . ED, indIn BPD, ED is characterised by severe feelings of heightened and unstable reactivity of mood (DSM-5 criterion six) and difficulty controlling anger (DSM-5 criterion eight) , substanExperience sampling methods (ESM), also referred to as ecological momentary assessment (EMA)  can be uSo far, only one ESM study has investigated ED in adults with ADHD . In an aSeveral other studies investigated differences in emotion intensity and instability in BPD compared to other clinical groups. Compared to participants with depression, those with BPD reported a greater long-term (between-day) and short-term (within-day) instability of negative emotions , 22–24, Overall, these ESM studies support the notion that affective instability is not disorder-specific. And while results are consistent with overlapping symptoms of ED in ADHD and BPD as shown using retrospective questionnaire measures –30, to dADHD and BPD have both been associated with greater adversity and acute stressful situations in everyday life , 32. Thibad social events; involving other people or social situations, and bad functional events; involving practical and everyday life tasks), rated eight times daily over 5 days, in adult females with ADHD only, BPD only, comorbid ADHD+BPD, and controls. We hypothesised that in line with differences in diagnostic criteria for ADHD and BPD, participants with BPD would show heightened intensity and instability of positive and negative emotions compared to participants with ADHD. And consistent with criterion two of the DSM-5; “pattern of unstable and intense interpersonal relationships” in BPD, we further hypothesised that bad social events will be a stronger predictor of negative mood reactivity in BPD compared to ADHD, potentially setting apart the two conditions.We conducted a direct comparison of ADHD with BPD using an ESM approach. The study investigated the dynamics of positive and negative emotions and explored the occurrence and impact on intensity of negative emotions of self-reported adverse events , with a final sample of 98 participants used in this study. Controls, screened with the Barkley Adult ADHD Rating Scale  and the ED was assessed using one self-rated questionnaire and one investigator-rated interview scale; the Affective Lability Scale- Short form (ALS-SF)  and the ESM was carried out using a pseudorandomised fixed schedule of rating periods, eight times daily, across five consecutive days, according to established procedures . We usedMoodMapper employed a total of five continuous analogue scale questions on negative and positive emotions with ratings ranging from 0  to 100 (extremely), and one categorical multiple-choice question (see Table n = 7).To reduce self-selection bias of monitoring instances, all reports not completed within 16-min of the signal were excluded from analyses , 17. Comi-ti-1)2 [To obtain a measure of emotion instability, we calculated squared successive differences (SSD) for each continuous item: the squared value of the difference between successive responses (ti-ti-1)2 . SSD is i-ti-1)2 , 49 evali-ti-1)2 , incorpoi-ti-1)2 .  bad functional events: lost something, late/missed something I wanted, hurt/accident/pain, failed something, need to do something I dislike; which were non-social events relating to everyday life situations and involving the subject only. The total number of events reported for each category across the whole rating period per participant was then calculated and used as variables in subsequent exploratory analyses.Finally, multiple choice answers for the bad events question . Mean ratings were computed for each questionnaire-based self-report measure and compared between groups. Normality of data was assessed by examining histograms and QQ plots, and with the Shapiro-Wilk statistic. Parametric and non-parametric Kruskal-Wallis tests were used, as appropriate. For ESM data, multilevel models were used to account for correlated observations nested within individuals, which also perform well with missing data , 23.p = .01 for the multilevel analyses. Main findings reported in this paper are focused on the ESM analyses, we therefore did not correct for multiple testing for the analyses of questionnaire-based measures.In the multilevel models, adjustments for multiple testing contrast tests were made by applying Bonferroni and Bonferroni-Holm corrections. We further made Bonferroni correction across the five ESM items and used an adjusted We investigated differences across the four groups by contrasts, evaluating (1) intensity of emotions using raw data and (2) instability of emotions using SSDs. Normally distributed data were analysed with a linear multilevel model; a linear mixed model with a random intercept (SAS procedure GLIMMIX). As an example, we present the below model single equation representation we used to calculate intensity of emotions with a main effect of group.Yij represents the level of emotion intensity at time i for person j. The β coefficients represent the intercept and the fixed main effects for group, while the u0j denote random intercepts for person j and the εij the residuals at level 1.Here, 2 distribution, which is a special case of the gamma distribution and were analysed with generalised multilevel models with gamma distributions and log links (SAS procedure GLIMMIX), which relies on linearization and Taylor series techniques, to construct Wald-type test statistics and confidence intervals to estimate these models [SSDs follow a χe models . For fure models .bad social and bad functional events, we run a set of exploratory analyses. First, we investigated differences in the frequency of reported events in the groups. Second, multilevel models were run to investigate the relative contribution of bad events in the intensity of negative emotions across the whole sample and per group, and finally, additional models were run with a group  by bad events interaction to investigate potential group differences in negative emotion reactivity to bad events.Regarding self-reported Given the significant co-occurrence of depression and anxiety in both ADHD  and BPD age = 33.4, SD = 11.4): 28 with ADHD only, 19 with BPD only, 22 with comorbid ADHD+BPD, and 29 controls. The groups significantly differed on age, X2(3) = 14.53, p = .002, and IQ, F  = 4.6, p = .005. Both age and IQ were initially controlled for in the analyses of retrospective report measures and ESM data but did not have significant effects in the models. We therefore report models unadjusted for age and IQ. There were no group differences in ESM compliance rates (X2(3) = .12, p = .989; M = 74.8%, SD = 14.9).Group demographics and post-hoc comparisons are documented in Table Descriptive statistics and group comparisons of the measures are listed in Table 2(3)= 82.41, p < .001 for the ZAN-BPD, and X2(3)= 72.23, p < .001 for the DIVA). Post-hoc analyses indicated that all three clinical groups had significantly more BPD symptoms than the control group (ps < .01). Additionally, the ADHD group had significantly less BPD symptoms than the BPD and comorbid ADHD+BPD groups (p < .001), whereas no significant differences were seen between the BPD and comorbid ADHD+BPD groups (p = 1). Post-hoc analyses also indicated that the three clinical groups had elevated current ADHD symptoms compared to controls (ps < .05). The BPD group had significantly less ADHD symptoms compared to both the ADHD (p < .001) and comorbid ADHD+BPD (p < .01) groups, who showed no differences between each other on the measure (p = 1).Kruskal-Wallis tests revealed significant group differences in ADHD and BPD symptoms measured by retrospective report by the DIVA and ZAN-BPD respectively (X2(3) = 52.21, p < .001 for the ALS-SF, and X2(3) = 68.34, p < .001 for the WRAADDS-EDS). Post-hoc tests showed significantly elevated ED in all clinical groups compared to controls on both scales (p < .001). The three clinical groups did not differ on the ALS (ps ≥ .41). Regarding the WRAADDS-EDS, the ADHD+BPD group reported significantly elevated ratings compared to the ADHD group (p = .005), and comparisons between all other clinical groups were non-significant (ps ≥ .44).Kruskal-Wallis tests revealed significant group differences in ED measured by retrospective report (X2(3) = 61.85, p < .001 and anxiety, X2(3) = 66.59, p < .001. Post-hoc tests showed significantly elevated depression and anxiety in the clinical groups compared to controls (p < .001), except non-significant differences in depression between ADHD and controls (p = .08). Additionally, the ADHD group showed less depression and anxiety compared to comorbid ADHD+BPD (p < .001), and less depression compared to BPD (p = .001). No differences were seen between the ADHD and BPD groups on anxiety (p = .07), and between the BPD and ADHD+BPD groups on both subscales (p = 1).There were significant group differences in depression, XHappy: F = 11.96, p < .001; Excited: F = 4.44, p = .006; Sad: F = 15.04, p < .001; Irritable: F = 19.61, p < .001; Angry: F = 9.47, p < .001).Multilevel models revealed a significant main effect of group on the intensity of all positive and negative emotion items  in the control group compared to the BPD and ADHD+BPD groups (ps ≤ .0002). The control group also reported significantly elevated intensity of excited compared to the BPD group (p = .011) only. Compared to controls, the ADHD group reported heightened intensity of irritable (p < .0001), but no differences were seen between these two groups on the intensity of sad (p = .046) and angry (p = .097), and positive emotion items . All significant findings were robust to Bonferroni correction (adjusted p = .01).Case-control post-hoc comparisons  between the BPD and comorbid ADHD+BPD groups (ps ≥ .54). Participants with ADHD showed significantly higher intensity of happy (p ≤ .01), and a significantly lower intensity of sad (p ≤ .01) and angry (p < .05) compared to the BPD and comorbid ADHD+BPD groups, and a significantly lower intensity of irritable (p = .034) compared to the comorbid ADHD+BPD group. The clinical groups did not differ in the intensity of excited (ps ≥ .07). Differences between the clinical groups on intensity of angry and irritable were no longer significant after correction for multiple testing (adjusted p = .01).Post-hoc comparisons in the clinical groups showed no differences in the intensity of all positive and negative emotion items (p ≥ .38), except irritable  = 2.87, p = .04), whereby the ADHD group reported significantly elevated intensity of irritable compared to the control group. However, this finding was no longer significant after correction for multiple testing (adjusted p = .01)  = 2.88, p = .04; Sad: F = 7.67, p < .001; Irritable: F = 7.57, p < .001; Angry: F = 9.06 p < .001), except excited  = 1.46, p = .23). Only instability models for the negative emotion items remained significant after correcting for multiple testing (adjusted p = .01).Multilevel models revealed a main effect of group on the instability of all items  in the three clinical groups compared to controls (p ≤ .01). There were no differences in the instability of sad, irritable and angry between the three clinical groups (ps ≥ .16).Post-hoc comparisons (see Table p ≥ .09).  = 16.61, p = .001; bad functional event: X2(3) = 12.90, p = .005). Pairwise comparisons indicated that bad social events were more frequent in the ADHD (p = .03), BPD (p = .003) and comorbid ADHD+BPD (p = .009) groups compared to controls, with no differences between the three clinical groups (p = 1). However, bad functional events were only more frequent in the ADHD group compared to the control group (p = .003), with all other group comparisons being non-significant, ps ≥ .17 . Further models also indicated a significant main effect of bad social and bad functional events in the three negative emotion items for all four groups . All findings were robust to the Bonferroni adjusted p = .01. Therefore, group differences for all models  remained unchanged indicating that bad events predict overall greater intensity of sad, irritable, and angry but don’t fully account for the group differences.Multilevel models for intensity of bad functional events on the intensity of sad  = 1.75, p = .15) and irritable  = .36, p = .78). However, there was a significant diagnosis by bad functional events interaction for intensity of angry  = 4.82, p = .002). Findings indicated that the effect of bad functional events on intensity of angry was significantly higher in the BPD  and comorbid ADHD+BPD  groups compared to the ADHD group. Significant group differences were robust to the Bonferroni adjusted p = .01. For bad social events, models indicated no significant interaction with diagnosis on the intensity of sad  = 1.01. p = .39), irritable  = 2.47, p = .06) and angry  = .50, p = .68). Results were unchanged in models controlling for anxiety and depression symptoms, and we therefore only reported results from unadjusted models.Finally, to test group differences in the affective response to bad events, multilevel models were repeated including an interaction term for bad events with group. There was no significant interaction between diagnosis and irritable but not sad and angry), and increased instability of negative emotions  compared to controls. No differences were detected in the instability of positive emotion items between clinical groups and controls. Overall, these findings suggest that intensity and instability of positive emotions are not able to distinguish between individuals with ADHD and controls, contrary to clear differences in the intensity of emotions between controls and BPD populations.The main aim of this study was to assess whether ED substantially differs between ADHD and BPD. Using questionnaire measures of ED, individuals with ADHD and those with BPD did not differ from one another, but reported significantly increased ED compared to controls. High-frequency assessment over 5 days provided more fine-grained data. Using this approach, the BPD and comorbid ADHD+BPD groups displayed significant differences compared to controls, with less positive and more negative intensity of emotions, and more instability of negative emotions. In contrast, the ADHD group did not differ from controls in the intensity of positive emotion items, but showed heightened intensity of certain negative emotions  had the same effect for both the ADHD and BPD groups. The exception was that the BPD group reported higher intensity of lleagues , where BThis study was the first to compare ADHD and BPD on measures of ED using a prospective ESM approach. Despite using multiple measures of ED and including carefully selected and diagnosed clinical cases, the findings should be considered in light of several limitations.The compliance rate of around 75% was low compared to previous BPD studies with rates around 90% and above , 19, yetWe recruited an all-female clinical sample, limiting confounding by sex differences. BPD is more common in women in clinical samples , as apprn = 31). Excluding participants on anti-depressants would have made our sample unrepresentative of the ADHD and BPD populations, as the high rate of 45% in this study shows. To run the main analyses without these cases, the clinical sample size would have greatly decreased , making between group comparisons unmeaningful. Therefore, we could not run any sensitivity analyses with the exclusion of these cases.Care was taken to exclude individuals with current comorbid major depressive disorders and anxiety disorders. Yet, all three clinical groups showed high levels of anxiety and depression symptoms compared to controls, and significant differences between groups in measures of ED in ESM data were all accounted for by anxiety and depression symptoms. Additionally, eight ADHD cases, 15 BPD cases and eight comorbid ADHD+BPD cases were on concomitant anti-depressants for co-occurring mild depressive symptoms, which constituted around 45% of the total clinical sample  comorbidities, and attribute findings accurately to the disorders under investigation. This has nevertheless the limitation of our sample not being representative of ADHD and BPD populations, which often present with comorbidities.Whether assessed using retrospective questionnaires or by ESM, all reports were based on the subjective view of the individuals of their affective states. Future investigations of ED in ADHD and BPD using ESM approach should consider incorporating more objective physiological measures  that capture objective autonomic responses which can be associated with emotional changes .Finally, although our findings indicate that ED is expressed to a similar degree of intensity and instability in ADHD and BPD, it’s worth acknowledging that this conclusion is based on two widely used markers of ED only, and future research could incorporate other markers such as cue reactivity or return to baseline.The current study characterised the intensity and instability in emotions experienced by adult females with ADHD and/or BPD over a period of five days. Findings supported the notion that ED has a valuable trans-diagnostic clinical pattern in both conditions and is unlikely to be helpful in distinguishing between ADHD and BPD. Further research should now explore overlapping mechanisms of ED using dimensions of neurobiology and observable behaviour, as suggested by the Research Domain Criteria  and use Additional file 1.


Participants were administered tasks and questionnaires to confirm their initial diagnosis, and a battery of executive function (EF) tasks testing inhibition, shifting, and verbal and visuospatial updating. Using one-way ANOVAs, our results showed that all children in the clinical samples exhibited impairments on EF measures (inhibition and shifting tasks) when compared with TD children. A more specific pattern only emerged for the updating tasks. Only children with SLD had significant impairment in verbal updating, whereas children with ADHD, and those with SLD in comorbidity with ADHD, had the worst performance in visuospatial updating. The clinical and educational implications of these findings are discussed.The present study examines the comorbidity between specific learning disorders (SLD) and attention deficit and hyperactivity disorder (ADHD) by comparing the neuropsychological profiles of children with and without this comorbidity. Ninety-seven schoolchildren from 8 to 14 years old were tested: a clinical sample of 49 children with ADHD ( The extant research has clearly shown that various developmental problems tend to co-occur  and specific learning disorders (SLD) has been widely studied, mainly because of their high prevalence  domains . According to the DSM-5, SLD is characterized by problems in academic skills, such as reading, writing, or arithmetic, which provide the foundations for other, more advanced academic learning , despite some studies highlighted the importance of EF as potential shared risk factor between SLD and ADHD  were administered. Samples of children with a clinical diagnosis were matched with TD children for chronological age and intelligence level. Our main aims were to investigate specific impairments in EF domains in the clinical groups and to test the potential additive effect of the comorbidity between ADHD + SLD.Based on previous studies, we expected all children in the clinical groups  to show EF impairments . Children with a clinical diagnosis of ADHD, SLD, or ADHD + SLD were recruited at the child and adolescent neuropsychiatry services. TD children were enrolled at primary and secondary schools. The children in the clinical groups had already been independently diagnosed according to the DSM-5 ; 18 with SLD ; and 13 with ADHD + SLD . They were matched with 48 TD children  for chronological age  = 1.56, p = 0.20, 2AdjustedR = 0.02), gender (χ2(df = 3) = 5.16, p = 0.16, Cramer-V = 0.231), and FSIQF = 0.39, p = 0.76, 2AdjustedR = 0.02).All participants were native Italian speakers, and none had any diagnosed neurological conditions. Exclusion criteria for all participants were: a history or concurrent diagnosis of other neurodevelopmental disorders; a history of neurological problems; current use of medication; medical illness requiring immediate treatment; psychological treatments in progress; or a certified intelligence quotient (IQ) below 80 . The cliFor the study, all diagnoses were confirmed by assessing ADHD symptoms and learning difficulties as explained below in the “Group Selection Measures” section.The Research Ethics Committee of the University of Padua approved the study.CPRS R:S Conners, . This par = 0.74 to r = 0.96  shown on the computer screen. A detailed description of both verbal and visuospatial updating is reported in the Two updating tasks were devised with different types of stimuli, verbal in one and visuospatial in the other. Both tests, administered using E-prime  or at the Child Neuropsychiatry Department of the hospital to which they referred for their diagnosis . At the same time, parents completed a rating scale to assess their children’s ADHD symptoms.Participants completed both the group selection measures and the cognitive tasks, administered in a counterbalanced order, during two individual sessions lasting approximately 1 h each. Instructions were given for each task, and participants practiced with each task before starting the experiment. All experimental tasks were preceded by two practice trials. For the computer-based tasks, the children sat in front of the computer screen and the experimenter sat on the child’s right to present the tasks.Data analyses were conducted using R RC Team, . One-wayThe analyses were run in two stages. In the first, Group was included as an independent variable. In the second, to answer the question of whether or not the comorbid group has an additive profile, the same analyses as in the first stage were run, with the presence of ADHD (no/yes) and SLD (no/yes) as factorsAIC, Akaike, The Akaike information criterion  allowed us to collect accurate data for each item from each participant. Generalized mixed-effects models were used  = 6.80, p < 0.001, 2AdjustedR = 0.15), and shifting  = 3.27, p = 0.025, 2AdjustedR = 0.07). For both conditions, children with a clinical diagnosis performed significantly worse than TD children . No other differences emerged between the groups. In the second stage, the same analyses were run using the presence of ADHD and SLD as factors. In the inhibition task, a main effect of ADHD emerged  = 11.04, p = 0.001, full model: AIC = 451.96, model without ADHD AIC = 460.74) and SLD  = 4.30, p = 0.04, model without SLD AIC = 454.30). As shown in F = 2.40, p = 0.12, model with interaction AIC = 451.49).F = 4.60, p = 0.03, full model: AIC = 472.32, model without ADHD AIC = 474.96), but not for SLD  = 1.94, p = 0.16, model without SLD AIC = 472.31). As shown in F = 2.12, p = 0.15 model with interaction AIC = 472.13).In the shifting task, a main effect emerged for ADHD  = 3.40, p = 0.02, 2AdjustedR = 0.07), as children with a clinical diagnosis of SLD performed significantly worse than children with TD or ADHD . There was also a main effect of Group in Visuospatial updating  = 3.59, p = 0.02, AdjustedR2 = 0.07), as children with ADHD and ADHD + SLD performed significantly worse than the TD or SLD groups . No other differences emerged between the groups.F = 7.90, p = 0.006, full model: AIC = 133.77, model without SLD AIC = 139.94), but not for ADHD  = 1.04, p = 0.31, model without ADHD AIC = 140.69). As shown in F = 1.85, p = 0.18, model with interaction AIC = 133.68). In the Visuospatial updating task, there was a main effect of ADHD  = 10.87, p = 0.001, full model: AIC = 55.64, model without ADHD AIC = 64.26), but not of SLD  = 0.15, p = 0.70, model without SLD AIC = 66.11). Here again, the interaction was not significant  = 0.004, p = 0.95, model with interaction AIC = 62.27), as shown in In the second stage, using ADHD and SLD as factors, a main effect on the Verbal updating task emerged for SLD (χ2(3) = 184.52, p < 0.001, model without Span: AIC = 1,993.9). No significant interaction between Group and Span emerged. In the Visuospatial updating task, there was a main effect of Group (χ2(3) = 10.55, p = 0.01, full model: AIC = 2,013.5, model without Group: AIC = 2,018) and Span (χ2(3) = 100.11, p < 0.001, model without Span: AIC = 2,107.6). The interaction between Group and Span was also significant (χ2(9) = 33.63, p < 0.001, model with Interaction: AIC = 1,997.8).Finally, in the mixed-model analysis , by comparison with TD children. We were particularly interested in understanding whether the EFs profiles of four groups differed and whether the comorbid group (ADHD + SLD) showed an additive  or rather an interactive effect . Children in the clinical groups had been previously diagnosed at centers specialized in neurodevelopmental disorders. In the first part of the assessment, all their diagnoses had been confirmed through specific questionnaires for parents and appropriate academic achievement tests.To test potential differences in EFs profiles, children with a clinical diagnosis of ADHD, SLD, and comorbid ADHD + SLD were compared with TD children on measures of inhibition, shifting, and updating . In our analyses, we first compared our groups considering EF measures separately. Then, we ran the same analyses considering the presence of ADHD (no/yes) and/or SLD (no/yes) as factors to see whether the comorbid group reveals an additive profile. Finally, mixed-effects models were used to analyze in detail performances at different span levels for the updating tasks.In the group comparisons, our findings showed that all clinical groups performed worse than the TD group, and no differences emerged between any of the clinical groups on measures of inhibition and shifting. A more specific pattern emerged when the groups were compared on updating measures. Children with SLD performed less well than the other groups in the verbal task, while the groups with ADHD or ADHD + SLD performed less well than either the SLD or the TD groups in the visuospatial task. This would contradict the idea of an additive effect of the two disorders combined  and math . Dyslexia and dyscalculia seem to involve distinct cognitive profiles in terms of domain-specific processes , but similar domain-general cognitive processes (particularly concerning WM). Domain-general cognitive processes like WM may therefore substantially overlap between dyslexia and dyscalculia (Peters and Ansari, As concerns comorbid ADHD + SLD, our data would support the claim that ADHD + SLD is not a third, separate disorder with a specific pattern of EF impairments since we could find no specific profile distinctive of children with both conditions. Thus, we could not rule out the possibility of ADHD and SLD shared the same biological and environmental risk factors, increasing the likelihood of their co-occurrence and supporting the correlated liabilities hypothesis (Pennington et al., Although our study produced some interesting findings, our results should be considered explorative because it has some limitations. First of all, the sample size was small and the children in the SLD group had significant impairments in both reading and math, which prevented us from analyzing their influence separately. Second, the SLD group also had some attention-related problems, though they were not clinically relevant, and some differences in achievement emerged between groups of ADHD and typical development and SLD and ADHD + SLD. It is worth emphasizing that the children in our clinical groups had previously received a clinical diagnosis, and the heterogeneity of our sample’s difficulties was typical of neurodevelopmental disorders and the impairments were not fulfilling criteria for different diagnoses. Another limitation of our study lies in that we only administered a limited set of EF tasks, without differentiating between verbal and visuospatial tasks for inhibition and shifting. We chose these particular tasks because the procedure was already long and hard, particularly for children with ADHD, and because they reflected our theoretical background (Miyake et al., Even with the above-mentioned limitations, our study has some important clinical implications. Understanding the specific type of interaction, the similarities, and differences between ADHD and SLD, and the combination of the two is fundamental to our ability to assess and treat all three conditions. The DSM-5 (American Psychiatric Association, To conclude, it is important to emphasize that no important differences emerged from our study between the clinical conditions considered as regards the children’s EF impairments. All three clinical groups were significantly impaired by comparison with TD children. However, a more specific pattern emerged for the WM updating, in which verbal and visuospatial presentation format seems to better differentiate the SLD and ADHD profiles. Nevertheless, further studies are needed to confirm our findings.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Psychology Research Ethics Committee of the University of Padua. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.SC and IM developed the study concept. Testing was performed by GC. RC and GC performed the data analysis. GC and SC drafted the manuscript and IM provided revisions. All authors contributed to the article and approved the submitted version.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.


Modeling the behavior of motorcyclist with Millon and ADHD: Regression Modeling Abstract Background and Objectives: Road traffic accidents are one of the serious public health problems in the world and human factors can be effective. This study was carried on modeling of the relationship between MRBQ with Millon and ADHD.In this case-control study, 300 cases and 156 controls were selected using a cluster random sampling in Tabriz, Iran. Regression modeling to investigate the relationship between MRBQ with Millon and ADHD was studied with SPSS25 software.Due to the R Square was predictable for the overall model approximately 30%, case group models 35% and for the control group was approximately 18% of MRBQ by Millon and ADHD. The standard coefficients  and the probable significance of the relationship between MRBQ with Millon and ADHD were obtained as follows. In generally: Millon (B= 0.17 (CI (0.95) 0.06, 0.17), P<0.001) ADHD (B= 0.48 (CI (0.95) 0.80, 1.15), P< 0.001) In Case group: Millon (B= 0.20 (CI (0.95) 0.06, 0.18), P< 0.001) ADHD (B= 0.50 (CI (0.95) 0.82, 1.15), P< 0.001) In Control group: Millon (B= 0.10 (CI (0.95) -0.04, 0.20), P=0.204) ADHD (B= 0.39 (CI (0.95) 0.44, 1.07), P< 0.001).The results showed, that the behavior of the people who accident (case group), There was a stronger relationship with Millon and ADHD. Therefore, planning appropriate and fits with the conditions of individuals it is necessary to accident avoidance and improved their quality of life.MRBQ, ADHD, Linear regression, Millon


Mice exposed to high-efficiency particulate air (HEPA)-filtered room air served as the CS control group. High-dose (3 × 107 cells/kg) hUC-MSC administration significantly decreased tumor necrosis factor (TNF)-α in the bronchoalveolar lavage fluid (BALF) of CS-exposed mice (p < 0.05). The chemokine (CXC motif) ligand 1/keratinocyte chemoattractant (CXCL1/KC) in BALF were significantly reduced by low-dose (3 × 106 cells/kg) and high-dose (3 × 107 cells/kg) hUC-MSC (p < 0.05). Medium-dose hUC-MSC administration decreased interleukin (IL)-1β in lung of mice, and TNF-α and caspase-3 were decreased in the lung of CS-exposed mice by medium- and high-dose MSC (p < 0.05). Low-dose hUC-MSCs significantly elevated serum CXCL1/KC and IL-1β in CS-exposed mice (p < 0.05). Our results suggest that high-dose hUC-MSCs reduced pulmonary inflammation and had antiapoptotic effects in acute pulmonary inflammation.Cigarette smoke (CS) has been reported to induce oxidative stress and inflammatory process in the lungs. However, the role of human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) in the regulation of pulmonary inflammation remains unclear. The objective of this study is to investigate the effects of hUC-MSCs on lung inflammation in the acute CS-induced pulmonary inflammation animal model. Eight-week-old male C57BL/6 mice were intravenously administered 3 × 10 Cigarette smoke (CS) contains numerous toxic chemical compounds and carcinogens . The med+ T cells increased in severe emphysema  in immunoregulation has been investigated for clinical purposes. A decreased level of angiopoietin-2 after the administration of a single dose of MSC has been reported in moderate to severe acute respiratory distress syndrome . Followimphysema . Accordiin vivo  have a more steady doubling time, rarely produce teratomas, and possess a higher differentiation capability than bone marrow-derived MSCs. Reduced expression of major histocompatibility complex classes I and II has been observed to reduce immunogenicity in hUC-MSCs . Recentlin vivo . hUC-MSCin vivo .Promoting cytokine and chemokine production can induce the homing process of MSCs in damaged tissue . Most MSg) were obtained from the National Laboratory Animal Center . A constant temperature (22 ± 2°C) and relative humidity (55 ± 10%) and a 12 h:12 h light:dark cycle were maintained throughout the study. The mice were housed in plastic cages and were administered Lab Diet 5001 , and they had ad libitum access to water during acclimatization. The animal experiments were performed in compliance with the Animal and Ethics Review Committee of the Laboratory Animal Center at Taipei Medical University .Male C57BL/6JNarl mice  was determined using a DustTrak monitor . The PM2.5 emitted from cigarette combustion was measured four times (1 time/cigarette) per day.The CS exposure system had three major components, namely, a CS generator, a whole-body exposure system, and measurement devices, as illustrated in 2 at 37°C for 3 days, at which point the culture medium was replenished, and the non-adherent cells were removed. hUC-MSCs were passaged once reached 80–90% confluence to the sixth generation. For long-term storage, hUC-MSCs were suspended in CryoStor CS10  and cryopreserved in a vapor phase liquid nitrogen tank. This study was approved by the Ethics Committee of the National Cheng Kung University Hospital Institutional Review Board . All subjects received written and oral information prior to inclusion and provided informed consent. All study processes were carried out in accordance with the approved study protocol (A-BR-104-045).Human umbilical cord-derived mesenchymal stem cells were obtained from Meridigen Biotech Co., Ltd. . The cells used in the present study were followed by the International Society for Cellular Therapy Guidelines. Umbilical cord tissue was harvested under sterile conditions and digested with collagenase  for 120 min in a 37°C incubator. Digestion was terminated in α-minimal essential culture medium  supplemented with 18% fetal bovine serum (Invitrogen), 4 ng/ml basic fibroblast growth factor , and 50 mg/ml gentamicin. The cells were subsequently incubated in a humidified incubator with 5% COvia tail vein) a single dose of hUC-MSCs  provided by Meridigen Biotech Co., Ltd., in clinical grade normal saline containing 2% clinical grade human serum albumin and 16.7% clinical grade CS10. Control mice were given the same volume of vehicle alone. On Day 8, all mice were anesthetized [intraperitoneally (i.p.)] under Zoletil  and xylazine, followed by CO2 euthanasia. The facial blood, bronchoalveolar lavage fluid (BALF), and whole lungs were collected (n = 10 per group). The BALF was collected by washing the lungs three times with 0.5 ml of phosphate-buffered saline (PBS). The BALF samples were centrifuged at 200G for 10 min at 4°C. The supernatant and pellets were collected for biochemical and hematology analysis, respectively. The submandibular method was used for blood collection. The blood samples were stored at room temperature for an hour following centrifugation at 200G under 4°C for 10 min.The experiment design is depicted in The mouse body weight was measured on Day 1 (the day before CS exposure), Day 4 (the day before hUC-MSC administration), and Day 8.The BALF pellets were resuspended with 40 μl of PBS for hematology analysis . The total cell, neutrophil, lymphocyte, monocyte, and eosinophil counts were measured using a hematology analyzer. For the differential cell analysis, the data were presented as percentages (%) of the total cell number.Lung tissues were homogenized in 490 μl of lysis reagent  with 5 μl of protease inhibitor  and 5 μl of ethylenediaminetetraacetic acid using a homogenizer , according to the manufacturers’ instructions.Enzyme-linked immunosorbent assay (ELISA) was used to investigate the tumor necrosis factor (TNF)-α , chemokine (CXC motif) ligand 1/keratinocyte chemoattractant , and interleukin (IL)-1β (Invitrogen) in the BALF and serum samples. TNF-α, KC, IL-1β, matrix metallopeptidase (MMP)-9 (R&D Systems), and caspase-3 levels  in lung lysates were determined. All of the ELISA kits were conducted following the manufacturers’ instructions. The levels of these markers determined in lung tissues were adjusted based on the total protein in lung lysates. The detailed information of these ELSA kits was shown in t test. Comparisons within multiple groups were performed through analysis of variance (ANOVA) with Fisher’s post hoc test. Statistical analyses were conducted using GraphPad ver. 7  for Microsoft Windows. The significance criterion was set to p < 0.05.Ten mice in each group were included in each analysis. The Shapiro–Wilk’s test was used to examine the normality. The data are expressed as mean ± standard deviation (SD). The data from repeated measurement were compared using the paired 2.5 was generated at an average of 108.7 ± 72.8 mg/m3 during the first 10 min of combustion. The concentration peaked at 194.2 ± 33.7 mg/m3 approximately between 5 and 6 min and started to decline afterward.As presented in 7 cells/kg; p < 0.05). Conversely, monocytes significantly decreased after medium- (1 × 107 cells/kg), and high-dose (3 × 107 cells/kg) hUC-MSC administration (p < 0.05). No significant difference was observed in lymphocytes and eosinophils among the groups.The total cell counts and differential cell counts (%) in the BALF were determined, and the results are shown in 7 cells/kg) significantly reduced the level of TNF-α (p < 0.05). Low- (3 × 106 cells/kg) and high-dose (3 × 107 cells/kg) hUC-MSC administration also significantly decreased CXCL1/KC (p < 0.05). No significant decrease in IL-1β was caused by hUC-MSCs after CS exposure.After hUC-MSC administration, TNF-α, CXCL1/KC, and IL-1β levels in the BALF were determined, as illustrated in 7 cells/kg) and high-dose (3 × 107 cells/kg) hUC-MSC administration (p < 0.05). No significant difference was observed in CXCL1/KC production after hUC-MSC administration. Medium-dose (1 × 107 cells/kg) hUC-MSC administration significantly reduced IL-1β in lung tissues (p < 0.05). There were no significant differences in MMP-9 between the groups. The hUC-MSCs exhibited a significant mitigating effect on apoptosis by reducing caspase-3 (p < 0.05).The levels of TNF-α, CXCL1/KC, IL-1β, and MMP-9 in lung lysates were determined. As displayed in 6 cells/kg) hUC-MSC administration compared with after CS and high-dose (3 × 107 cells/kg) hUC-MSC administration (p < 0.05). The administration of low (3 × 106 cells/kg) and medium (1 × 107 cells/kg) doses of hUC-MSCs significantly increased IL-1β levels compared with RA (p < 0.05), whereas IL-1β was increased by the medium dose of hUC-MSCs when compared with that of the CS group (p < 0.05).The serum levels of TNF-α, CXCL1/KC, and IL-1β were determined, and the results are shown in in vivo.Human umbilical cord-derived mesenchymal stem cells have been reported to regulate inflammation and protect host cells from apoptosis . In our 2.5 at an average of 108.7 ± 72.8 mg/m3 during the study period. Consistently, in previous reports, mice were exposed to CS at an average of 90–100 mg/m3 -2] within 2 h, which was followed by a reduction of immune reactivity . By contin vivo, our study has some limitations. We observed the effects of hUC-MSCs on the acute pulmonary inflammation model; however, the regulation of hUC-MSCs in the chronic CS exposure model remains unclear. hUC-MSCs were administered for 4 days, but the chronic effects of hUC-MSCs on lungs have not been determined in the present study. We noted that high-dose hUC-MSCs reduced lung inflammation but resulted in neutrophil infiltration. Additional studies are required to better understand this phenomenon. The quantity of oxidative stress and mechanistic experiments  will be used to investigate the role of hUC-MSC in CS-induced pulmonary inflammation in vivo. The chronic CS-induced pulmonary inflammation mouse model will be used in future works.Although we determined the effects of hUC-MSCs on acute pulmonary inflammation The present study adds to the recent research by demonstrating that hUC-MSCs mitigate pulmonary inflammation in the acute CS-induced pulmonary inflammation mouse model. Moreover, the administration of hUC-MSCs reduces apoptosis in the lungs. Our findings demonstrate that hUC-MSCs can attenuate pulmonary inflammation and may exhibit antiapoptotic effects in the short-term CS-exposed pulmonary inflammation model. hUC-MSCs may be a novel therapeutic strategy for acute pulmonary inflammation disease.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the National Cheng Kung University Hospital Institutional Review Board. The patients/participants provided their written informed consent to participate in this study. The animal study was reviewed and approved by Animal and Ethics Review Committee of the Laboratory Animal Center at Taipei Medical University. Written informed consent was obtained from the owners for the participation of their animals in this study.H-CC and X-YC contributed to the completion of interpretation of the data and the manuscript. H-CC, WL, and C-WC contributed substantially to the concept, design, interpretation of the data, and completion of the study and the manuscript. Y-YC, C-HC, and Y-CW contributed substantially to the completion of the study. T-CH contributed to the establishment of the cigarette smoke generation system and particle measurement. All authors contributed to critically revising the manuscript for important intellectual content. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We investigated whether “late-onset” ADHD that emerges in adolescence/adulthood is similar in risk factor profile to: 1) child-onset ADHD, but emerges later because of scaffolding/compensation from childhood resources; and 2) depression, because it typically onsets in adolescence/adulthood and shows symptom and genetic overlaps with ADHD.We examined associations between late-onset ADHD and ADHD risk factors, cognitive tasks, childhood resources and depression risk factors in a population-based cohort follow-up to age 25 years (N=4224-9764).Parent-rated late-onset ADHD was like child-onset persistent ADHD in associations with ADHD polygenic risk scores and cognitive task performance, although self-rated late-onset ADHD was not. Late-onset ADHD was associated with higher levels of childhood resources than child-onset ADHD and did not show strong evidence of association with depression risk factors.Late-onset ADHD shares characteristics with child-onset ADHD when parent-rated, but differences for self-reports require investigation. Childhood resources may delay the onset of ADHD. The DSM-5 currently conceptualises ADHD as a neurodevelopmental disorder that onsets in childhood, prior to age 12 years . HoweverFindings that late-onset ADHD is associated with higher cognitive ability than child-onset ADHD  could suInterpreting findings on late-onset ADHD is complicated by methodological issues. One important consideration is who reports the symptoms. In childhood, ADHD symptoms are usually reported by a parent, but this typically changes to self-report after the age of 18 years. Agreement between parent- and self-reported ADHD symptoms is typically low. In clinical studies, affected individuals even in adult life tend to under-report symptoms e.g.  comparedA second methodological consideration is how late-onset ADHD is operationalised. Most longitudinal studies have defined late-onset ADHD in individuals who surpass validated thresholds for ADHD symptom counts . An alteOur study aimed to investigate the nature of late-onset ADHD, utilising different informants , operationalisations  and measures . We tested two hypotheses: (1) late-onset symptoms reflect a similar disorder to child-onset ADHD, but with delayed symptom onset. If this hypothesis is correct, we would predict that young-adults with late-onset and child-onset ADHD symptoms will show similar ADHD risk factor profiles and cognitive impairments, but that those with late-onset would have higher levels of childhood internal and external resources that may allow compensation for underlying ADHD liability or obscure the presence of symptoms in childhood (i.e. “compensation” or “scaffolding”). (2) late-onset ADHD symptoms reflect a variant of depression: in this case, compared to those with child-onset ADHD symptoms, young-adults with late-onset symptoms will show stronger associations with depression risk factors.We analysed data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a well-established prospective birth cohort study. Pregnant women resident in Avon, UK with expected dates of delivery 1st April 1991 to 31st December 1992 were invited to take part in the study. When the oldest children were approximately 7 years of age, an attempt was made to bolster the initial sample with eligible cases who had failed to join the study originally, resulting in a total of 14,901 study offspring alive at 1 year of age. Where families included multiple births, we included the oldest sibling. Full details of this study are provided in the ADHD symptoms were measured using the 5-item ADHD subscale of the Strengths and Difficulties Questionnaire (SDQ) and the Genetic risk for ADHD was indexed using polygenic risk scores (PRS). PRS were generated using PRSice version 1.25  based onPreterm birth (<37 weeks gestation) and low birth weight (<2500g) were included as risk factors for ADHD  for singletons (99% of the primary sample).We investigated cognitive tasks that index characteristic features of ADHD: attention and response inhibition.Sustained attention was assessed using the Tests of Everyday Attention for Children (TEA-Ch) Sky SearInhibitory control was assessed using the TEA-Ch Opposite Worlds task, which is a type of Stroop task  at age 8We examined internal and external resources in childhood that may compensate for, or scaffold symptoms. These included (i) verbal IQ, given evidence that this may facilitate compensation in relation to autistic behaviours , (ii) chChildhood verbal ability was assessed using the Wechsler Intelligence Scale for Children  at age 8Family income was measured by mother-report when the child was approximately age 11 years as the average household income including social benefits each week on a 10-point scale from <£120 to ≥£800. Maternal education was assessed by mother-report during pregnancy as the highest educational qualification on a 5-point scale from CSE or no qualifications to university degree.Genetic risk for depression was indexed using PRS based on GWAS of major depression . GenotypHistory of depression in the mothers was assessed during pregnancy. Assessment was by self-report of a lifetime ever history of severe depression.Late-onset ADHD was defined using different informants, operationalisations and measures to assess consistency of findings across definitions.child-onset persistent ADHD if they had high symptoms at either age 17 or 25 years, otherwise they were classified as having child-limited ADHD. Individuals with low ADHD symptoms at ages 7, 8, 9 and 12 years, but who had elevated symptom levels at ages 17 or 25 years were classified as having late-onset ADHD. Those with subthreshold symptoms in childhood, but high symptoms at ages 17 or 25 were categorised as subthreshold late-onset and are presented for descriptive purposes only. Individuals without high symptoms at any time-point were classified as having low symptoms. The definitions of all groups are shown in ADHD symptoms were categorised using a similar procedure to our previous work , using SGrowth mixture modelling (GMM) was used to derive trajectories of ADHD symptoms from ages 4 to 25 years in Mplus  separateWe report the means or proportions for each examined variable for each ADHD group. Our primary analyses compared late-onset versus child-onset persistent ADHD. We used multinomial logistic regression to test associations. We used child-onset persistent ADHD as the reference group for the primary analyses and ran secondary analyses using low ADHD symptoms as the reference. For trajectory analyses we used a bias-free three step approach which accounts for measurement error in class assignment . OrdinalEstimates of late-onset ADHD across definitions are shown in ADHD groupings based on self- and parent-reported SDQ cut-points in adulthood are shown in Comparing parent- and self-rated late-onset definitions, 44.6% of those with late-onset ADHD according to parent-reports were also categorised as late-onset based on self-report. In contrast, only 16.6% of those with late-onset ADHD based upon self-report also had late-onsetADHD by parent-reports. Additional details of overlap between self- and parent-reported adult symptoms are given in the Post-hoc analyses suggested 3.4-6.6% of the sample experienced fluctuating (temporarily-remitted) symptoms; results are presented in the For trajectory analyses, only parent-reports were used to enable a consistent informant across time points. As shown in The means and proportions for examined variables by ADHD group are shown in Regardless of informant or classification system, male sex was consistently associated with a decreased likelihood of having late-onset compared to child-onset persistent ADHD. ADHD PRS were similar in those with late-onset and child-onset persistent ADHD when using parent-reported symptoms but were lower in those with late-onset ADHD when using self-reported adult symptoms. We did not find strong evidence that prevalence of preterm birth or low birth weight differed in the late-onset compared to child-onset persistent group.ADHD cognitive task performance did not consistently differ between late-onset and child-onset persistent ADHD when using parent-reported symptoms but was higher in those with late-onset ADHD when using self-reported adult symptoms.Higher levels of childhood verbal and reading ability, family income and maternal education were associated with late-onset compared to child-onset persistent ADHD.There was not strong evidence for an association with late-onset ADHD compared to child-onset persistent ADHD for depression PRS or maternal depression. There was also not a female preponderance in the late-onset group.This study aimed to investigate the nature of late-onset ADHD using different informants, operationalisations and measures in a prospective, longitudinal population sample spanning childhood to young-adulthood. We tested two hypotheses on the nature of late-onset ADHD symptoms: (a) late-onset symptoms reflect a similar phenotype to child-onset ADHD, but with delayed symptom onset, and (b) late-onset ADHD symptoms reflect a variant of depression.Regardless of ADHD informant, operationalisation or measure, we found evidence for a group of individuals with high levels of ADHD symptoms that start for the first time after childhood. In late-adolescence/young-adulthood, the prevalence of late-onset ADHD was higher for self-reports than for parent-reports. The majority of late-onset ADHD identified was adult-rather than adolescent-onset: while for categorical definitions this could have been due to the lower cut-point used in young-adulthood compared to adolescence, this would not apply to trajectory analyses which used continuous symptom scores. Adult-onset being more common than adolescent-onset may explain why previous trajectory analyses in this same cohort with follow-up to age 17 years did not identify a late-onset trajectory  whereas Our analyses investigating associations with ADHD and depression risk factors, and internal and external resources generally supported the hypothesis that late-onset ADHD reflects a similar phenotype to child-onset ADHD, rather than a variant of depression when parent-ratings were used. However, findings for self-rated ADHD were not clear. We did not find evidence of a female preponderance in the late-onset group, which would have been expected for depression , althougOur “alternative disorder” hypothesis focusses specifically on depression, because this typically onsets at the same age as late-onset ADHD (adolescence or early adulthood)  and deprWe found similarly elevated levels of genetic risk for ADHD (indexed by PRS) in those with late-onset ADHD as those with child-onset persistent ADHD when defined using parent-reports, but found lower PRS in those with late-onset ADHD when using self-reported adult symptoms. This PRS finding for parent-reported late-onset ADHD was consistent across different operationalisations and measures of ADHD. Previous studies have not found evidence of elevated ADHD PRS in those with late-onset ADHD: these have either used self-reports  or have One explanation for why the same underlying disorder (ADHD) may onset later in development for some is that higher levels of childhood internal and external resources may allow individuals to compensate for underlying ADHD difficulties or obscure/delay the presence of symptoms (i.e. compensation or scaffolding). This is supported by reported associations between late-onset ADHD and higher IQ  and is sOur findings should be considered in the context of study limitations. Like many population cohorts, ALSPAC suffers from non-random attrition, whereby individuals at elevated risk of psychopathology are more likely to drop-out of the study . Thus, pIn summary, across different operationalisations and measures, we found similar levels of ADHD genetic liability (PRS) in those with parent-rated late-onset compared to child-onset persistent ADHD, suggesting that parent-rated late-onset ADHD is indexing ADHD genetic liability. Those with late-onset ADHD had higher levels of individual-based and family-based resources. Self-ratings however defined a different late-onset ADHD group which did not show the same profile as child-onset ADHD. Taken together our findings suggest that at least for some, ADHD may onset later in development in the context of childhood compensation or scaffolding resources and further challenges the assertion that ADHD always first onsets before age 12 years.Supplementary Material


This study assessed the co-occurrence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in newly diagnosed adults of normal intelligence and the contribution of trait-based dimensions deriving from the Barkley Adult ADHD Rating Scale-IV (BAARS-IV), the Autism-Spectrum Quotient (AQ), and the Empathy Quotient (EQ) to the differentiation of patients with ADHD, ASD, and ADHD/ASD. A total of 16.1% of patients with ADHD received a co-occurring ASD diagnosis, while 33.3% of patients with ASD received an ADHD diagnosis. Subjects with ADHD or ADHD/ASD had higher scores in all ADHD traits compared to ASD subjects. Compared to the ADHD group, the ASD group had AQ scores that were significantly greater, except for attention to detail. ADHD/ASD co-occurrence significantly increased the score of attention to detail. The total EQ score was greater in the ADHD group. In the stepwise logistic regression analyses, past hyperactivity, current inattention and impulsivity, attention switching, communication, imagination, and total EQ score discriminated ADHD patients from ASD patients. Attention to detail, imagination, and total EQ score discriminated ADHD cases from ADHD/ASD cases, while past hyperactivity and current impulsivity discriminated ASD subjects from ADHD/ASD subjects. Our findings highlight the importance of particular trait-based dimensions when discriminating adults with ADHD, ASD, and co-occurring ADHD/ASD. Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are amongst the most prevalent neurodevelopmental disorders. ADHD is characterized by developmentally inappropriate inattention, impulsiveness, and/or hyperactivity that remain relatively persistent over time and result in impairment across multiple domains of life activities. ASD is characterized by persistent deficits in social interaction and communication, as well as restrictive, repetitive patterns of behavior or interests . These dAlthough carrying out a diagnosis following the DSM or International Classification Diseases (ICD) criteria has been the norm in child and adult psychiatry, a dimensional or hybrid model approach has been adopted for polythetic syndromes . There iIt has also been reported that ADHD prevalence in ASD decreases with age and preliminary data suggest that the association between ASD and ADHD traits may be somewhat lower in adulthood than in childhood/adolescence . HartmanThe concept of empathy includes the identification of another’s mental state and the appropriate response to their mental state . AbnormaData from studies that try to estimate the phenotypic and etiological overlap between self-rated trait dimensions of ADHD and ASD derive from a general population sample and, as such, the results might not be extrapolated directly to clinical settings. Clinicians performing an ASD/ADHD assessment are able to use their judgment to distinguish between ASD/ADHD and other conditions that can mimic ASD/ADHD symptoms  but ofteAs part of a comprehensive assessment of adults, self-rated questionnaires are often used. They can be useful either for screening purposes or in support of the diagnostic procedure. We hypothesize that individual trait dimensions that derive from questionnaires with widely accepted psychometric properties may offer helpful information for the differential diagnosis of adults with normal intelligence that are referred with a suspected ADHD, ASD, or ADHD/ASD diagnosis.The aim of the present study was twofold: first, to estimate the rate of co-occurrence of ADHD and ASD in adults with normal intelligence that were referred for the first time in their lives to an Adult Neurodevelopmental Department, and second, to examine how the total score and individual trait dimensions, such as the current and past inattention, hyperactivity, and impulsivity that are derived from the Barkley Adult ADHD Rating Scale-IV (BAARS), the five subscales deriving from the Autism-Spectrum Quotient (AQ), and the total score of the EQ could help a clinician in everyday clinical practice to identify variables that could differentiate patients with ADHD, ASD, and ADHD/ASD. We particularly focused on the extent to which these trait dimensions can be helpful in disentangling the most puzzling group of patients with a dual ADHD/ASD diagnosis.The present study was part of a larger research project on de novo diagnosed adults with ADHD and ASD . The resThe assessment procedure was built on a standard diagnostic routine that is described in detail in Pehlivanidis et al. . InitialResponses to the questionnaire were then discussed with the patient and a family member when possible. Patients underwent a thorough psychiatric examination by experienced psychiatrists in our department by exploring the existence and pervasiveness of a suspected neurodevelopmental disorder and the presence of co-occurring psychopathology. If needed, patients were referred to other members of the multidisciplinary team or for a laboratory workout. The semi-structured interview DIVA was administered to all patients, while the ADOS and ADI-R were administered to selected cases that were considered to be more complicated. The final diagnosis regarding the presence of ADHD and/or ASD was given during a consensus meeting of the multidisciplinary team and was based on the DSM-5 criteria while taking into consideration all available information.A modified version of the BAARS-IV was used in order to assess self-reported ADHD traits. This 18-item questionnaire assesses the DSM-IV criteria for ADHD, with clinical response and recovery cutoffs that are derived from population-based norms. The BAARS-IV shows adequate internal consistency, test–retest reliability, and strong construct validity and discriminant validity . It compThe AQ was originally developed to identify ASD among adults with normal intelligence . It consThe EQ is a self-assessment instrument for measuring the construct of empathy in adults of normal intelligence, both as a one-factor and a three-factor dimension ,53,54. Ip for removal was set at 0.1 and p for entry was set at 0.05) were also performed in order to identify the variables that could differentiate the studied disorders. Adjusted odds ratios with 95% confidence intervals were computed from the results of the logistic regression analyses. We performed a series of multiple logistic regression analyses with dependent variables that were used to define the groups with different disorders. All reported p-values are two-tailed. Statistical significance was set at p ≤ 0.05 and the analyses were conducted using SPSS statistical software (IBM SPSS Statistics Base 22.0).The normal distribution of the variables was evaluated using the Kolmogorov–Smironov test. Qualitative variables are expressed as absolute and relative frequencies. The chi-square test was used for the comparison of proportions. For the comparison of continuous variables between the three study groups, one-way analysis of variance (ANOVA) was used. A Bonferroni correction was applied in the case of multiple testing in order to eliminate type I errors. Multiple logistic regression analyses with a stepwise method (n = 180), 29 (16.1%) received a comorbid ASD diagnosis, while of the 87 subjects diagnosed with ASD, 29 (33.3%) fulfilled the criteria for an ADHD diagnosis. Sample characteristics of all groups are shown in The sample consisted of 238 participants (172 men and 66 women) with a mean age of 30.2 years (SD = 9.8 years). A total of 151 subjects (63.4%) were diagnosed with ADHD, 58 (24.4%) with ASD, and 29 (12.2%) with both ADHD and ASD. Of the total number of patients that received an ADHD diagnosis, either as a sole or co-occurring diagnosis .As expected, the total AQ score and most of the AQ subscale scores were higher in adults with ASD compared to adults with ADHD, with the exception of the subscale score of attention to detail. Furthermore, patients with ADHD/ASD scored higher in all AQ scores compared to patients with ADHD.When comparing patients with ASD to patients with ADHD/ASD, no difference was found, with the exception of the subscale attention to detail, whose scores were higher in the combined group. It seems that attention to detail scores did not significantly differ between ADHD and ASD, but the co-occurrence of the two disorders significantly increased the score in this subscale. Furthermore, stepwise logistic regression multiple analysis showed that attention to detail, along with imagination, were two of the three dimensions (the third one being EQ score) that discriminated ADHD/ASD cases from those having ADHD, with imagination being lower, while attention to detail being higher in the dual-diagnosed group.Our results for “attention to detail” are in line with previous reports separating this subscale from the other subscales of AQ. In confirmatory factor analyses in both a general population and a student sample , four ouImagination was the other dimension deriving from the AQ that differentiated individuals with ADHD from individuals with ASD or ADHD/ASD, indicating that a lack of imagination could be considered a discriminating trait in adults with ASD, regardless of ASD being a sole or co-occurring diagnosis. It is well known that people with ASD form a group of individuals for whom spontaneous and fantastical acts of imagination appear to be a challenge. Children with autism do not engage in spontaneous pretend play in the ways that typically developing children do, engaging instead in repetitive activities, and adults with autism are less interested in fiction ,64,65,66Τhe EQ total score was lower in ASD and ADHD/ASD patients compared to ADHD patients, while no difference was found between ASD and ADHD/ASD patients . FurtherThe EQ has not been systematically studied in adults with clinical ADHD diagnosis. Groen et al.  reportedThe EQ is designed to measure how easily a person can detect other people’s feelings and is affected by them. Since empathy is a core skill that facilitates effective social interaction , a lowerThe finding that EQ discriminates adults of normal intelligence with co-occurring ADHD/ASD from patients with ADHD has important clinical implications. Interviewing for the capacity to detect other people’s feelings when assessing adults for a possible ADHD diagnosis might reveal symptoms indicating the possible co-occurrence of ASD. Treating ADHD with co-occurring ASD is much more complex than treating ADHD as a sole diagnosis.A number of limitations of this study should be taken into consideration. First, our subjects represent a specific clinical population, and thus, the results cannot be generalized to other samples, such as community or low-functioning samples. Second, the study population was not very large, especially the combined ADHD/ASD population. Third, we used structured interviews only in selected cases that were considered to be more complicated. However, previous research has shown that there is a moderate agreement between clinical diagnoses and ADOS4, while ADI-R might not be reliable in adults without an intellectual disability ,70,71. ADespite the limitations, our results illustrate that apart from considering diagnostic categories, individual trait-based dimensions deriving from screening instruments  might be of particular help in the comprehensive assessment and differential diagnosis of adults of normal intelligence with a suspected ADHD or ASD diagnosis, and in particular, of those with the more perplexing ADHD/ASD diagnosis. Being able to successfully categorize individuals with ADHD, ASD, or ADHD/ASD by using clinical dimensions is an important first step toward identifying the atypical brain function and structure underlying these clinical features. Our findings highlight the importance of the dimensions of current impulsivity, attention to detail, imagination, and empathy when discriminating adults with ADHD, ASD, and co-occurring ADHD/ASD. They also suggest the need to study the neural underpinnings of these particular traits using a lifespan approach in order to understand the persistence and co-occurrence of ADHD and ASD in adulthood.


This study aimed to assess the influence of live body weight (LBW) and age on reproductive performance in buffalo heifers synchronized by different treatments. The study was carried out on 146 Mediterranean buffalo heifers , divided into 2 homogeneous groups and synchronized by Ovsynch-TAI Program  or double prostaglandin administered 12 days apart . All the buffaloes were inseminated twice and follicle dimensions and ovulation rate (OR) were assessed by ultrasound 24 and 48 h post-insemination. Pregnancy was assessed on day 25, 45 and 90 post-insemination and the incidence of late embryonic (LEM) and fetal (FM) mortality were respectively recorded. Data were analyzed by ANOVA, Chi-square test and multiple logistic regression. The LBW was significantly (P<0.05) higher in inseminated animals, compared to those that did not respond to the treatments . Total OR was similar between groups, although OR at 24 h tended to be higher (P = 0.06) in OVS . A (P<0.01) higher LBW was observed in ovulated heifers of PGF, while no differences were recorded in OVS. LBW affected OR  only in PGF, while no effects were recorded in OVS. Total pregnancy rate, LEM and FM were similar between groups. In conclusion, the LBW would be considered before including buffalo heifers in a synchronization program and both synchronization treatments can be useful. Only heifers in good health, without any abnormalities of the genital tract and with the presence of a CL in at least one examination were included in the study. Furthermore, in correspondence with the second ultrasound examination, all the animals were weighed. Only the animals with a LBW > 270 kg (n = 146) were chosen. This because puberty is related to the age at first oestrus, (at about 16.5-19.0 months) and to the LBW (at around 340-360 kg) . The study was carried out on 146 Italian Mediterranean buffalo heifers, previously chosen (see below), with a mean age of 25.3±13.4 months and a mean LBW of 424±47 kg, between February and March 2017. To ensure the best welfare conditions, buffalo heifers were maintained in open yards that allowed 10 m-360 kg) .2α analogue  injection on day 0 and 12, at a random day of the cycle. AI were performed by the same operator and each buffalo was inseminated twice: at 16 and 40 hours after the second injection of GnRH in OVS and at 60 and 84 hours after the last PGF2α in PGF  and underwent ultrasound examination to record preovulatory follicle. The ovulation rate was assessed by ultrasound in each group, 24 and 48 hours after the first insemination. Frozen/thawed semen of two bulls of proven fertility was utilized in the AI program in both groups. Finally, the body condition score was assessed on the day of AI, by using a 1 to 9 scale  underwent synchronization of ovulation by O-TAI Program . Heifersα in PGF . Becauseα in PGF , the hei 9 scale .Twenty-five days after AI, buffaloes underwent trans rectal ultrasonography to assess embryonic development and the heartbeat. Pregnancy diagnosis was confirmed on day 45 and 90 after AI: heifers pregnant on day 25 but not on day 45 were considered to have undergone late embryonic mortality. Similarly, buffaloes pregnant on day 45 but not on day 90 were considered to have undergone fetal mortality.st AI and pregnancy between treatments were assessed by Chi-square test. Differences in age, LBW, BCS, pregnancy rate, LEM and FM between treatments were assessed by ANOVA. Two separate logistic regression models were estimated to assess the ovulation rate at different time within each treatment with respect to the LBW. Pregnancy outcome was evaluated by a logistic regression second order model using LBW and treatment as independent variables. All statistics were performed using the IBM SPSS Statistics for Windows, version 20.0” program . LBW was (P<0.05) higher in animals that were inseminated, compared to those that did not respond to the synchronization treatment , whereas a similar age was recorded . No differences were recorded in preovulatory follicle dimensions between OVS and PGF, neither on the day of TAI  nor at 24 h . Ovulated buffaloes showed a significantly (P<0.05) higher LBW compared to not-ovulated counterparts  regardle4 rise at a value over 1 ng/ml, at about 16.5-19.0 months of age and at around 340-360 kg of body weight (4 value > 1 ng/ml at about a ten-day interval was achieved at 20.7 months of age and at a body weight of 380-390 kg (This study aimed to assess the influence of LBW on reproductive efficiency in buffalo heifers. An optimal management in this category of subjects influences the age at first calving and allows to anticipate the start of their productive life, reducing the generational interval and favoring the genetic improvement of the herd. Accordingly, reproductive development in heifers and the attainment of puberty are determined primarily by nutrition from the time of weaning . Some sty weight . Cyclic 0-390 kg . On thes0-390 kg . After t0-390 kg . On the 0-390 kg , and bov0-390 kg , because0-390 kg . In buff0-390 kg . The ovu0-390 kg . On the 0-390 kg . In a pr0-390 kg . On the