Since the first description of bisphosphonate-related osteonecrosis of the jaw (BRONJ), numerous research groups have focused on possible pathological mechanisms including the suppression of the bone turnover of the jaw, antiangiogenic effects and soft tissue toxicity. In our review we focused on summarizing the role of the soft tissues in the development and progression of BRONJ. The biological behavior of fibroblasts can be significantly influenced by bisphosphonates (BP) such as a concentration dependent reduction of cell viability. High concentrations of BP can induce apoptosis and necrosis of the cells. Comparable effects could be detected for keratinocytes. Compared to non-nitrogen containing bisphosphonates, nitrogen-containing BP have worse effects on cell biology by blocking the mevalonate pathway. Further, the cell architecture and expression levels of several genes and proteins are significantly disturbed by BP. These inhibitory effects of BP are in accordance with BP-related reduced angiogenesis and neovascularization and could underline the hypothesis that inhibition of fibroblasts and keratinocytes results in delayed wound healing and can induce and trigger BRONJ. Bisphosphonates (BP) are widely used in different benign and malignant diseases such as Paget’s disease, osteoporosis, multiple myeloma and bone metastases of breast or prostate cancer. From 2003, Marx et al. and other international research groups have reported on a medication-associated osteonecrosis of the jaw and called it bisphosphonate-related osteonecrosis of the jaw (BRONJ) . PreviouIn recent decades, various international research groups have attempted to analyze the pathophysiology of BRONJ ,5,6,7. BApart from the inhibitory effect of bisphosphonates (BPs) on osteoclasts and osteoblasts, nitrogen-containing BP in particular interacts with cell soft tissue cells such as fibroblasts and keratinocytes ,11. AfteIn comparison to other parts of the human body, the oral gingiva is unique showing special features. Unlike other epitheliums, the oral gingiva is in direct contact with the underlying bone. Under BP treatment, there is a direct cytotoxic effect by blood support as well as the BPs enriched underlying bone. No soft tissue layer, such as fat, fascia, or muscle, buffers the negative effect of BPs released from the underlying bone .Under normal conditions, the mucosal immune system suppresses pathogenic organisms such as bacteria and fungi.These physiological and anatomical factors are unique to the oral environment and may represent an important factor for the course of the BRONJ disease. Furthermore this explains the fact that oral mucosa is strongly inhibited by BPs. Different research groups additionally showed, in vivo and in vitro, that BP can directly counteract and inhibit cells of the immune system such as neutrophils and lymphocytes ,19. The Collaboration between osteoblasts and osteoclasts is strongly required for normal bone turnover. This physiological link is disturbed in patients treated with BP . Under nFor sufficient oral wound healing, viability of keratinocytes is mandatory. Reduction in cell viability may result in exposed bone, which could serve as the ignition spark for BRONJ. Pabst et al. demonstrated that nitrogen-containing BPs have a strong influence on keratinocytes. BPs decrease cell viability, migration ability, and increase apoptosis rate , i.e., kTaken together these studies support, but cannot categorically confirm, the theory that pausing the drug administration during oral surgical procedures could be beneficial for normal keratinocytes function which support wound healing and tissue regeneration ,29; as, Besides the direct cytotoxic effect on fibroblasts and keratinocytes, different research groups have detected a direct inhibition of wound healing and impaired mucosa function. The development of gastric erosion and ulcers is a well described side effect of BPs. Several studies demonstrated that especially nitrogen-containing BPs show a negative effect on different gastric cell types. Wallace et al. showed, in an ex vivo gastric chamber model, that the gastric mucosa is inhibited by nitrogen-containing BPs . LandesbThe development and maintenance of BRONJ is a multifactorial event. The adverse impact of BPs results in inhibition of cellular function of the hard tissue, as well as inhibitory effects of the mucosal layer. Inhibition of fibroblasts and keratinocytes leads to disturbed integrity of the mucosal layer and has a negative influence on bone metabolism via the RANK-L-OPG-system. Besides this, the mucosal immune system is compromised and vulnerable to infection. Further, the mucosal architecture is influenced by BPs and results in mucosal thinning.


The interest of scientists for the transcription of the eukaryotic genome started four decades ago with the purification of the three RNA polymerase (Pol) enzymes. Pol I, II and III transcribe different species of RNA with the help of several general/basal transcription factors (TFs). Messenger RNA (mRNA) transcription by Pol II has been intensely studied owing first to the protein-coding function of mRNA and also to the apparent complexity of this system compared to the transcription of ribosomal RNAs by Pol I or small RNAs by Pol III. Indeed, it was shown very early that mRNA transcription required, apart from Pol II, additional enzymatic activities that didn’t seem to be needed in the Pol I or III systems. Surprisingly enough, all these activities reside in TFIIH, a multi-subunit transcription/repair factor that is involved, through its CDK7 and XPB subunits, both in the phosphorylation of the carboxyl-terminal domain of the largest Pol II subunit and in the ATP-dependent opening of the promoter around the transcription start site, respectively . Consequin vitro helicase activity of XPB appeared very low [Recent results contradicted the above Pol II model and have deeply modified our view of transcription initiation in eukaryotes. First of all, in contrast to its ATPase activity that is robust, the very low . Rather,very low .Moreover, technical advances in our capacity to localize transcription factors inside the preinitiation complex (PIC) have revealed that XPB was binding to the promoter DNA downstream from the transcription start site, a location that was not compatible with its role in promoter opening . In additripterygium wilfordii, which binds XPB and inhibits its ATPase activity [in vivo. Through the inhibition of the ATPase activity of XPB, Triptolide and Minnelide probably inhibit the translocation of XPB downstream of the transcription start site thereby disrupting the release of the transcriptional block imposed by XPB itself. Similar observations concerning the involvement of XPB in basal transcription have been made in the last months [The new regulatory step described above depends on the ATPase activity of XPB and is probably the target of the very promising anti-cancer compound Minnelide. This small molecule is a synthetic prodrug of Triptolide, a diterpenoid epoxide endogenously produced by the thunder god vine, activity . Minneliactivity . Severalactivity , validatt months , 6. They


Punica granatum L.) fruit has been used for the prevention and treatment of a multitude of diseases and ailments for centuries in ancient cultures. Pomegranate exhibits strong antioxidant activity and is a rich source of anthocyanins, ellagitannins, and hydrolysable tannins. Studies have shown that the pomegranate fruit as well as its juice, extract, and oil exert anti-inflammatory, anti-proliferative, and anti-tumorigenic properties by modulating multiple signaling pathways, which suggest its use as a promising chemopreventive/chemotherapeutic agent. This review summarizes preclinical and clinical studies highlighting the role of pomegranate in prevention and treatment of skin, breast, prostate, lung, and colon cancers.Cancer is the second leading cause of death in the United States, and those who survive cancer may experience lasting difficulties, including treatment side effects, as well as physical, cognitive, and psychosocial struggles. Naturally-occurring agents from dietary fruits and vegetables have received considerable attention for the prevention and treatment of cancers. These natural agents are safe and cost efficient in contrast to expensive chemotherapeutic agents, which may induce significant side effects. The pomegranate ( Cancer is a disease of unrestricted cell proliferation. Normally considered a disease of genetic origin, research over the last several decades has established beyond doubt that various epigenetic/environmental factors play an important role in the development and/or progression of cancer ,2. With Almost 2500 years ago, Hippocrates recognized the importance of food for overall health. Medicinal systems across different cultures have professed and promoted the use of edible substances, especially those derived from plants, to prevent/treat diseases over last several centuries, hence, creating awareness of the potential of natural agents also known as phytochemicals as cancer chemopreventive/chemotherapeutic agents. As of today almost 47% of the available anticancer drugs in the market are derivatives of natural products or natural product mimics . There iPunica granatum L.) is obtained from a deciduous tree belonging to the family Lythraceae. There are reports that indicate that it first originated in modern day from Iran and has been cultivated through the Mediterranean region and Northern India since ancient times pyran-6-one glucuronide), together with traces of urolithin B glucuronide,  and dimethyl ellagic acid  and ted mice . Anotherted mice . Punicalted mice . The rested mice . Similarted mice  tested tted mice .Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer deaths in both men and women in the United States. According to the American Cancer Society’s most current estimates, approximately 134,490 new cases of colorectal cancer will be diagnosed in the United States in 2016 . IncreasThe consumption of PSO rich in conjugated linolenic acid in the diet was found to significantly inhibit the growth of azoxymethane-induced colonic adenocarcinomas in male F344 rats without causing any adverse effects . Furthern = 10) CRC patients, found an in vivo specific modulatory effect of the intake of PEs enriched in ellagic acid or ellagitannins  on specific miRs  in human malignant and normal colon tissues from CRC patients [Earlier studies have shown that urolithins with potential cancer chemopreventive effects can reach high concentrations in the colon of animals following ellagitannins intake . Recentlpatients . The datIn the current setting, cancer prevention via dietary agents is quite a promising arena of oncology that has drawn a significant amount of attention from both scientists in basic and clinical sciences and the general masses due to dietary agents’ proven ability to prevent or suppress cancers, their low cost, and easy availability. However, current challenges relate to establishing the key component of these dietetic agents responsible for the anticancer effects and the mechanisms through which they suppress cancer. Accumulating research provides extensive evidence related to biological activities of pomegranate-derived products particularly with respect to their anticancer properties. Studies have suggested the whole pomegranate fruit, as well as its juice and oil, as promising chemopreventive/chemotherapeutic agents, as they exert anti-inflammatory, anti-proliferative, and anti-tumorigenic effects by modulating multiple signaling pathways. More in vitro and in vivo studies are needed to assess the combinatorial effect of pomegranate with other compounds to determine whether additive or synergistic, or even antagonistic, effects are observed. Considerable data demonstrates the in vitro and in vivo efficacy of pomegranate against cancer growth and promotion; however, well-designed human clinical trials are necessary to validate the usefulness of these natural agents either alone or in combination with current therapy for the prevention and treatment of skin, breast, prostate, lung, and colon cancers.


The need for extended liver resection is increasing due to the growing incidence of liver tumors in aging societies. Individualized surgical planning is the key for identifying the optimal resection strategy and to minimize the risk of postoperative liver failure and tumor recurrence. Current computational tools provide virtual planning of liver resection by taking into account the spatial relationship between the tumor and the hepatic vascular trees, as well as the size of the future liver remnant. However, size and function of the liver are not necessarily equivalent. Hence, determining the future liver volume might misestimate the future liver function, especially in cases of hepatic comorbidities such as hepatic steatosis. A systems medicine approach could be applied, including biological, medical, and surgical aspects, by integrating all available anatomical and functional information of the individual patient. Such an approach holds promise for better prediction of postoperative liver function and hence improved risk assessment. This review provides an overview of mathematical models related to the liver and its function and explores their potential relevance for computational liver surgery. We first summarize key facts of hepatic anatomy, physiology, and pathology relevant for hepatic surgery, followed by a description of the computational tools currently used in liver surgical planning. Then we present selected state-of-the-art computational liver models potentially useful to support liver surgery. Finally, we discuss the main challenges that will need to be addressed when developing advanced computational planning tools in the context of liver surgery. Systems biology applied to human diseases is an interdisciplinary approach broadening our understanding of mechanisms involved in disease development and progression. Thus, mathematical models of human diseases can enable us to discover new therapy strategies and targets.Systems biology is characterized by the application of computational models and methods to a biological question, focusing on entire biological systems and the complex interactions therein. In systems biology, an iterative cycle of model building and validation based on experimental data generation and analysis is pursued. The key purpose of computational models is the integration of biological knowledge into a mathematical representation of the underlying processes allowing Using the systems biology approach in a clinical setting is termed systems medicine function could provide many benefits for patients undergoing liver surgery, including faster recovery, less infections, and reduced mortality, altogether leading to improved patient outcome.Employing models from systems biology in the context of surgery, thus aiming at considering all relevant biological processes by the means of predictive computational models, is an approach that could be termed as “Systems Surgery.” Numerous computational models simulating selected hepatic functions have been developed in the field of systems biology. These models were primarily developed to improve the understanding of hepatic physiology, but their integration into current surgical planning tools is lacking so far. Extending these tools by integrating computational models involving the hepatic stress response, metabolic function, and liver regeneration would allow better prediction of the surgical risk and the postoperative course and outcome.In this review, we provide an overview of mathematical liver modeling and its prospective application to computational liver surgery. Following a comprehensive summary of the biological and medical background relevant for liver surgery, we present an overview of state-of-the-art computational approaches supporting current liver surgical planning. Next, we provide an outline of selected liver-specific models from the field of systems biology with a special focus on their relevance for liver surgery. Finally, we identify the main challenges associated with the application of computational models in liver surgery.The liver is a highly complex organ. It is characterized by (a) its multi-scale architecture, (b) its special perfusion system with two parallel inflows  and one outflow (hepatic vein), (c) its multitude of functions including metabolic homeostasis, synthesis of essential compounds, detoxification, and excretion of toxic substances, and (d) its high regenerative capacity after injury. Despite the seemingly regular microstructure of the liver, perfusion, functional, and regenerative capacity are distributed heterogeneously in the organ at different spatial scales, see Figure The multi-scale structure of the liver consists of cells, lobules, segments, and lobes  separating opposing pathways in spatially separated zones, (b) preventing substrate competition between different metabolic pathways, and (c) connecting consecutive pathways.Sinusoids draining into the same central vein form the liver lobule, the functional unit of the liver on the tissue level. Perfusion of the liver lobules, also called hepatic microcirculation, is unique since the sinusoidal network receives both oxygenated blood from the hepatic artery (~20%) and  deoxygenated blood from the portal vein (~80%). Alterations in the sinusoidal morphology Figures  lead to Liver lobules in the region supplied by the same segmental branch of the portal vein form one of eight segments of the liver, the so-called Couinaud segments   receive oxygen-rich blood from the hepatic artery and nutrient-rich blood from the portal vein and are specialized in oxidative metabolism comprising gluconeogenesis, β-oxidation of fatty acids, and cholesterol synthesis. In contrast, hepatocytes close to the central vein  receive lower oxygen and nutrient levels and perform glycolysis, lipogenesis, bile acid synthesis, and drug detoxification by cytochrome P450 (CYP) enzymes  progressing to large droplet formation (macrovesicular steatosis). Depending on the etiology, fat accumulation often starts in one specific zone, e.g., in the pericentral zone in case of ethanol-induced toxic etiology. Besides zonal accentuation Figure , fat disPatients with steatosis have a higher surgical risk than patients without steatosis  PET-CT , 99mTc-galactosyl, or 99mTc-mebrofenin.A variety of imaging techniques is available for the detection and differential diagnosis of liver pathologies, the assessment of liver anatomy, and more lately also for the spatially resolved evaluation of liver function. The armamentarium includes ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) as well as nuclear medical imaging modalities. The latter, for instance, play an important role in detecting microvascular invasion of carcinoma preoperatively using CT is a core technology for tumor staging and volumetric evaluation of the liver. It enables precise visualization of the tumor location with respect to the intrahepatic vascular anatomy. In fact, the first computational planning tools considering the individual hepatic anatomy were developed on the basis of CT imaging  and MRI have gained ground with regard to their use in the detection, characterization, and assessment of the response to treatment of focal and diffuse liver diseases , monitoring the perfusion dynamics and the uptake of the agent allows functional assessment of the liver FTaken together, a diversity of imaging modalities and methods is currently available which, however, are not evenly spread and readily available at all centers for daily routine yet. While basic CT, US, and MRI are ubiquitously performed, particularly the more recently developed methods in magnetic resonance imaging and spectroscopy, contrast-enhanced US and nuclear medicine, despite being very promising, are so far largely limited to specialized centers.Presently, most computational models supporting liver resection planning are based on individual patient anatomy , but not within one comprehensive risk assessment tool.One first attempt to extend surgical planning beyond mere visualization and volume estimation has been provided recently by a model, which simulates postoperative liver regeneration in a patient-specific manner . Various biological processes play a role for hepatic function in liver surgery, particularly important are the hepatic stress response, metabolic adaptations, and regeneration.Thus, multi-scale-oriented modeling approaches are especially suited to provide a more comprehensive understanding of hepatic processes and mechanisms. Multi-scale-oriented modeling consists of developing “simple” separate models of certain sub-aspects or scales of the function of interest. Subsequent model integration links input and output variables of these separate models and leads to a more comprehensive combined model, possibly spanning multiple scales. This so-called hierarchical modeling approach  the hepatic stress response following physical damage, (b) the metabolic pathways affected by surgery, as well as (c) the regeneration of liver volume and function recovery.Resection induces a hepatic stress response, which involves a modulation of signaling pathways and gene expressions. Understanding the signaling network of the liver and how the signaling affects metabolism, inflammatory processes, and regeneration is important to assess the overall hepatic stress response to resection. Signaling pathways are interconnected in a non-linear fashion, involving complex interactions as well as feedforward and feedback loops . Aspects covered by such models include, e.g., the origin of zonation patterning  the hepatic surgical stress response. Based on ODEs, several computational models have considered various aspects of the production and degradation of ROS  to analyze the flow of metabolites through hepatic metabolism based on steady state approaches. The most popular approach is Flux Balance Analysis  using detailed perfusion models in vessel geometries. CFD was applied to the liver to study blood flow in a segment of a lobule consisting of a resolved hepatic microvascular system  models  and global (organ) scale could be achieved.Surgical planning using model-based predictions of functional liver volumes could substantially improve clinical outcome. Importantly, computational models of hepatic metabolism could provide insights into the heterogenous distribution of metabolic liver functions like the heterogeneity of fat in NAFLD and its consequences for the regional functional capacity. Multi-scale metabolic models of NAFLD/steatosis would allow to calculate hepatic functional capacity based on given fat content, tissue properties like stiffness and elasticity, and perfusion. Thereby, they would provide important insights into surgical planning. Multi-scale computational models of metabolic functions may also improve evaluation of quantitative liver function tests, like galactose elimination capacity or LiMAx. Integrated with surgical planning tools, computational models of such liver function tests could provide a more accurate prediction of metabolic function after resection and during regeneration.Integrating omics data with metabolic models for predicting changes after liver surgery seems a promising future direction. Personalizing generic models based on individual omics data, a personalized prediction of metabolic liver function and its alteration after resection could be achieved. This personalization as well as the stratification of patients into subgroups has already been demonstrated  embedded into a biomechanical framework. This allows the integration of underlying biological mechanisms, see among others  has mostly been addressed in terms of postoperative liver failure. Well-known risk factors for postoperative liver failure are, e.g., preexisting disease, age, nutrition  precise determination of the preoperative state and functional capacity of the liver, taking preexisting disease into account (model input data), (b) estimation of the extent of surgical damage inflicted on the liver during the resection, and (c) prediction of the impact of hepatic tissue loss and surgical damage on the functional capacity of the (diseased) future liver remnant and its recovery process (model output data).in silico function and regeneration after resection in respect to variation of resection surface and safety margins.Future surgical planning software should include a workflow for function-based risk assessment. Input data data comprise in addition to the liver anatomical architecture also spatially resolved data assessing hepatic perfusion and function as well as clinical data, e.g., quantitative dynamical liver function tests, and information about existing liver disease as summarized graphically in Figure Functional predictive models need to be integrated into the existing individual 3D planning of the liver representing the vascular structure of the liver and the location of the tumor.Such an integrated planning tool will improve individualized risk prediction for hepatic surgery and provide important information about the expected liver function after surgical intervention and during subsequent liver regeneration. This tool will ultimately support surgeons in their decision about a patient's operability and the choice of a suitable intervention, but will also make them aware of possible postoperative complications allowing therapy adjustments after resection.The integrated tool will support risk assessment depending on preexisting liver disease and damage of the liver. This requires integrating underlying pathophysiologic conditions and preexisting risk states on an individual basis. For example, steatosis and other chronic liver diseases  substantially impact the function of the future liver remnant and its regeneration, and hence increase the risk of postoperative complications and liver failure. Surgeons and patients will benefit from more comprehensive risk predictions taking functional aspects into account without the need of own expertise in multi-scale computational modeling in the implementation.Further development of such an integrated liver model can be envisioned to obtain better disease- or cohort-specific predictions and to enhance the prognostic power for the individual patient.Reaching better disease- or cohort -specific predictions would call for including further cohort-specific data to tune the integrated model according to the specific aspect in question. Doing so will contribute to getting a better insight into disease progression and curation. However, this will require to generate considerably more animal experimental data of the specific disease and of course to collect a substantial amount of additional cohort-specific clinical data.Such data are needed to generate probabilistic disease models, which have to be integrated into the proposed “liver resection and regeneration” model.Enhancing the prognostic power for the individual patient could be achieved by extending the knowledge-based selection of relevant patient-specific pre-, peri-, and postoperative data considered to be relevant. Additional input data regarding the activity and severity of the complicating liver disease as well as data regarding the general patient condition  appears extremely useful for this purpose. Similarly, additional outcome data would be necessary, requiring an detailed follow-up of the patient to collect data regarding extra-hepatic surgical and general complications  and reflecting the recovery of the patient's general condition . However, increasing the number of entry variables would call for a higher number of outcome observations.Alternatively, this could also be achieved using a “big data” approach by focussing on creating an interface with the currently used hospital information systems to have access to all patients and all patient-specific information. Following this approach, a rather large number of patients would be needed to reflect the high data variability as presented in true patient cohorts.Determining the preoperative state of the liver and the expected alterations after surgery must be improved to optimize surgical planning and reduce the probability of postoperative liver failure. This involves several challenges.Here, the key point is to improve spatial resolution, which will benefit the assessment of morphological and structural alterations due to the underlying preexisting hepatic disease, the assessment of hepatic perfusion, and most importantly, the quantitative assessment of hepatic function.Identifying meaningful and relevant diagnostic assays from the multitude of available assays is a major challenge. These assays should be non-invasive and serve as a basis for valid predictions regarding surgical complications, surgical outcome, and changes in liver functions following liver surgery.It is not sufficient to only quantify the loss of liver volume due to tissue removal, but also necessary to quantify the volume of liver tissue at risk due to alterations of hepatic perfusion. The key challenge is to estimate the loss of functional tissue with respect to the extent of resection, the resection surface, and the resection technique. In addition, preexisting global liver diseases impair hepatic function in a spatially heterogenous way (cf. the section “Hepatic Diseases”), which has to be taken into account during the surgical planning phase.The functional capacity of the remnant liver should be predicted based on the preoperative disease state and the predicted loss of liver tissue and liver function by resection.Building a comprehensive model for the prediction of the hepatic functional capacity after resection faces many challenges.A prerequisite for building a comprehensive model of functional prediction is the availability of high quality models reflecting those aspects that are important for liver surgery, such as liver function depending on perfusion, liver volume regeneration in case of preexisting damage, or recovery of hepatic metabolic function after resection. The key processes and mechanisms of all these aspects must be understood in sufficient detail and transferred to a suitable mathematical formalism. Part of the challenge is to extend compatible model components and to develop interfaces to bring these building blocks together.Besides understanding the processes, further key steps for model building are parameterizing and subsequently validating parametrized models. A key requirement for these steps is the availability of high-quality experimental and clinical data.Many existing studies have only looked at a single aspect of liver surgery, such as regeneration, liver function, or changes in perfusion. Assembling data from different sources is difficult, since the experimental and clinical conditions are in general vastly different. A multitude of experimental resection studies has been performed in rodents under controlled conditions and with various liver diseases, but using a variety of experimental conditions and read-out parameters. Consequently, comparability is often limited and data integration into a single model questionable. A similar problem is the extrapolation from clinical data measured in one cohort to another cohort with different characteristics, e.g., data from young subjects to old subjects. For similar reasons, translation of results from animal studies to the human situation is even more challenging.One recurring problem is the quality of experimental and clinical data, e.g., inaccurate or high-variance data, with model predictions strongly depending on the accuracy of the measured patient-specific data. The aforementioned issues with experimental data require new comprehensive and targeted data sets to ensure all needed input data were generated under the same conditions. One key aspect is to perform targeted experiments and studies to collect the information for model parameterization and validation. Alternatively (or in addition), analysis of the effects of the underlying datasets on model predictions and quantification of the resulting uncertainties in the predictions must be performed in order to analyze sensitivity.One major challenge is the integration of different types of data  and to handle the heterogeneity within similar datasets  with computational models. Standardization of data formats and models for simple and reproducible integration of the different data sets into the models is important , and that coupling of different modeling is often not supported in simulation software and difficult to implement. Multi-scale computational modeling requires connecting models via clearly defined interfaces between the different scales and sub-models. General challenges of computational modeling like parameter fitting/overfitting, model selection, parameter selection, or parameter identifiability are also major challenges in multi-scale models, often aggravated due to the large number of parameters in models spanning multiple scales.Often, model reduction is necessary for efficient model simulation  and reduction of the parameter space for analysis. The overall goal is to reduce complexity without compromising the aspects relevant for the question at hand. Different approaches of model reduction have been applied in the field of liver simulations, e.g., representative sinusoids  limits model validation, so this will need to be done mostly in animal models.Important questions to be answered in the context of model validation are (a) What is the uncertainty in input data and model parameters? and (b) How sensitive is the overall system? Together, this can quantify how robust model predictions are against uncertainty in the generic model parameters and individualized input data. There are various sources of uncertainty, e.g., direct or indirect measurement of biochemical and biophysical parameters, clinically measured physiological and systemic functional parameters, limited resolution, and noise in imaging. An analytic assessment of the sensitivity is only feasible for sub-models of limited complexity. Quantifying the robustness of an integrated multi-scale model will require thorough parameter studies to quantify the sensitivity against uncertainty in individual parameters and, e.g., Monte-Carlo simulations to determine confidence ranges of model predictions under combined parameter uncertainty.Addressing these clinical and modeling challenges to achieve such model-assisted risk predictions requires a truly multidisciplinary approach involving basic and applied, clinical and computational scientists and engineers. On the one hand, anatomical and physiological phenomena, as well as clinical diagnostic and surgical procedures, need to be accurately described and translated to suitable, improved or novel, computational models. On the other hand, such models must be made available in the form of interactive and user-friendly software and thus usable not only by domain experts in systems biology. Practical usability requires user interactivity, easy and quick handling, automation, minimum of editing, and expert input in the final usage, model adaptation to work on standard workstations available in the clinics, etc. Moreover, interfaces have to be developed, which allow integration of computational models with widely used hospital information systems, e.g., using patient data for the personalization of models and adding model-based risk evaluation to electronic patient records.Already today, patients benefit from computational support in the planning of liver resections. This is, however, limited to an assessment of remnant liver volume and taking into account a number of risk factors for postoperative liver failure. A prediction of liver function recovery is currently not included, but would be particularly useful in case of preexisting liver disease.Basic biological processes involved in liver metabolism, disease, and regeneration are well-understood, and various computational models for these aspects are available. However, no comprehensive model integrating all these effects on different scales has been presented yet.With increasing knowledge of disease mechanisms, availability of experimental and clinical data as input for model-based predictions, and expertise in design and integration of computational models, the next logical step is to develop a comprehensive model for predicting liver function and regeneration. This type of outcome prediction will be an indispensable part of a strategy for a patient-tailored optimization of intervention and therapy after liver surgery.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Severalepidemics of ZIKV infection occurred in tropical countries in South America (includingBrazil), central Africa, Central America, and Indonesia, as well as in India,5. A growing body of evidence allowed scientific and clinical committeesto establish a causal relationship between ZIKV infection during pregnancy and adverseneurodevelopmental outcomes,6-8. This condition has come to be known as congenital Zika syndrome(CZS).In late 2015, a congenital syndrome drew worldwide attention: infection with the Zikavirus (ZIKV) was associated with a marked increase in the number of cases of fetal andneonatal microcephaly or other neurodevelopmental anomaliesAedes, ZIKV was first isolated in Uganda in 1947. However, verticaltransmission of ZIKV was not recognized until recently. In 2016, the World HealthOrganization declared the ZIKV epidemic a public health emergency of internationalconcern because of its association with microcephaly and other neurologicaldisorders,6. Further clinical studies demonstrated vertical andperinatal transmission, confirming the presence of ZIKV RNA in amniotic fluid andplacental tissue,3,9,10. In addition, ZIKV was isolated not only in thesaliva and urine of infected adults but also in the semen of infected males, sexualtransmission of the virus being therefore considered possible-13.A mosquito-borne flavivirus, transmitted by mosquitoes of the genusin vitro and in vivotechniques helped clarify how ZIKV infects the fetal nervous system. An invitro model involving neurospheres and cerebral organoids derived fromhuman stem cells demonstrated that human neural progenitor cells are vulnerable to ZIKVinfection, showing impaired organoid growth and transcriptional dysregulation changes inthe cell cycle during the proliferative phase of neurodevelopment,8,14. It is of note that such changes havenot been seen in cases of infection with similar viruses, such as the denguevirus.Translational models using ,2. Computed tomography and magnetic resonance imaging have beenused as adjuncts to ultrasound, confirming the morphological abnormalities but alsoallowing the description of subtle changes and providing a more specific evaluation ofseverity and prognosis of CZS.Although there are no imaging and clinical findings that are specific for ZIKV, somehave been found to be quite common and highly prevalent in a variety of cohorts ofindividuals infected with ZIKV. The most striking findings were microcephaly, gyralsimplification (including pachygyria and agyria), hydrocephalus , linear calcifications in the cortical andsubcortical white matter, cortical dysplasia, cortical development abnormalities,hypoplasia of the corpus callosum, and arthrogryposis,15.Prenatal and postnatal imaging techniques have proven to be important for mapping thespectrum of central nervous system changes in CZS. Ultrasound analysis of the anatomicalstructure of the brain parenchyma revealed gross neurodevelopmental changes in fetusesand neonates, published in the previous issue of RadiologiaBrasileira, draws a very interesting trajectory for ZIKV, which is currentlythe most widely discussed arbovirus. The authors described the main historical aspectsof the emergence and discovery of the virus, as well as how the ZIKV epidemic spread toother tropical and subtropical areas of Africa before reaching Brazil. The routes ofZIKV transmission and the associated clinical findings are well covered. The authorsalso detail the spectrum of neurological manifestations of ZIKV infection observed inBrazil-from the immune-inflammatory neurological involvement in adults  to the dramatic, severe presentation seen in many cases of congenitalmalformation.The study conducted by Ribeiro et al. describe the wide range of morphologicalmanifestations, from the bluntest presentation of microcephaly  to other findings that could also be related to theneurotropic and neurotoxic capacity of this virus. This article, together with othersrecently published in the literature, plays a relevant role in the dissemination ofclinical, epidemiological, and radiological information regarding ZIKV infection, aswell as its neurological and congenital manifestations.In detailing the radiological aspects of CZS, Ribeiro et al.


The existence of the superior fronto-occipital fasciculus (SFOF) in the human brain remains controversial. The aim of the present study was to clarify the existence, course, and terminations of the SFOF. High angular diffusion spectrum imaging (DSI) analysis was performed on six healthy adults and on a template of 842 subjects from the Human Connectome Project. To verify tractography results, we performed fiber microdissections of four post-mortem human brains. Based on DSI tractography, we reconstructed the SFOF in the subjects and the template from the Human Connectome Project that originated from the rostral and medial parts of the superior and middle frontal gyri. By tractography, we found that the fibers formed a compact fascicle at the level of the anterior horn of the lateral ventricle coursing above the head of caudate nucleus, medial to the corona radiate and under the corpus callosum (CC), and terminated at the parietal region via the lower part of the caudate nucleus. We consider that this fiber bundle observed by tractography is the SFOF, although it terminates mainly at the parietal region, rather than occipital lobe. By contrast, we were unable to identify a fiber bundle corresponding to the SFOF in our fiber dissection study. Although we did not provide definite evidence of the SFOF in the human brain, these findings may be useful for future studies in this field. The superior fronto-occipital fasciculus (SFOF) was first described as a longitudinal ridge in autopsies of acallosal patients by Eichler . Since tUsing isotope tract-tracing in the monkey brain, Schmahmann and Pandya confirmed that the SFOF courses above the caudate nucleus, medial to the corona radiate, and lateral and ventral to the CC, connects the parietal lobe with the frontal lobe, and plays a role in the rapid top-down modulation of visual processing and spatial aspects of cognitive processing  and diffusion tractography have provided a unique opportunity to study white matter architecture in vivo tractography findings may be attributed to the methodological limitations of these techniques. For example, DTI-based tractography is unable to resolve multiple fiber orientations within an magnetic resonance imaging (MRI) voxel, and as such, cannot resolve fiber crossings either as tract intersections in the white matter or the intricate architecture of the gray matter  were included in this study. All procedures were approved by the Ethics Committee of the First Affiliated Hospital of China Medical University, and written consent was obtained from all participants before testing. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the the Ethics Committee of the First Affiliated Hospital of China Medical University.http://dsi-studio.labsolver.org/download-images).We also performed fiber tracking on a template of 842 subjects from the Human Connectome Project (HCP-842), which represents the largest and highest quality data set available to date. The Wu-Minn HCP consortium is an ongoing project led by Washington University, University of Minnesota and Oxford University, involving a systematic effort to map macroscopic human brain circuits and their relationship to behavior in a large population of healthy adults. Data from a total of 900 subjects were released for the first four quarters , and 842 subjects had diffusion scans. The reconstructed data of the 842 subjects were averaged to create a representative template . We also included the high-resolution anatomical imaging as anatomical comparisons, employing a 9-min T1-weighted axial magnetization prepared rapid gradient echo sequence . DSI data were reconstructed using a generalized Q-sampling imaging approach  using a 32-channel coil. This involved a 43-min, 257-direction scan using a twice-refocused spin-echo EPI sequence and multiple b-values of 1000, 2000 and 3000 s/mm2. The total number of diffusion sampling directions was 270. The total scanning time was approximately 55 min . The 842 subjects underwent diffusion scans in a Siemens 3T Skyra scanner using a two dimensional spin-echo single-shot multiband EPI sequence with a multi-band factor of three and a monopolar gradient pulse  was used for fiber tracking. A whole brain seeding approach using multiple region of interest (ROI) masks was performed. In voxels with multiple fiber orientations, fiber tracking was initiated separately for each orientation, and fiber progression continued with a step size of 1.2 mm, minimum fiber length of 20 mm and turning angle threshold of 60°. If multiple fiber orientations existed in the current progression location, the fiber orientation that was nearest to the incoming direction and formed a turning angle smaller than 60° was selected to determine the next moving direction  to analyze the spatial relationship of the SFOF with these association fibers. For the SLF, the angular gyrus, supramarginal gyrus, superior parietal lobule, and precuneus were used as seed regions, and an ROI mask was drawn along the precentral region on the coronal plane  were obtained at routine autopsy. Operations were approved by the ethics committee at China Medical University. The fiber dissection study was performed using the Klingler technique , SLF-II and putamen were removed, the internal capsule was exposed Figure . We thenWe also performed a fiber dissection from the medial to lateral direction. After removal of the cortex, the hippocampus, the CC, and the fornix, the caudate and the thalamus were exposed Figure . We thenDuring our fiber dissection, we were unable to find a bundle of fibers that coursed around the head of caudate and traveled to the parietal and occipital regions. Above the head of the caudate and medial to the internal capsule, we did observe some fibers coming from the frontal lobe Figure , arrow. In the fiber tractography study, we found an anteroposterior bundle of fibers passing through the ROIs in 12 hemispheres Figure , which mThe DSI template HCP-842) showed similar results to the subject-specific findings above , which can identify nerve fibers and their spatial orientation in microtome sections of postmortem brains based on the birefringent properties of the myelin sheaths (Dammers et al., Despite reconstructing the SFOF based on advanced HARDI in the present tractography study, we cannot conclude that SFOF exists in the human brain as we did not find it by fiber dissection, and there is also potential for false connections in tractography data. The combination of There were several limitations in our study. First, a subject-specific approach was completed in only six subjects. More subjects are required to manifest whether the SFOF can be reconstructed in each subject. Second, although fiber dissection can provide key macroscopic information on fiber tract anatomy, it has limited value for the study of white matter trajectory in areas of crossing fibers. Finally, the potential functional role of the SFOF in the present study is only based on correlation analysis, and remains to be proven.Using HARDI tractography, we identified the SFOF in six human subjects, and described the trajectory and cortical endpoint of the SFOF. Based on its shape, trajectory, and anatomical relationship with related structures, we consider that this fiber bundle observed by tractography may be the SFOF, although it terminates mainly at the parietal region, rather than occipital lobe. Nevertheless, we were unable to identify a fiber bundle corresponding to the SFOF in our fiber dissection study, which is likely because of limitations in the fiber dissection technique. Although we did not provide definite evidence of the SFOF in the human brain, these findings may be useful for future studies in this field.YiW and YB: conceived and designed the experiments, wrote the article and revised the manuscript. YB, YiW and YoW: performed the experiments. YB and WW: data interpretation and picture preparation. YiW and YoW: collected the biopsy samples. YiW and WW: contributed reagents/materials/analyses tools.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.


Aspirin  is the chemically synthesized prodrug of salicylate and is therapeutic used since the end of the 19th century. Until nowadays, aspirin is one the most widely used medications globally. As for many other drugs, the mode of action of aspirin has not been known when it was introduced into human medicine as a nonsteroidal anti-inflammatory drug to treat pain, fever and inflammation. Aspirin is also widely used for the prevention of heart attack, ischemic stroke and blood clots. Epidemiological studies revealed that daily long-term use of aspirin for more than a decade reduces the incidence of most carcinomas, in particular gastrointestinal cancers.  As such,The principal mode of action of aspirin was thought to reside in the irreversible inactivation of cyclooxygenase-1  and the inhibition of COX-2/PTGS2, thus suppressing the production of pro-inflammatory and thrombocyte-aggregating prostaglandins and thromboxanes. The discovery of this mode of action in 1971) led the British pharmacologist John Robert Vane to earn the Nobel Prize in 1982. . Moreove1 led theRecently, we have discovered another plausible mechanism that explains the broad pro-health activity of aspirin and its active metabolite salicylate Fig. . Indeed,The physiological, evolutionarily conserved (from yeast to humans) stimulus of autophagy is nutrient scarcity. Insufficient external supply of carbohydrates, proteins or lipids obliges cells to mobilize their own reserves, a process that is best achieved by the macroautophagic sequestration of cytoplasmic structures, followed by the lysosomal digestion of macromolecules into micromolecules that can be used to fuel the bioenergetic demand of the cell and to synthesize molecules required for stress adaptation. The molecular link between nutrient depletion and autophagy induction apparently involves a depletion of the cytosolic pool of AcCoA, thus ultimately causing cellular protein deacetylation for the simple reason that AcCoA is the sole acetyl donor for acetyltransferases including EP300. This protein deacetylation affects hundreds of different proteins including multiple regulators and effectors of autophagy, thus setting of the autophagic cascade. in vitro, in mammalian cells, and in vivo, in the nematode Caenorhabditis elegans. This contrasts with the fact that cells lacking AMPK are still able to mount an autophagic response upon exposure to salicylateAccordingly, mutation of EP300 resulting in reduced salicylate binding causes aspirin to lose its pro-autophagic activity. Deletion or depletion of EP300 by genetic means is epistatic to salicylate with respect to autophagy induction, both All these results are compatible with the interpretation that salicylate induces autophagy via the inhibition of EP300 rather than the activation of AMPK. Autophagy has prominent antiaging, antineoplastic and anti-arteriosclerotic effects, explaining the broad pro-health effects of EP300 inhibitors such as spermidine. It is tempting to speculate, yet remains to be demonstrated in further detail, that aspirin may mediate its anticancer and anti-cardiovascular disease effects also via the induction of autophagy.


While visible tumors are easy to detect and resect, controversy still exists regarding the optimal technique to identify prostatic involvement by TCC. Prostatic urethral sampling by a transurethral resection biopsy or a cold-cup biopsy, particularly in the high-risk group of bladder cancer patients, has been recommended for detecting prostatic urethral involvement. Management of superficial prostatic involvement by TCC is also unclear. Currently, there is increasing recognition of the value of conservative treatment options with intravesical agents when there is superficial involvement of the PU. Particularly, intravesical bacillus Calmette-Guèrin (BCG) seems to be an effective treatment alternative in the management of superficial involvement of the PU by TCC. Close follow-up by cystoscopy and PU biopsy at 3-month intervals, particularly in intermediate and high-risk patients who respond to intravesical therapy and in whom cystectomy is appropriate, is recommended in order to detect persistent tumor, recurrences, or progression.Transitional cell carcinoma (TCC) is a multifocal disease of the urinary tract that can also involve the prostatic urethra (PU). The exact incidence of superficial involvement of the PU in patients with bladder TCC is not well known. Bladder TCC may involve the prostate in 12—40% of the patients and the degree of involvement can include urethral mucosa, ducts, acini, and stroma of the gland, which has been shown to affect the outcome. Risk factors for superficial urothelial cancer in the PU are high-grade, multifocal bladder TCC and presence of carcinoma


Given the rising prevalence of PAD, the detriment in quality of life for patients, and the associated significant healthcare resource utilization, new alternate therapies that ameliorate lower limb symptoms and the functional impairment associated with PAD are needed. A clear understanding of the role of mitochondria in the pathophysiology of PAD may contribute to the development of novel therapeutic interventions.Peripheral artery disease (PAD) is a serious but relatively underdiagnosed and undertreated clinical condition associated with a marked reduction in functional capacity and a heightened risk of morbidity and mortality. The pathophysiology of lower extremity PAD is complex, and extends beyond the atherosclerotic arterial occlusion and subsequent mismatch between oxygen demand and delivery to skeletal muscle mitochondria. In this review, we evaluate and summarize the available evidence implicating mitochondria in the metabolic myopathy that accompanies PAD. Following a short discussion of the available  Peripheral artery disease (PAD) is the third leading cause of cardiovascular morbidity after coronary heart disease and stroke , ~10% exhibit classic symptoms of intermittent claudication , and the remainder present with atypical leg symptoms, i.e., exertional leg symptoms that are not consistent with classic intermittent claudication. Atypical leg symptoms commonly include leg pain on exertion and rest , and leg pain/carry on  generation  and the associated prolonged hyperemic effect in the post-exercise resting period (reperfusion) trigger a cascade of pathophysiological responses , which in turn shuttle electrons to the electron transport chain of the inner mitochondrial membrane. Electron transfer results in the translocation of protons across the inner mitochondrial membrane, resulting in electro-chemical potential. This membrane potential is used by ATP synthase to phosphorylate adenosine diphosphate  converts to acetyl-CoA. The subsequent condensation of acetyl-CoA with oxaloacetate within the mitochondrial matrix forms citrate, initiating the tricarboxylic acid cycle (TCA). Generation of TCA cycle intermediates results in the reduction of electron carriers  in vitro determination of mitochondrial respiration in tissue samples or isolated mitochondria preparations, assaying ATP production rates, membrane potential, or ROS production in isolated organelles, or the quantification of mitochondrial protein abundance/enzyme activity. The pros and cons of these approaches are discussed in brief below.The numerous analytical techniques and read-outs of mitochondrial function can often lead to confusion as to the role of the mitochondrion in a given pathology. Thus, careful consideration in selecting appropriate analytical endpoints and interpretation of the data that these techniques provide is important if robust conclusions are to be made. Available techniques for measuring mitochondrial function Figure  can be bin vivo by 31Phosphorus Magnetic Resonance Spectroscopy  offers a non-invasive approach for the assessment of the kinetics of (muscle) tissue O Jobsis, . Analogoin vivo offers several advantages. Firstly, oxidative capacity is determined under physiologic conditions. Further, measurements can be made non-invasively. While determination of PCr recovery can be costly, NIRS offers a more affordable alternative to highly costly MRI scanners, which correlates well with MRI-based approaches  for complex I was 2.5 times lower in PAD vs. healthy older adults, which may serve as an index of intrinsic mitochondrial dysfunction at complex I. Moreover, the coupling control factor (and index of respiratory control) for complex II was greater in PAD patients vs. controls, perhaps suggesting a compensatory response to impaired complex I function. Here, it should be noted that this study  be sufficiently-powered; (ii) use appropriate controls to draw comparisons to by matching PAD and control groups on potential confounders, such as age, gender, weight, smoking status, coronary artery disease, diabetes, dyslipidemia, and hypertension; (iii) stratify PAD based on severity/clinical manifestations ; (iv) integrate a combination of methodologies in order to assess oxidative capacity in vivo, determine intrinsic mitochondrial respiratory capacity, and coupling control ratios , and muscle mitochondrial volume density in muscle biopsies of the same patients; (v) determine the relationships between mitochondrial function, clinical PAD parameters, and functional limitations which was not feasible in the majority of prior studies due to being relatively underpowered. Inclusion of patients with unilateral PAD and assessments on both limbs would also be highly informative. Moreover, analysis of mitochondrial function in biopsies collected from different regions of the affected muscle in the same patient will provide additional important information on the nature of mitochondrial dysfunction in muscle from PAD patients. Furthermore, data on the long-term effects of revascularization procedures on mitochondrial function is currently lacking. Finally, transcriptome-wide analysis of muscle from patients with PAD would be useful and may identify new therapeutic targets worthy of further investigations.Collectively, current evidence from The lack of a clear understanding of the role of mitochondrial dysfunction in PAD represents a significant roadblock in the development of novel strategies to restore muscle function, ameliorate limb symptoms, and improve functional capacity in PAD patients. Therefore, generation of new data concerning the role of bioenergetics in PAD may contribute to the development of novel therapies aimed at reducing morbidity in patients living with PAD. Considering the rising prevalence of PAD, the persistence of PAD-associated myopathy after revascularization, its functional and economic impact, and the limited therapeutic options that currently exist, further research in this field is warranted.Substantial contribution to the concept and interpretation of available evidence (All authors); Drafted the work (VR and CP). Revising it critically for important intellectual content . Final approval of the version to be published (All authors). Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved (All authors).Seed funding for this project was supplied by the Department of Surgery, UTMB. This work was also supported by the following grants: R56 AG051267, P30 AG024832 and SHC-84090, and was conducted with the support of the Institute for Translational Sciences at UTMB, supported in part by a Clinical and Translational Science Award (UL1TR000071).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.


In 1977, a major breakthrough in cardiovascular medicine was introduced by Dr. Andreas Gruentzig. In September of that year, Gruentzig performed the very first percutaneous transluminal coronary angioplasty (PTCA) procedure in a human. Twenty-three years later, the coronary artery was still patent. Despite the "elastic recoil" of the artery was abrogated with the stent deployment, there was still a non-depreciable rate of in-stent restenosis due to the neointimal proliferation inside the stents. In an attempt to fight the exaggerated proliferation after coronary stent implantation, our lab first used rapamycin in an animal model of restenosis showing the effectiveness of this antiproliferative drug in preventing this neointimal proliferation.  Soon aftThree are the major players involved in the pathological processes leading to late in-stent thrombosis: the stent coated with an antiproliferative drug, the vulnerability (thrombogenicity) of the patient's blood, and the antiplatelet therapy.Several factors related with the stents are associated with an increased risk of thrombosis, including the procedure itself  and stent design . The coating of stents with antiproliferative (sirolimus) and/or cytostatic (paclitaxel) drugs should have the additional advantage of inhibiting the proliferation of vascular cells. Reendothelialization occurs after vascular injury and similarly after stent placement. But then two questions arise since damaged and/or dysfunctional endothelium is directly related with the development and progression of atherosclerosis ,17: CoulSeveral risk factors correlate with "vulnerable/hyperreactive blood" . Also, several patient-related factors have been associated with the development of in-stent thrombosis, including low ejection fraction, diabetes mellitus, advanced age, renal failure, and acute coronary syndromes. In particular, in this last situation it could be due to delayed healing, lack of endothelialization, and presence of a pronounced inflammatory and thrombogenic environment combined by enhanced platelet reactivity. Furthermore, certain lesion characteristics (bifurcation complex or in-stent restenosis lesions) are reported to be associated with an increased risk of stent thrombosis. ,19The majority of the retrospective studies on the rate of late in-stent thrombosis have identified the window of 6 to 9 months post stenting as the peak of more incidence. The majority of the studies using multivariate analysis have identified the discontinuation of dual antithrombotic therapy as the principal parameter responsible for stent thrombosis. ,21 StentTherefore, in an example of individualized medicine, many factors should be taken into account for the selection of the type of stent to be implanted. Among these factors, the patient characteristics , the severity of the disease and the characteristics of the lesions, and finally the possibility and/or compliance to a prolonged antithrombotic treatment. What seem to be clear is that a longer period of dual anti-platelet therapy is needed for patients undergoing DES implantation than for those receiving a bare metal stent. However, at this point it is completely unknown how longer that period should be. Despite the current recommendations from the AHA/ACC suggest 12 months of dual antiplatelet therapy, some experts highly suggest a chronic dual antiplatelet therapy until new data with longer follow up periods is available.


One-sentence summary for tables of contents: Measures taken by the Venetian administration to combat plague were successful. During the 17th and 18th centuries, measures were taken by the Venetian administration to combat plague on the Ionian Islands. At that time, although the scientific basis of plague was unknown, the Venetians recognized its infectious nature and successfully decreased its spread by implementing an information network. Additionally, by activating a system of inspection that involved establishing garrisons along the coasts, the Venetians were able to control all local movements in plague-infested areas, which were immediately isolated. In contrast, the neighboring coast of mainland Greece, which was under Ottoman rule, was a plague-endemic area during the same period. We conclude that even in the absence of scientific knowledge, close observation and social and political measures can effectively restrain infectious outbreaks to the point of disappearance. Yersinia pestis. This disease is transmitted from animals to humans by the bite of infected fleas, direct contact, inhalation, and, rarely, ingestion of infective material. Untreated plague has a high case-fatality rate  and has eliminated large colonies of these animals in the northwestern United States. Although these animals are susceptible, it is believed that other rodents and their fleas are the reservoirs and spread the disease during epizoonotics and maintain the pathogen . Gradually and through conflicts after this crusade, this city-state on the Adriatic Sea gained control of the Ionian Islands, Crete, and some coastal cities of mainland Greece and established a network of trading posts. The islands of Corfu (Greek name Kerkyra), Zante (Zakynthos), Cephalonia, and Leukada were incorporated into the Venetian State in 1386, 1485, 1502, and 1684, respectively, and remained part of it until its demise in 1797  dispacci rettori, and 3) archives of the Venetian health inspectors  regarding the Venetian health policy for the Ionian Islands. Additionally, several historical sources providing information about plague epidemics in the Mediterranean area during the 17th and 18th centuries were reviewed. This investigation was related to the doctoral dissertation of this article’s first author (K.K.), a historian at the University of Athens. This dissertation (On-site research was conducted in the Venetian state archive (Archivio di Stato di Venezia). Unpublished archival material dealing with the Ionian Islands during the 17th and 18th centuries was investigated with emphasis on periods of epidemiologic crises. We studied the following: 1) total number of registers of legislative bodies of the Venetian Republic (Senato mar and Senato rettori) for 1600–1797 to locate laws dealing with curtailment of plague and organization of health services on the Ionian Islands, 2) daily correspondence of Venetian authorities of the islands with Venice through the Archival sources show that most cases of plague on the Ionian Islands during the 17th and 18th centuries were imported from the neighboring coast of mainland Greece and ports in the southwestern Ottoman Empire. Only 2 epidemics were imported from the trade routes of the Mediterranean Sea. Of 11 epidemics, 8 occurred during the 17th century and 3 occurred during the 18th century. Plague struck Corfu in 1611, 1630, 1648, and 1673; Zante in 1617, 1646, 1692, and 1728; and Cephalonia in 1646 and 1760. Leukada had a disastrous epidemic in 1743, a few decades after the island became part of the Venetian Republic.During the 18th century, plague had waned despite an outbreak along the southwestern coast of the Ottoman Empire, a short distance from the coasts of the Ionian Islands. In the 18th century, the southern Balkans had repeated waves of plague in 1718–1720, 1728–1731, 1733–1740, 1756–1765, 1782–1784, 1787–1789, and 1790–1793 (lazzarettos (institutions where those with plague or other similar diseases were isolated) mainly because of negligence. In contrast, 2 of the 3 epidemics during the 18th century were caused by incorrect diagnoses or delayed notification of the authorities. Success of these measures became apparent in Corfu where plague was eradicated after 1673, only to reappear during British rule in the early 19th century (Under these conditions, waning of plague epidemics during the 18th century may be attributed to sanitary measures taken by the Venetian government. These measures, among other regulations, dictated strict control of population movements, particularly during periods of epidemiologic crises. The efficacy of these measures is better appreciated because plague during the 17th century spread from lazarettos, public health offices, and cordoni di sanità, which on the Ionian Islands were coastal garrisons that controlled access to Venetian territories (The city-states of northern Italy, including Venice, organized their defense against plague from the time of the Black Death (lazzarettos were established in Corfu and Zante in 1588 and in Cephalonia and Leukada at the beginning of the 18th century.Archival sources showed that health board officers in Corfu and Zante were initially elected around 1545. However, it is likely that health boards had previously existed. The first The Venetian health policy was reformed in the 18th century. These reforms likely emphasized disease prevention and dealt with health emergencies (lazzarettos. During the 18th century, new lazzarettos were established, and existing ones underwent extension and changes. In 1726, a new statute defining the obligations and responsibilities of the heads of the institutions was introduced. According to this statute, during periods with no or low disease activity, lazzarettos referred directly to Venetian authorities and bypassed authority of local health boards (The main goal of these reforms was improvement of the structure and function of cittadini (Despite these new regulations, Venetian archives reported occasional problems in health services of the islands because of poorly trained health officers, who were elected from the local upper class and were eager to acquire greater political autonomy. This situation resulted in conflicts between Venetian representatives and local health officials, as well as between local factions known as lazzarettos functioned as protective shields for Venice and transferred responsibility of plague control from Venice to peripheral areas (senato, and trade commenced only after the state of emergency had ended. During these periods, the Venetian government did not intervene in the responsibilities and actions of local health inspectors because such intervention could provoke social unrest (Archives show that until the end of the Venetian rule on the Ionian Islands, cordoni di sanità. Additionally, when plague occurred, residents were separated by health authorities into groups of healthy and sick persons regardless of social hierarchies. Persons affected by plague were kept in lazarettos, and large numbers of infected persons were kept in hospitals, houses, or neighborhoods on the assumption that plague in these persons remained isolated. Isolation was ensured by military force. Thus, plague-stricken areas resembled a large institution under constant inspection and surveillance and disconnected from the rest of society (Prevention was based on widespread use of an information network of daily reports of Venetian consuls in Mediterranean areas to Venetian authorities, detailed interrogation of sailors who arrived in Venetian ports, effective control of all local movements in plague-infested areas, and activation of the In contrast to measures taken on the Ionian Islands during the 17th and 18th centuries, mainland Greece, which was under Ottoman rule, had a different mentality in dealing with plague. Isolation of patients and quarantine were not common practices. Thus, plague continued to cause epidemics in mainland Greece during the first half of the 19th century. These epidemics had devastating demographic and financial consequences. After 1830, when the Ottoman administration implemented sanitary measures such as quarantine, spread of plague in mainland Greece decreased substantially (Although modern medical regimens can successfully treat patients with plague and stop its spread, prevention and isolation policies can contribute to control of this disease. This finding has been demonstrated by successful management of a plague epidemic in Surat, India, in 1994, in which prevention techniques similar to those used during Venetian rule were used (In conclusion, although the scientific basis of plague was not known, the Venetian administration recognized the infectious nature of this disease and took successful measures that dramatically decreased the spread of the plague epidemic on the Ionian Islands during the 18th century. The results of these measures are more impressive if compared with those in the neighboring coastal region of the Greek peninsula, which under Ottoman rule had endemic plague during the same period. Results of the present historical investigation lead to the conclusion that even in the absence of scientific knowledge, observation and well-organized public health services can effectively restrain infectious outbreaks to the point of disappearance, as occurred with plague in Corfu during the 18th century.