Mode of action, pre-clinical in vitro and in vivo or clinical data as well as clinical applicability are discussed here. Given the precious multi-year clinical experience with these non-antineoplastic drugs their repurposing in oncology is a challenging alternative that would aid towards the development of therapeutic schemes with less toxicity than those of conventional chemotherapeutic agents. More importantly, harnessing the antitumor function of these agents would save precious time from bench to bedside to aid the fight in the arena of cancer.The development of efficacious antitumor compounds with minimal toxicity is a hot research topic. Numerous cancer cell targeted agents are evaluated daily in laboratories for their antitumorigenicity at the pre-clinical level, but the process of their introduction into the market is costly and time-consuming. More importantly, even if these new antitumor agents manage to gain approval, clinicians have no former experience with them. Accruing evidence supports the idea that several medications already used to treat pathologies other than cancer display pleiotropic effects, exhibiting multi-level anti-cancer activity and chemosensitizing properties. This review aims to present the anticancer properties of marketed drugs ( Pleiotropy in biological systems is a long known phenomenon, commonly attributed to the complexity of intracellular signaling networks or tissue-specific cellular responses ,2,3,4. Cin vitro and in vivo data or clinical data from studies in DM type II patients or nondiabetic individuals. Despite the fact that many anti-diabetic medications are currently available in the market, only the biguanide metformin and the thiazolidinedione (TZD) pioglitazone are mentioned. This is why insulin administered for the management of DM type I and insulin secretagogues (sulfonylureas) have been associated with an increased incidence of cancer [Herein, the antitumor activity of the marketed anti-diabetic drugs metformin and pioglitazone is reviewed. This is evidenced either by pre-clinical f cancer ,17,18. Sf cancer ,20. On tf cancer ,22 wheref cancer ,25,26,27f cancer  due to tf cancer ,30,31, bf cancer .Metformin is a first-line anti-diabetic agent  widely pThere is convincing evidence for a direct correlation between DM type II  and cancer ,37,38,39Metformin acts as an activator of AMP-activated protein kinase (AMPK) which serves as a master metabolic sensor and is a negative modulator of the mammalian target of rapamycin (mTOR) ; a pointOn the other hand, pioglitazone serves as an activator of the peroxisome proliferator-activated receptor γ (PPARγ). This nuclear receptor is widely expressed in human epithelial tissues and apart its role in glucose/lipid homeostasis it is also critically involved in cell differentiation and inhibition of cell growth ,55. BothIn vitro experimentation suggests a plausible repositioning of metformin in the field of gynecologic oncology. Metformin is known to decrease the proliferative capacity and clonogenicity of breast cancer cell lines, regardless of p53 status and the status of estrogen and ErbB2  receptors [in vitro [eceptors . In the eceptors . This fieceptors  and in aeceptors  underlineceptors ,66. Unfoeceptors . In ovareceptors . Consisteceptors , it was in vitro . Besidesin vitro .Metformin displays antitumor properties not only in studies using breast cancer and ovarian cancer cells, but also in a series of experiments with other types of malignant cells. In human pancreatic cancer cells metformin acts in a cytostatic manner. Drug-induced cytostasis in these cells coincides with an alteration in the expression profile of microRNAs and cell cycle-modulatory molecules . On the in vitro. Significantly, the expression of the organic cation transporter 3 (OCT3) which mediates the uptake of metformin into HNSCC cells is necessary for the drug-induced growth suppression via the inhibition of the mTOR pathway [Head and neck cancer (HNC) encompasses different pathological entities including nasopharyngeal carcinoma (NPC) and head and neck squamous cell carcinoma (HNSCC), with HNSCC patients running the risk to develop second primary esophageal squamous cell carcinoma (ESCC) . Metform pathway . In esop pathway  and DNA  pathway , respect pathway .in vitro, i.e., in gastric [Metformin, apart from its growth-inhibitory properties has also been reported to affect cancer cell viability. Actually, metformin triggers apoptosis  gastric , pancrea gastric , colon c gastric  and sali gastric . P53-nul gastric . This fi gastric . Similar gastric . In pros gastric . These s gastric . In high gastric . In hepa gastric  while in gastric .Besides, metformin influences the migratory/metastatic activity of various cancer cells. Metformin can possibly inhibit the metastatic potential of prostate cancer cells through upregulating miR30a that, in turn, prevents an EMT program mediated by its target SOX4 . The invin vivo evidence of the preclinical anti-neoplastic activities of metformin, as presented immediately below. Data from an animal model of mammary tumor virus (MMTV)-ErbB2 tumorigenesis underscore the preventive antitumor function of metformin, since it selectively inhibits the proliferation of a specific cellular subpopulation which is being incriminated for tumor initiation; those with the CD61(high)/CD49f(high) immunophenotype. Importantly, the “Achilles heel” of the tumor-initiating cells (TIC)/CSC-rich tumorspheres was shown to be the elevated ErbB2 whose expression is ablated by metformin [+/CD24−/low breast CSCs is associated with sensitization to the humanized anti-ErbB2 monoclonal antibody trastuzumab [There is a considerable amount of etformin . A similstuzumab . Of notestuzumab . Moreovestuzumab  and exhistuzumab . Also, mstuzumab .in vivo evidence for the antitumor properties of metformin has been also provided for glioblastoma [In vivo evidence for the AMPK-dependent antitumoral activity of metformin associated with mTOR inhibition was also provided in murine models of chemical-induced colorectal carcinogenesis where metformin was found to suppress the formation of ACFs [Pre-clinical, blastoma , esophagblastoma ,78,98 asblastoma , ovarianblastoma  and saliblastoma  in mouseblastoma . In addiblastoma . In vivo of ACFs . In nude of ACFs . Of note of ACFs . In PC-3 of ACFs .A marked antitumor synergy among metformin and paclitaxel has been found in transgenic animal models of ovarian cancer since tumors exposed to both of these agents are 60% lighter than those solely exposed to paclitaxel or metformin . Metformin vitro studies are suggestive of the future exploitation of pioglitazone for the therapy of upper gastrointestinal (GI) tract cancers (pancreas and liver cancer), gynecologic cancer (breast cancer), primary brain tumor (glioma) as well as hematological tumors. A drug-induced downregulation of the transcription of cyclooxygenase-2 (COX-2) and interleukin-8 (IL-8) was reported throughout the course of in vitro experiments using pioglitazone and the proliferation of various pancreatic cancer cells was halted [A series of s halted . In biops halted . In humas halted . The ants halted . This iss halted . In glios halted . Moreoves halted . The latE-cadherin down-regulation is a common event in prostate cancer whereas the expression of PPARγ is elevated in this type of malignancy [in vivo evidence for a pyruvate dehydrogenase kinase 4 (PDK4)-dependent pathway activated by pioglitazone by which this PPARγ ligand increases the oxidative stress experienced by lung cancer cells, thereby ceasing their proliferation [Pioglitazone was found to suppress the growth of BxCP-3 xenografts in mice and to inhibit their ability to give rise to lymph node and distal (pulmonary) metastases . In a molignancy . In animlignancy  and to slignancy . Furtherferation .In the KK-Ay mouse model for DM type II and obesity pioglitazone both improves several metabolic parameters and impairs the development of precancerous lesions in colon  upon exposure to the potent carcinogen azoxymethane. This finding suggests the chemopreventive value in colorectal tumorigenesis . ImportaA large body of literature indicates that the usage of metformin both lowers the incidence of various types of cancer  in diabetics ,125,126 per os and intravenous gemcitabine, at six months [Retrospective studies reviewing the clinical outcome of HER2-positive breast cancer patients with diabetes suggest that metformin beneficially affects their cancer-specific survival ,137. Anox months .Altogether, metformin seems to be a promising chemopreventive agent in breast and colorectal cancer. However, although there is ample evidence for the antitumor function of metformin principally stemming from population-based case-control studies and retrospective studies as extensively has been elsewhere reviewed , more evObjective responses and stabilization of disease were observed in a phase II clinical trial recruiting patients with chemorefractory melanoma and soft tissue sarcoma who were treated with a combinational scheme of metronomic therapy using trofosfamide, rofecoxib  and clinically relevant doses (45 mg/day) of pioglitazone . EncouraUnfortunately, clinical data indicate that usage of pioglitazone may jeopardize health since it has been found to increase the incidence of bladder cancer in DM type II patients ,148. ForΟngoing clinical experimentation (e.g. NCT00780234) may hopefully decipher the relationship between pioglitazone and the risk of organ-specific carcinogenesis or even overall neoplasia before an inference can be drawn regarding the anti-cancer or cancer-promoting function of this anti-diabetic agent. In fact, numerous clinical trials are currently active both for pioglitazone and metformin. Metformin, unlike other anti-diabetic drugs such as sulfonylureas, is devoid of major adverse effects such as drug-induced hypoglycemia or lactic acidosis that is more commonly caused by the biguanide phenformin . Would mAnother issue of concern is that at least in mouse models of lung cancer metastasis there is evidence supporting a dichotomized behaviour of PPARγ that inhibits cancer cell invasiveness but on the other hand, it fuels the pro-tumorigenic function of non-malignant cells of the myeloid lineage upon its activation . FurtherIt should be noted that although animal models that have been used successfully to recapitulate many aspects of human carcinogenesis, there are several limitations . CharactFurther, there are well-characterized bioenergetic inter-species differences  as well The aforementioned “atypical” antitumorigenic agents would not displace classical chemotherapy regimens but they could possibly augment their efficacy at as low doses as possible, by virtue of new combinational schemes. In addition, many of them exhibit chemopreventive value. The data obtained by clinical studies so far are very encouraging towards this direction. These non-antineoplastic drugs should not been considered as “novel” antitumoral compounds since most of them have been introduced within the market for more than a decade. Consequently, a multi-year clinical experience has been obtained regarding their use; at least dosing and mode of administration for their current therapeutic index. From this point of view, they don’t belong to the same category with hundreds of synthetic or physically isolated compounds which are daily evaluated for their antitumor activity with no former knowledge by clinicians. Further, since these drugs exhibit potent dual therapeutic indices, proper dosing/administration schedule could achieve multiple therapeutic benefits in the exhausted organism of cancer patients (cancer cachexia) which can’t be overloaded with pharmacological agents. Hence, their potent future use in oncology seems quite advantageous. Hopefully, the above-mentioned agents could alter the status quo of cancer therapeutics. This is consistent with the fact that drug repurposing is an emerging concept.Inarguably, more phase II and phase III clinical studies are needed to assess the anti-cancer properties of metformin and its applicability at the clinical setting far beyond the prevention of breast/colorectal cancer as well as to extirpate any doubts regarding the double-edged sword role of pioglitazone in cancer. The completion of several ongoing clinical studies (e.g. NCT01627067 and NCT00780234) is much-awaited.The major goal is the design of therapeutic schemes with maximization of the efficacy and minimization of the adverse effects. Researchers and clinicians should always bear in mind that the clinical goal is a reasonable benefit-hazard ratio. Experimentally, pharmaceutical compounds could be considered as molecular “probes” revealing a perplexed cellular microworld which can be molecularly manipulated by them. At the clinical level, they could possibly control pathological processes including tumorigenesis and target their root causes. The experimental results from pharmacological intervention in animals should be extrapolated to humans with great caution. Exploiting the already available knowledge of approved non-antineoplastic drugs against cancer could save precious time from bench to bedside and pave the road for alternative efficacious medical practices.


Carcharhinus limbatus, and the extent that these bacteria possess multi-drug resistance. Swabs were taken from the oral cavity of nineteen live blacktip sharks, which were subsequently released. The average fork length was 146 cm (±11), suggesting the blacktip sharks were mature adults at least 8 years old. All swabs underwent standard microbiological work-up with identification of organisms and reporting of antibiotic susceptibilities using an automated microbiology system. The oral samples revealed an average of 2.72 (±1.4) bacterial isolates per shark. Gram-negative bacteria, making up 61% of all bacterial isolates, were significantly (p<0.001) more common than gram-positive bacteria (39%). The most common organisms were Vibrio spp. (28%), various coagulase-negative Staphylococcus spp. (16%), and Pasteurella spp. (12%). The overall resistance rate was 12% for all antibiotics tested with nearly 43% of bacteria resistant to at least one antibiotic. Multi-drug resistance was seen in 4% of bacteria. No association between shark gender or fork length with bacterial density or antibiotic resistance was observed. Antibiotics with the highest overall susceptibility rates included fluoroquinolones, 3rd generation cephalosporins and sulfamethoxazole/trimethoprim. Recommended empiric antimicrobial therapy for adult blacktip shark bites should encompass either a fluoroquinolone or combination of a 3rd generation cephalosporin plus doxycycline.Sharks possess a variety of pathogenic bacteria in their oral cavity that may potentially be transferred into humans during a bite. The aim of the presented study focused on the identification of the bacteria present in the mouths of live blacktip sharks,  C. limbatus) based on witness and victim accounts, and to some extent scientific determination Florida consistently boasts the highest number of shark attacks in the world, accounting for nearly one-third of all incidents in 2013 with about 20% caused by blacktip sharks  in marine animals, including sharks C. leucas) and tiger sharks  revealed a high-level of antimicrobial resistance among Enterobacteriaceae, including 20% of Proteus mirabilis resistant to imipenem, a broad-spectrum antibiotic Ginglymostoma cirratum), bull sharks, blacktip sharks and lemon sharks (Negaprion brevirostris) also demonstrated resistance to several tested antibiotics, including approximately 20–35% resistance amongst amikacin, ceftazidime and piperacillin Several studies have identified the presence of pathogenic bacteria  identify the bacteria present in the oral flora of blacktip sharks, and 2) quantify the extent of antibiotic resistance in these live sharks in order to provide definitive microbiologically based guidance for appropriate empiric antimicrobial therapy for respective victims.Research was conducted in accordance with a special activity license (License#SAL-12-1429C-SRP) issued by the state of Florida and with approval of the Institutional Animal Care and Use Committee (IACUC Control#042-398-13-0102) at Nova Southeastern University. All sharks caught for the purpose of the presented research were released unharmed and all efforts were made to minimize suffering of the sharks sampled; moreover, no shark was killed, harvested or sold as a consequence of this study.Blacktip sharks were caught with a surf rod and a sixty-five pound fishing line with a 12/0 circle hook off of beaches in Martin and Palm Beach Counties in Florida, which have been previous identified by research as high-risk cluster areas of shark attacks along the Florida coast Pasteurella sp., Bacillus sp., Micrococcus sp. and alpha-hemolytic Streptococcus sp.), as outlined in the CLSI guideline, were considered routinely susceptible to typical recommended agents. Additionally, if antibiotic susceptibility testing indicated an organism was intermediate, it was deemed resistant. Multi-drug resistance was defined as resistance to three or more different antibiotic classes, excluding antibiotics or antibiotic classes that select bacteria possess intrinsic resistance against  All swabs were placed in a cooler with ice packs and transported to the microbiology lab at St. Mary’s Medical Center within 48 hours. After receipt of each swab, samples were streaked on several different agar plates, including sheep blood, MacConkey, chocolate and CNA media. Aerobic and anaerobic media were incubated at 35°C for 24 hours and 48 hours, respectively. All microbiological work-up was conducted in accordance with the policies and procedures governed by the College of American Pathologists (CAP), the American Society for Microbiology (ASM) and the Clinical and Laboratory Standards Institute (CLSI). Organisms were identified and antibiotic susceptibilities were performed using an automated microbiology system, the Siemens Microscan Walk-Away 96 SI. Antibiotics used for susceptibility testing can be found in Types of bacteria and antibiotic susceptibilities are reported as frequencies, and the number of bacteria per shark is expressed as a mean (± standard deviation). A one and two-sample t-test was applied to bacteria composition of all the samples and compare mean number of bacteria and resistant antibiotics per shark by gender, as appropriate. A Pearson’s Chi-square test was used to compare the proportion of antibiotics with resistance amongst gram-positive and gram-negative bacteria. The relationship between fork length of the shark with bacterial density and antibiotic resistance was tested using Pearson correlation coefficients. Additionally, antibiotic resistance, bacterial composition  and mean number of bacteria were extracted from the study by Interaminense et al. A total of 19 blacktip sharks were caught and swabbed; however, one sample was excluded due to contamination prior to transportation to the lab. Twelve sharks were male, four were female and two sharks did not have their gender documented. The fork length spectrum of the sharks ranged from 122 to 168 cm with an average of 146 cm (±10.54). Using published growth curves for blacktip sharks, the range and mean fork length suggest all sampled sharks were mature sharks at least 8 years of age Vibrio alginolyticus (14%), other Vibrio sp. (14%) and Pasteurella sp. (12%). The most common gram-positive organisms included a composite of various coagulase-negative Staphylococcus spp. (16%) , S. aureus (8%) and Bacillus sp. (6%). When bacterial composition was compared to the aforementioned Interaminense et al. study Enterobactericeae comprised 17% (95% CI 3–31) of gram-negative organisms isolated from blacktip sharks, which was significantly less than bull sharks  and tiger sharks  Gram-negative bacteria comprised a significantly higher proportion of the isolated bacteria compared to gram-positive bacteria  . Gram-neEnterococcus faecium), vancomycin and tetracycline. Oxacillin resistance was observed in 42% and 0% in coagulase-negative Staphylococcus spp. and S. aureus, respectively. No association was found between fork length and resistance  (Antibiotic susceptibilities for isolated and tested gram-negative and gram-positive bacteria are listed in = 0.389) .S. hominis and Vibrio sp. met the definition of a multi-drug resistant organism, accounting for 4% of all bacteria. No difference was seen between female and male blacktip sharks regarding the number of resistant bacteria. When specifically extracting and evaluating resistance rates for antibiotics tested in both this study and the comparator The overall antibiotic resistance rate was 12% for all antibiotics tested . A signiC. brevipinna) and silky sharks  are similar in appearance, making a proper identification even more challenging for lay people. Outside of external appearance, teeth morphology is similar amongst the three species, leading to nearly identical wound patterns. Such resemblances lead to confusion when trying to pinpoint the true species involved, resulting in a higher or lower true number of bite incidents by blacktip sharks in Florida waters.Blacktip sharks are responsible for many, if not most, shark incidents along Florida’s coast Vibrio sp. and Pasteurella sp., were anticipated based on the halophilic nature and composition of typical oral flora, respectively. Both species are pathogenic and known to cause life-threatening infections in humans S. aureus, non-fermenting gram-negative bacilli  and Enterobacteriaceae . These enteric gram-negative organisms are not only pathogenic, but may also reflect exposure to sewage effluent. Several of the studies that identified antibiotic resistant enteric gram-negative bacteria with marine animals including sharks, also noted a close proximity to sewage discharge Enterobacteriaceae than bull and tiger sharks The most commonly isolated bacteria in this study, Lagodon rhomboides, pigfish, Orthopristis chrysoptera, spotfin mojarra, Eucinostomus argenteus, or silver perch, Bairdiella chrysoura), which are too large for smaller blacktip juveniles and sub-adults; in addition, younger blacktip sharks inhabit different areas during their earlier stages of life Sphyraena barracuda, gathers toxic dinoflagellates  in its system, especially in its muscles, that causes ciguatera in humans Echeneis naucrates, that commonly clean between blacktip sharks’ upper teeth The amount of rotted tissue present in the oral cavity, thus the density of bacteria, continuously evolves due to the dietary shift throughout the growth of a shark Compared to blacktip sharks, the larger bull and tiger sharks gouge more often when hunting, inevitably leaving more tissue matter stuck between their teeth as opposed to sucking where prey is swallowed whole. Under such a premise it is obvious that in order to pursue any bacterial count work among shark species, not just a clear understanding about their preferred way of feeding is needed but also their tooth morphology and accompanying overlapping of teeth. In blacktip sharks, the upper anterior and lateral teeth vary in overlap close to the base, which is not observed with lower teeth . This isTursiops truncatus) in Florida and South Carolina found overall resistance was comparable; however, there was a significant difference in the resistance patterns of select antibiotics . Blacktip sharks routinely follow baitfish along Florida’s coast, mainly during early spring months; moreover, this is important because blacktip sharks are highly migratorial, thus their geographical distribution will nearly constantly reflect a different bacterial composition in their oral cavity It is essential to consider the geographic influence on diet since bacterial composition likely also varies accordingly It remains to be seen how the presented results match with bacteria composition and density sampled throughout the other seasons, or at least over a longer period of time, at alternate geographic locations, as well as through the different ontogeny stages of these sharks. For example, one study The overall level of antibiotic resistance observed in our study was comparable to similar published studies Vibrio sp., Pasteurella sp., S. aureus and enteric gram-negatives. Although isolated, but due to low pathogenicity in skin infections, coverage against Bacillus sp., Micrococcus sp., and coagulase-negative Staphylococcus sp. may not be necessary and would likely be adequately addressed by irrigation during surgery or general medical treatment. Antimicrobials determined to be therapeutic options as single agents for the highest percentage of isolated bacteria are ciprofloxacin, levofloxacin and a 3rd generation cephalosporin such as ceftazidime or ceftriaxone. Additional empiric regimens that may be considered include combinations of a 3rd generation cephalosporin with a fluoroquinolone or tetracycline. Likely also important to consider is the skin flora of the patient when selecting empiric therapy, which may contaminate the wound, or other potentially non-sterile materials  used during the initial care by lay person prior to medical care. Dependent upon local community incidence of methicillin-resistant S. aureus (MRSA), the addition of an antibacterial with MRSA activity may be appropriate.The intent of empiric antimicrobial therapy is to provide the most appropriate antibiotics to cover the pathogens most likely encountered for a given infection; moreover, based on our results, empiric therapy for adult blacktip shark bites should be designed to target This study about the identification of bacteria in the oral cavity of a blacktip shark has to be seen as a first attempt, lacking a thorough understanding about the composition of bacteria throughout the shark’s life. There are several limitations to the study that must be acknowledged. First, sampled sharks were seasonally and geographically limited, thus application of the results to other areas or seasons is uncertain. Second, based on the size of the captured sharks in this study, only adult blacktip sharks were sampled. It is unknown if juvenile blacktip sharks would demonstrate similar antibiotic resistance patterns or bacteria composition. Although analysis suggested no difference between female and males, a larger sample size is desired to confirm these findings. Also, while every effort was made to swab all essential anatomy within the oral cavity, it is possible that certain bacteria were not captured during the culturing process or were not viable for adequate growth. To best understand the impact of blacktip shark ontogeny and prey composition on oral bacteria and antibiotic resistance, analysis of the stomach contents for swabbed sharks is needed in future studies. Such sampling will reveal most if not all the bacteria species a blacktip shark likely carries in its oral cavity during any time of its ontogeny. However since the above-mentioned closely related species (i.e. spinner and silky sharks) are not easy to differentiate from blacktip sharks, sampling of those two species also seems prudent to get a thorough understanding of involved bacteria.rd generation cephalosporin plus doxycycline is recommended.Antibiotic resistant bacteria are present within the oral flora of adult blacktip sharks in Florida; however, the bacteria composition and antibiotic resistance fluctuate and these results only reflect a moment in the shark’s life. Several factors may influence the oral flora throughout its ontogeny, including age, diet, gender and geographic location, all of which require further investigation. Given the worldwide concerns of antimicrobial resistance, research should continue to monitor this trend in marine animals as well. In the instance a person falls victim to an adult blacktip shark, empiric treatment with either a fluoroquinolone or combination of a 3


Corneal endothelium is formed of 1 layer of mitochondria-rich cubic cells whose main role is to maintain corneal transparency. Corneal endothelial disorders represent group of both inherited and noninherited and may affect proper vision.A 36-year-old male patient with suspicion of corneal endothelial dystrophy underwent visual acuity, intraocular pressure, the basic slit-lamp examination, anterior segment optical coherence tomography (AS-OCT) , and corneal confocal microscopy in vivo . During the 3-year observation the patient reported symptoms mainly in the right eye. Slit-lamp examination revealed endothelial changes, much more pronounced in the right eye. Examination by the AS-OCT Visante showed hyperreflective dots within the right corneal endothelium. In order to assess endothelial cell morphology, analysis using corneal confocal microscopy in vivo was performed. Scans revealed presence of single endothelial deposits and severe cell changes of different morphology in both eyes. In the right eye, less pronounced changes of the polymorphic structure—polygonal guttas in different stages, linear and branched loss with “nuclear-like” formations and accompanying sediments. In the left eye, severe homomorphous polygonal “guttas-like” changes with “nuclear-like” formations were observed. Endothelial cysts’ features were dynamically changing during follow-up time with different effects on the patient's clinical state.Corneal confocal microscopy allows accurate imaging of the endothelial cells and their detailed characteristics. Structural changes within the endothelial cells are not always proportional to visual acuity and slit-lamp image. The presented case is an example of an unusual corneal endothelial syndrome with probably nondystrophic background due to observed dynamic state with regressive tendency. On the other hand, there are some corneal abnormalities which are excluded from the corneal dystrophies group, despite fulfilling defined conditions .2 Corneal endothelial dystrophies concern diseases characterized by corneal endothelial cells layer abnormalities, what usually leads to slowly progressive degeneration of corneal endothelium, decreasing of cells density and affecting visual acuity.3The term “dystrophy” is commonly used to describe an inherited disorder, fulfilling certain criteria. In ophthalmology, the term “corneal dystrophy” has no strictly defined borders. It is a group of corneal disorders usually with the following features: inherited, noninflammatory, typically bilateral, symmetric, slowly progressive , and without relationship to environmental or systemic factors.5On the contrary, there are nondystrophic endothelial syndromes that include variants of iridocorneal endothelial syndromes (ICE) and endothelial  deposits. In such cases, changes might be observed unilaterally with tendency for both progression and regression while they are secondary pronunciation of other eye disorders .The aim of this report is to describe abnormal phenotype of corneal endothelium in a 36-year-old patient, with features of clinical regression accompanied by progressive endothelial pathology.The study was approved by the institutional review board of the Medical University of Silesia, Katowice, Poland, and informed consent was obtained from the patient after providing an explanation of the nature and possible consequences of the study.A 36-year-old patient with suspicion of corneal endothelial dystrophy underwent the following examination: best-corrected visual acuity (BCVA), intraocular pressure (IOP), refraction, the basic slit-lamp examination including anterior and posterior segment examination before and after mydriasis, corneal imaging with anterior segment optical coherence tomography (AS-OCT) including central corneal thickness (CCT) and corneal topography measurements , and corneal confocal microscopy in vivo . During the 3-year follow-up, the patient reported symptoms of decreased and blurred vision mainly in the right eye. In anamnesis, no history of any type of ocular surgery (including refractive surgery), no family history of ocular diseases, no use of contact lenses or eye drops usage at present or in the past. In blood samples, no inflammatory markers elevation was observed . The patient was referred to our outpatient clinic after he underwent detailed ophthalmic examination in a foreign clinic (the Netherlands), where corneal changes have been described as a case of an “unknown dystrophy.”During the 3-year follow-up the clinical status of the patient changed. Decimal BCVA over the years of observation ranged from 20/63 to 20/25 for the right eye and was constant at 20/20 for the left eye Table . IOP valIn order to assess endothelial cell morphology, analysis using corneal confocal microscopy in vivo was performed. The scans revealed presence of massive endothelial deposits in the right eye and severe cell changes of different morphology in both eyes. In the right eye, we found less pronounced changes of the polymorphic structure—polygonal guttas in different stages, linear and branched loss with “nuclear-like” formations, and cells polymegathism Figure A–L. In tBetween regular examination visits, we observed dynamic regression in clinical status, which was concurrent with BCVA improvement. Endothelial changes in the right eye presented regressive features for their localization  as well as for decreasing presence of sediments; however, progressive endothelial cells loss was observed. Regression was accompanied by releasing of endothelial deposits material from endothelium to anterior chamber causing aqueous humor convection (probably noninflammatory). Both lenses showed no visible features of pseudoexfoliation (PEX) syndrome. In the left eye, endothelial abnormalities and clinical status remained stable.In the described case, suspected corneal endothelial dystrophy presents some features that could be characteristics for posterior corneal dystrophies, however, not fully matching any of already described dystrophies. There is also no clear relation to any nondystrophic secondary endothelial pathology. Changes appeared bilaterally, but they have asymmetric morphology. Severity of changes did not correlate with clinical state and (based on anamnesis) seemed not to be inherited.6 In Fuchs endothelial corneal dystrophy (FECD) characteristics are symmetric guttas of different size and round shape, polymegathism and pleomorphism of cells, with presence of corneal edema due to degeneration of the corneal endothelium. Changes involve usually both eyes.1 In congenital hereditary endothelial dystrophies (CHEDs), changes are bilateral, symmetric or asymmetric. Massive endothelial cells degeneration cause corneal edema from the time of birth or shortly after. In cell structure, the characteristic features are atrophy, vacuolization, and metaplasia with keratotic epithelial cells.8 X-linked endothelial corneal dystrophy (XECD)—with characteristic “moon crater–like” endothelial changes—develop in early age.9 Based on description of endothelial dystrophies, there might be similarities observed between changes in the patient's right eye and PPCD; however, the expression is not typical. The left eye does not present any features of already known dystrophies. In this case, very likely explanation is a coexistence of 2 different types of corneal dystrophies or 2 different phenotypes of the same dystrophy. Descriptions of this kind of rare combinations can be found in the literature.12 Considering 3-year follow-up of presented patient's disease, it is rather unlikely to search for dystrophic background, mostly due to regression in patient's clinical state that is untypical for dystrophic intercourse. In comparison with available confocal description of ICE syndrome, where authors describe presence of epithelioid cells within endothelium, hyperreflectivity of cells nuclei, sac-like blisters, and ruptured blisters, revealed no such cell abnormalities in the presented report.14In the case of posterior polymorphous corneal dystrophy (PPCD), changes appear mostly bilaterally and have similar morphology, however, can also be asymmetric. Clinical state usually does not correlate with severity of changes. In endothelial cells, dominant features are polymegathism, vesicular, band, and diffuse lesions. Additionally, peripheral iridocorneal adhesions and elevated IOP can appear.Corneal confocal microscopy allows accurate imaging of the endothelial cells and their detailed characteristics. Structural changes within the endothelial cells are not always proportional to visual acuity and slit-lamp image. The presented case is an example of an unusual corneal endothelial phenotype with probably nondystrophic background due to observed dynamics of endothelial changes with regressive tendency.


Intensified selection of polled individuals has recently gained importance in predominantly horned dairy cattle breeds as an alternative to routine dehorning. The status quo of the current polled breeding pool of genetically-closely related artificial insemination sires with lower breeding values for performance traits raises questions regarding the effects of intensified selection based on this founder pool.We developed a stochastic simulation framework that combines the stochastic simulation software QMSim and a self-designed R program named QUALsim that acts as an external extension. Two traits were simulated in a dairy cattle population for 25 generations: one quantitative (QMSim) and one qualitative trait with Mendelian inheritance . The assignment scheme for qualitative trait genotypes initiated realistic initial breeding situations regarding allele frequencies, true breeding values for the quantitative trait and genetic relatedness. Intensified selection for polled cattle was achieved using an approach that weights estimated breeding values in the animal best linear unbiased prediction model for the quantitative trait depending on genotypes or phenotypes for the polled trait with a user-defined weighting factor.Selection response for the polled trait was highest in the selection scheme based on genotypes. Selection based on phenotypes led to significantly lower allele frequencies for polled. The male selection path played a significantly greater role for a fast dissemination of polled alleles compared to female selection strategies. Fixation of the polled allele implies selection based on polled genotypes among males. In comparison to a base breeding scenario that does not take polledness into account, intensive selection for polled substantially reduced genetic gain for this quantitative trait after 25 generations. Reducing selection intensity for polled males while maintaining strong selection intensity among females, simultaneously decreased losses in genetic gain and achieved a final allele frequency of 0.93 for polled.A fast transition to a completely polled population through intensified selection for polled was in contradiction to the preservation of high genetic gain for the quantitative trait. Selection on male polled genotypes with moderate weighting, and selection on female polled phenotypes with high weighting, could be a suitable compromise regarding all important breeding aspects.The online version of this article (doi:10.1186/s12711-016-0228-7) contains supplementary material, which is available to authorized users. The routinely-used practice of dehorning in dairy and beef cattle worldwide has attracted increased negative public perception, and contributes to conflicts between modern intensive livestock management and animal welfare. Undoubtedly, it is well documented that dehorning of calves is associated with stress, pain and temporary negative impact on calf growth –3. Currepolled” and “scurs”, determine the variety of phenotypes that are associated with the polled trait in cattle  after 25 generations. Nevertheless, the realized genotype frequencies in scenario PHENO-ALL show that a strict selection on polled individuals based only on phenotype also substantially increased the number of homozygous polled individuals within a time span of 25 generations.Both overall polled selection strategies GENO-ALL and PHENO-ALL resulted in phenotypically complete polled active populations. Moreover, application of GENO-ALL resulted in full fixation of the polled of 0.03 in generation 0 to a high percentage of polled sires and dams in the active population was clearly faster in scenarios GENO-M and PHENO-M compared to female scenarios GENO-F and PHENO-F, respectively . The results show that the transition from the low initial allele frequency for polled among the dams after 25 generations was substantially lower than in the corresponding scenario PHENO-ALL . In contrast, scenario PHENO-M resulted in a moderate increase in the number of polled dams, but the allele frequency of see Fig. . Restricsee Fig. . Therefopolled and 99 % of homozygous polled individuals, as in scenarios GENO-ALL and GENO-M.The sex-dependent combination of both general selection strategies (scenario GENO-M-PHENO-F) led to a phenotypically completely polled active population with an allele frequency of 0.99 for polled  displayed higher average TBV than those with significant increases in the allele frequency for polled . In the latter scenarios, genetic gain after 25 generations was reduced by 4–2 % compared to the CONTROL scenario (Table In the preceding five generations (=generations −5 to −1) before polledness was simulated, the rate of genetic gain was similar and positive in all breeding scenarios  reduced the average rate of genetic gain per generation in selected sires and dams compared to the CONTROL scenario within 10 generations after the polled allele was assigned. For the later generations 10–25, the rates of average genetic gain for all scenarios were quite constant  that could potentially act as donors of the  related , 24. In ed trait .polled locus using the available gene test cannot be carried out in practice due to the current genotyping costs  resulted only in minor gains regarding the final frequency of the polled allele. Commercial herds should focus on balanced selection strategies with regard to the use of available polled AI and elite horned AI sires following traditional selection strategies [polled allele into the herd. Nevertheless, Segelke et al. [polled allele and genetic gain among potential polled AI bull selection candidates.With regard to practical selection decisions, our results strongly suggest that application of GENO selection strategies among males will maximize selection response for polled. The corresponding scenarios GENO-M and GENO-M-PHENO-F resulted in a completely polled active population in a reasonable time span with reduced costs and efforts for genotyping and phenotyping. Scenario GENO-ALL led to a similar result, but the broad genotyping of commercial milking cows at the per cow, ). As an per cow, . From a rategies . Such a e et al.  suggestepolled allele through the male pathway of selection. Continuous use of only a small number of available polled AI sires has resulted in a population of closely-related polled individuals and in higher inbreeding in the polled subpopulation [polled allele in dairy cattle breeds [polled allele within a reasonable time span. The success of the polled AI breeding program in Simmental cattle is exemplarily in this regard [In Holstein AI programs, male polled selection candidates were generally outperformed by horned sires. There are only a few exceptions, e.g. the polled sires Lawn Boy in red Holstein and Mitey P in black-and-white Holstein that disseminated the pulation , 24. Thee breeds , 30 is ce breeds  and boths regard .polled allele through selection, which implies a completely homozygous polled active population. In scenario GENO-ALL, all new born progeny are homozygous polled ongoing from generation 17. In scenarios GENO-M and GENO-M-PHENO-F, we observed a small number of heterozygous polled progeny up to generation 25. In addition, the results in Fig. polled sires, allows commercial farmers to apply assortative polled matings for a faster dissemination of the polled allele in their herds.For calf dehorning to be completely abandoned requires 100 % phenotypically-polled new born progeny, which was achieved in scenarios GENO-ALL, GENO-M, GENO-M-PHENO-F within 10 generations, respectively Fig. . Howeverpolled allele  also indicated that nearly all the individuals in the active population and new born progeny were polled after 25 generations.We focused on scenario GENO-M-PHENO-F for a further extension of the presented simulation approach aiming at reducing the loss in genetic gain concurrent to the increase in frequency of the see Fig. . For thasee Fig.  comparedReducing the weighting factor among males (wf-M-0.1) limited the loss in overall genetic gain for the quantitative trait in sires and dams to 2 % compared to CONTROL . Such a suggested rather mild selection strategy for the polled trait among male AI candidates is possible with GENO-M and a moderate weighting factor, combined with more intensive selection among females based on polled phenotypes (PHENO-F). This strategy reflects current practical breeding programs that use assortative elite mating schemes and genomic selection, which results in improved EBV for polled Holstein AI bulls , 25, 37.polled allele across 25 generations implies a strict selection strategy based on polled genotypes. Considering the current characteristics of the available polled AI bulls in most dairy cattle breeds, simulation results indicate that such a strategy is coupled with significant decreases in genetic gain for quantitative performance traits. Selection strategies based only on phenotypic information for the polled trait also led to high frequencies of the polled allele, but without its fixation after 25 generations. Such strategies based on phenotype information result in significant increases in the number of heterozygous individuals remaining in the population and in the number of horned progeny born up to the final generations. Therefore, abandoning completely dehorning is not possible when selection is based on polled phenotypes only. The application of polled selection strategies based on gene tests for the male selection pathway combined with moderate weighting of polled genotypes during selection, and a phenotypic polled selection strategy for females using high weighting of polled phenotypes, appears to be the optimal compromise regarding all important evaluation criteria.A fast and lasting dissemination and fixation of the


Plasmodium falciparum (Pf). Current diagnostic and surveillance systems in much of sub-Saharan Africa are not designed to identify or report non-Pf human malaria infections accurately, resulting in a dearth of routine epidemiological data about their significance. The high prevalence of Duffy negativity provided a rationale for excluding the possibility of Plasmodium vivax (Pv) transmission. However, review of varied evidence sources including traveller infections, community prevalence surveys, local clinical case reports, entomological and serological studies contradicts this viewpoint. Here, these data reports are weighted in a unified framework to reflect the strength of evidence of indigenous Pv transmission in terms of diagnostic specificity, size of individual reports and corroboration between evidence sources. Direct evidence was reported from 21 of the 47 malaria-endemic countries studied, while 42 countries were attributed with infections of visiting travellers. Overall, moderate to conclusive evidence of transmission was available from 18 countries, distributed across all parts of the continent. Approximately 86.6 million Duffy positive hosts were at risk of infection in Africa in 2015. Analysis of the mechanisms sustaining Pv transmission across this continent of low frequency of susceptible hosts found that reports of Pv prevalence were consistent with transmission being potentially limited to Duffy positive populations. Finally, reports of apparent Duffy-independent transmission are discussed. While Pv is evidently not a major malaria parasite across most of sub-Saharan Africa, the evidence presented here highlights its widespread low-level endemicity. An increased awareness of Pv as a potential malaria parasite, coupled with policy shifts towards species-specific diagnostics and reporting, will allow a robust assessment of the public health significance of Pv, as well as the other neglected non-Pf parasites, which are currently invisible to most public health authorities in Africa, but which can cause severe clinical illness and require specific control interventions.Malaria in sub-Saharan Africa has historically been almost exclusively attributed to  Plasmodium vivax (Pv) is the most widely distributed malaria parasite globally, but conspicuously “absent” from Africa. The majority of African populations do not express the Duffy blood group antigen, which is the only known receptor for Pv infection. Since this discovery in the 1970s, the low clinical incidence of Pv in Africa has resulted in a perception of Pv being completely absent and any apparent cases being misdiagnoses, and no public health allowances are made for this parasite in terms of diagnosis, treatment or surveillance reporting. As more sensitive diagnostics become available, Pv infection in Africa is increasingly reported from a variety of different survey types: entomological, serological, community prevalence surveys, as well as clinical infection data from local residents and travellers returning to malaria-free countries. A literature review was conducted to assemble these reports and assess the current status of evidence about Pv transmission in Africa. Moderate to conclusive evidence of transmission was available from 18 of the 47 malaria-endemic countries examined, distributed across all parts of the continent. Mechanisms explaining this reported transmission are evaluated, as well as alternative explanations for the observations. Combinations of complementary explanations are likely, varying according to regional ecology and population characteristics. The public health implications of these observations and recommendations for increased awareness of Pv transmission on this continent are discussed. Plasmodium falciparum (Pf). The identification of the Duffy antigen as the obligate trans-membrane receptor for P. vivax (Pv) infection of red blood cells by Miller et al. during the 1970s ”, with the seven dominant vector species across the Africa region [Anopheles arabiensis, An. funestus, An. gambiae, An. melas, An. merus, An. moucheti and An. nili; An. pharoensis was also included as a WHO-defined “major Anopheles species” in certain African countries [Pv sporozoite-positive mosquitoes found in each survey location were recorded.A further literature search for references about African a region : Anophelountries . The numwww.map.ox.ac.uk) PR surveys database, the product of nearly ten years of archiving [Pv infections reported since 1985 (last updated 17/2/15).The most commonly used epidemiological metric of malaria endemicity is the parasite rate (PR), assessed by cross-sectional surveys of infection prevalence . The Malrchiving , was revA dataset of imported malaria infections into malaria-free countries by travellers returning from sub-Saharan African countries was assembled from national and regional  surveillance programme reports (search window November 2014 –January 2015). A selection of malaria-free countries with robust surveillance systems were contacted to obtain summary surveillance data since 2000 on imported malaria cases into their country. Given that individuals from these non-endemic countries would have similar prior exposure , their country of origin was not relevant to the analysis, although varied countries were approached to increase the coverage of countries of infection . Contributing countries and the reporting time intervals which could be assembled are listed in Pv transmission at the first sub-national administrative level (Admin1). First, the data available for each data type from each Admin1 were classified as being of category 1 (strongest), 2, or 3 (weakest) evidence , the denominator size, and the diagnostic method sensitivity/specificity. For example, due to their limited range of movement, infected vector specimens were considered relatively strong evidence of local transmission. In contrast, the longer window of exposure detected by serological surveys meant sero-positivity could result from a transmission event in a different location prior to relocation to the study site. To reflect the reduced temporal specificity of the serological evidence, a relatively higher number of reports of sero-positive individuals was therefore necessary to provide the same strength of evidence of transmission as infections observed in real-time. The single time-point snapshot investigated during a community prevalence survey contrasts with a much larger time window and population denominator for clinical case reporting across a region. Therefore, evidence of parasitaemia from prevalence surveys was considered stronger evidence of ongoing transmission than routine reporting of symptomatic cases, and a larger number of positive symptomatic individuals was required to equate to the strength of evidence of asymptomatic infections from prevalence surveys. Annual Parasite Incidence data (API) indicating stable transmission  equated to the strongest category 1, while unstable transmission  was category 3.Clinical cases diagnosed by molecular diagnostic tools based on nucleic acid amplification techniques (notably PCR) were considered stronger evidence of transmission than by light microscopy or rapid diagnostic tests (RDT) due to the increased species-specific diagnostic accuracy. In the case of prevalence surveys, however, where infections were more likely to be of low parasitaemia, RDT and microscopy were expected to diagnose a smaller proportion of total infections than PCR-based diagnostics due to their differing limits of the detection . It has Pv infection among travellers returning from African countries could not be attributed the same strength of evidence as observations of infection among local residents. The relapsing nature of Pv parasites means that infections could have been acquired from travel prior to the reported journey. Furthermore, the nature of the imported infections dataset assembled here is highly opportunistic and incomplete. This data type was therefore down-weighted relative to reports of local infections.Reports of Pv infections was divided by the total number of Admin1 units in the country. These infections were therefore strongly down-weighted relative to the other data.The data were mapped to the Admin1 level. Where multiple surveys within a data type were available from a single administrative region, the scores were based on the total number of reports. Returning traveller infections were only reported to the national level, so to allocate scores to Admin1 units, the overall number of reported Pv transmission, the higher the overall strength of evidence. The highest level, “conclusive evidence”, was only attained if two or more category 1 sources of evidence were available. The lowest level, “very weak evidence” corresponded to Admin1 units from which no direct evidence was available, only a relatively small number of infected traveller reports .Finally, once the component data types were categorised and mapped, these were summed together in ArcMap 10.1 . The weiPv transmission were overlaid onto a 2015 population surface to estimate the PvPAR. Medical intelligence data and biological exclusions were applied to define the limits of potential transmission. First, API and routinely reported incidence data were reviewed [Pv sporogony at any time in an average year were excluded by a modelled temperature suitability mask [PvPAR estimates have “downgraded” risk from stable to unstable transmission levels based on aridity, but the lack of distinction between these levels here means no aridity exclusion was applied. Third, urban areas, as identified based on the Global Rural Urban Mapping Project (GRUMP) urban extents layer [PvPAR estimates [Using an approach similar to that previously published ,31, the ity mask . Aridityts layer , were exstimates ,31, and stimates ,39.www.worldpop.org), supplemented by data from the Gridded Population of the World (GPW) v3 (http://sedac.ciesin.columbia.edu/data/set/gpw-v3-population-count-future-estimates) for the Comoros and São Tomé and Príncipe, which were not available from WorldPop. This was adjusted to the Duffy positive population using the previously published Duffy blood group frequency maps developed by geostatistical modelling of population surveys of blood group frequencies [PvPAR estimates were derived for the three Duffy thresholds within the defined limits of transmission. All spatial manipulations were run at 5 x 5 km resolution in ArcMap and ArcScene 10.1 [A population surface for 2015 was compiled from the WorldPop Project projections  how the prevalence of infection and relative risk of infection differed between species among their specific subset of known susceptible hosts (based on the assumption that the PvPAR was limited to Duffy positive hosts: PvPRFy+ = PvPR/Proportion of Duffy positive hosts), (iii) the relationship between infection prevalence of the two species, and whether prevalence of one could inform predictions of the other. Full methodological details are available in Text S1.This dataset was used to assess: (i) whether the observed Pv infections in Duffy negative hosts were compiled from the different data types reviewed. Only studies that used molecular confirmation of both Pv infection and Duffy genotype were included. The reports were geopositioned and presented in relation to the local prevalence of Duffy blood group phenotypes estimated by the modelled geostatistical maps [Reports of cal maps .Pv in Africa. All reports of Pv infection were collated and geopositioned . Overall, reports of Pv were available from 21 of the 47 malaria-endemic countries examined. The maps in The literature search identified 1,479 publications, of which 529 were considered relevant to studies of sitioned . A totalentified , as wellsitivity , 109 sit reports  and 643 Plasmodium infections in travellers were accessed for 31 malaria-free countries, corresponding to a period of 182 surveillance-years between 2000 and 2014  region . The weaker evidence categories represent areas of relatively higher uncertainty.The composite map in Pv infection (PvPAR) across sub-Saharan Africa in 2015 , 7.2 million in West Africa, 4.1 million in Southern Africa and 3.3 million in Central Africa  whether the observed infection rates could be consistent with transmission exclusively limited to Duffy positive hosts, and (ii) how Pv and Pf infection rates were related to one another in sub-Saharan Africa. Full discussion of the results of these analyses and additional figures are available in the Supplementary Information  indicates that the proportion of individuals infected does not exceed the proportion of the population considered susceptible, thus fulfilling the necessary condition (but without proving) that Duffy negativity imposes an upper threshold on PvPR by infections being limited to Duffy positive hosts. Six PvPR values (1.7% of positive surveys) were outliers to this, all from coastal areas of Western/Central regions, including 4 from São Tomé and Príncipe. The survey with the highest discrepancy was from Cameroon, where 13 of 269 individuals were PCR-Pv positive [PvPR rising as the frequency of susceptible hosts increases, as would be expected.The data  were firPvPR estimates were re-scaled to prevalence of infection among the subset of Duffy positive hosts (PvPRFy+ = PvPR/Proportion of Duffy positive hosts). PvPRFy+ against PfPR, revealing distributions of points across the graphs without any clear trends emerging between infection rates between species. Regional trends, however, were apparent, with higher relative risk of infection in regions of lower host availability. For instance, where PvPRFy+ was positive in the Western region (n = 13), all surveys showed higher likelihood of infection by Pv than Pf (among the respective susceptible population sub-groups)   Figs. Inan by Pf . As DuffPfPR was a highly significant predictor of PvPRFy+ (p = 4.4x10-6) up to 15% PfPR, after which increases in PfPR did not result in further predicted increases in PvPRFy+; in contrast, PvPRFy+ within the HoA+ was a significant linear predictor of PfPR at all levels of endemicity. Substantial scatter and heterogeneity in the data, however, resulted in wide 95% confidence intervals around the predicted relationship even when a significant relationship was identified.Finally, a logistic regression model was developed to test for an association at the population level between the parasite rates of the two species: could PR data from one species predict PR of the other? No significant relationship could be identified from the paired PR dataset for surveys outside the HoA+, and the association was not significantly different from a flat line . Within Pv infections in Duffy negative hosts (Fy-Pv+ infections), providing an additional potential mechanism sustaining Pv transmission across sub-Saharan Africa. These observations are from diverse geographic, demographic and host genetic landscapes. The PubMed literature review identified 19 sites across 6 countries of sub-Saharan Africa where Fy-Pv+ infections in 54 individuals have been confirmed by molecular diagnosis, all published 2010–2015  as well as in populations where Duffy negativity was at near fixation . All Fy-Pv+ infections  were from areas classified as “rural” by GRUMP. The observations were from areas of varied population densities, ranging from <100 to >500,000 individuals in the surrounding 25 km2 area (WorldPop Project data). Both symptomatic and asymptomatic Fy-Pv+ infections were reported. The reported repartition of Pv infections among Duffy negative and positive hosts ranged widely between surveys  the data assembled here are incomplete, formed from an opportunistic selection of countries and reporting years. The numbers of infections cannot be interpreted in any absolute sense; (ii) data are reported only to the national level, whereas the analysis was sub-national; (iii) suspected countries of infection may not be fully reliable given Pv’s ability to form latent infections. In recognition of these limitations, traveller data were therefore strongly down-weighted relative to other data types but nevertheless represented an important and complimentary component of the evidence of Pv transmission.The opportunistic and highly varied nature of the available surveys restricted the sophistication of potential analyses, limiting the composite map to being a qualitative assessment of available evidence rather than providing any quantitative measures or comparisons with other parasite species. For instance, varied molecular diagnostic methodologies or inconsistent approaches for calculating sero-prevalence meant that standardization was not possible even within each data type, therefore favouring the categorical approach. The limited distribution of the data means that the resulting evidence map is both a map of sampling effort and of Pv”, these were not incorporated into the evidence synthesis as they could not be interpreted as “absolute absences” [Pv than Pf [Pv [Pv means that very large sample sizes and diagnostic tools with higher sensitivity for detecting Pv would be needed to reliably give any confidence of “absence”.Although there were additional surveys reporting “zero bsences” , particu than Pf ,29 whichn Pf [Pv –48, espen Pf [Pv . The lowPv infection levels appear plausible with transmission being restricted to the Duffy positive population at risk (estimated at 86.6 million), a number of other explanations discussed here have also been hypothesised to explain the observed infections.While PvPRFy+ and PfPR in regions outside the HoA+ suggests that change in the prevalence of one species is not reflected by the prevalence of the other species at the host population level. This outcome may indicate that the two infection rates are determined by different drivers of transmission linked to their differing biological characteristics, notably capacity to relapse. For instance in these areas of low Duffy positive host availability, the environmental drivers that are highly significant determinants of PfPR endemicity [PvPRFy+. Alternatively, the noise from the heterogeneity of the small dataset (exacerbated by the PvPR adjustment to PvPRFy+) may be masking a relationship similar to that in the more data-rich HoA+ region which would be possible to detect through a larger dataset.The PR data were found to be consistent with transmission being potentially sustained by Duffy positive hosts alone. However, an important limitation to the PR comparative analysis was the skewed distribution of positive surveys, with the majority coming from the HoA+ (73%), while the main area of interest was outside this region. The lack of any predictable association between demicity , may be Pv in Africa being limited to Duffy positive individuals [Bespoke transmission models accounting for relapse risks and the peculiarities of the predominantly Duffy negative landscape are required in order to estimate the critical community sizes and determine the transmission dynamics needed to sustain infection, to verify the plausibility of ividuals –56.PvPAR estimate a potentially significant underestimate. Furthermore, the historical waves of migration from Duffy positive British, French, Indian, Lebanese, Portuguese etc, populations may also be underrepresented. The wide confidence interval of the PvPAR (43.9–156.7 million) indicates the potential impact of changes to the Duffy maps. Furthermore, the GRUMP map which was used to identify urban populations for exclusion from the PvPAR, overestimate urban areas, so many high density rural populations may have been excluded, further contributing to a conservative PvPAR estimate.The quantitative PR data analysis presented here is heavily contingent on the Duffy negativity frequency map . Of the Plasmodium ovale represents an important potential confounder to the reliability of microscopic reports of Pv due to their morphological similarities [Pv reports actually being misdiagnosed Po infections. Conversely, the opposite may also be true with Pv infections being misclassified as Po due to the belief of Pv absence [Po- and Pv-specific antigens in serological screening. Little is known about the diversity of Po in particular, so there is a need for the development of additional species-specific reagents to reliably distinguish the two species.larities  and the  absence . MicroscPv being a common cause of traveller infections is consistently reported from varied sources  of the plausibility of cross-infection of parasite strains between ape and human hosts with similar clinical presentation [et al therefore argue that Pv infections reported from regions of high Duffy negativity frequency are zoonotic infections spilling over from ape reservoirs. Entomological evidence suggests that An. moucheti and An. vinckei may be potential vector species bridging transmission between apes and humans [Liu et al  have pubentation ,64. Liu d humans , althougPv across predominantly Duffy negative regions of Africa.The natural ranges of these ape reservoir species are restricted to the forests of Central Africa . So, whiPv transmission across Africa. The public health burden of these infections is unclear. While the protective effect of Duffy negativity may not be as absolute as previously considered, this blood group’s high frequencies across Africa do nevertheless appear to represent a limiting force on potential Pv endemicity. In the absence of any limiting factor, and given the presence of competent vectors and a suitable climate, rates of Pv infection comparable to those in Asia or the Americas [Pv+ infections demand further investigation, ideally across diverse epidemiological settings. The impact of reduced protection conferred by Duffy negativity (currently assumed to be 100%) would have important impacts on the resulting PvPAR .Pv transmission in Africa, and evaluates the varied mechanisms hypothesised to explain these observations across an area where transmission is largely unexpected. Here we argue that no single theory is sufficient to explain transmission across this varied continent, but instead, transmission pathways vary according to the complex ecology and epidemiology of each area and population.For the first time, this paper synthesises all available evidence of Pv transmission across Africa appears inconsistent. Pv is clearly widely present, causing a substantial proportion of returning traveller malaria infections, clinical illness and asymptomatic infection among local residents, infecting vectors and presenting a history of exposure by local communities to infected bites. However, extensive surveys using high-sensitivity molecular methods have repeatedly failed to diagnose Pv [Pv [PvPR  [Pv was found in the remote, rural village communities [Pv [Evidence relating to gnose Pv –70. For e Pv [Pv , while aections) . The keymunities , the multies [Pv .Pv outside these ape natural ranges, and furthermore, the main group of travellers returning from Africa with Pv infections are visiting relatives [While there is some evidence of an ape reservoir enabling zoonotic infections, this does not preclude the possibility of endemic transmission. elatives ,72, and elatives . TherefoPv in Africa are not mutually exclusive. Instead, given the limitations to each hypothesis for explaining the overall diversity of transmission, it seems probable that all are involved to some degree. The dominant source of infection would vary between location: in remote forest areas, infections may be from the ape reservoir [Pv are in fact Po misdiagnoses, but the sheer abundance of data from various diagnostic methods means this cannot be universal. Similarly, while there is convincing evidence of Fy-Pv+ infections, these are not reflected by the widespread Pv endemicity levels that would be expected if these infections were commonplace. The epidemiology of Pv in Africa is likely to be complex and multi-faceted, driven by different mechanisms in different regions, determined by the unique host genetic, vector, and reservoir characteristics of each area. These complimentary theories together may explain the observed evidence of Pv transmission. High sensitivity molecular methods could allow further insight into the population genetics of Pv infections diagnosed in Africa and therefore their epidemiology [The multiple theories discussed so far for explaining the observations of eservoir , while ieservoir  means themiology , as wellPv, Po and Pm infected patients who present in clinics with fever symptoms will test negative and could leave untreated. The patients will persist in the community as sources of onward transmission, and, in the case of Pv and Po, be susceptible to the cumulative impact of clinical relapses.The non-specific clinical presentation of malaria means that diagnosis is only possible with a parasitological test . The WHOPv are inadequate. While Pf-targeted control will treat Pv clinical symptoms, it will not impact on the parasite reservoir sustaining the observed blood-stage clinical infections. Even in terms of blood-stage therapy, drug policy in Ethiopia  [Po radical cure. It has been hypothesised that the high prevalence of G6PDd may be the result of a selective advantage against malaria [Pv patients and thus primaquine therapy a lesser concern. However, given Pv’s preference for invading reticulocytes–young red cells with highest levels of G6PD enzyme activity–it is unlikely that a relatively mild G6PD variant  maintaiglobally . A furth (G6PDd) , causing (G6PDd) . The sam malaria –81, mean variant ), would Pv mapping. First, where PvPR surveys are available, the infection rates reported are consistent with transmission only among Duffy positive hosts. This therefore supports the approach previously followed of restricting the PvPAR to Duffy positive hosts [PfPR surface cannot be used to predict Pv infection prevalence in Duffy positive hosts, except potentially in transmission settings up to 15% PfPR in the HoA+ region.Finally, the evidence presented here has two main implications for ve hosts ,83 and ove hosts . Second,Pf. Current epidemiological data overwhelmingly indicates that Pf is the predominant malaria pathogen across most of sub-Saharan Africa [Pv prevalence remains low. Nevertheless, despite the estimated 86.6 million individuals at risk of infection, Pv is so drastically neglected across this vast and populous continent that without a commitment to add capacity for Pv in routine surveillance and reporting, this minor player will remain invisible and any quantitative burden estimates and evidence-based policy decisions impossible. Broadening the outlook beyond Pf would simultaneously also strengthen the evidence base relating to the other neglected endemic species, Po and Pm and increase access to diagnosis and treatment of these other neglected malaria species.The implications of this paper should not be misinterpreted. This is not a “call to arms” requiring huge additional resources above and beyond the considerable efforts already ongoing into control of n Africa ,31,68, aS1 Text(DOCX)Click here for additional data file.S1 FigPvPR exceeded the proportion of Duffy positive hosts were excluded as anomalies.Panels A and B show the full dataset ; Panels C and D have surveys reporting zero prevalence of either species excluded (n = 249). Panels A and C represent prevalence 0–1; while B and D provide higher resolution of 0–20% prevalence. The six surveys where (TIF)Click here for additional data file.S2 FigPanel A boxplot summarises differences within regions, while Panel B shows relative risk of infection between species in relation to the proportion of Duffy positive hosts, and Panel C shows the relative infection risk in relation to the density of Duffy positive hosts (n = 249).(TIF)Click here for additional data file.S3 FigPvPR values are adjusted to infection rates in the subset of Duffy positive hosts (PvPRFy+). The solid line represents a significant model fit, while a dashed line indicates that there is no relationship significantly different from zero.The dependent variable is plotted on the y-axis. The (TIF)Click here for additional data file.S1 Table(NR: not reported.)(XLSX)Click here for additional data file.S2 Table(NR: not reported.)(XLSX)Click here for additional data file.S3 Table(NR: not reported.)(XLSX)Click here for additional data file.S4 Table(NR: not reported.)(XLSX)Click here for additional data file.S5 Table(NR: not reported.)(XLSX)Click here for additional data file.S6 Table(NR: not reported.)(XLSX)Click here for additional data file.


A 30-year-old male presented with a 1-day history of left scrotal pain and a tender left testicle and epididymis on physical exam. Scrotal ultrasound showed an avascular, heterogeneous, hypoechoic lesion in the superior left testis suggestive of infarction or neoplasm. The patient was managed conservatively; however, his pain continued and follow-up ultrasound 6 days later showed interval increase in the size of the mass. Left radical orchiectomy was done and pathology result showed segmental infarction of the left testis. Segmental testicular infarction is a rare condition that presents with acute scrotal pain and is often clinically indistinguishable from other etiologies of scrotal pain. The diagnosis often relies on imaging studies, with testicular neoplasm being the most important differential diagnosis. If the condition is diagnosed or suspected on imaging studies, patients can be managed conservatively and often improve. However, orchiectomy to obtain pathologic diagnosis may be required in a significant number of patients when the diagnosis is uncertain. We present a patient with segmental scrotal infarction who did not improve with conservative management and subsequently underwent orchiectomy.A 30-year-old male with history of motor vehicle accident leading to urinary frequency and occasional incontinence 1.5 years ago presented with 1-day history of left groin pain, which was gradually improving. On physical examination, he had a tender left testicle and epididymis with no significant swelling or systemic signs of inflammation. High frequency ultrasound including color-Doppler showed an avascular, heterogeneous, hypoechoic lesion in the superior left testis suggestive of infarction or neoplasm. Bilateral microlithiasis was also noted . The patThe unique anatomical location of testis, lying within an external body sac while hanging from its vascular pedicle, makes it hypermobile and prone to vascular accidents compared to other body organs. Congenital abnormalities like “bell-clapper” deformity with abnormal attachment of the testis to its muscular and facial layers increase the chance of testicular ischemic events , 2. Compβ-HCG can help to differentiate it from a malignant process.Although the majority of cases with STI are idiopathic, conditions like vasculitis, sickle cell disease, polycythemia, epididymitis, intimal fibroplasia of spermatic artery, hypersensitivity angiitis, trauma, or prior testicular torsion can predispose to this condition. It can happen in any age range; however, it is a rare condition in the pediatric population –5. SuddeUltrasound is usually the first step to diagnosis; however, seminomatous and nonseminomatous testicular masses can easily mimic the STI appearance on ultrasound.On gray-scale imaging, a wedge-shaped hypoechoic lesion with the apex pointing to the rete testis can be suggestive of arterial infarction. Arterial infarctions are more often seen in the upper poles of the testes , 7. A roMagnetic resonance imaging (MRI) has also occasionally been used to aid in diagnosis. MRI can better show the lesion borders and the T2-weighted images can show low intensity signal (but can be variable) in patients with infarction. The surrounding enhanced rim can also be seen in MRI after administration of contrast , 10.Despite the available imaging modalities, the diagnosis of segmental testicular infarction remains challenging. The radiologic-pathologic correlation in most case series remains suboptimal and definitive diagnosis in many patients is obtained after orchiectomy , 11. WheAcute onset of testicular pain with normal levels of tumor and inflammatory markers and presence of a wedge-shaped, avascular hypoechoic heterogenous lesion on color-Doppler ultrasound can be highly suggestive of segmental testicular infarction. The clinical and radiographic aspects of a case should be considered altogether to avoid unnecessary orchiectomy.


A 76-year-old male presented to the emergency department complaining of intense abdominal pain. He reported one week earlier an upper respiratory illness with violent coughing spells. Past medical history included recent percutaneous coronary intervention for a myocardial infarction 6 months prior where he received three drug-eluting stents and was subsequently discharged home on Prasugrel (Effient) and Aspirin.Physical exam revealed a large tender right lower quadrant mass with areas of ecchymosis appreciated over the supra-pubic and right lower abdominal region. Abdomen was otherwise soft and non-distended. Basic laboratory tests were noted to be within normal limits. A computed tomography (CT) of the abdomen and pelvis was performed and revealed a 12cm rectus sheath hematoma in the right lower quadrant  and 2.Rectus sheath hematomas (RSH) are often misdiagnosed and overlooked as a cause of acute abdominal pain. It has been estimated that RSH account for 1.5–2% of unexplained abdominal pain in hospitalized patients,RSH result from the accumulation of blood in the rectus sheath, secondary to disruption of the blood vessels that course through it. The most common inciting factors are direct trauma, strenuous straining , and anticoagulants.The mortality rates associated with RSH can be as high 25% for those patients on anticoagulation drugsManagement of RSH is dependent on the grade of hematoma that encompasses the size, degree of anti-coagulation, and the patient’s hemodynamic status. Low-grade RSH can usually be managed with conservative treatment. Higher-grade hematomas require more aggressive treatment including blood products, reversal of anticoagulation, and in certain cases surgical evacuation.5Our patient was treated conservatively with Desmopressin and was discharged without additional complications.