Septencoracias morsensis gen. et sp. nov. (Primobucconidae), based on a new specimen from the Early Eocene (about 54 million years ago) Fur Formation of Denmark. The new fossil is a nearly complete, three-dimensionally preserved and articulated skeleton. It lies at the lower end of the size range for extant rollers. Salient diagnostic features of Septencoracias relative to other Coracii include the proportionally larger skull and the small, ovoid and dorsally positioned narial openings. Our discovery adds to the evidence that the Coracii had a widespread northern hemisphere distribution in the Eocene. Septencoracias is the oldest substantial record of the Picocoraciae and provides a reliable calibration point for molecular phylogenetic studies.The fossil record of crown group birds (Neornithes) prior to the Cretaceous-Paleogene boundary is scarce and fragmentary. Early Cenozoic bird fossils are more abundant, but are typically disarticulated and/or flattened. Here we report the oldest roller (Coracii),  The Fur Formation of Denmark is a unique offshore marine deposit of Early Eocene age famous for its spectacular preservation of numerous fossils, including insects, fishes, turtles and birds1233569112468614Here we report a new, exquisitely preserved avian fossil from the Fur Formation. The new specimen was found in 1986 by NB and two students during a geology field course in the abandoned diatomite quarry Klovbakker on the Island of MorsThe new bird is a nearly complete, mostly articulated skeleton that is preserved uncrushed and in three dimensions, which is very rare . The fos356718191621222324252627282930Coracias and Eurystomus, and the Madagascan ground rollers (Brachypteraciidae). Rollers generally have a brightly coloured plumage, and most species exhibit some brownish and/or bluish feathersGeranopterus alatus and Geranopterus milneedwardsi (Geranopteridae) from the Late Eocene fissure fillings of the Quercy (France)Eocoracias brachyptera (Eocoraciidae) from the Early Eocene deposits of Messel (Germany)Paracoracias occidentalis from the Early Eocene Green River Formation (Wyoming)Primobucco mcgrewi (Primobucconidae) from the Early Eocene Green River Formation263435Primobucco frugilegus and Primobucco perneri (Primobucconidae) from the Early Eocene of Messel33The new fossil is the oldest representative of the rollers (Coracii). Crown group Coracii are a species-poor clade that comprises medium-sized birds with big heads and stout beakssensu Clarke et al.25Coracii Primobucconidae Feduccia and Martin, 1976Septencoracias morsensis gen. et sp. nov.Coracias’. The specific epithet refers to the Island of Mors, from where the fossil bird came.From the Latin word ‘septentrio’ meaning north, and the genus name ‘MGUH.VP 9509, 3-D preserved skeleton lacking sternum and most shoulder girdle elements.Moclay pit (Klovbakker), Island of Mors, north-western Jutland, Denmark . Fur ForSeptencoracias morsensis is a small roller that differs from all other Coracii  in the small, ovoid and dorsally positioned narial openings (unknown in Geranopterus) and in the significantly larger skull. Septencoracias also differs from all Coracii except Paracoracias in the equal distal extent of major and minor metacarpals.Septencoracias is assigned to the Primobucconidae based on the following derived characteristics: unossified nasal septum; strongly developed deltopectoral crest of humerus; alular claw present. Moreover, the morphology of the tarsometatarsus of Septencoracias matches well with that of the Primobucconidae. However, Septencoracias differs from Primobucco in many characters: culmen evenly curved; mandibular symphysis longer and more ventrally projected; triangular pygostyle with tall and craniocaudally narrow lamina; acromion of scapula smaller; deltopectoral crest of humerus more prominent; bicipital crest straighter and shorter in distal extent; terminal process of ischium shorter; first phalanx of hallux markedly longer.Septencoracias differs from Eocoracias in the following characteristics: longer beak; hand skeleton longer relative to the other wing elements; femur shorter and tarsometatarsus longer relative to the tibiotarsus. Septencoracias differs from Paracoracias in the following features: extensor process of carpometacarpus larger; minor metacarpal thicker; first phalanx of hallux longer. Septencoracias differs from Geranopterus in the following characters: acromion of scapula not bifurcated; process on ventral side of proximal end of minor metacarpal smaller; plantarly projected metatarsal trochlea II.The skull of the new fossil is slightly eroded, because it had been exposed at the time of its discovery  and 2a. Septencoracias was a small bird the size of a Northern carmine bee-eater (Merops nubicus), and slightly smaller than the Blue-throated roller (Eurystomus gularis), which lies at the lower end of the size range for extant rollers and has a body length of 25 cmSeptencoracias are roughly equal in size to those of Primobucco frugilegus, but its skull is much larger than that of the latter species  and Primobucco perneriSeptencoracias is shorter than in Coracias (Coraciidae) and significantly longer than in Primobucco mcgrewi, Primobucco frugilegus and Eocoracias , e.g. Dacelo.The beak of  rollers . In Priml length , as in Ecoracias . The narEleven heterocoelous cervical vertebrae are observable, including the atlas and axis . Seven fGeranopterusSeptencoracias is less prominent than in Primobucco. The deltopectoral crest of the humerus is well developed, as in Primobucco, but differs from that of the latter in the stronger development and the straight, elongated proximal margin  and bee-eaters (Meropidae), in which this bone measures less than half the length of tibiotarsus  I is markedly longer than the first phalanx of PDIII . In agreement with recent molecular and morphological studies, we provide evidence that the Coracii are nested within the clade Picocoraciae2540Phylogenetic analysis based on morphological data indicates that Septencoracias constitutes the oldest record of the Primobucconidae and the earliest occurrence of the Coracii. It indicates that the Coracii were already diversified by the earliest Eocene, some 54 MA. The second oldest record of that clade consists of a tarsometatarsus from the Early Eocene  of Condé-en-BrieSeptencoracias unambiguously shares with Primobucco an unossified nasal septum (Septencoracias within the rollers (Coracii) is strongly supported. Septencoracias unambiguously shares with extant and extinct rollers the derived presence of a small depression on the cranial face of humeral head  and Paracoracias. These triangular narial openings are associated with a rhamphotheca forming slit-like nostrils in extant rollers and ground-rollersSeptencoracias is not represented with slit-like nostrils in our life reconstruction, since its osseous nasal apertures strongly differ in shape and position to those of extant rollers , including: large temporal fossae approaching each other at midline; transverse sulcus of humerus deep and bipartite; presence of foramen on the ventral process of proximal end of minor metacarpal. rollers . SeptencSeptencoracias constitutes the oldest substantial record of the Picocoraciae, since the only other contemporaneous record of that clade is only tentativeSeptencoracias, PDIII and PDIV lie on top of each other, with PDII separated from these  were taken from previous phylogenetic analyses25How to cite this article: Bourdon, E. et al. A roller-like bird (Coracii) from the Early Eocene of Denmark. Sci. Rep. 6, 34050; doi: 10.1038/srep34050 (2016).


Stem cells have been used in the clinic for very specific pathologies, but research has been conducted to develop new therapies for a wider range of human diseases. Currently, there is a great need for step-by-step investigations that consider all aspects related to cell therapy in disease-specific contexts. The objective of this special issue is to bring together timely reviews as well as original papers on different aspects related to the use of stem cells or their progeny in transplantation procedures that can positively modify degenerating or accidentally damaged tissues and organs. A considerable number of manuscripts were submitted, and after peer review, eight papers were published. The topics of these papers are diverse, including the generation of immortalized cells with inducible systems, the biological behavior of transit-amplifying cells, the expansion capacity of mesenchymal cells over hematopoietic cells, and the influence of growth factors in the maintenance of a differentiated phenotype. Regarding transplantation procedures, the nonimmunogenic intrauterine grafting of muscle cells and cell replacement therapies for retinal degenerative conditions are reviewed. Evaluation scales to assess the effects of therapies including cells and biocompatible support agents after damage to the spinal cord are also discussed. Grafting of pluripotent stem cell products poses a risk for the development of teratomas; thus, several factors were studied to identify strategies to eliminate tumorigenic cells. We think that these papers cover several of the areas that are important for the proper handling of stem cells to become therapeutically relevant and suggest improvements on the evaluation after grafting of biological materials, which in the long term might lead to new therapeutic interventions.The paper by K. An et al. presents a potentially relevant tool for the analysis of stem-cell based therapies in the field of pain therapy. First, they immortalized rat bone marrow mesenchymal stromal cells (BMSCs) by introducing the human telomerase reverse transcriptase (hTERT). Then, they introduced a tetracycline-inducible lentivirus delivery system to express the rat GAL gene into the immortalized rat BMSCs. The authors further characterized the phenotypic properties of these cells and confirmed their ability to produce GAL in a doxycycline-controlled manner. Finally, the authors advise that further studies are necessary to rule-out the possibility of transformation after long-term expansion of hTERT-BMSCs and to eliminate the leakiness of this inducible system.The field of in utero transplantation (IUT) has, until recently, been focused on the hematopoietic system. The review by N. Chowdhury and A. Asakura comprehensively describes the literature on in utero stem cell transplantation, covering hematopoietic applications as well as multiple other cell types and organ systems. The detection of genetic disorders in utero is now possible due to advances in cell-free fetal DNA diagnostics in maternal blood. This provides an opportunity for intervention and the application of in utero stem cell transplantation therapies. The authors explore the emerging area of IUTs for muscle disorders, in particular muscular dystrophies. Attempts to treat children with muscular dystrophy with muscle stem cell transplantations have failed partially due to the sheer number of cells needed to treat a patient. One solution outlined in detail by the authors is to treat the fetus in utero by transplantation of muscle stem cells.in vitro maintenance of Schwann-like cells produced from hASCs. Authors found that basic fibroblast growth factor (FGF-2) was essential for the maintenance of the Schwann-like phenotype. In contrast, differentiation was partially preserved in absence of glial growth factor 2 (GGF-2), platelet-derived growth factor (PDGF), or forskolin. The lack of forskolin in the culture medium reduced mRNA and protein levels of brain-derived neurotrophic factor (BDNF), suggesting that an elevated cAMP concentration and the consequent CREB activation are required for BDNF expression. Finally, they identified that GGF-2 alone supports the expression of Krox20, a transcription factor indispensable for myelination. The evidence presented in this paper indicates that maintenance of the Schwann-like cells requires the synergistic activation of different signaling pathways.Human adipose-derived stem cells (hASCs) are a source of differentiated cells that could be employed in regenerative medicine. A. E. Mortimer et al. examine the role of different stimuli in the Oct4 and Nanog, more readily than EC cells and then gained some, but not all, differentiation markers with faster kinetics. In particular, Activin A, BMP4, TGFβ1, and Nodal were more highly expressed in differentiating ES cells when compared to EC cells. The addition of these TGFβ superfamily members as recombinant proteins to the differentiation conditions further enhanced loss of pluripotent markers and increase commitment to differentiated lineages. This also further reduced the tumorigenicity in teratoma assays. This work shows that activation of TGFβ signaling in ES cells can decrease their tumorigenicity and increase their safety profile for cell-based therapies.The paper by O. Gordeeva and S. Khaydukov explores the differences in the differentiation potential between embryonic stem (ES) cells and embryonal carcinoma (EC) cells in a retinoic acid differentiation protocol. During differentiation, the ES cells lost pluripotency markers, such as The review by E. Rangel-Huerta and E. Maldonado describes the different biological properties of transit amplifying cells (TACs), early intermediates in tissue regeneration. With special focus on epidermal skin studies, they discuss important aspects of TACs such as gene expression profiles, division rates, asymmetric cell division, and environmental cues that may regulate their behavior. The authors propose that understanding TACs' biology is a key issue for their implementation in regenerative medicine.Foxn1-null) to the RCS rat that suffers from a progressive form of retinal degeneration. Although the larger animal models are useful for refining the surgical techniques, the rodent studies have the benefit of larger animal numbers and genetic manipulation to more closely model the human condition. A consensus on the most informative models of efficacy and safety for testing RPE cell products requires further exploration.Transplantation of stem cell-derived retinal pigmented epithelium (RPE) has already began in human clinical trials. However, there are no universally agreed upon animal models to assess the efficacy and safety of these therapies to treat these retinal degenerative conditions. The review by T.-C. Lin et al. systematically surveys all the animal models in use for this type of stem cell-based therapy. They cover mouse, rat, rabbit, dog, cat, pig, and nonhuman primate models of preclinical retinal degeneration. Since the therapies are using human cells, they discuss various methods to deal with immunosuppression in the animal models. A particularly novel one is the description of the crossing of immunodeficient nude rats  is a common lesion in accidents, which cause disability in people; currently, there are no efficient therapeutic interventions in the clinic. The review paper by W. R. Kim et al. relates to the importance of having grading scales that are both easy to use and reproducible to assess the damage, as well as the recovery, on experimental animals subjected to SCI. The damage to this part of the central nervous system can have severe and long-lasting affections to the anatomy and the function of motor aspects that are greatly influenced by the extension and the anteroposterior position of the injury. After describing the most widely used animal models for SCI, a summary of the beneficial effects of stem cell grafting, either alone or combined with biomaterials, is presented. This section clearly shows that several types of cells, trophic factors, and polymers can all contribute to the correction of disturbed functions. The final part discusses the different scales to measure spinal cord function for rodents and nonhuman primates, highlighting its advantages and limitations.in vivo. Mesenchymal stem/stromal cells (MSCs) have also been isolated from other sources such as adipose tissue, umbilical cord, and placenta. Hematopoietic stem and progenitor cells (HPCs) can be expanded or differentiated by coincubation with bone marrow MSCs in vitro. Perinatal sources of MSCs such as the umbilical cord and placenta are more accessible than the bone marrow aspirates. In the paper by G. R. Fajardo-Orduña et al., the ability of cord blood and placenta MSCs to expand HSCs was compared to the standard bone marrow MSCs. After immunophenotypic and functional characterization of the three types of MSCs, the expansion potential for primitive HSCs was tested without significant differences between the different MSCs. Also, the induction of myeloid colony forming units was very similar for bone marrow, umbilical cord, and placenta. These results suggest that MSCs from different origins might be used in the expansion of HSCs aimed to transplantation.Mesenchymal stromal cells are found in the bone marrow and contribute to the microenvironment that preserves hematopoietic stem cells


Sexually transmitted infection with high-risk, oncogenic strains of human papillomavirus (HPV) still induces a relevant burden of diseases on both men and women. Although vaccines appear to be highly efficacious in preventing the infection of the most common high-risk strains , important questions regarding the appropriate target population for prophylactic vaccination are still debated. Models in the extant literature seem to converge on the cost-effectiveness of high coverage (>80%) of a single cohort of 12-year-old girls. This vaccination strategy should provide an adequate level of indirect protection (herd immunity) to the unvaccinated boys. This argument presupposes the ecological validity of the cost-effectiveness models; the implicit condition that the characteristics of the individuals and the sexual behaviours observed in the models is generalisable to the natural behaviours of the population.The primary aim of this review is to test the ecological validity of the cost-effectiveness models of universal HPV vaccination available in the literature. The ecological validity of each model will be defined by the number of representative characteristics and behaviours taken into consideration.Nine bibliographic databases will be searched: MEDLINE (via PubMed); Scopus; Science Direct; EMBASE via OVID SP, Web of Science, DARE, NHIR EED and HTA (via NHIR CRD); and CINHAL Plus. An additional search for grey literature will be conducted on Google Scholar and Open Grey. A search strategy will be developed for each of the databases. Data will be extracted following a pre-determined spreadsheet and then clustered and prioritised: the main outcomes will report the inputs to the demographic and epidemiological model, while additional outcomes will refer to basic inputs to the cost-effectiveness valuation.Each study included in the review will be scored by the number of representative characteristics and behaviours taken into consideration (yes or no) on both dimensions. Individual study’s scores will be plotted in a 2 by 2 matrix: studies included in the upper right quadrant will be defined as ecologically valid, since which both individuals’ characteristics and their sexual behaviours are representative.The proposed systematic review will be the first to assess the ecological validity of cost-effectiveness studies. In the context of sexually transmitted diseases, when this condition is violated, an error in predicting the protective impact of herd immunity would occur. Hence, a vaccination policy informed on ecologically invalid models would potentially expose boys to a residual risk of contracting HPV-induced malignancies.CRD42016034145PROSPERO The online version of this article (doi:10.1186/s13643-017-0409-7) contains supplementary material, which is available to authorized users. Sexually transmitted infection with high-risk, oncogenic strains of human papillomavirus (HPV) imposes a significant economic burden on public health providers. Much of the information on HPV centres on women since having the virus increases the risk of invasive cervical cancer. But HPV virus may cause other neoplastic benign and malignant lesions, equally affecting men and women . The totOver the last decade, the advent of the bivalent  and the quadrivalent  vaccine in addition to screening paradigms held promise for reducing the long-term, cumulative burden of HPV-induced diseases. The trade-off was an incremental annual investment in vaccination programmes. Under the constraint of scarce public resources, policy makers relied on economic valuation to inform the decision to add the HPV vaccination to existing immunisation programmes. According to previously published reviews, most cost-effectiveness studies in the extant literature evaluated women-only direct immunisation programmes –5. The fThe unresolved dichotomy between public health leaders who advocate the urgency of vaccinating boys against HPV  and poliThe primary aim of this review is to test the ecological validity of the cost-effectiveness models available in the literature. This can be framed by asking if the models provide an acceptable representation of the intended reality on all relevant dimensions.This systematic review protocol will adhere to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement . The PRIEcological validity has typically been taken to refer to whether or not one can generalise from observed behaviour in the laboratory to natural behaviours in the world . In factThe demand for ecological validity stems from the Brunswick’s concept of representative design, a construct used to assess whether an experiment or a model captures the relevant features of intended realities . Using tApplied to cost-effectiveness of universal HPV vaccination, models chosen to inform public immunisation policies should take into account most of the dimensions relevant to the population  as well as to the specific situation .Traditionally, patterns of sexual behaviour have been characterised by focusing on the individual as unit of analysis, e.g. by measuring an individual’s number of sexual partners. However, adopting a network approach to the epidemiology of sexually transmitted infections reveals that behaviours and sexual preferences may influence the spread of infection . The ecoNumber of susceptible individuals (population size and growth)GenderAgeEthnicitySelf-defined sexual identityBuilding upon the same methodological premise of ecology of infectious disease, the Natsal survey is aimed to understand the most current characteristics of sexual partners and partnerships in the general British population. Three Natsal surveys have taken place up to day: Natsal-1 in 1990–1991, Natsal-2 in 1999–2001 and Natsal-3 in 2010–2012. In the Natsal-3 , 28, theSexual activity Concurrent sexual partnershipsAt least one sexual partner from outside the UKPaid for sexFrequency of unprotected sexThe following five behaviours have been identified as representative of situation :Individual characteristics and sexual mixing behaviours are relevant to the ecological validity of modelling sexually transmitted infections. For the normative outcomes of cost-effectiveness of universal HPV vaccination to be generalisable and inform public health policies, claims need to be established for the representative design of their underlying models. Ex ante, valid inferences should only be drawn by models which include all the eleven dimensions relevant to individuals and their sexual partner network. Ex post, the relative degree of representativeness of cost-effectiveness studies can be assessed by the number of relevant characteristics and behavioural patterns taken into consideration by their underlying models.The aim of this review is to test the ecological validity of the cost-effectiveness models of universal HPV vaccination available in the literature.Ecological validity refers to the relation between real-world phenomena and the investigation of these phenomena in experimental contexts or models. This can be framed by asking if the models provide an acceptable representation of the intended reality on all relevant dimensions. In the context of sexually transmitted diseases, patterns of sexual behaviour have been traditionally characterised by focusing on the individual as unit of analysis, e.g. by measuring an individual’s number of sexual partners. However, adopting a network approach to the epidemiology of sexually transmitted infections reveals that behaviours and sexual preferences may influence the spread of infection.For results to be generalisable, not only should attributes of participants be representative but also their expected behaviour in the sexual mixing.From the perspective of ecological validity, are the economic models included in the review representative of real-life sexual attitudes and lifestyles?To what degree would an ecological bias threaten the generalisability of the outcomes?What are the possible implications on public health policies?The review seeks to answer the following research questions:http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016034145The protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) CRD42016034145, available at: The current stage of the systematic review, as defined by PROSPERO, is:2. Piloting of the study selection process.Studies reporting the incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained of adding males to a female-only HPV vaccinationVulvar cancerVaginal cancerAnal cancerPenile cancerOropharyngeal cancerRecurrent respiratory papillomatosis (RRP)Health outcomes not limited to cervical cancer and genital warts but including additional HPV-induced diseases, such as:Cervical cancer screeningVaccination of females onlyStudies will be included if HPV universal vaccination will be compared to:Studies reporting a full disclosure of the inputs chosen to inform the economic modelIndividual modelsStatic modelsTransmission dynamic modelsHybrid modelsTypes of economic models:Inclusion criteria are as follows:Health outcomes limited to the valuation of cervical cancer and genital wartsStudies not published in English languageExclusion criteria:The following bibliographic databases will be searched: MEDLINE (via PubMed); Scopus; Science Direct; EMBASE (via OVID SP); Web of Science; EconLit (via EBSCO); DARE, NHIR EED and HTA (via CRD); and CINHAL Plus. An additional search for grey literature will be conducted on Google Scholar and Open Grey. Reviews will be included to reduce the possibility of missing relevant articles.A search strategy will be developed for each of the main databases. Additional file The PubMed “related articles” search feature will be used to reduce the risk of missing relevant articles. References of the included studies will be searched in order to identify additional relevant studies missed. A pilot of the study selection process will be conducted before initiating the systematic search of relevant articles.Two graduate research associates (GRAs) will independently identify through database searching, screen, assess for eligibility and include in the review the relevant studies. Opinion of one of the reviewers will be sought to arrive at a consensus in case of disagreement on a study for inclusion.Data will be extracted and recorded independently by two additional graduate research associates (GRAs) from the studies included in the review, according to a predefined data extraction table reported in Additional file Data extracted will be clustered and prioritised: the main outcomes will report the inputs to the demographic and epidemiological model, while additional outcomes will refer to basic inputs to the cost-effectiveness valuation.Monetary values in different currencies will be transformed in US dollars using purchasing power parities (PPPs). Subsequently, all the monetary values will be adjusted to 2015 dollar value using the US consumer price index (CPI). Corresponding authors of various studies may be contacted by email to clarify methods and results if the need arises.http://handbook.cochrane.org/index.htm#chapter_8/figure_8_6_c_example_of_a_risk_of_bias_summary_figure.htmThe Cochrane Risk of Bias tool  for randhttps://sites.google.com/site/riskofbiastool/welcome/homeThe Cochrane ROBINS-I tool (Risk Of Bias In Non-randomized Studies – of Interventions)  for obseA preliminary stage, aimed to assess the risk of bias in the estimates of treatment effect (e.g. vaccine efficacy) used as data inputs in the economic evaluation. The effectiveness of the HPV vaccines currently available has been preliminarily evaluated by the randomized clinical trials which supported regulatory approval . Vaccinehttp://www.equator-network.org/wp-content/uploads/2013/04/Revised-CHEERS-Checklist-Oct13.pdf.A main stage, aimed to identify additional risks of bias and, ultimately, to assess the validity of the included studies. The risk assessment will follow the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) approach . The CHETwo external experts  will independently assess the risks and threats to validity relative to each of the studies included in the review. The critical appraisal of included economic evaluations will be carried out in two subsequent stages:In case of misalignment of views, differences will be resolved in a dedicated meeting among reviewers.Each study included in the review will be scored by the number of representative characteristics and behaviours taken into consideration (yes or no) on both dimensions. Individual study’s scores will be plotted in a 2 by 2 matrix  reportedThe upper right quadrant represents the ideal situation, in which both individuals’ characteristics and their sexual partner networks are representatives; hence, the studies are ecologically valid. In the upper left quadrant, we have models describing representative individuals but not in a representative network. In the lower left quadrant, the network is representative but the individuals are not. Finally, in the lower right quadrant, neither the individuals nor the network are representative. Only models in the upper right quadrant provide normative economic recommendations that are fully representative, hence generalisable to inform public health policies.This protocol describes a systematic review of cost-effectiveness evaluations of universal vaccination programmes against HPV. The primary aim of this review is to test the ecological validity of these models, defined as the degree of representativeness of the individuals susceptible to infection and their sexual preferences and lifestyles.Eventual gaps identified in this systematic review would have a significant impact on current public health policies. Models in the extant literature seem to converge on the cost-effectiveness of high coverage (>80%) of a single cohort of 12-year-old girls. This vaccination strategy should provide an adequate level of indirect protection (herd immunity) to the unvaccinated boys. This argument presupposes the ecological validity of the cost-effectiveness models; the implicit condition that the characteristics of the individuals and the sexual behaviours observed in the models is generalisable to the natural behaviours of the population. If the ecological validity condition is violated, an error in estimating the protective impact of herd immunity would occur. Hence, a vaccination policy informed on ecologically invalid models would potentially expose boys to a residual risk of contracting HPV-induced malignancies.


Heterohelix and Hedbergella were recovered among an assemblage dominated by calcareous and agglutinated benthonics. Marine dinocysts are curiously absent from among the palynomorph assemblage, which consists dominantly of pollen grains from land plants (angiosperms and gymnosperms) and pteridophytic spores, together with a few fungal remains. Two benthonic foraminiferal assemblages that include the Campanian-Maastrichtian Bolivina afra-Haplophragmoides talokensis and the Paleocene Anomalinoides umboniferus-Eponides pseudoelevatus are well established at this outcrop. The palynomorphs include a few typical Late Cretaceous and typical Paleogene species, while the majority are long ranging forms that straddle the Cretaceous-Tertiary boundary. The foraminiferal and palynomorph biostratigraphic distributions permitted us to recognize the succession of Campanian-Maastrichtian and Paleocene strata and the Cretaceous-Tertiary boundary for the first time in this basin. Lithofacies change from a monotonous thick pile of shales below, succeeded by sandstones, frequently alternating with mudstone, above. This indicates a general fall in sea level during the Early Paleocene earlier reported within this subregion, and the boundary marks the start of the out building of the Niger Delta which the Tertiary Rio del Rey Basin is part of. Both microfossils and lithofacies analyses aided the reconstruction of an open marine, probably middle to inner neritic shallow and transitional intertidal paleodepositional environments for the sediments exposed at this outcrop.Late Cretaceous-Paleocene foraminiferans and palynomorphs were recovered from the upper section of the Djega outcrop in the Rio del Rey Basin. Only a few planktonic foraminiferan species of the genera The Cretaceous-Tertiary (K/T) boundary, also referred to as the Cretaceous-Paleogene (K/P) or (K/Pg) boundary , 2, defiAs a petroliferous and integral part of the greater Tertiary Niger Delta, which is a world class hydrocarbon producer located within the Gulf of Guinea, the Rio del Rey Basin of Cameroon presents a stratigraphy that straddles the Cretaceous and Tertiary geologic time intervals. Hitherto thought to be an exclusively Tertiary basin adjoining the Niger Delta, a major significance of the present work is the description of Cretaceous sediments in the Rio del Rey Basin. This has set the stage for the amendment in the nearest future of the basin's stratigraphic framework. Moreover, locating the K/T boundary provides a rare opportunity for us to study an important global geologic event from this local section and to correlate it with others described elsewhere in the world. The use of foraminiferans and palynomorphs also significantly permitted the study of the trend of the biotic turnover event of these important microfossil groups at this geologic boundary.The planktic foraminiferans are well known to be affected by even slight climatic fluctuations, and their fossilized calcareous shells are capable of holding a perfect record of such changes. They are therefore expected to have been severely affected by the impact of the large meteorite and any other global events that might have caused climatic changes and should serve as very good indices to study the biotic changes across this K/T boundary.The initial objective of this work was to study the newly exposed upper section of the road at the Djega outcrop using foraminiferans and palynomorphs and compare the age with that of the lower strata previously dated by Njoh , Njoh anThe Rio del Rey Basin, located at the extreme west coast of Cameroon, is one of the Equatorial Atlantic marginal basins within the Gulf of Guinea .It is genetically part of the Niger Delta and Calabar Flank Basins in the west and is bordered in the north by the Pre-Cambrian Oban Massif Basement and the Rumpi volcanics, in the south by the Rio Muni Basin in Equatorial Guinea and is separated in the east by the Cameroon Volcanic Line (CVL) from the Douala Basin. The Djega outcrop lies about 2 km northwest of Illor Village, along the Illor-Didonda road in the northern part of the Rio del Rey Basin . The tecμm sieve under a gentle stream of running water from a tap. The clean residues were collected and dried at 50°C in an oven. The dried samples were then sieved into the coarse, medium, and fine size portion to facilitate picking. Picking and identification were done under the binocular microscope with the aid of regularly used monographs from standard publications based on materials from the basins of the subregion and elsewhere [μm nylon mesh. The sieved samples were then oxidized with HNO3 before mounting on slides, which were then studied using the Leitz Diaplan microscope.12 outcrop samples were selected at approximately 1 m intervals to represent the portion (18–30 m) of the outcrop and each sample was processed for both their foraminiferal and palynological content. 30 gms of each sample was processed for foraminiferans, and the indurated samples were first disaggregated and soaked with kerosene for up to 4 hours and in water with detergent overnight. The soaked samples were each washed over a 63 lsewhere , 12–15 alsewhere , Faegri lsewhere , and othThe entire Djega outcrop section from base to top measures about 32 m thick; however, the present work has focused only on the upper section (18 m–30 m) of the outcrop Figures . This seThe upper portion of this section includes the 4 m high roadside cut above  which exThe preservation and species diversity of microfossils yield from the Djega outcrop is described as fair but the abundance is poor. Foraminifera, palynomorphs, ostracods, and echinoderm spicles including bivalves and their moulds were recorded from the fossiliferous intervals. Heterohelix and Hedbergella. Of the 23 benthic foraminifera taxa 17 are Cretaceous  and 6 are tertiary . These samples also yielded a palynomorph assemblage of 33 taxa of which 17 are gymnospermous and angiospermous pollen grains, 10 are pteridophytic spores, and 4 are fungal spores and hyphae. Most of these spores and grains of pollen are derivatives of terrestrial plants but for a few swamp and salt marsh dwellers, the typical marine palynomorphs are noticeably absent. Some of these microfossils were identified down to species level, while others could only be identified to the genus. Amongst these, only a few short-ranging, age diagnostic taxa are included, some of which are well known to be typically Cretaceous and others typical Paleogene forms, while the rest are long ranging.In this work, palynostratigraphy of the Djega outcrop was carried out for the first time as well as foraminifera biostratigraphy of the Tertiary section. Samples from the Cretaceous section were again analyzed for foraminifera and data compared with previous work. A total of 29 foraminifera taxa were recovered out of which 23 are benthics and only 6 planktics characterized by species of two strictly Cretaceous generaThe foraminifera and palynomorphs recovered from the Djega outcrop represent three categories: (i) restricted Late Cretaceous forms known not to have ranged any younger than the Maastrichtian, (ii) long ranging forms, commonly the palynomorphs that crossed the Cretaceous-Tertiary boundary, and (iii) those forms that have been recorded to have appeared for the first time only during the Paleocene and in younger strata. Bolivina afra-Haplophragmoides talokensis zone and the Early Paleocene (Danian) Anomalinoides umboniferus-Eponides pseudoelevatus zone. Typical members of the Bolivina afra-Haplophragmoides talokensis zone that have been recorded from the Djega outcrop include the several species of the genera Preabulimina and Orthokastenia, Bolivina afra (Petters) cf Afrobolivina afra (Reyment) and Kogbe and Me'Hes), Bolivina explicata (Cushman and Hedberg), Neobulimina albertensis , Nonionella robusta (Plummer), Valvulina umbilicatula (D'Orbign), Pseudonodosaria sp. (Cushman and Renz), Planulina nacatochensis (Cushman), Cibicides harperi (Sandidge), Textularia biafrae (Reyment), Trochamina texana (Cushman and Waters), Trochamina sp., Haplophragmoides bauchensis (Petters), H. sahariensis (Petters), H. numenhensi (Petters), and Ammobaculites coprolithiformis (Shwager), while Cushman [ Preabulimina and Orthokastenia in the lower Benue Trough and Dahomey Embayment in Nigeria and the top is marked by the complete disappearance of Bolivina afra, Ammobaculites coprolithiformis, Cibicides harperi, Planulina nacatochensis, and the genera Preabulimna and Orthokastenia. With their planktonic counterparts, this zone defines the Campanian-Maastrichtian age [ Bolivina afra cf Afrobolivina afra [The benthic foraminiferal assemblage obtained from the Djega outcrop and presented herein (Plate 1) have been recognized to undoubtedly belong to two assemblage zones of Petters , the Lat Cushman  and othe Cushman  remarkedtian age . The speina afra , 23 has  Heterohelix and Hedbergella, amongst which there are Heterohelix planata, H. globolusa, H. pulchra, Hedbergella holmdelensis, H. planispira, and H. monmouthensis; others are Pseudotextularia elegans and Rugoglobigerina sp. , Arz et al. (2004), and Petters [ Bolivina afra, and others to diagnose the Campanian-Maastrichtian strata.The planktic foraminifera is characterized by two genera,rina sp. . The pla Petters  noted th Anomalinoides umboniferus-Eponides pseudoelevatus Zone of Petters [ Anomalinoides umboniferus, Nonionella insecta, Textularia hockleyensis, Bulimina sp., and Pleurostemella paleocenica. The base of this zone is said to coincide with the Cretaceous-Tertiary boundary and is marked by the extinction of almost all of the Maastrichtian species described above and the top also is marked by the disappearance of the Early Paleocene forms, notably Anomalinoides umboniferus and Eponides pseudoelevatus [The benthic foraminifera were recorded from the upper section of the Djega outcrop and belong to the Early Paleocene (Danian) Petters ; Anomalielevatus . Njoh anelevatus  and Njoh Retidiporites magdalensis , Longapertites marginatus (Van Hoeken-Klinkenberg), Syncolporites marginatus (Van der Hammen), Ulmipollenites undulosus (Wolf), Monocolpopollenites spheroidite (Pflug & Thomson), Ctenolophoridites costatus (Van Hoeken-Klinkenberg), Asplenium sp., Cyathidites sp., Deltoidospora sp., Laevigatosporites ovatus (Ibrahim), Filtrotrilites sp., and Psilatriporites sp., among others . Some Upper Cretaceous palynomorphs recovered from the Djega outcrop includeg others . Lawal a Longapertites marginatus, Syncolporites marginatus, Retidiporites magdalensis, Monocolpopollenites spheroidite, Ulmipollenites undulosus, and Asplenium sp. species which are well known to occur in the Upper Maastrichtian have equally been reported from Paleocene and younger strata. Syncolporites marginatus is a very important element of the assemblage Mbesse [ Deltoidospora sp. and Verrucatosporites sp. occur among the Paleocene species recovered from offshore Abidjan, Cote d'Ivoire, while several species of Longapertites, Retistephanocolpites, and Acrostichum characterize the Late Paleocene Patala and Lakhra Formations, respectively, in northern Pakistan [Thee Mbesse  used to Pakistan . Heterohelix and Hedbergella and many benthics that typify the Campanian-Maastrichtian age in this subregion and elsewhere and are known not to have ranged any younger than the Maastrichtian. Some of these benthics include Bolivina afra, Bolivina explicata, Orthokastenia clavata, Orthokastenia ewaldi, Preabulimina laddi, Preabulimina lata, and Textularia biafrae. This mass extinction was immediately followed above in sample S5 by the first appearances of typical Paleocene taxa: Anomalinoides umboniferus, Pleurostomella paleocenica, and Nonionella insecta. The Cretaceous planktics and benthic foraminifera were lastly recovered at this outcrop from sample S4 but were completely absent or had disappeared from Sample S5 1 m immediately above. Sample S5 equally witnessed the appearance for the first time of the Paleocene exclusively benthic forms indicating that at this outcrop there is rather an abrupt mass extinction of the Cretaceous foraminifera  and Paleocene (Danian) sedimentary strata and that in between them lies the K/T boundary. The logged section of the outcrop and the vertical distribution of the microfossils point out that this boundary lies between sample S4 at about 24 m of height and sample S5 at about 25 m . The forminifera . The ste Cycadophytes sp., Filtrotriletes nigeriensis, and Ctenolophoridites costatus.The palynomorphs on the other hand have equally confirmed the penetrative Paleocene-Upper Cretaceous ages at this outcrop by the record of the forms named above known to have straddled the K/T boundary and cooccur below with typical Upper Cretaceous forms and above with typical Lower Tertiary forms. The specimens recorded from this outcrop that define the Cretaceous are Zonocostites minor and Klukisporites pseudorecticulatus, had their first appearance in sample S5 and probably Asplenium sp. which was encountered only in sample S7  transitional environment characterized by lagoons, foreshore, and intertidal deposits for the upper section to a deeper open marine probably middle marine for the lower portion of this outcrop. The entire outcrop therefore represents a coarsening-upward sequence depicting a fall in sea level which also marked the onset of the outbuilding of the tertiary delta.The portion of the Niger Delta Basin of Nigeria that extends eastward into the territory of Cameroon is known as the Rio del Rey Basin . While tWe highlight in this work the Cretaceous sediments of the Rio del Rey Basin which outcrop onshore, contrarily to most previous publications that portray the basin as exclusively tertiary and restricted offshore. The tertiary sediments of this basin have previously been described uniquely from offshore, but this work has revealed that Paleocene strata are also exposed onshore. Apart from demonstrating the level at the Djega outcrop section of the Rio del Rey Basin where the Upper Cretaceous strata are overlain by the Paleocene, the aforementioned highlights will clearly disperse some misleading concepts erroneously propagated in past literature.Foraminifera and the palynomorphs recovered from the studied outcrop have helped us to date Lower Tertiary  and the Upper Cretaceous (Campanian-Maastrichtian) sediments in the Rio del Rey Basin. These microfossils in concert have equally permitted the tracing of an approximated contact between these two important units and therefore the K/Pg boundary in this region from outcrop. We note that many foraminifera species in this basin never crossed the boundary unlike the palynomorphs in which many did cross. This indicates that the fauna turnover event at this time was much more noticeable in the foraminifera than with the palynomorphs. Apart from the frequent reports on petroleum geology, the K/Pg boundary and events have permitted us to report yet another yet global aspect of the geology of this basin and correlate it with others, especially outcrops that have been studied in Brazil, Mexico, Spain, Ghana, and other parts of the world.Probably due to field conditions which did not permit a more refined sampling, we conclude that no sharp contact or physical boundary was encountered on the field to directly point the K/T boundary at a particular bedding plane or surface of unconformity as in similar studies elsewhere , 2 but oAnalysis of the lithofacies combined with the microfossil data suggests that these sediments were deposited in an open shallow marine (middle to inner neritic) and transitional intertidal environments.


Muscle force estimation could advance the comprehension of the neuromuscular strategies that diabetic patients adopt to preserve walking ability, which guarantees their independence as they deal with their neural and muscular impairments due to diabetes and neuropathy. In this study, the lower limb’s muscle force distribution during gait was estimated and compared in diabetic patients with and without polyneuropathy.p < 0.05).Thirty individuals were evaluated in a cross-sectional study, equally divided among controls (CG) and diabetic patients with (DNG) and without (DG) polyneuropathy. The acquired ground reaction forces and kinematic data were used as input variables for a scaled musculoskeletal model in the OpenSim software. The maximum isometric force of the ankle extensors and flexors was reduced in the model of DNG by 30% and 20%, respectively. The muscle force was calculated using static optimization, and peak forces were compared among groups  using MANOVAs, followed by univariate ANOVAs and Newman-Keuls post-hoc tests (p=0.024) and the DNG showed lower forces in the gastrocnemius medialis compared to the DG (p=0.037). At the terminal swing phase, the semitendinosus and semimembranosus peak forces showed lower values in the DG compared to the CG and DNG. At the late stance, the DNG showed a higher peak force in the biceps short head, semimembranosus, and semitendinosus compared to the CG and DG.From the middle to late stance phase, DG showed a lower soleus muscle peak force compared to the CG , knee (flexors and extensors), and hip abductors distinguished DNG from DG, and both of those from CG. Both diabetic groups showed alterations in the force production of the ankle extensors with reductions in the forces of soleus (DG) and gastrocnemius medialis (DNG) seen in both diabetic groups, but only DNG showed an increase in the hamstrings (knee flexor) at push-off. A therapeutic approach focused on preserving the functionality of the knee muscles is a promising strategy, even if the ankle dorsiflexors and plantarflexors are included in the resistance training.The online version of this article (10.1186/s12984-017-0327-x) contains supplementary material, which is available to authorized users. Walking is one of the most automated motor activities in human behavior, with a stereotyped and predictable biomechanical pattern that results from a harmonic coordination between the actions of the neural and musculoskeletal systems. Its regularity and well-described biomechanical patterns allow for objective criteria distinguishing between normal and pathological patterns to be established and, therefore, guide a more focused therapeutic approach aimed at maintaining individuals’ autonomy in daily living activities.. Loss of ankle maximal muscle strength ).There was no significant difference in gait speed among the groups , the DG showed lower gluteus medium force (posterior and middle portions) compared to the CG (large effect) and DNG (large effect). In the late stance (35–60% gait cycle), the DG also showed lower peak forces in the three portions of the gluteus medium compared to the CG (anterior and posterior portions with intermediate effect sizes and middle with large), and in the middle portion of the gluteus medium compared to the DNG (intermediate effect size) Table , Fig. 2.Hip extensor- knee flexor muscles showed differences among the groups in the MANOVA analysis. At the end of the swing phase (80–100% gait cycle), the semitendinosus and semimembranosus peak forces showed lower values in the DG compared to the CG and DNG (both comparisons with large effect sizes) Table , Fig. 1.The MANOVA output of the knee extensor muscles revealed differences among the groups. Univariate ANOVAs showed that in the early stance (0–35% gait cycle), the DG exhibited higher peak forces in the vastus medialis and lateralis compared to the CG and DNG  , where the DG showed a lower soleus muscle peak force compared to the CG (large effect size) Table , Fig. 1,The MANOVA output of the evertor muscles (peroneus longus and brevis) revealed differences among the groups. Univariate ANOVAs showed that at an early stance (0–35% gait cycle), the DG showed higher peak forces for both muscles. At a late stance (35–60% gait cycle), the DNG revealed higher peak forces for both muscles compared to the CG and DNG  Table , Fig. 1.The focus of this study was to investigate how diabetic individuals with and without neuropathy alter their muscle activation and force production to compensate for the greater involvement of distal musculoskeletal structures consequent to the disease. The main findings partially confirmed the hypothesis, as there was observed ankle plantarflexor force reduction in the DG and DNG, but surprisingly, the proximal muscles  did not show a significant increase in their peak force. There was not an accentuated change in the force distribution of the proximal and distal muscles between the controls and the diabetic patients, and from those to the diabetic neuropathic patients, as was hypothesized. Both diabetic groups showed alterations in the force production of the ankle extensors, with reductions in the forces of soleus (DG) and gastrocnemius medialis (DNG), but only the DNG had increased forces of the hamstrings (knee flexor) at push-off. The DG presented a greater reduction in the force production of gluteus medium, and this might suggest a consequence for the latero-lateral stabilization of the pelvis.Ankle extensor muscles perform distinct mechanical functions over different joints and distribute power in particular ways . Thus, tLower maximal isometric force of the tibialis anterior has been described in diabetic neuropathic individuals , 3, 5, aThe same reasoning used for the absence of significant alterations in the tibialis anterior could be applied to all ankle extensors  whose maximal isometric forces were reduced by 30% in the model. To maintain a similar force pattern of these muscles, it is also plausible that the DNG patients had to increase the corresponding muscle activations. Thus, a focus on therapeutic strategies directed to muscle efficiency could help these patients maintain a more functional gait. However, both assumptions for ankle extensors and flexors need further EMG confirmation.DNG patients exhibited a 14% and 10% increase in psoas muscle forces compared to the DG and CG, respectively. Although this increase was not statistically significant, the psoas muscle is a powerful monoarticular hip flexor, and the DNG presented a lower soleus muscle force – a monoarticular ankle extensor, at the transition between stance and swing (40–70% of gait cycle) compared to the DG and CG. The individual contributions of the distal and proximal muscles at the push-off phase of the DNG might suggest the existence of the hip strategy at the individual-muscle level, particularly for the monoarticular muscles of the ankle and hip, although there was no observed reduction in the net ankle extensor moment or increase in the net hip flexor moment, which characterize the so-called hip strategy, as previously reported  requires the adoption of a cost function , which iAlthough the use of generic models and cost functions will probably lead to inaccuracies in muscle force estimations, the presented study does, at a minimum, provide trends and directions of changes in muscle force distributions and offers a solid basis for the formulation of hypotheses to be confirmed in upcoming studies. In view of the aforementioned limitations, future studies should focus on the development of representative models of the diabetic population, which in turn will require collecting quantitative, currently unavailable, data on typical musculoskeletal properties of diabetic individuals in different stages of the disease. In addition, further studies should also focus on the determination of an optimal objective function to advance our understanding of diabetic gait strategies.In summary, the results indicate that muscle forces of the ankle , knee (flexors and extensors), and hip abductors distinguished the gait pattern of diabetic individuals with neuropathy from diabetic individuals without neuropathy and from the controls. The findings are expected to contribute to more focused therapeutic interventions based on the relative contribution of muscles to the gait patterns adopted by each group. Taking into account that preserving the force capacity of the ankle extensors is critical for the maintenance of normal walking, it is important to intervene in the function of these muscles in diabetic patients with or without neuropathy because of their earlier impairment in the course of the disease. Moreover, it is important to maintain and improve the function of the proximal muscle groups, particularly the hamstrings, in response to the force deficit of the ankle muscles.In conclusion, there are four main takeaway points from this study. First, there was no observable progressive worsening in gait patterns from the controls to diabetic patients and from those to the diabetic neuropathic patients. Instead, each diabetic group showed a particular and distinct adaptation pattern in terms of muscle force distribution. Second, both diabetic groups showed alterations in the force production of the ankle extensors, with reductions in the forces of soleus (DG) and gastrocnemius medialis (DNG). Third, diabetic patients compensated for deficiencies in their ankle extensors with an increase in the vasti muscle forces in early stance and a decrease in hamstring forces at the final swing. The neuropathic patients also redistributed their lower limb muscle forces, increasing the hamstring forces at push off. Finally, although there were no changes in the ankle extensor moment of the DNG patients and there was a decrease in hip flexor moment, contrary to the traditional description of the hip strategy, the analysis of the individual muscle contributions suggested the existence of a hip strategy on a muscular level.


Pseudomonas oryzihabitans is a Pseudomonas bacterial organism rarely implicated in human infections. The bacterium has been isolated in a few reported cases of neurosurgical infections and patients with end-stage cirrhosis, sickle cell disease, and community-acquired urinary tract infections. Limited information exists in developing countries, however, because of the lack of advanced microbiological tools for identification and characterization of this bacterium. This case report describes the isolation of a rare Pseudomonas bacterium in a patient presenting with sepsis and skin infection.Pseudomonas oryzihabitans was identified in the patient’s blood culture using the 16S ribosomal deoxyribonucleic acid sequencing technique. The rash on the patient’s scalp and skin resolved after continuous treatment with gentamicin while her condition improved clinically.A 1-year-old girl was presented to a hospital in the northeastern part of Ghana with a 1-week history of pustular rashes on her scalp and neck, which occasionally ruptured, along with discharge of yellowish purulent fluid. The child is of Mole-Dagbon ethnicity and hails from the northern part of Ghana. Pseudomonas bacteria in clinical samples and thus supports the use of 16S ribosomal deoxyribonucleic acid in making the diagnosis.This finding suggests the potential of this bacterium to cause disease in unsuspected situations and emphasizes the need to have evidence for the use of the appropriate antibiotic in clinical settings, particularly in rural settings in Africa. It also brings to the fore the unreliability of conventional methods for identification of  Pseudomonas oryzihabitans is the current name of a non-lactose-fermenting bacterium that used to be called Chromobacterium typhiflavum and Flavimonas oryzihabitans  with nucleotide sequence identity of 1455/1460 (99.7%). The molecular phylogeny also indicated that the new sequence is clustered with other P. oryzihabitans strains, which strongly supports the findings displayed in Fig. Agogo to reflect its geographic origin and the sequence deposited in the GenBank database [accession number KX812763].The isolated strain reported in this study was found to be most similar to Antimicrobial susceptibility testing was done on the isolated bacteria using the Kirby-Bauer disk diffusion method following Clinical Laboratory Standards Institute guidelines . The isoP. oryzihabitans is a rare bacterial isolate that has been linked to meningitis, endocarditis, diabetes mellitus, and infection with other organisms, especially in immunocompromised individuals [P. oryzihabitans is still a subject of debate in the scientific community, hence the need for adequate information to enable clinicians and public health practitioners to manage episodes associated with this pathogen.ividuals , 15. TheP. oryzihabitans in the blood in our patient is of importance, being the first such case reported from West Africa and only the second in sub-Saharan Africa [P. oryzihabitans have been reported in patients with a previous histories such as surgery, immunosuppression, diabetes mellitus, trauma, bites, and lactation [Although it might be difficult to determine to what extent the severity of our patient’s illness was due to malaria or sepsis, the presence of the rare pathogen n Africa . It is pn Africa . Six casactation . AlthougP. oryzihabitans by being positive for gelatin hydrolysis and capric acid assimilation and negative for mannose and maltose assimilation [et al. [An important feature we observed was the unique microbiological characteristics of this bacterium and the failure of the API to accurately identify the pathogen. The biochemical properties of our isolate using the Analytical Profile Index Non-Enterobacteriaceae (API NE) differed from the usual reported cases of milation . Bosshar [et al.  observedOur report shows that a combination of conventional and molecular technologies is the best approach to identifying Pseudomonas bacteria which may be implicated in the clinical condition of this child.


Dermoid cysts of the floor of the mouth are rare, accounting for 11% of all dermoid cysts in the head and neck region. We report a case of a dermoid cyst of the floor of the mouth in a 12-year-old boy investigated with ultrasonography, magnetic resonance imaging (MRI), and non-enhanced computed tomography (CT) scans. The lesion contained free calcified corpuscles  considered pathognomonic for a dermoid. Diagnostic imaging may allow diagnosis of a dermoid of the floor of the mouth and plays a pivotal role in depicting the anatomic location of a cyst, thus guiding the surgeon for an optimal surgical approach. Cysts on the floor of the mouth are classified into three types: epidermoid cysts, dermoid cysts, and teratomatous cysts. Each type is lined by an epithelial layer, but each type exhibits different histologic patterns. Dermoid cysts contain skin appendages and cystic teratomas present tissue originating from all the germinal layers. Dermoid cysts of the head and neck are relatively rare, accounting for 7% of all dermoid cysts . DermoidDermoid cysts are slow growing and painless masses; when large enough, they can cause dysphagia, dysphonia, and dyspnea . DiagnosA 12-year-old boy was referred to the Department of Radiology of the San Bortolo Hospital  for a submandibular soft, painless mass. Ultrasonography showed an inhomogeneous hyperechoic mass, measuring 20 x 15 x 15 mm localized just above the mylohyoid muscle; intracystic highly hyperechoic corpuscles with shadowing were also noted  confirmed the location of the lesion above the mylohyoid muscle, between the geniohyoid muscles Figure . The masIntracystic corpuscles appeared calcified on non-enhanced computed tomography (CT) scans Figure .The patient underwent the surgical operation via a submandibular incision. The surgical specimen consisted of a cystic lesion with a 2.5-cm maximum diameter surrounded by a small amount of soft tissue.The histopathologic examination revealed a cyst lined by a keratinizing squamous epithelium, which was partly ruptured and replaced by a granulomatous reaction and contained adnexal structures in the wall Figure .Cysts on the floor of the mouth are classified into three categories: dermoid, epidermoid, and teratomatous cysts.The mouth floor represents the second most common location of all dermoid cysts (approximately 11%) of the head and neck region, yet dermoid cysts are much more frequent there than epidermoid cysts . With reAmong imaging modalities, MRI is the gold standard for diagnosing cystic mass and depicting anatomy of the mouth floor given its excellent soft tissue contrast and multiplanar imaging capability ,8.Diagnostic imaging can reveal intracystic floating corpuscles  which are usually hypodense on CT scans, hyper/hypointense on T1-weighted MRI and hypointense on T2-weighted MRI scans because of their lipid contents, the presence of which is pathognomonic for a dermoid cyst ,7; the “Diagnostic imaging plays a pivotal role in the preoperative workup; the exact location of a cystic mass of the mouth floor is essential for determining the optimal surgical approach . In our Dermoid cysts of the floor of the mouth should be differentiated from other purely cystic and cyst-like lesions of the neck. Key differentiation may be suggested by a characteristic location or by enhancing the radiologic pattern after intravenous contrast medium administration.Ranulas are retention cysts arising from a sublingual gland or accessory salivary glands and are rarely found in the midline. They can be simple or plunging in the submandibular space extending through a defect in the mylohyoid muscle  or because it ruptures posteriorly. Evidence of a beak of the cyst towards the sublingual space (tail sign) is considered typical of ranulas ,8. HowevThyroglossal duct cysts are located in the midline or within 2 cm of the midline; most are detected at the level and below the hyoid bone, but they can be exceptionally discovered at the mouth floor ,7,9. InfBranchial cleft cysts are unilateral lesions that show different localization depending on the type of cyst -9. FirstCystic hygromas usually involve the posterior cervical space or the floor of the mouth cavity; they show an infiltrative growth irrespective of anatomic planes. Very large unilocular lymphangioma can spread within the mediastinum and the axilla. Because of their high proteinaceous content, they show fine intracystic echoes on sonography and high signal on T1-weighted MRI; sometimes an intracystic fluid-fluid level can be appreciable -9.The diagnosis of an oral abscess is easily suspected in the appropriate clinical setting; diagnostic imaging reveals an uninoculated or multiloculated fluid collection with an enhanced rim after an intravenous contrast medium is administered ,9. Post-Diagnostic imaging may help in the correct diagnosis of a dermoid cyst of the floor of mouth; the sack-of-marbles sign is characteristic for a dermoid. MRI is specifically useful in depicting the anatomic relationship of the dermoid cyst and muscles of the floor of the mouth, and, therefore, in guiding the surgeon to the more appropriate approach for surgical excision. Knowledge of both imaging patterns and typical location of another cystic lesion of the mouth and neck may help in the differential diagnosis.


Mesial drifting of molar teeth in maxillary arch is corrected by movement of the molars distally. In addition to traditional distal movement techniques, such as extraoral force application and removable appliances, various intra-arch devices have been introduced since 1980s. These intra-arch appliances have nearly eliminated the need for patient cooperation. The purpose of this paper is to report a case of 10-year-old male patient with loss of space in maxillary molar teeth treated by intra-arch appliance-pendulum appliance by distalization of maxillary first permanent molar teeth. Distaliza-tion of the permanent molar teeth helped in proper eruption of second premolar teeth without any extensive treatment procedures. In the present case report, the treatment of developing malocclusion was corrected by utilizing the concept of interceptive orthodontics. Hence, correction of space loss in mixed dentition period using pendulum appliance can eliminate the fixed orthodontic therapy. Paranna S, Shetty P, Anandakrishna L, Rawat A. Distalization of Maxillary First Permanent Molar by Pendulum Appliance in Mixed Dentition Period. Int J Clin Pediatr Dent 2017;10(3):299-301. More recently, the subjectivity and problems of predicting patient behavior have led many clinicians to devise appliances that minimized reliance on the patient and that are under the control of the clinician.4 Hilgers5 of California introduced the "Pendulum Appliance" in 1992 as a mechanism for class II noncompliance treatment. The pendulum appliance uses a large Nance acrylic button for palatal anchorage and 0.032" titanium-molybdenum alloy (TMA) springs to deliver a light, continuous force to the upper first molars without affecting the palatal button. The appliance produces a broad pendulum of force from the midpalate to the upper molars.6Another popular method of molar distalization that requires no cooperation is the so-called "pendulum" appliance system.5 stated that it is typical to see approximately 5 mm of distal molar movement in a 3 to 4 months period of time and that 20% of the space opening can be ascribed to anterior anchorage loss.HilgersThe purpose of this case report is to describe the correction of space deficiency by distalization of maxillary permanent first molars using pendulum appliance.A healthy 10-year-old male patient presented to the Department of Pediatric and Preventive Dentistry, M.S. Ramaiah Faculty of Dental Sciences, Bengaluru, Karnataka, India, for routine dental care. Oral examination revealed mixed dentition, with deficient space for eruption of second premolar teeth  and 2. TAt the end of 4th month sufficient space was regained and second premolars started erupting into the space gained. At 7th month with the complete eruption of premolars and canines proper maxillary arch alignment was achieved  and 5. T7 In the present case report, only the first permanent molars were erupted, which indicates the best time for distaliza-tion of molars using pendulum appliance.Distal movement of the molars appears to be more efficient before the eruption of the upper second molars.The indications for the pendulum appliance are:  First phase of orthodontic treatment for unilateral or bilateral distalization of maxillary first molar teeth for correction of Class II molar relationship in noncompli-ant patients. Space regaining in cases of mesial drift of upper first molars due to early loss of primary molars; and8 Nonextraction treatment of mild-to-moderate crowding.8The major advantages of the appliance lie in its minimal dependence on patient compliance, ease of fabrication of appliance, allow correction of minor transverse and vertical molar positions by adjustment of the springs, and last but not the least patient-acceptance.9 Torquing or rotation of molars: If the helix loop is not adjusted correctly, the pendulum spring can be distorted and can result in undesirable rotation or torquing of the molars. Tissue irritation:– Food and plaque accumulation under the palatal acrylic causes slight tissue inflammation. This does not limit the use of this appliance.– The activated helix loop of the pendulum springs causes anterior reciprocal forces to be generated against the palatal acrylic and the palate. With a larger palatal acrylic, the generated forces are spread over a wider area with minimal palatal irritation.Patient tolerance of the pendulum appliance is excellent. It is simple and easy to fabricate, with minimal laboratory support. The cost of a pendulum appliance is a fraction of the cost of commercially available molar distalization appliances.


Non-contrast cardiac computed tomography in order to obtain the coronary artery calcium score has become an established diagnostic procedure in the clinical setting, and is commonly employed in clinical and population-based research. This state-of-the-art review paper highlights the potential gain in information that can be obtained from the non-contrast coronary calcium scans without any necessary modifications to the scan protocol. This includes markers of cardio-metabolic health, such as the amount of epicardial fat and liver fat, but also markers of general health including bone density and lung density. Finally, this paper addresses the importance of incidental findings and of radiation exposure accompanying imaging with non-contrast cardiac computed tomography. Despite the fact that coronary calcium scan protocols have been optimized for the visualization of coronary calcification in terms image quality and radiation exposure, it is important for radiologists, cardiologists and medical specialists in the field of preventive medicine to acknowledge that numerous additional markers of cardio-metabolic health and general health can be readily identified on a coronary calcium scan.The coronary artery calcium score substantially increased the use of cardiac CT.• Cardio-metabolic and general health markers may be derived without changes to the scan protocol.• Those include epicardial fat, aortic valve calcifications, liver fat, bone density, and lung density.• Clinicians must be aware of this potential additional yield from non-contrast cardiac CT.•  Over the past decade, non-contrast cardiac computed tomography (CT) has become an established diagnostic tool in clinical practice. The main purpose of these coronary calcium scans is to obtain the coronary artery calcium score (CACS) , 2, whicMost clinical radiologists and cardiologists will be aware of other cardiac imaging properties that can be obtained from coronary calcium scans, such as large myocardial scars or dimensions of the heart and the thoracic aorta . These cWith the increasing focus on preventive medicine and the accompanying demand for individual risk stratification, the ability to calculate a patient’s risk of a clinical event relies greatly on the accuracy and amount of the acquired information. The coronary calcium scan can provide us with additional information regarding the patient’s cardiovascular health beyond the CACS. In the following paragraphs we address several of these markers.The Agatston-based CACS is a summary measure based on the total volume and density of epicardial coronary calcification into a single number ranging from 0  to scores of several thousand indicating extensive coronary atherosclerosis. However, more recent evidence suggests that calcium volume and density each separately harbour additional information with regard to the risk of subsequent clinical events –19. ImpoUsing the same software as is used to obtain the CACS, one can quantitatively assess the burden of aortic valve calcification Fig. , blue 22, 23 or Epicardial fat is defined as the layer of metabolically active adipose tissue that surrounds the myocardium and the coronary arteries , 33. GivIn most instances, a coronary calcium scan also includes visualization of the upper part of the liver. Despite this being only a limited part of the whole liver, measurement of the mean attenuation value at two or three locations – which can readily be done using any CT-image viewer – appears to reflect the total amount of fat in the liver , 42. In The diameter of the pulmonary artery Fig. , orange In addition to aforementioned markers of cardio-metabolic health, other structures that are imaged provide additional information on for example fracture risk and the presence or risk of pulmonary events Table .With regard to measuring the bone density Fig., pink, iMeasuring lung density (Fig. When performing imaging, both in the clinical setting as well as in the research setting, incidental findings can be expected. However, the spectrum of potential incidental findings is relatively limited for coronary calcium scans . Apart fA topic of concern accompanying the use of the coronary calcium scan is the ionizing radiation exposure to the patient or, in the research setting, to the study participant . Two genThe clinical value of the CACS in terms of individual risk assessment of future cardiac events has led to an increased use of non-contrast cardiac CT in both clinical and research settings during the past decades. Many other markers of cardio-metabolic health and general health may readily be evaluated on these examinations. Clinical cardiologists, cardiovascular radiologists and medical specialists in the field of preventive medicine should be aware of this potential diagnostic and prognostic extra-coronary yield of the coronary calcium scan, and widen their professional field-of-view to look beyond the heart.


People with osteoarthritis desire high quality care, support and information. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators can be used to benefit patients by measuring whether minimum standards of quality care are being met from a patient perspective.The aim of this study was to describe how a Research User Group (RUG) worked alongside researchers to co-produce a set of self-reported quality indicators for people with osteoarthritis when visiting their general practitioner or practice nurse (primary care). These were required in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE quality standards for OA.This article describes the public involvement in the MOSAICS study. This was 1) the co-development by RUG members and researchers of an Osteoarthritis Quality Indicators United Kingdom (OA QI (UK)) questionnaire for use in primary care, and 2) the comparison of the OA QI (UK) with a similar questionnaire developed in Norway.This study shows how important and effective a research user group can be in working with researchers in developing quality care indicators for osteoarthritis for use in a research study and, potentially, routine use in primary care. The questionnaire is intended to benefit patients by enabling the assessment of the quality of primary care for osteoarthritis from a patient’s perspective. The OA QI (UK) has been used to examine differences in the quality of osteoarthritis care in four European countries.BackgroundPeople with osteoarthritis (OA) desire high quality care, support and information about OA. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators (QI) can be used to benefit patients by measuring whether minimum standards of quality care  are being met from a patient perspective. A Research User Group (RUG) worked with researchers to co-produce a set of self-report, patient-generated QIs for OA. The QIs were intended for use in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE guidelines. We report on 1) the co-development of the OA QI (UK) questionnaire for primary care; and 2) the comparison of the content of the OA QI (UK) questionnaire with a parallel questionnaire developed in Norway for the Musculoskeletal Pain in Ullensaker (MUST) study.MethodsResearchers were invited to OA RUG meetings. Firstly, RUG members were asked to consider factors important to patients consulting their general practitioner (GP) for OA and then each person rated their five most important. RUG members then discussed these in relation to a systematic review of OA QIs in order to form a list of OA QIs from a patient perspective. RUG members suggested wording and response options for a draft OA QI (UK) questionnaire to assess the QIs. Finally RUG members commented on draft and final versions of the questionnaire and how it compared with a translated Norwegian OA-QI questionnaire.ResultsRUG members  attended up to four meetings. RUG members ranked 20 factors considered most important to patients consulting their GP for joint pain. Following discussion, a list of eleven patient-reported QIs for OA consultations were formed. RUG members then suggested the wording and response options of 16 draft items – four QIs were split into two or more questionnaire items to avoid multiple dimensions of care quality within a single item. On comparison of this to the Norwegian OA-QI questionnaire, RUG members commented that both questionnaires contained seven similar QIs. The RUG members and researchers agreed to adopt the Norwegian OA-QI wording for four of these items. RUG members also recommended adopting an additional seven items from the Norwegian OA-QI with some minor word changes to improve their suitability for patients in the UK. One other item from the draft OA QI (UK) questionnaire was retained and eight items were excluded, resulting in a 15-item final version.ConclusionsThis study describes the development of patient-reported quality indicators for OA primary care derived by members of a RUG group, working in partnership with the research team throughout the study. The OA QI (UK) supports the NICE quality standards for OA and they have been successfully used to assess the quality of OA consultations in primary care in the MOSAICS study. The OA QI (UK) has the potential for routine use in primary care to assess the quality of OA care provided to patients.Ongoing research using both the UK and Norwegian OA-QI questionnaires is assessing the self-reported quality of OA care in different European populations.The online version of this article (doi:10.1186/s40900-016-0019-x) contains supplementary material, which is available to authorized users. Osteoarthritis (OA) is a leading cause of joint pain and years lived with disability worldwide causing considerable detrimental impact on daily activities and quality of life –4. OA isHigh quality care is described as clinically effective, personal and safe, which is delivered to all users of a health service in all aspects of care . HoweverSeveral international guidelines exist which provide recommendations for the management of OA , 15, 16.Quality indicators (QI) are ‘specific and measurable elements of practice that can be used to assess the quality of care’ . They arA systematic review identified 15 QIs which are broadly applicable with current international guidance for the assessment of non-pharmacological and pharmacological management of OA in primary care ; howeverThe Management of OSteoArthritis In ConsultationS (MOSAICS) study  developeDuring the course of the MOSAICS study, the research team became aware of a questionnaire capturing the patient perspective of the quality of OA primary care being developed in Norway. The OsteoArthritis Quality Indicator (OA-QI) has since been validated for use to measure the quality of primary care for OA in a Norwegian population . The NorWe report on the co-production of a set of self-report, RUG-generated QIs to capture the quality of primary care management of OA. We also compare the RUG-generated OA QI (UK) questionnaire with a Norwegian OA-QI questionnaire developed in parallel, leading to a final recommended OA QI (UK) questionnaire.The manuscript was written using the Guidance for Reporting Involvement of Patients and Public (GRIPP) checklist for reporting Patient and Public Involvement (PPI) in research . This chThe PPI described in this article took place at the Arthritis Research UK Primary Care Centre, Keele University. This institution takes an explicit and systematic approach to involvement of patients and the public in research . Formed Our good practice principles include holding meetings in accessible venues at convenient times; allocated parking; meeting and greeting on arrival; training and support; inclusion of regular breaks during meetings; payment for RUG members’ time and contribution (if wanted); and reimbursement of expenses. Meetings between researchers and RUG members are made actively ‘jargon-free’ and any technical terms are explained in plain English.The MOSAICS study investigated whether a new way of supporting self-management, delivered during an OA consultation in primary care, could offer a clinically practical approach to implementing the core NICE recommendations . We descIn 2009, RUG members with OA were invited to form an OA PPI group to work in partnership with researchers throughout the MOSAICS study, including the development of patient-reported QIs, set within a wider five year programme of research into OA , 38. FurDuring the course of the MOSAICS study, members of the research team met with RUG members to co-produce the OA QI (UK) questionnaire for use in the MOSAICS study. The discussion meetings were facilitated by the Centre’s PPI Support Worker/Coordinator, the MOSAICS study Chief Investigator and a trial coordinator. The PPI Support Worker/Coordinator provided a key role by attend the meetings with RUG members to provide assistance and support, prior, during and after meetings. The MOSAICS study Chief Investigator (KD) has collaborated with the RUG on numerous research studies and is currently the senior academic lead for PPI in the Centre. All trial coordinators at the Centre have a responsibility for ensuring PPI in their respective studies and have lots of experience of collaborating with RUG members.Discussion notes from the meetings were recorded on flip charts and in meeting minutes. Following each meeting, a summary of the outcomes and decisions written in plain English was sent to the RUG members to acknowledge their contribution and verify that all views had been captured. RUG members were also given the opportunity for further comment at the start of the next meeting.It was not intended to formally evaluate the PPI interaction and the RUG members’ experience in the process. However, the impact of the RUG members is described in this article in the form of the co-produced OA QI (UK) questionnaire for use in the MOSAICS study.Ethical approval for the PPI activities was not sought because the RUG members were acting as specialist advisers, providing valuable knowledge and expertise based on their experience of a health condition or public health concern and their involvement did not raise any ethical concerns . Howevern = 10) were invited to a series of four discussion groups with the research team to develop the patient-reported QIs for patients with OA treated in primary care. The discussion groups took place over a three year period from 2009–2012. The objectives of the discussion groups were i) to understand the aims of MOSAICS and roles and expectations of the RUG members, ii) to identify important and relevant quality indicators for patients with OA when consulting in primary care, and iii) to develop wording and response options for a self-report OA QI (UK) questionnaire to assess the identified quality indicators Understanding the aims of MOSAICS and roles and expectations of the RUG membersIn the first meeting, a plain English summary of the MOSAICS study was introduced to set the context for the meetings and outline roles of the RUG members.ii)Identifying important and relevant quality indicators of OA in primary care consultations from a patient’s perspectiveDuring facilitated discussions, RUG members identified factors they considered to be important to patients with OA consulting their general practitioner (GP) to help identify potential QIs for OA consultations. Each RUG member then ranked (1 to 5) the top five factors they considered the most important. Any factors not selected as ‘most important’ by at least one RUG member were excluded from further discussions.The research team then presented RUG members with five QIs identified from a previous systematic review  Fig. 2)2). Theseiii)Developing the wording and response options for a self-report OA QI (UK) questionnaireBased on the list of important factors suggested by RUG members, an initial set of patient-reported OA QIs were generated. From this list, wording for questionnaire items to assess the QIs were drafted for an OA QI (UK) questionnaire. Over a further two meetings, RUG members and the research team worked together to refine and finalise the questions so they were suitable for use in a research trial.  properties of the OA QI (UK) questionnaire. As mentioned earlier in this article, a similar OA QI questionnaire was being developed for use in primary care in Norway (the Norwegian OA-QI) .In order to establish the measurement properties of the OA QI (UK) questionnaire, the Norwegian developers  produced an English translation of a draft version of the Norwegian OA-QI for item content and scoring comparison. RUG members reviewed this and compared its content with the OA QI (UK) questionnaire during the third meeting. Based on this comparison, RUG members suggested how the OA QI (UK) questionnaire could be refined and modified to include items in the validated Norwegian OA-QI. Where QIs in each questionnaire were similar, RUG members considered the appropriateness of the wording used in the Norwegian OA-QI for potential use.During the last meeting, the RUG reviewed, commented and suggested refinements to the OA QI (UK) questionnaire for primary care. RUG members were also asked to assess the face validity of the questionnaire by commenting further on its appearance and layout, ease of completion, and to identify anything ambiguous or difficult to understand. The research team also compared the content of the OA QI (UK) questionnaire with the other questionnaires and data collected in the MOSAICS to check for unnecessary duplication.All of the RUG members  had OA and were aged 52–80 years. Four meetings were held during the three year period. All meetings were attended by between three and ten members.information about OA; information about treatment for OA; information about self-management for OA; advice about using medications to relieve joint pain; information about exercise and activities; referrals to activity or exercise programmes, and the quality of the consultation with the GP. These domains formed an initial list of seven patient-reported QIs for OA consultations. Following the review of the five quality indicators identified from a systematic review [patient has received a follow-up review of his/her joint problem’; ‘patient has received a referral for physiotherapy’; ‘patient has received advice about body weight and joint pain’, ‘patient has received a referral for weight loss services’) were added. Therefore, 11 unique QIs were identified  was split into four questions, two QIs  into three items, and one other QI (follow up review) was split into two questions, respectively.The resultant draft OA QI (UK) questionnaire comprised 16 items. In the second group meeting, RUG members reviewed the draft questionnaire and worked with the research team to refine its content. RUG members provided further comments on the ease of understanding and relevance of the questions. They suggested wording for the questionnaire instructions and changes to improve the clarity, specificity and order of the questions. RUG members suggested changing the wording for the ‘don’t know’ response option where relevant if the respondent could not remember, if they had not received an aspect of care, or if the question was not applicable.information about OA, information about treatment for OA, information about self-managing OA, advice about exercise or activities for OA, referral to exercise or activity programmes for OA, advice about the use of medications to relieve joint pain) used comparable wording to those included in the draft Norwegian OA-QI  questionnaire and the draft Norwegian OA-QI were similar. Seven items in the draft OA QI (UK) questionnaire capturing six quality indicators:  were captured elsewhere in the MOSAICS study and therefore not required for the OA QI (UK) questionnaire. Nine items from the draft OA QI (UK) that were not present in the Norwegian OA-QI were retained at this stage. Therefore, at the end of Stage 2, the draft version of the OA QI (UK) questionnaire contained 23 items  included in the Norwegian OA-QI were relevant and should be added to the UK questionnaire. They suggested minor changes to wording to make them more appropriate for the UK Table . Three osupport for self-managing OA). Eight items from the draft OA QI (UK) ; current participation in exercise; exercise programme suggested; referral for physiotherapy; advice about taking paracetamol received; advice about taking capsaicin cream received) were either covered elsewhere in the MOSAICS study [The iterative process of redrafting and reviewing the questionnaire continued into the fourth meeting until the RUG members and researchers agreed on the final draft version. Along with subtle changes to item wording suggested by RUG members, the research team and RUG members agreed to retain one item from the draft OA QI (UK)  has been successfully used in a large randomized control trial of a new model of supported self-management of OA (the MOSAICS study)  and a stThe active, meaningful and on-going involvement of patients as partners in the research process is a strength of this study. The perspectives of patients may differ from the perspectives of healthcare professionals or information recorded by professionals in medical records , 41. TheThe RUG group identified important factors related to the quality of OA care provided by a primary care healthcare professional and suggested item wording for a questionnaire. By comparing the OA QI (UK) questionnaire with a similar one developed in Norway, the RUG members helped redraft and refine the final questionnaire. The RUG collaborated with the research team throughout the development of the OA QI (UK) but were also involved on other aspects of the MOSAICS study such as developing a self-management guidebook for patients with OA and participant information sheets , 42). ReThe research team embraced the contribution of the RUG members and implemented many of their suggestions. The concepts included in the finalised OA QI (UK) were generated by the RUG members. Working in collaboration the RUG members and the research team shaped the items in survey questions suitable for use in a research trial. The Chief Investigator did not make decisions on the final content of the questionnaire without the fully informed RUG and explained if information was already captured elsewhere in the MOSAICS study. For example, RUG members did identify eight other important and relevant QIs not included in the final version of the OA QI (UK). So, to avoid repetition and participant burden in the MOSAICS study, these eight items were not included in the final 15-item OA QI (UK) questionnaire. These decisions were fully explained to the RUG members. Therefore, the RUG members' contribution ensured that the resulting OA QI (UK) incorporated issues relevant to patients with OA, written in a language that patients found easy to understand.The OA QI (UK) was developed to assess the uptake of treatment recommended by NICE  and compEstablishing the measurement properties of a questionnaire is an important step in its development. The use of scientifically sound and decision-relevant measures allows the collection of evidence on the benefits of intervention (or care practices) from a patients’ perspective . The OA The overall positive feedback from RUG members on the Norwegian OA-QI enabled adaptations to the OA QI (UK) to be made with confidence. The development of the both questionnaires was coincidental. Although there was differences in how they were developed (one mainly patient-led and the other mainly researcher/clinician derived), this study has demonstrated that patients and researchers have similar expectations about what constitutes good quality care in OA in different European countries. It also highlights the value of the active, meaningful and useful contribution of patients in the research process. Furthermore, the consistency of quality indicators for OA consultations in two European countries has now provided a unique opportunity to compare QIs across European countries . This maThis study has demonstrated that active involvement of patients in research, working in partnership with researchers, identified important and relevant OA quality indicators, and developed a self-reported questionnaire to measure them. The OA QI (UK) questionnaire aligns with current national and international standards and process measures of OA care  and is consistent with quality indicators validated for Norwegian OA consultations. The development of two OA quality indicator questionnaires was coincidental but has led to further research to compare patient-reported OA QIs across European countries. Following this work, a single refined OA QI questionnaire for use in routine clinical practice is planned.Additional file 1:Overview of the Managing Osteoarthritis in Consultations (MOSAICS) study. (DOCX 12 kb)Additional file 2:Overview of Patient and Public Involvement in the Institute of Primary Care and Health, Keele University. (DOCX 12 kb)Additional file 3:The Osteoarthritis Quality Indicators (UK) Questionnaire. (DOCX 56 kb)