Muscle attachment sites (entheses) on dry bones are regularly used by paleontologists to infer soft tissue anatomy and to reconstruct behaviors of extinct organisms. This method is commonly applied to fossil hominin hand bones to assess their abilities to participate in Paleolithic stone tool behaviors. Little is known, however, about how or even whether muscle anatomy and activity regimes influence the morphologies of their entheses, especially in the hand. Using the opponens muscles from a sample of modern humans, we tested the hypothesis that aspects of hand muscle architecture that are known to be influenced by behavior correlate with the size and shape of their associated entheses. Results show no consistent relationships between these behaviorally-influenced aspects of muscle architecture and entheseal morphology. Consequently, it is likely premature to infer patterns of behavior, such as stone tool making in fossil hominins, from these same entheses. Biologists and paleontologists frequently have scant data available to them from which to reconstruct the anatomy, physiology and behaviors of past populations. Consequently, fossils and artifacts are scoured for information on the lives of the individuals that left them behind. Entheses (attachment sites of soft tissue) are popular osteological features used to reconstruct soft tissue anatomy, and those reconstructions are regularly employed to infer behavior of past populations. Their use stems from the fact that some entheses tend to be overtly visible on bone, and are thought to reflect some aspects of the anatomy and physiology of the corresponding muscle  is thought to demarcate an important adaptive shift and to have provided the impetus for other influential changes throughout human evolution141516However, the anatomy, physiology and mechanical properties of tendon-bone interfaces are complex and the use of entheses as direct behavioral indicators fails to consider the multifactorial influences on entheseal morphologies. These influences include muscle function12425234272825Here, we conducted the first direct assessment of the assumed relationships between muscle anatomy and entheseal morphology that are most commonly used to infer levels of participation in stone tool behaviors among fossil hominins: the entheseal markings of opponens pollicis (OP) and opponens digiti minimi (ODM) on the first and fifth metacarpals (MC), respectively. Working with the other thenar and hypothenar muscles, the opponens muscles participate in full and forceful opposition of the pads of the distal phalanges of the first and fifth digits. Opposition is regarded as a significant biomechanical component of stone tool behaviors311833f] and physiological cross-sectional area [PCSA]) and their associated entheses . All correlations between opponens muscle architectural variables and their associated entheseal surface morphology variables lacked statistical significance (P > 0.05), regardless of metacarpal and sex , we tested whether any correlations existed between a series of functionally-influenced architectural variables describing the opponens muscles  and three variables describing the associated entheses . In all comparisons, correlations were very weak and statistically insignificant. These results provide evidence that the entheseal morphologies of the opponens muscles are not direct correlates that can be used to reconstruct the associated muscle architecture, and therefore, function. Consequently, these data further argue against the practice of inferring behavior, stone tool or otherwise, from entheseal morphology preserved on the surfaces of the first and fifth metacarpals of fossils.Some scientists studying the osteological remains of past populations have made a practice of reconstructing muscle anatomy and behavioral patterns of skeletal or fossil individuals from the entheseal morphology preserved on the surface of dry bones. This method has always been questionable given the complexity of osteotendinous interfaces and the number of variables known to influence bone and muscle growth  insert along or close to the same areaWhile it is premature to extend our results across the human body, or to other mammalian taxa, a consistent pattern has begun to emerge in which multiple direct tests have failed to support assumed relationships between enthesis morphology, location, or even presence of the muscle with muscle anatomy or behavior39421Soft tissues were obtained from 23 adult humans from Duke University School of Medicine, including 12 males and 11 females (average age: 77.9 ± 12 years). All cadavers were fixed according to standard preservation protocol used by Duke University. All donors signed informed consent forms to formally donate tissues to Duke University for education and research purposes. Duke University School of Medicine approved all experimental methods and all research was conducted in accordance with the umbrella IRB of Duke University School of Medicine.in situ using digital calipers prior to muscle removal. Muscle belly length (Lb), total tendon length (LT) and the full muscle-tendon unit (MTU) were measured to the nearest 0.1 millimeter. The muscle belly length (Lb) was defined as the length of the muscle fasciculus between the proximal and distal myotendinous junctionsT) was defined as the sum of the lengths of the proximal and/or distal muscle tendonsb and LT. Following measurement, the muscles and their associated tendon(s) were removed in a manner that preserved as much of the tendon and muscle tissue as possible, and cleaned of excess tissues. Each muscle was stored in a separate storage container in a 10% formalin solution to maintain preservation and fixation. Remaining superficial soft tissues and fibers were removed from the first and fifth digits, and the digits were detached from the hand at the carpometacarpal joints and stored in a 10% formalin solution.The sample was comprised of the opponens pollicis (OP) and the opponens digiti minimi (ODM) muscles from the first and fifth metacarpals, respectively, of the right hand. To begin dissection, the skin and superficial fascia across the palmar surface of the hand, the first and fifth digits, and the forearm was removed. Muscles and tendons of interest were differentiated, photographed, and measured f: for a given muscle fiber, the distance between the central tendon of origin to the distal tendon of insertion) and (b), the perpendicular distance between the central tendon to the tendon of insertion f). Physiological cross-sectional area (PCSA) was defined as:Prior to further analysis, muscles were removed from the formalin and partially dried to remove excess liquids. Each muscle mass was measured to the nearest 0.1 gram using a digital scale. The muscle was then pinned to a vinyl dissecting pad and three longitudinal incisions were made along the line of action . Two measurements were taken for each incision: (a), fiber length  bath to further remove soft tissues. The bath was changed every other day for one month. After this period of time, the digits were boiled in individual Terg-A-Zyme baths for two hours and wiped clean of remaining soft tissues. Once the bones dried to completion, the length of the opponens ridge  was measured on each metacarpal using digital calipers. Each ridge was measured three times and the mean was used for the correlation analyses.2 or 4.0% of measurement of interest; average intra-observer error = 0.69 mm2 or 2.6% of measurement of interest). Given the negligible differences, the remaining 36 entheses were divided and measured by either KGH or EMWH.Area of each enthesis was measured on three-dimensional digital models of each bone, as virtual surface area measurements could incorporate the complex three-dimensional topography of each enthesis. Three-dimensional models of each bone were created by photogrammetry. Approximately 20 photos of each bone were taken from various angles using a Canon 5D Mark III 22.3 megapixel camera fitted with a 50 mm macro lens. Photos were loaded into Agisoft PhotoScan Professional software  such that 3-dimensional polygonal models could be rendered from the images using structure from motion algorithms. The maximum length of each enthesis was demarcated on each metacarpal in order to scale the 3-D models for analysis. Following their creation, polygonal models were exported and loaded into Geomagic Studio 2014  for geometric analysis. Entheseal surface area was determined based on a combination of visual observations of the bone of interest and of the resulting models . The areh), and maximum base breadth (Bb) were measured on each metacarpal. Maximum length was defined as the line bisecting Bh and Bb, running along the long proximal –to-distal axis of the metacarpalr) was measured from the point at 65% of ML to the lateral margin of the metacarpal as represented in the palmar photograph.Maki and Trinkausf and mass) and variables describing their associated enthesis . Post-hoc tests of significance were run on each correlation. All analyses were conducted using custom-written scripts in the R programming language and environmentData and analyses were separated by metacarpal and by sex. Spearman’s rank correlations were used to test the relationship between three variables describing the opponens muscles .


Aspergillus fumigatus and other Aspergillus spp. are ubiquitous in our environment. However, their potential to cause severe disease in humans was ignored for many centuries. The first reported case of presumed human aspergillosis is from 1791 during the French revolution. A 22-year old soldier sought medical attention for painful cheek swelling because of a fungus ball of the maxillary sinus invading the mouth and orbit  has now emerged as a major infectious threat and the prevalence and spectrum of the disease has progressed in parallel with advances in medicine and the advent of new therapies with potent immunosuppressive effects. The cumulative 12-month incidence of IA is estimated at 1.6% in hematopoietic stem cell transplant recipients and 0.7% in solid organ transplant recipients, with an overall 1-year mortality of 40–75%  often confers pan-azole resistance and the increasing use of posaconazole prophylaxis in patients with hematologic malignancies raises concern about breakthrough infections due to resistant Aspergillus spp. or other fungi  or cell wall . A better understanding of the molecular pathways involved in fungal metabolism, virulence, stress response, and resistance are therefore important steps toward the discovery of novel therapeutic approaches.Aspergillus community. Scientists purposefully chosen from various countries and continents have contributed to this special issue dealing with all the medical aspects of IA, including taxonomy, genetics, epidemiology, pathogenesis, antifungal resistance, and novel therapeutic perspectives. Multiple species have now been identified within the Aspergillus section Fumigati and the possible relationship between their metabolite profiles and pathogenicity are discussed (Frisvad and Larsen). The worldwide problem of emerging azole resistance among Aspergillus spp. is illustrated by an interesting epidemiological study and update of the situation in Asia . In addition, the existence of mechanisms of azole resistance other than mutations of the Cyp51A gene, such as increased expression of ATP-binding cassette (ABC) transporters, is highlighted (Moye-Rowley). To counteract emerging resistance, novel potential antifungal targets are being investigated and several research groups present their latest updates on the cell wall integrity signaling pathway , the Ras pathway , the Hsp90-calcineurin network , and the regulation of zinc and iron homeostasis . Finally, because innate and adaptive immunity are key determinants in the development of IA, the analysis of host-pathogen interactions represents a promising research area. The current knowledge about the immune responses mediated via T-helper cells is presented in two reviews . The recent identification of host genetic determinants of IA, such as TLRs polymorphisms, also opens perspectives for preventive strategies .The purpose of this research topic is to provide an overview on the current state of research and to strengthen the links within the A. fumigatus pathobiology suggests that we are entering a new era in the approach and management of IA. The epidemiology and pathophysiology of the disease has become more complex, with emerging resistance to triazoles and the increased diversity of immunosuppression types and host susceptibilities. Combination therapies of existing compounds or novel molecules that may enhance their activity or modulate the pattern of host immune recognition, as well as personalized diagnostic and therapeutic strategies based on individual susceptibility profiles of high risk patients, may change our conventional approach of IA and hopefully result in better outcomes.This overview on the recent advances in FL: Design and writing; PJ: Design and writing; WS: Design and writing.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 present a case of osteonecrosis of femoral head (ONFH) that occurred after stent angiography of femoral artery for the treatment of arteriosclerosis obliterans (ASO) of left inferior limb in a 76-year-old woman. No case of late collapse of femoral head as a complication of endovascular procedure such as stent placement has been previously documented. We considered that ONFH occurred after detaining stent at a junction of left deep femoral artery for the treatment of the ischemia of left lateral and medial femoral circumflex artery. ASO is a disease that significantly impacts patients' quality of life because of leg pain, ulceration, and gangrene. We report a case of the ONFH that occurred after the stent placement for the treatment of the ischemia of lateral and medial femoral circumflex artery.A 76-year-old woman complained of left inferior limb pain and intermittent claudication. She was diagnosed with ASO in another clinic about 10 years ago. While the prolonged conservative medical treatment was undergone, the condition got worse. Then, she consulted a vascular surgeon in another hospital and the angiographic examination was undergone. The complete obstruction of left femoral artery was observed. Percutaneous transluminal angiography (PTA) was performed and stent was detained at the left femoral artery . RevascuPlain radiography showed the stent which is detained in left femoral artery, collapse of left femoral head, and disappearance of joint space . MRI T1WONFH is a pathologic process that results from interruption of blood supply to the bone. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment. Focusing on nontraumatic osteonecrosis, there are various possible theories, such as fat-emboli theory , increasKubo et al. reported that the collapse of femoral head progressed in an average of 3 years and 4 months (8 months to 7 years) after steroid use for renal transplanted patients . Ohzono In summary, we experienced a case of ONFH after stent placement at a junction of left deep femoral artery for the treatment of the ischemia of left lateral and medial femoral circumflex artery. There are several reports of ONFH after the medical treatment such as embolization , 12; how


Current trends in medical services and health economy clearly demonstrate that without innovation in healthcare, e.g. in years around 2030 the prevalence of Diabetes mellitus will reach the dimension of a half of billion of affected people worldwide additionally burdened with a spectrum of secondary complications  and enormous economical burden linked to the required treatments. In the same period of time, neurodegenerative pathologies  can reach more than 30% of global disease burden. The pandemic of some cancer types is evident for both children and adults, men and women, developed and developing countries altogether linked to the enormously increasing economical pressure within healthcare systems. In contrast, effective utilisation of advanced early/predictive diagnostics, targeted prevention and medical services tailored to the person could enable a significant portion of population to reach the 100-year age limit remaining vibrant in excellent physical and mental health as actively contributing members of society. This task requires intelligent political regulations and creation of new guidelines to advance current healthcare systems. Targeted preventive measures should be well regulated by innovative reimbursement programmes introduced by policy-makers. This is considered as preventive medicine of future to effective costs. The overall concept in the field is conducted by the “European Association for Predictive, Preventive and Personalised Medicine” (EPMA).versus Pessimistic Scenario depends much on diagnostic, preventive and treatment approaches which healthcare will preferably adopt in the near future. Global research and implementation programmes in bio/medicine, communication among scientific societies, healthcare-providers, policy-makers, educators and organised patient groups and, finely, a consolidation of professional groups in the branch will play a decisive role to drive the situation in favour of one of two scenarios over the next 5-10 years.Optimistic th 2013 and concomitant consultation of our experts group with the legislation relevant bodies in the Europe and worldwide. Issue-related innovative European and intercontinental projects, which EPMA introduces for further consideration at the EU-Commission, European Parliament and UNO are elaborated by the consortium of the world-leading professionals and professional groups (Europe-unrestricted) .The PPPM related legislation would play a key role in the adequate regulation for the positive scenario. The stakeholders realise that without a correct juristic platform in healthcare, the global market cannot be created for a spectrum of PPPM related technological innovations and advances medical services; global industry is not motivated to bring corresponding products to the market; patenting of PPPM related innovation remains unrequested that altogether leads to a stagnation of the validation of novel disease specific biomarkers and unutilised research data (see Figure


Neurogenic thoracic outlet syndrome is an underestimated cause of brachial weakness and pain. The subclavius posticus muscle (SPM) is an aberrant muscle originating from the medial aspect of the first rib reaching to superior border of the scapula, which may cause, depending on its activation, dynamic compression of the brachial plexus.In the present study, we report about a 32-year-old male caucasian patient with weakness in radial deviation of his left hand. An isolated macrodactyly of his left middle finger had been operated twice. Electroneurography showed a carpal-tunnel-syndrome (CTS) on the left side. MRI of the brachial plexus revealed an additional muscle in the costoclavicular space, identified as SPM. To our knowledge, this is the second case report of a neurogenic thoracic outlet syndrome due to SPM, and the first case described with isolated macrodactyly and CTS in the same patient.If complaints about hand weakness are only reported in cases of distinct hand positions, a dynamic compression of the brachial plexus by SPM may be the cause. A neurogenic thoracic outlet syndrome may facilitate the development of CTS. Neurogenic thoracic outlet syndrome (NTOS) is an underestimated cause of brachial weakness, pain and sensory deficits, which is hard to diagnose. The subclavius posticus muscle (SPM) has first been described by Rosenmuller in 1800 . HoweverAn apparently healthy 32-year-old male patient complained of reduced strength in his left hand. Over the past few months this phenomenon occurred especially and repeatedly when holding a frying pan, but there was no pain or weakness in any of the other muscles. He had two operations on his left middle finger at the ages of 10 and 18 due to a macrodactyly. Neurological examination gave evidence for a reduced sensitivity for touch in his left middle finger. In neutral position, there was no deficit of strength. Electroneurography showed mild CTS, without sign of axonal lesion of the radial nerve. In abduction of the left arm, there was a slight weakness in pronation, radial deviation and elevation of his left hand. Occasional fasciculations were observed in his left brachioradial muscle. Overall, we hypothesized a possible brachial plexus pathology. MRI of the left brachial plexus (Fig. Overall, NTOS with compression of the brachial plexus which increases with arm elevation and abduction was likely . The musThis case illustrates that SPM is a rare, but probably underestimated cause of NTOS. Its presence may enable the occurrence of CTS  as well.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. The consent form signed by the patient is in accordance with the BMC research guidelines.


Aedes- and Anopheles-borne diseases.Vector control remains the most effective measure to prevent the transmission of mosquito-borne diseases. However, the classical entomo-parasitological methods used to evaluate the human exposure to mosquito bites and the effectiveness of control strategies are indirect, labor intensive, and lack sensitivity in low exposure/transmission areas. Therefore, they are limited in their accuracy and widespread use. Studying the human antibody response against the mosquito salivary proteins has provided new biomarkers for a direct and accurate evaluation of the human exposure to mosquito bites, at community and individual levels. In this review, we discuss the development, applications and limits of these biomarkers applied to  Plasmodium protozoan parasites that infect the human host through the bite of female anopheline mosquitoes—was responsible for 207 million cases and 627,000 deaths in 2013 [Aedes mosquitoes, is the most prevalent MBD in the world and currently affects more than 100 countries with up to 390 million cases annually [Aedes- and Anopheles-borne diseases, the two main MBDs in terms of burden, is essentially based on insecticide indoor residual spraying (IRS), the use of insecticide-treated bed nets and larval control. These strategies aim to significantly reduce the density of the vector population, the level of the contact between mosquito vectors and human populations, and then the transmission of pathogens. Such interventions are associated with recent declines in MBD burdens across a range of settings over the world. However, the general burden of MBDs is increasing in several tropical countries primarily due to human travel, rapid urbanization and failures of preventative public health measures [The control of mosquito-borne diseases (MBDs) represents a major worldwide public health challenge, especially in tropical and subtropical regions. Only a few diseases essentially carry out the worldwide burden of MBDs. Among them, malaria—caused by annually . In addimeasures . The evaAnopheles and Aedes bites and the effectiveness of control measures against these vectors. We then expose the new concept of “salivary biomarkers” (SBs) of mosquito bites and the impact of such SB tools on the assessment of risk of MBDs and the effectiveness of vector control measures in different settings. The effects of some epidemiological parameters  on the reliability of these SBs as well as the limits of such method are also discussed in order to highlight current drawbacks in using SBs for operational research.In this review, we highlight the current entomological and parasito-clinical methods that are routinely used to assess the level of exposure to The evaluation of the human exposure to vector bites, the risk of MBD transmission and the effectiveness of vector control strategies are routinely based on entomological methods and on parasito-clinical assessments. However, these methods are labor-intensive and difficult to sustain on large scales, especially when transmission and exposure levels are low during dry season, in high altitude, in urban settings, or after vector control). In addition, they give a measure at the community level rather than an individual assessment, which can be useful since heterogeneity in host exposure could have a significant impact on vector control effectiveness .Plasmodium transmission intensity to humans, is highly dependent on the density of human-biting Anopheles [Anopheles bites. However, the technique of HLC poses ethical concerns as the human “bait” could be exposed to malaria and other MBDs. In addition, this trapping technique is only applicable to human adults. It is difficult to extrapolate HLC results to children or to pregnant women who are the most vulnerable groups to malaria [Aedes bites. Several techniques including the Breteau index, the container index, the premise index, and the premise shading, are used to estimate the density of Aedes pupae and larvae. The counting of these aquatic stages gives an indirect estimation of the level of human exposure to adult Aedes bites. However, the mortality of the immature stages that influences the adult density can limit the accuracy of such estimations. In addition, large scale Aedes immature stages surveys are needed for a reliable assessment.The entomological inoculation rate, the gold standard measure for nopheles . This de malaria . MosquitThe entomological tools routinely used to estimate MBD transmission and the efficacy of vector control strategies can be complemented by parasitological and clinical data. However, these latter strategies could be subjected to variability between sites and may not be appropriate for early phase studies of vector control or for epidemic prediction . TransmiAltogether, evaluating the risk of MBDs and the effectiveness of vector control strategies using the current entomo-parasitological methods is challenging. Thus, the development of new tools to reliably assess human exposure to vector bites and monitoring changes over time at both population and individual levels have been prioritized. The use of an SB approach offers a certain improvement as it gives a direct measure of the level of exposure to vector bites. Indeed, an SB approach measures the markers that are specific to the contact between the vertebrate host and the invertebrate vector during the blood meal uptake.The bite of the mosquito for a blood meal is the key component of the interactions between the vector and the human. During the infection of the female mosquito, parasites or viruses progress from the blood meal to the midgut before reaching the salivary glands (SGs). From the SGs, they can be transmitted through subsequent bites of the female mosquito that needs to feed on vertebrate blood to gain nutriments required for the development and the maturation of its eggs. However, the proboscis of the vector is more than a simple syringe, allowing the mosquito to feed and to potentially transmit microbes to the vertebrates. Indeed, during the bites, the mosquito injects saliva, which has an important physiological action allowing the mosquito to safely take a blood meal. It is well known now that mosquito saliva injected in human skin during a blood meal contains a cocktail of bioactive molecules . These mAn. gambiae and Ae. aegypti mosquito saliva contain up to 15 and 10 salivary proteins, respectively [Aedes and Anopheles salivary antigens have been shown to be very antigenic [The immunological interactions between the human and the mosquito vector have been studied in the aim to develop SBs of mosquito bites. This concept is based on the fact that mosquito saliva injected into the human host skin during the mosquito bite is immunogenic and can induce the production of specific human antibodies (Ab). The fundamental principle of the use of SBs is therefore simply to use mosquito salivary proteins to probe specific Abs in human sera. To this end, several immunological techniques have been developed. The enzyme linked immunosorbent assay (ELISA) represents the most widely used technique due to its relative simplicity and affordable cost. Indeed, the ELISA technique does not require sophisticated instrumentation and can give both qualitative and quantitative evaluation of the Ab anti-mosquito saliva. Two main steps are crucial in the development of an SB: the collections of human blood samples potentially containing anti-mosquito Abs and the production of salivary gland extracts (SGEs) which represent the source of antigens. Two major techniques have been used to collect human blood sample containing anti-saliva immunoglobulin (Ig). Plasma can be used to detect the presence of anti-saliva Ig. However, the use of dried blood spots on filter paper is now widespread as it avoids invasive blood collecting methods ,14. The ntigenic . In addiAnopheles mosquito bites. In addition to their immunogenicity, gSG6 and cE5 SBs are specific to anopheline mosquitoes. These two SBs present different features: gSG6 induces a short lived IgG4 response compared to a longer lived IgG1 response produced against the cE5 protein [Aedes and Anopheles bites. The gSG6-P1 and the Nterm-34 kDa peptides represent two powerful SBs evaluating the human exposure to Anopheles and Aedes bites, respectively [Recent progresses in sialotranscriptomic studies ,18,19 ha protein . Howeverectively ,22.Anopheles and Aedes mosquitoes and the effectiveness of vector control interventions as well as the risk of disease transmission.Specific salivary recombinant proteins and peptides can be easily expressed in cell culture and by chemical synthesis, respectively. This contrasts with the production of whole SGEs that requires dissecting a large number of mosquitoes to have the optimal protein concentration for the immunological test. However, changes in the salivary proteome according to vector physiology or diet could affect the reliability of SGE-based SB. The change in salivary proteome could also result from SGE conservation, which is very challenging . In factAnopheles and Aedes bites and thus to the risk of MBD transmission [Aedes and Anopheles bites regardless the age of individuals [Anopheles and Aedes vector bites. To answer that question, many studies on SB have used the environmental parameters that mostly determine the density and fluctuation of mosquito vectors. In mosquito endemic areas, rainfall intensity and the geographical situation can have a considerable impact on vector density and their heterogeneous distribution. It is well known that an increase in vector population is observed during the rainy season compared to the dry season. This feature has been used to test if the level of anti-saliva Ab can follow the level of exposure to vector bites.The quantification of the specific Abs response to mosquito salivary proteins has allowed the development of biological markers for the assessment of individual exposure to the smission . This prividuals . The queAnopheles bites is higher during the rainy season periods. The individual levels of anti-gSG6 IgG are higher during the peak of exposure to Anopheles bites in the rainy season compared to the dry season. Furthermore, the prevalence of immune responders decreased during the dry season to less than 60% while it ranged between 60% and 75% during the rainy seasons periods [Ae. caspius in Southern France [Ae. caspius SGE IgG followed the seasonal fluctuation of this mosquito species during a season of low exposure (T1), followed by the peak (T2) and a second period of low exposure (T3). The SB indicated an increase of immune responders going from 29% to 54% at T1 and T2, respectively. This study emphasized also the fact that the seroprevalence decreased after the peak of exposure at T3 and returned to the baseline level at 29% [Longitudinal studies conducted in a rural malaria endemic area in Burkina Faso have shown that the anti-gSG6 IgG could give an indication of the seasonal fluctuation of vector density. The use of indoor pyrethrum catch has shown that the exposure to  periods . The samn France . Despitel at 29%   than in Fos-sur-mer (40%) [The distribution of vector populations according to different geographical features also helped to validate the use of the SB approach as an indicator of exposure to er (40%) .Anopheles density is lower at higher altitude compared to lower altitude areas. In Kenyan highland areas, the use of SB gSG6-P1 showed a difference of exposure between populations residing in “uphill” to those living in “valley bottom” areas. Indeed, the median IgG level was twice as high in the valley population than in the “uphill” population. Similarly, the prevalence of the immune responders was 36% and 50% in “uphill” and bottom valley areas, respectively [The density of some vectors varies according to altitude. It is well known that ectively  . In this context, the use of SB could be a complementary tool. Indeed, in Angola, it has been proven that the efficacy of LLINs use is accompanied by a decrease of the level of exposure to Anopheles bites and/or the prevalence of Plasmodium within a population [Plasmodium coincided with the collapse of both the intensity of anti-An. gambiae saliva IgG and the prevalence of immune responders measured before and after the implementation of LLINs [Anopheles mosquitoes, measured by classical entomological methods, was observed [Anopheles aggressiveness has essentially been due to the use of nets [SBs have been also used to monitor the efficacy of vector control targeting pulation . The decpulation . The perof LLINs . These robserved   was three times higher in anti-gSG6-P1 IgG positive individuals than negative ones [Plasmodium-infected children and clinical malaria cases. Indeed, the level of anti-gSG6-P1 is low, moderate and high in uninfected-, infected-asymptomatic and infected-symptomatic individuals, respectively [An. darlingi saliva IgG is higher in asymptomatic P. vivax carriers than symptomatic patients [In contrast to IgM, IgG Abs are often used to evaluate the risk of malaria transmission and this Ab isotype has given reliable indication on the capacity of both the gSG6-P1 and gSG6 SBs to highlight malaria infection in endemic areas. For example, in Kenya, the level of anti-gSG6-P1 IgG varied according to malaria transmission intensity. Indeed, the percentage of anti-gSG6-P1 IgG responders was 28% in a hypoendemic region, 34% in a mesoendemic region, and 54% in a hyperendemic region, where the parasite prevalences were shown to be 4%, 19.7% and 44.6%, respectively. Furthermore, the risk of seroconversion to Merozoite Surface Protein1-19 (MSP-1ive ones  (Figure ive ones . Remarkaectively . HoweverAe. aegypti salivary proteins may depend on the severity of dengue disease [Further studies are needed to clearly define the link between the level of IgG Ab against vector salivary proteins and malaria outcomes. This could be of particular importance when it is known that the antigenicity of  disease . However disease . The use disease . These sAedes or Anopheles specific and other are widely distributed within genera, orders or classes of blood sucking Diptera. Therefore, the evaluation of Anopheles/Aedes exposure or vector control effectiveness based on the immunogenicity of whole SGEs could be skewed and over- or under-estimated by possible cross-reactivity between common epitopes between mosquito species or other organisms [Anopheles bites. In hyperendemic malaria areas, residents are also highly exposed to non infectious bites. Thus, they present very high levels of anti-gSG6-P1 Ab, which does not necessarily reflect the intensity of malaria transmission. Therefore, there is a need for biomarkers of exposure specific to infective bites in order to assess directly the risk of malaria transmission. Indeed, the tests for pathogen proteins within human are currently used in estimating the risk and prevalence of disease transmission. However, in humans, this estimation may not provide a true indication of transmission risk as some people are asymptomatic pathogen carriers and have developed a relative immunological protection against the disease. An SB of infective bites would help to identify individuals who have been in contact with an infected vector and therefore would help to more accurately evaluate the risk of disease transmission. Its combination with the current test for pathogen detection would be beneficial in the context of the latter stages of a malaria pre-elimination strategy when transmission levels would be very low. Recent studies demonstrate the feasibility of an SB of infective bites as the amount of some antigenic salivary proteins is significantly changed with vector infection [The pertinence and the large-scale application of SB for epidemiological purposes have been hampered by several limitations. First, the whole saliva of mosquitoes is a cocktail of various molecular components with different chemical natures and biological functions. Some components are rganisms . Second,rganisms , which mnfection . AnotherSalivary biomarkers based on the human Ab reaction against mosquito salivary proteins could represent complementary tools to the current entomological techniques. The SBs could be used for a broad range of populations of different ages and in different contexts of MBD transmission. Their use could help to improve the evaluation of vector control interventions and the risk of disease transmission. Their high sensitivity constitutes an input for the current mosquito control strategies particularly when vector density is low as in areas where malaria pre-elimination programs are implemented. However, further improvements are needed to overcome some constraints related to their use.


The aging of the nervous system is often associated with chronic diseases typical of old age, which can offer in their pathogenesis, and in their susceptibility to particular therapies, the key to understanding the determinants of senescence. In recent years, the need to distinguish normal from pathological aging and the obligation to execute the diagnosis as early as possible, addressed dementia research to the field of biomarkers. The biomarkers are easily recognizable, quantifiable, and reproducible, biological entities, that can identify in a timely manner different profiles of disease. It is widely believed in the scientific community that the diagnosis of Alzheimer's disease (AD) can be made early in the integrated analysis of structural, biological, clinical, and functional biomarkers.Neurophysiology, and in particular electroencephalography (EEG), has proved a reliable tool in the biomarkers research of dementias. The ability to highlight the state of the underlying brain network, even with very advance, the ease of application, the widespread reproducibility and, not least, the low cost of operation, makes this method very suitable for studies of with a large number of subjects.In this special issue dedicated to the neurophysiology of dementia, contributions of different cultural origins are presented, contributing to the general richness, and the scientific significance of the issue.Raymundo Cassani addressed the methodological aspect of removal of artifact from EEG, demonstrating that a wavelet enhanced independent component analysis (wICA) algorithm alone outperforms other methodics, thus opening the doors for fully-automated systems that can assist clinicians with early detection of AD, as well as disease severity progression assessment.Francesco Di Lorenzo, addressed the basic neurophysiological aspect of the cholinergic system in AD through the theta burst stimulation (TBS) that modulate central cholinergic function using the neurophysiological determination of Short-Latency Afferent Inhibition (SLAI). The SLAI was decreased in AD patients compared to healthy controls (HS). Cerebellar TBS partially restored SLAI in AD patients but did not modify SLAI in healthy subjects. These results demonstrate that cerebellar magnetic stimulation affects cortical cholinergic activity and suggests that the cerebellum could have a direct influence on the cholinergic damage in AD.A lot of studies addressed the clinical aspect of the early diagnosis in AD.Christos A. Frantzidis demonstrated an impaired organization of brain networks even in the prodromal phase of Alzheimer's disease (AD) due, in hypothesis, to compensation mechanisms.Zhijie Bian proposed that the theta/alpha EEG power band ratio recorded in the frontal and temporal region of the left hemisphere could be a diagnostic tool in patients with amnesic mild cognitive impairment (aMCI) affected by diabetes.Simon-Shlomo Poil showed that EEG activity in the beta frequency range (13–30Hz) could be a helpful prognostic marker to predict the conversion from the MCI state to the overt AD condition. Of note, the authors found that the prediction power is higher (sensitivity of 88% and specificity of 82%) when EEG biomarkers are considered in an integrated way.Davide V. Moretti demonstrated that the increase of EEG alpha3/alpha2 power ratio is related with prodromal phase of AD. The association with hippocampal atrophy, cortical thickness and reduction of brain regional cerebral perfusion suggests that alpha3/alpha2 power ratio could detect the MCI subjects who will convert to AD.Natalya Ponomareva confirmed the reliability of the increase of the EEG alpha3 spectral power investigating the age-related influence of the polymorphism of clusterin (CLU) genotype, associated with AD. In particular, the homozygous variant of CLU C allele is related with the increase of EEG alpha3 power, suggesting a possible susceptibility of this genetic variant carriers to hippocampal atrophy.Very interestingly, Monica Lindin explored the field of event-related potentials demonstrating that the Mismatch Negativity (MMN) amplitude was significantly smaller in aMCI subjects than in healthy controls.Pilar Garcés found a pathological alpha slowing in MCI patients when compared to healthy controls investigating the changes in the spatial distribution of the frequency and amplitude values of MEG alpha peak.Beyond EEG, also magnetoencephalography (MEG) could be a useful research tool. Davide V. Moretti found that EEG frequency rhythms are sensible also to different stage of Fronto-Temporal-Dementia (FTD) and could detect changes in brain oscillatory activity affected by progranulin (GRN) mutations.Finally, besides AD, It is commonly thought that research in neuroscience is the researcher's effort to understand his own brain. If it is true, I want to thank all the authors for helping me to understand also something more of myself.Somewhere, something incredible is waiting to be discovered (Cari Sagan)The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Ciprofloxacin is a widely used antibiotic with large spectrum activity both on Gram negative and Gram positive bacterial pathogens, valued for its rare incidence of hypersensitivity reactions. Delayed-type reactions are reported more often then the immediate-type. Herein we present the case of a 53 years old female patient who developed a symmetric maculopapular exanthematous rash, mainly on the trunk, in association with fever, dysphagia and oral mucosal involvement on the tenth day of ciprofloxacin therapy for recurrent urinary tract infection. The allergic history of the patient revealed two contact dermatitis episodes due to exposure to propolis. The clinical presentation as an early phase of a Stevens-Johnson syndrome was confirmed by the histological findings. The evolution of the cutaneous lesions was rapidly improved by oral corticosteroids and antihistamines. Due to the frequent use of the ciprofloxacin, the potential life-threatening hypersensitivity reactions should be taken into consideration.


Experimental research has always been the cornerstone of pathophysiological and therapeutic advances in critical care medicine, where clinical observations and basic research mutually fed each other in a so-called translational approach. The objective of this review is to address the different aspects of translational research in the field of critical care medicine. We herein highlighted some demonstrative examples including the animal-to-human approach to study host-pathogen interactions, the human-to-animal approach for sepsis-induced immunosuppression, the still restrictive human approach to study critical illness-related neuromyopathy, and the technological developments to assess the microcirculatory changes in critically ill patients. These examples not only emphasize how translational research resulted in major improvements in the comprehension of the pathophysiology of severe clinical conditions and offered promising perspectives in critical care medicine but also point out the obstacles to translate such achievements into clinical practice. Experimental research has always been the cornerstone of pathophysiological and therapeutic advances in medicine. Accurate modeling of human pathology remains challenging but is essential to draw relevant conclusions from experiments. With respect to critical care medicine, the high mortality rate and morbidity imposed by severe acute conditions prompted an intense research activity in which clinical observations and experimental research mutually fed each other in a so-called translational approach. The objective of this review is to address the different aspects of translational research in the field of critical care medicine. We herein highlighted some demonstrative examples of translational research including the animal-to-human approach to study host-pathogen interactions, the human-to-animal approach for sepsis-induced immunosuppression, the human-to-human approach to study critical illness-related neuromyopathy, and the technological developments to assess the microcirculatory changes in critically ill patients. We will not only discuss how the promises of translational research could be fulfilled in the bedside management of critically ill patients but also the obstacles to translate such achievements into clinical practice.Drosophila fruit fly and showed that the mutation of a receptor called Toll inhibited the production of an antifungal peptide and increased susceptibility to fungal infection, a discovery that was awarded by the 2011 Nobel Prize for Medicine and Physiology. [Drosophila larvae carrying a mutation on a protein of the Toll signaling pathway (18-wheeler) had an increased susceptibility to bacterial infections [The discovery of Toll-like receptors (TLRs) and the resultant advances in the understanding of pathophysiology of sepsis represent an excellent example of both complementarities and limits of translational research. The story began in the late nineteenth century when Elie Metchnikoff conducted experiments on the transparent starfish larvae in which he planted pine needles. Using a single optical microscope, he observed a cellular infiltrate that rapidly surrounded the foreign body with vesicles of phagocytosis and described for the first time the cellular immune response against a foreign agent . For hissiology. . Williamfections . Based ofections . Followifections ,7. Moreopathway 1-wheeler fections .Such findings provided a strong rationale for the development of new therapeutic approaches based on the modulation of the dysregulated immune response responsible for organ failures during sepsis. However, experimental animal models do not fully elucidated the clinical conditions they aim to mimic, and both scientists and physicians have raised several criticisms on the relevance of pre-clinical experimental research based on animal models and its translation to human pathology. Some shortcomings are directly related to the type of animal models of sepsis. Thus, endotoxinic shock has often been used as a surrogate of septic shock, and experimental immunomodulatory drugs have most often been administrated prior to or concomitant to the infectious insult . In addiWhether data observed in animals are really relevant to the human conditions is certainly a major concern in medical research. Discrepancies between species have been recently highlighted in a study that explored the variation of genomic response  in human and murine blood-derived leucocytes following several types of injuries  including stimulation by lipopolysaccharide (LPS) . ChangesThe concept of sepsis-induced immunosuppression represents a striking example of the potential of translational research in critical care medicine. It illustrates the full virtuous circle of research performed from man to mouse and from mouse back to man, with the ultimate purpose of developing novel therapeutic strategies.in vitro cytokine production by monocytes, both associated with increased mortality [Severe sepsis and septic shock remain associated with high mortality rate despite advances in the management of infection and organ failures ,24. It iortality -30.On this basis, the conception of the immune pathophysiology of sepsis dramatically evolved and now encompasses both an initial tremendous systemic inflammatory response responsible for organ failures and a compensatory anti-inflammatory response with multiple immune defects that may result in complex immunosuppression in some patients . The maiA reliable appraisal of the role of sepsis-induced immunosuppression in clinical settings is limited by the multiple confounding risk factors of nosocomial infections. This prompted the development of experimental research programs aimed to mimic the common clinical situation of severe sepsis followed by secondary infections in rodent double-hit models. The increased susceptibility of post-septic animals to subsequent infectious insults either to weakly virulent pathogens or to low pathogen loads known to be innocuous in immune-competent animals provided a firm proof-of-concept of sepsis-induced immune suppression ,37. ThesThe accumulation of clinical and experimental evidence has fed the emerging idea that restoring immune competency might represent an innovative therapeutic target in patients during the immunosuppressive phase of sepsis, in order to improve survival and/or to prevent nosocomial infections Table . AttemptStudies of the mechanisms of critical illness-associated neuromyopathy (CINM) illustrate how a human-to-human translational research program can be effective for investigating pathological disorders and eventually improving care -46. CINM31P, 1H, or 13C spectroscopy, allows studying the biomechanical and functional properties of skeletal muscle in vivo [The pathophysiology of CINM is complex and encompasses various and intertwined mechanisms at different stages of critical illness, from insult to recovery. Observational studies have enabled to identify risk factors of CINM related both to the critical illness and to the ICU management, giving clues to underlying pathogenic mechanisms. The main factors contributing to CINM appear to be an intense systemic inflammatory response, unloading, malnutrition and endocrine-related anabolism/catabolism imbalance, drugs (such as steroids or neuromuscular blocking agents), and electrolyte disturbances ,52. Neur in vivo . ConstraHence, a ‘human-to-human’ translational research was able to provide a comprehensive assessment of the clinical entity of CINM and resulted in very significant insights into the underlying pathophysiological mechanisms. Recognition of CINM is based on clinical examination, while imaging and neurophysiological explorations can contribute to the prognosis and follow-up of the disorder. However, current therapeutic interventions for CINM remain quite limited, based on reducing the exposure to risk factors, sustaining appropriate nutritive supply during the ICU stay and early rehabilitation . Beyond In vivo video microscopy revealed intestinal mucosal hypoperfusion during murine endotoxemia. Most importantly, a decrease in arteriolar diameters and in tissue blood flow occurred in both hypotensive and normotensive animals [Microcirculatory perfusion deals with the circulation of blood through the small arteries, capillaries, and venules of different tissues. This complex microvascular network is responsible for regulation of vascular tone, adaptation of tissue oxygenation to local metabolic demand, exchange of nutrients and waste products between blood and cells, and regulation of immune response . Experim animals . Using i animals . The inc animals . As such animals .The evaluation of microcirculation in human pathology started only later, when the side-stream dark field (SDF) imaging technique became available at the bedside . Almost However, most human studies only evaluated the sublingual area that may not fully encompass microvascular flow or changes in tissue oxygenation and metabolism within organs. Recent experimental studies have contributed to better understand the role of microcirculation in organ dysfunction during sepsis. In a porcine model of cholangitis-induced septic shock, Verdant et al. showed that severity and time course of microcirculatory changes were similar in the gut and the sublingual areas, suggesting that this latter region would be appropriate to monitor systemic microcirculatory alterations . MicrociDevelopments in the monitoring of the microcirculation illustrate how sophisticated technological tools may improve our comprehension of pathophysiology, as well as their limits to implementation into routine clinical practice. Altogether, the aforementioned experimental findings clearly demonstrated that microvascular dysfunction occurs during sepsis in several peripheral organs. Given the heterogeneous aspect of microcirculatory perfusion and the mechanisms involved in the development of such dysfunctions, it is unlikely that classical interventions aimed to restore global hemodynamics might result in significant improvement in microvascular flow. Nevertheless, we are still lacking some appropriate devices for clinical settings, which should ideally combine assessment of microcirculation and tissue oxygenation. Future research should be directed towards improvement in technologies that may increase the accuracy of microcirculatory assessment in septic patients. Most importantly, it remains unknown whether assessment of microcirculation and changes induced by therapeutic interventions may lead to improved management of critically ill patients. A number of questions remain to be supported by robust clinical and experimental data, including the type of therapeutic interventions and their optimal timing after hemodynamic stabilization, and the relevant target goals in capillary flow or tissue oxygenation that should then be achieved.From a clinical point of view, translational research has produced contrasted results in critical care medicine. It clearly offered major advances in the understanding of the pathophysiology of sepsis, and animal models have underscored the importance of early antibiotic treatment and aggressive resuscitation that are now commonly implemented during the so-called golden hours of clinical management. However, advances in the comprehension of the immunopathology of sepsis that relied on imperfect animal models failed to translate into successful innovative therapeutic approaches in humans. Nevertheless, we learned important lessons from negative trials, and focusing on a single therapeutic target can now be viewed as simplistic with respect to the complexity of the immune response. In order to sustain innovative approaches in critically ill patients, the French Society of Intensive Care is committed to promote translational research in critical care medicine.


The exact knowledge of popliteal artery and its branches' anatomic variations is important for the clinical practice of angiology, vascular surgery, and interventional procedures. Congenital absence of the artery leads, in some cases, to early malformations of the extremity in the childhood; however, it may also remain asymptomatic. We present an unusual case of a 76-year-old male patient complaining of paraesthesia in both limbs and bilateral aplasia of posterior tibial artery (PTA). Physical examination, ankle-brachial indexes, before and after exercise, arterial duplex scan, and magnetic resonance arteriography were performed. Arterial pulses for PTA at the level of the ankle were normal; arterial duplex study showed biphasic arterial flow at the level of the ankle. Color duplex ultrasound as well as magnetic resonance arteriography revealed the absence of the PTA in both limbs. The vascularization of the fibula was bilaterally normal. The patient underwent also neurological examination and electromyography, which were normal. The evaluation of the possible clinical signs and symptoms and the hemodynamic consequences of this condition are further discussed. The vascular system is known to exhibit a wide range of anatomical variations. The presence of vascular anomalies in patients' lower extremities has been documented. Recent studies analyzed these variations using angiography as a method of choice and came to the conclusion that variation in popliteal branching was seen in almost 10% of cases. Absence or aplasia of the posterior tibial artery (PTA) has been rarely described . Senior However, none of the above studies mention the presence of clinical symptoms or signs and hemodynamic consequences as determined in the vascular laboratory and patients' clinical course. We report an unusual case of a male patient who presented with paraesthesia in both legs, with congenital absence of PTA bilaterally but without signs or symptoms of peripheral artery disease.A 76-year-old male patient was referred to our department complaining of paraesthesia in both legs throughout the last six months. His medical history included aspiration of a kidney cyst 10 years ago and the occurrence of calf vein thrombosis in the right leg 6 years ago (treated with warfarin for 6 months). He had no vascular risk factors , no comorbidities , and no family history of major cardiovascular events, while he was not receiving any medication.On examination, palpable pulses of the femoral-popliteal-dorsalis pedis axis and the posterior tibial arteries were present bilaterally, whereas no difference in muscle strength was observed. The ankle-brachial index (ABI) at rest was 1 in both legs. In addition, the levels of toe pressures were normal and the toes-brachial index was >0.7 in both legs. Moreover, treadmill exercise was carried out without significant drop of the ankle pressure and the ABIs. The patient underwent neurological examination and electromyography, which were normal.Arterial Doppler study  showed bVascularization of the fibula was bilaterally normal through an increased collateral arterial network. More specifically, a recurrent branch of the anterior tibial artery vascularized the proximal epiphysis of the fibula and the peroneal artery vascularized the diaphysis and the distal epiphysis.The patient underwent follow-up examination every six months for 2 years, including physical examination and arterial duplex studies. Complaints of paraesthesia have been diminished and were definitely not associated with the patient's arterial anatomic variation.The patient gave informed consent about possible publication of his case. The study was approved by the ethics committee of our hospital.The knowledge of the popliteal artery variations is important for those performing surgical or percutaneous vascular procedures in the lower leg. Popliteal and peroneal arteries arise from the axial artery whereas the ATA and PTA arise from the femoral system . Stieda In our case, the patient presented without congenital malformation of the lower extremity, while mild paraesthesia was the only symptom. The enlargement of PA according to the ultrasound study and the possible adequate collateral circulation to the fibula represent the main reasons why the patient remained asymptomatic. Vascularization of the fibula remains normal even in the absence of PTA since the nutrient vessel to fibula is provided by the PA .As shown in this case, physical examination alone is not sufficient for the detection of the anatomic variations in the lower extremity arteries. Palpable arterial pulses at the level of the ankle do not exclude congenital absence of even the whole artery. This concurs with studies showing that clinical examination is not independently sufficient to include or exclude a diagnosis of peripheral artery disease . MoreoveIn conclusion, absent tibial arteries may present totally asymptomatic. In addition, normal arterial pulses and normal ABIs do not exclude PTA absence. Therefore, there is a need for detailed preoperative investigation of arterial patency and its normal anatomy before specific types of reconstructive procedures or when endovascular techniques are indicated , 9.


Multiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households.Data was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households.There was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors.Mechanisms for broader risk spreading and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest. Health systems that rely on health insurance to finance health care often have multiple insurance funds covering different segments of the population. In low-income countries, this is regarded as the most feasible option for securing universal access to quality and affordable health care services –3. This The NHIF is a single risk pool covering members across the nation. This factor, together with the mandatory nature of the scheme and income based contributions promotes broad risk spreading and cross-subsidisation from the healthy to the sick, and from the rich to the poor. However this risk sharing is limited to the population covered by NHIF. The CHF comprises multiple risk pools, with risk sharing restricted to each district. This lack of risk sharing across districts limits the degree of risk spreading and cross-subsidisation. Furthermore, the flat rate contributions limit cross-subsidisation from the rich to the poor. The voluntary nature of the CHF also makes it vulnerable to adverse selection, where individuals with high health care needs self select into the fund, resulting in a concentration of less healthy relative to healthy individuals within the fund. The CHF and NHIF operate in parallel within the districts, with no risk sharing across the schemes despite the likelihood that some CHFs will have higher health care needs relative to their revenue bases. The fragmented health insurance system, with no transfers between the risk pools contributes to inequity within the health system and limits the necessary cross-subsidisation for achieving universal coverage. However, beyond the theoretical assumptions outlined above, little is known of the variation in risk distribution across the two funds. Risk distribution in health insurance funds provides information about the influence of individual characteristics on health care costs and determines the health risk profile of the funds. This is based on the assumption that individual characteristics partly determine health care utilisation, which in turn partly determines health care expenditure , 14. TheStudies have shown that demographic risk factors have an indirect influence on health care utilisation and expenditure by predisposing individuals to illness. Age has been found to be positively correlated with chronic morbidity while negatively correlated with self reported health status , 17–19. Study area: Data was obtained as part of a larger study from Kongwa and Mpwapwa districts in Tanzania over a period of eight weeks between July and September 2011. The two districts were selected due to their different levels of CHF enrollment, and for convenience in terms of logistics and costs. Kongwa has a total of 63,612 households of which 5,800 (9%) are registered with CHF [with CHF . Mpwapwawith CHF . Each diSampling method and Sample size: In each district multistage sampling was used to select first wards, then villages, followed by hamlets (administrative unit composed of a number of villages) and finally households. For the purposes of this study a household is defined as a person or group of people, related or unrelated, who live together, share a common pot of food and/or who share the same membership card (for CHF) or are dependents of the same principal member . The study population comprised of all households in the two districts, which met this definition. Due to the low proportion of CHF and NHIF households, stratified sampling was undertaken to ensure sufficient representation of each group. Additionally, due to difficulties in identification of households by membership status from the village household register, households were selected from listings of each membership category as follows: CHF households were randomly selected from the CHF register book kept in the health facilities. This was because health facilities are registration points for CHF. The health facilities were selected based on whether the facility catchment area falls within the selected hamlets. The selection was made from households registered from September 2010 to September 2011, to ensure only current CHF members were included. For NHIF households, a list of all Government institutions in the selected wards or villages was obtained from the District Council, from which all available (at the time of the study) NHIF principal members were selected. Non-member households were randomly selected from the village household register in each of the selected villages. All CHF and NHIF households were omitted from the village register using the list obtained from the facility and District Council respectively before selection of non-member households. The sample size was estimated based on the ability to detect a 25% difference in the proportion of CHF and NHIF using a two-sided test with a power of 80% and a significance level of 5%. We used the proportion of households (50%) with at least one health facility visit reported in a similar study in Burkina Faso [ina Faso . This reData collection: A pre-tested structured questionnaire was administered to all household members. For children below 12 years, a parent or guardian was asked to respond on their behalf. The survey included questions on demographic and socio-economic characteristics, self reported health status, the presence of chronic (illness for 3 months or longer) and acute (illness lasting month or less) illnesses, utilisation of health services, membership status, household ownership of assets and consumer durables. Three return visits were made to households where members were not available for interview during the first visit, resulting in a response rate of 90%, with a sample size of 695 households.Variables: Variables were measured at the household level since CHF membership is based on the household. For the purpose of using a common unit of analysis this was maintained even for NHIF households although membership in this scheme is individual based. Health care utilisation was defined as the number of health facility visit in a household during the past 4 weeks (for acute illnesses) or twelve months (for chronic illnesses) prior to the study. This was operationalised as “0” for households reporting less than the average number of visits for the sample (1 visit) and “1” for households with above average number of visits. Self reported health status was operationalised as the presence of household members reporting fair or poor health status with a value of 1 and 0 otherwise. Self-reported illness was defined as the presence of household members reporting acute or chronic illnesses with a value of 1 for presence and 0 otherwise. Age was defined as the presence of household members in age groups 0-5, 15-49 and 60 and above. These age groups were selected due to their association with higher health care needs [re needs . Althougre needs , 30. Edure needs . HousehoAnalysis: Logistic regression was used to estimate the influence of risk factors on health care utilisation for the whole sample irrespective of insurance status. This was done separately for health care utilisation to capture acute  and chronic illnesses . An adjustment was made for clustering effects at the household; hence robust standard errors are reported. Risk factors showing a statistically significant positive relationship with health care utilisation were then used in the risk distribution analysis. Chi-square tests were performed to test whether the distribution of risk factors varies across the CHF, NHIF and non-members.Ethical considerations: Ethical approval was sought from the Research and Ethics Committee of Muhimbili University of Health and Allied Sciences. Informed consent was obtained by asking those who agreed to participate in the study to sign a consent form.General characteristics of households: We obtained complete information on 695 households. Of these households, 224 are registered with NHIF, 233 with CHF and 238 are non-member households. Fifty percent of NHIF households belong to the highest wealth quintile, while more than 50% of CHF and non-member households belong to the lowest two quintiles (ρ < 0.05). CHF households, with a mean household size of 5.3, were larger than NHIF and non- member households, which both had a mean size of 4.7 members  paying the annual CHF contribution may not present a significant barrier to enrolment. Non-financial barriers to enrolment such as quality of care, distance to the facility, lack of understanding of the concept of prepayment and lack of trust in authorities have been cited as being more important for wealthier households in a number of studies –39. IncrGiven the cross-sectional nature of our study, variations in risk distribution over time could not be captured; hence our findings can only serve to highlight differential risk profiles at point in time and cannot confirm trends in risk distribution. Unlike other studies that analysed the risk distribution across the entire population, our study was limited only to the CHF, NHIF and non-members in two districts. Hence the results cannot be generalised to the entire country, rather provide an indication of the effects of fragmented risk pools. However, given the general similarity of characteristics of the formal versus informal sector population our results can still be useful for highlighting the effects of fragmented risk pools.The study findings provide lessons for policy makers in low- and middle-income countries where multiple health insurance funds have been established to achieve universal coverage. In particular, addressing the challenges of limited risk sharing and cross-subsidisation across multiple health insurance funds remains crucial for equitable access and financial protection. Reducing the existing fragmentation is essential for providing opportunities for cross-subsidisation across the schemes and promoting equity. In this respect, experience from Latin America  and Rwan


Agrobacterium tumefaciens. This includes the vir genes which drive genetic transformation of host cells and the catabolic genes needed to utilize the opines produced by infected plants. The Ti plasmid also encodes, an opine-dependent quorum sensing system that tightly regulates Ti plasmid copy number and its conjugal transfer to other agrobacteria. Many natural agrobacteria are avirulent, lacking the Ti plasmid. The burden of harboring the Ti plasmid depends on the environmental context. Away from diseased hosts, plasmid costs are low but the benefit of the plasmid is also absent. Consequently, plasmidless genotypes are favored. On infected plants the costs of the Ti plasmid can be very high, but balanced by the opine benefits, locally favoring plasmid bearing cells. Cheating derivatives which do not incur virulence costs but can benefit from opines are favored on infected plants and in most other environments, and these are frequently isolated from nature. Many agrobacteria also harbor an At plasmid which can stably coexist with a Ti plasmid. At plasmid genes are less well characterized but in general facilitate metabolic activities in the rhizosphere and bulk soil, such as the ability to breakdown plant exudates. Examination of A. tumefaciens C58, revealed that harboring its At plasmid is much more costly than harboring it’s Ti plasmid, but conversely the At plasmid is extremely difficult to cure. The interactions between these co-resident plasmids are complex, and depend on environmental context. However, the presence of a Ti plasmid appears to mitigate At plasmid costs, consistent with the high frequency with which they are found together.As with many pathogenic bacteria, agrobacterial plant pathogens carry most of their virulence functions on a horizontally transmissible genetic element. The tumor-inducing (Ti) plasmid encodes the majority of virulence functions for the crown gall agent  Plasmids play a key role in the ecology and evolution of bacterial populations as they frequently carry genes conferring traits such as antibiotic resistance, pathogenesis, and the ability to breakdown nutrients . These iRhizobiaceae have multipartite genomes that include several ecologically important plasmids  and Ri (root-inducing) plasmids found in many ectively . Ti plasA. tumefaciens cells encounter a specific set of environmental conditions  most indicative of wounded plant tissue  of Ti plasmid-borne genes (the transferred or T-DNAs) are replicated from the plasmid via a conjugation-like mechanism, delivered into the plant cell via a type IV secretion system, and integrated into the host plant’s genome . Ti plast tissue . Followit tissue . This git tissue . Opine ct tissue . Hairy rA. radiobacter K84 is the best characterized avirulent strain harboring such a plasmid. Interestingly, K84 also produces several antimicrobials that allow it to interfere with the growth of virulent agrobacteria , plant-released compounds often present at high levels in the soil and rhizosphere (A. tumefaciens cells inhabiting the rhizosphere. These catabolic systems include those for degradation of deoxyfructosyl-glutamine (DFG), mannopine (MOP), succinyl semialdehyde (SSA), γ-hydroxybutyrate (GHB), and γ-aminobutyric acid (GABA), and are discussed in greater detail in Sections “The Costs and Benefits Associated with the Ti and At Plasmids” and “Ecological Context of Ti and At Plasmids” of this review.Several pathogenic and avirulent strains of tabolism . One settachment . We now tachment , and thazosphere . In addiA. tumefaciens C58 have been shown to exhibit differential effects on the expression of pTiC58-encoded virulence (vir) genes  genes . For exaIn this review, we will focus on the genomic, ecological, and evolutionary significance of the two best-studied agrobacterial plasmids, the Ti and the At plasmids. We will first describe what is known about the function and regulation of replication, partitioning, and conjugation of these plasmids. Then we will discuss their diversity, ecology, and the genomic context of their evolution. Throughout, we will focus on the influence of the biotic and abiotic environmental conditions on the regulation of plasmid encoded genes and how this relates to the ecological costs and benefits associated with these plasmids. Finally, we will discuss how these genetic and ecological factors couple together to influence the evolutionary dynamics of these plasmids.Many agrobacterial plasmids are defined by their role in pathogenesis, as is the case for the Ti and Ri plasmids. The Ti and Ri plasmids are highly diverse and are characterized by the type of low molecular weight resources, the opines, that infectious agrobacteria cause host plants to produce. Opines are found within and around the tumors or root hairs of plant tissue that has been transformed by the T-DNA of pathogenic agrobacteria, but are not typically found in soil environments. The range of opines that are produced by the infected plant is determined by the T-DNA genes carried on the virulence plasmid, and these genes vary among strains of agrobacteria . The driAs a family, opines are incredibly diverse with over 30 species having been characterized . ChemicaA. tumefaciens strain can transform plants with one or more of a multiple array of opine biosynthetic genes  in the environment. For A. tumefaciens, opine-specific chemotaxis depends upon the Ti plasmid and as such, correlates with the specific opine biosynthetic and catabolism genes encoded by the plasmid  are actively repressed by the agrocinopine-responsive transcriptional regulator, AccR . Octopine is the conjugal opine for octopine-type plasmids, and agrocinopine A and B are the conjugal opines for nopaline-type plasmids . In at ll opines . This prl opines . Althougl opines . For exaor, AccR . When opraR gene . TraR di plasmid .repABC family of replicons. The transcriptional and post-transcriptional regulation of the repABC operon gene products plays a central role in the replication and partitioning of this family of replicons. In this paper, we will briefly describe the regulation of repABC replicon replication and partitioning. We will focus on the well characterized regulation employed by the Ti plasmid and describe how this relates to the quorum sensing dependent regulation of Ti plasmid conjugation. Several recent reviews cover these topics in detail  and replication (repC) genes of repABC replicons are typically expressed as one transcriptional unit controlled by a promoter region upstream of repA. RepC does not belong to a known larger protein family and the repC gene has only been observed in alphaproteobacteria  that allows for their stable coexistence within a bacterial cell. The location of centromere-like par sites composed of one or more palindromic sequences varies among repABC replicons. These sites play a key role in plasmid stability, partitioning, and incompatibility as they are thought to be the site where the partitioning machinery binds. In the cases of pTiC58 and pTiR10 these par sites are located between repA and repB within the repABC operon, while for other repABC replicons par sites can be found close to the repC stop codon or upstream of repA , an AHL signal molecule that is synthesized by the activity of traI, an AHL synthase also encoded by the Ti plasmid. TraR–AHL complexes stimulate transcription of the pTiR10 repABC operon from all four upstream promoters, resulting in a seven- to eightfold increase in plasmid copy number (tra box stimulating transcription of the divergently oriented traI-trb operon that controls expression of both traI and genes involved in mating pair formation (Mpf) functions required for conjugation of the Ti plasmid. The trb operon includes two genes, trbJ and trbK, which encode entry exclusion proteins that inhibit conjugal delivery of a Ti plasmid into the cell  and the coupling factor TraG.In addition to stimulating opine catabolic functions, the presence of opines in the plant tumor environment also indirectly controls Ti plasmid copy number and conjugation by inducing the expression of the quorum sensing transcriptional activator TraR, encoded on the Ti plasmid . The indy number . Under tthe cell . In additraR paralogs encoded by the plasmid  and opine uptake and catabolism genes are often linked together on the same plasmid, this is not always the case . There aoctopine . Anotherf carbon .Agrobacterium species are considered to be virulence elements, they exhibit blocks of high sequence similarity to the symbiosis plasmids of other rhizobia . Interestingly, the conjugal pili proteins of many of these symbiotic plasmids exhibit homology to the VirB proteins encoded on the Ti plasmid  are more abundant on the At plasmid than on other A. tumefaciens C58 replicons. Strains carrying At plasmids that have incurred these deletions have increased vir expression and possess a higher relative fitness in lab culture compared to strains with the full length plasmids, likely due to high carriage costs associated with these deleted segments  or combinations of the two resources . The shape and position of ZNGIs can vary depending on the attributes of the consumer and the way in which resources influence the growth of that species. The dashed arrows are vectors representing the rate at which the associated species consumes each of the resources.Predicting the establishment of these species in some environments is straightforward. All points in zone A are under the ZNGIs of both species 1 and species 2. Since populations of neither species can grow in zone A, then populations of neither will persist in environments with those combinations of resource levels. Similarly since populations of only species 1 can grow in zone B and only species 2 can grow in zone F, only those species can establish populations in those environments. In these models, one competitor displaces the other if growth of its population drives resource levels below the minimal needs of the other species. This occurs in zones C and E with species 1 driving resource levels below the minimal needs of species 2 in zone C, and species 2 driving resource levels below the minimal needs of species 1 in zone E. In this example, both species stably coexist in zone D since neither species drives resource levels below the minimal needs of the other species. See avhB operon  signal molecules. The BlcC lactonase can effectively degrade AHLs to form N-acyl-homoserines, rendering them inactive as quorum sensing signals. The transcriptional repressor blcR is divergently transcribed from the blcABC operon. Null mutants in blcR fail to accumulate the Ti plasmid encoded AHL, 3-oxo-C8-HSL, due to overexpression of blcC  cycle, which can also induce gligible . AdditioThe rhizosphere is the soil at the interface of plant root tissue. Here, plant roots influence the conditions of the soil to create a dynamic environment that is rich in microbial life . Becausede novo evolution of avirulent freeloaders via loss of virulence functions have both been observed  and a periplasmic binding protein , the acc genes and, more recently discovered, the noc genes through nocR. TraR is directly responsible for the expression of T4SS genes for the conjugal transfer of the Ti plasmid, meaning that agrocinopines, through AccR, control dissemination of this replicon. Similarly, it was recently shown that AccR also regulates expression of pAtC58’s rctB, orthologs of which have been shown to be involved in control of symbiotic plasmid conjugation in related rhizobia R. etli and S. meliloti . Further, competition with avirulent, opine-catabolic agrobacteria threatens the persistence of the pathogen in the host environment as well . One greenhouse study shows that a strain with an At plasmid outcompetes an isogenic strain lacking the plasmid in the rhizospheres of infected plants . When rhA. tumefaciens genotypes are determined by intracellular interactions. One example of this is the elevated expression of Ti plasmid virulence genes in cells that harbor a laboratory-evolved At plasmid . Consequent impacts on the competitive ability of plasmid-harboring strains thereby influence the spread and decline of these plasmids. A significant challenge remains in integrating these local scale competitive interactions into a meta-community framework that would predict population virulence levels and disease incidence. This effort will require additional information on other aspects of agrobacterial life-history, including their dispersal and dormancy. A secondary level of questions relates to the environmental benefits of the different variants of virulence plasmids. Do, for example, agrocinopine Ti plasmids confer a competitive advantage in P-limited environments while Ti plasmids conferring catabolism of secondary amine derivatives confer a competitive advantage in N-limited environments?Environmental resource levels play a key role in determining the relative costs and benefits associated with many agrobacterial megaplasmids (e.g., Conjugal transfer is a second factor determining the evolution of agrobacterial megaplasmids as it allows colonization of novel genetic backgrounds. An open question for future research is to what degree conjugation also impacts competition among variant agrobacterial plasmids. The fitness of conjugal plasmids is composed of contributions from both its vertical transmission during reproduction of the host cell and its horizontal transmission during conjugation. Because of this impact on plasmid fitness, conjugation may have a role in shaping the competitive ability of these plasmids.Conjugation may also play a role in allowing for interactions between competing plasmids mediated by the toxin-antidote systems that they encode , 2005. SOne of the strengths of agrobacteria as a model system for such questions is the ability to readily integrate lab, greenhouse, and field studies of this microorganism. Our understanding and ability to manipulate relevant environmental and genetic factors allows for experimental dissection of forces influencing the ecological success and evolution of these plasmids in the laboratory and more realistic greenhouse settings. Such work can be coupled with examination of the plasmid dynamics in field populations to provide a clear picture of what drives the success of agrobacterial megaplasmids in nature. These types of studies also address more general issues such as how the joint effects of dynamics in host and non-host environments influences the ecology and evolution of diseases caused by facultative pathogens. While many important diseases are caused by facultative pathogens, the dynamics of these pathogens occurring in non-host environments is poorly incorporated into most models of disease epidemiology and evolution. Consequently the experimental tractability and the established environmental context dependence to the fitness of agrobacterial pathogens makes these bacteria powerful model systems for studying the intersection of microbial ecology and disease dynamics for facultative pathogens.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.


Congenitally missing teeth are the most commonly seen dental anomalies. Agenesis of the permanent first molar has the least frequency of all the tooth types, and it usually occurs in association with oligodontia or anodontia. Thus, agenesis of the bilateral maxillary first permanent molar is an extremely rare occurrence, and no such case has been reported in ethnic Saudi Arabian population. We hereby report a case of nonsyndromic bilateral congenitally missing maxillary first permanent molar in an eight-year-old Saudi female patient. Comprehensive oral rehabilitation was done for the patient. The implications of the tooth agenesis are also discussed. The prognosis of this case is presented. Hypodontia is the term used to describe the developmental absence of one or more primary or permanent teeth, excluding the third molars. It is the most commonly seen dental anomaly and is found more in the permanent dentition . A toothThe occurrence of a congenitally missing first permanent molar is a rare finding as the common congenitally missing permanent teeth in the order of frequency are third molars, second premolars, and lateral incisors . CongeniSeveral hypotheses , 6 have An eight-year-old female patient reported to the Department of Pediatric Dentistry, College of Dentistry, Gizan, for routine dental examination. This was the patient's first dental visit. The patient was moderately built and nourished and the medical history was noncontributory. Extraorally, she exhibited a straight profile and normal facial appearance. The lips were competent.Intraoral examination revealed carious left primary maxillary canine and molars , primary mandibular first and second molars (74 and 75), and right and left mandibular first permanent molars (36 and 46). Another remarkable finding was the bilaterally missing maxillary first permanent molars (16 and 26) . There wAn orthopantomograph was then taken. It confirmed our clinical finding and revealed the agenesis of the maxillary first molars (16 and 26) . On the The parents were informed of the missing teeth. Glass ionomer restoration was done for all the carious molars. Stainless steel crown was placed over the multisurface restoration done on the left maxillary primary first molar 64) and the right mandibular primary second molar 75). Enamel defects on the primary maxillary right canine and primary mandibular left canine (53 and 73) were restored with composite resin. The patient is currently under follow-up every six months to monitor the eruption of the permanent maxillary second molar   does notThe deft index of the patient was recorded as 6, DMFT as 2. All the treated teeth were diagnosed as reversible pulpitis. The permanent mandibular molars were in good health. This clearly rules out any chances of early extraction of permanent maxillary first molar due to caries; and the same was elicited from the patient's past dental history also.Hence, all these findings support the hypothesis that the maxillary permanent molars present in our case are certainly the second molars associated with the congenital absence of the maxillary first molars. A PubMed literature search revealed that no such case has been reported in the ethnic Saudi Arabian population.Despite the low prevalence rate, maxillary first permanent molar agenesis presents clinically significant problems affecting treatment planning and outcome, because the first molars play an important role in the mastication of food, in supporting the vertical dimension of the face, and as anchorage teeth against orthodontic forces. The type of malocclusion, severity of crowding, and facial profile are of major concern in determining the final treatment plan . In our Congenitally missing permanent first molars are a rare entity. Permanent first molars have very strategic importance in the dentition because of their function and stability. Routine radiographic examination is mandatory for patients in whom certain teeth do not erupt at their scheduled time. It is important to recognize the anomaly as early as possible, to guide the occlusion, and to implement multidisciplinary management.


Chronic active EBV (CAEBV) infection is a rare condition associated to a chronic activation of Epstein Barr virus and therefore to a chronic and potentially lifethreating lymphoproliferation. Few cases of this condition have been described in the Asian population  and in North America . This condition presents a poor prognosis: most of the patients not treated with bone marrow transplantation die for lymphatic malignancies.To describe the clinical course of two patients with CAEB, initially misdiagnosed and treated as periodic fever syndromes.We describe the clinical course of two patients presenting with a condition of periodic fever due to the chronic activation of EBV virus.A boy of consanguineous parents at the age of 15 months presented, in complete wellbeing, a febrile episode associated to tonsillitis with exudates, lateral cervical lymphadenopathy and hepatosplenomegaly; the blood test revealed an infectious mononucleosis. The clinical course of the disease was regular. In the following months the child presented recurrent episodes of high fever with exudative tonsillitis, adenitis, splenomegaly and sweating, lasting 3-5 days and treated with NSAIDS or antibiotics. The blood examinations revealed neurofilic leukocytosis and elevation of acute phase reactants. An autoinflammatory condition with periodic fever was suspected and therefore on-demand steroidal treatment was suggested; this therapeutic approach was only partially effective. In the following months the boy continued to present periodic fever, occasionally associated to respiratory infections requiring antibiotics, and recurrent episodes of cheratitis. Several destructive dental caries were found as well as hyper sensibility to mosquitoes bite. In light of the persistence of the symptoms, monogenic periodic fevers were ruled out and immunologic test were performed: the level of plasmatic immunoglobulins was reduced and the lymphocytic count revealed an increase of CD20+ cells; the EBV PCR revealed 25000 copies for 100000 leucocytes with prevalence of infection in the B cells.MEFV gene; the diagnosis of FMF was point out and treatment with colchicine was started, without a clear improvement of the clinical picture. Due to an increase of the transaminase and reduction of the platlets’ count, a bone marrow aspiration was performed, negative for malignancies. Several destructive dental caries were found requiring the avulsion of 11 teeth. Immunologic tests were then performed: immunoglobulis were normal, while the lynphocyte populations’s count revealed a relevant increase of the NK cells, with reduction of the other populations. Virologic investigations revealed a high replication of EBV virus (600000 copies for 100000 monocytes) with a prevalence of infection of NK cells.A second non-related patient of non-consanguineous parents, at the age of four years started to present recurrent episodes of high-grade fever with pharyngitis, oral aftosis and abdominal pain with normal or slightly increased inflammatory markers. The genetic test for periodic fever revealed the presence of the R202Q variant in homozygosis in the Chronic active EBV infection is a rare condition, rarely individuated in the childhood. However this disease has to be ruled out in paediatric patients with periodic fever syndromes, especially in case of presence of unusual symptoms.None declared.


Missing data can arise in bioinformatics applications for a variety of reasons, and imputation methods are frequently applied to such data. We are motivated by a colorectal cancer study where miRNA expression was measured in paired tumor-normal samples of hundreds of patients, but data for many normal samples were missing due to lack of tissue availability. We compare the precision and power performance of several imputation methods, and draw attention to the statistical dependence induced by K-Nearest Neighbors (KNN) imputation. This imputation-induced dependence has not previously been addressed in the literature. We demonstrate how to account for this dependence, and show through simulation how the choice to ignore or account for this dependence affects both power and type I error rate control. MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate gene expression by targeting messenger RNAs. They were first discovered in 1993 during a study into development in the nematode Caenorhabditis elegans (C. elegans) regarding the protein gene lin-14 29], and From The imputation accuracy of the proposed KNN imputation method, using the aggregated metric distance matrices of the demographic and lifestyle data, in the simulation data sets was higher than that of the MI methods using MCMC and EM with bootstrapping algorithms. Moreover, the proposed KNN method was robust and imputed the miRNA features of missing normal samples with less computational expense than the other imputation methods.The DE tests of the KNN imputed data sets show that the KNN method while accounting for the dependence of the imputed values (KNN dependent) provided greater power than if no imputation were done (the case deletion approach) and maintained control of the FDR. The KNN method while ignoring the dependence (KNN independent), as well as MCMC and EM with bootstrapping algorithms had higher power than the power of KNN dependent, but failed to control the FDR. These effects are more clear for larger missing percents and number of subjects.Depending on the study goals, researchers could select the KNN method while ignoring the dependence  or considering the dependence . In the motivating CRC study, the chosen approach is the KNN method while accounting for the dependence, with moderate loss of power but maintaining control of the FDR.The case deletion method showed the lowest power to identify differentially expressed miRNAs, though it had similar FDR control as the KNN dependent method.In this paper, we applied the paired t-test to identify differentially expressed miRNAs from normally distributed simulated miRNA data while accounting for the dependence structure of the imputed data. However, miRNA data can be noisy and not normally distributed. Currently available nonparametric tests may also not be directly applicable because they assume independence. In this respect, it is challenging to construct a statistical model which tests for significant miRNAs from paired samples while accounting for the dependence. Our future work is to develop a nonparametric t-test method which enables paired t-tests on a large number of miRNA data, using permutations with manageable computational expense, while accounting for the dependence induced by KNN imputation.S1 Fig(TIF)Click here for additional data file.S1 File(ZIP)Click here for additional data file.