Magnapaulia laticaudus (new combination) are revised. The diagnosis of this species is amended on the basis on two autapomorphies  and a unique combination of characters . A maximum parsimony analysis supports a sister taxon relationship between M. laticaudus and Velafrons coahuilensis. Both taxa constitute a clade of southern North American lambeosaurines, which forms a sister relationship with the diverse clade of helmet-crested lambeosaurines from northern North America that includes well-known genera like Corythosaurus, Lambeosaurus, and Hypacrosaurus. According to the results of a Dispersal-Vicariance analysis, southern North American lambeosaurines split from the northern forms via vicariance from a common ancestor that lived in both the northern and southern regions of the continent.The taxonomy, osteology, phylogenetic position, and historical biogeography of the lambeosaurine hadrosaurid  Later, however, this author amended his referral to cf. Lambeosaurus based on the relatively narrow and elongate morphology of the external naris in the premaxilla of this animal, which more closely resembles that of Lambeosaurus than the shorter and broader naris of H. altispinusL. laticaudus. He provided a differential diagnosis in which this taxon is differentiated from other species of Lambeosaurus by having a deep tail characterized by caudal vertebrae with elongate haemal arches that match the great length of the neural spines. Additionally, Morris L. laticaudus (estimated in 14–15 m in length) as diagnostic for this species.Morris Although in his original work Morris AEHM, Amur Natural History Museum, Blagoveschensk, Russia; AMNH, American Museum of Natural History, New York, U.S.A.; CMN, Canadian Museum of Nature, Ottawa, Canada; FMNH, The Field Museum, Chicago, U.S.A.; GMV, National Geological Museum of China, Beijing, China; IVPP, Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, China; LACM, Natural History Museum of Los Angeles County, Los Angeles, U.S.A.; MOR, Museum of the Rockies, Bozeman, Montana, U.S.A.; MSNM, Museo Civico di Storia Naturale di Milano, Milan, Italy; NHM, The Natural History Museum, London, U.K.; NMMNH, New Mexico Museum of Natural History and Science, Albuquerque, U.S.A.; ROM, Royal Ontario Museum, Toronto, Ontario, Canada; SM, Senckenberg Museum, Frankfurt am Main, Germany; SDNHM, San Diego Natural History Museum, San Diego, U.S.A.; TMP, Royal Tyrrell Museum of Paleontology, Drumheller, Canada; UALVP, University of Alberta, Laboratory of Paleontology, Edmonton, Canada; YPM, Yale Peabody Museum of Paleontology, New Haven, U.S.A.; ZPAL, Institute of Paleobiology, Polish Academy of Sciences, Warsaw, Poland.Dinosauria Owen, 1842 Ornithischia Seeley, 1887 Ornithopoda Marsh, 1881 Hadrosauridae Cope, 1870 Lambeosaurinae Parks, 1923 Magnapaulia gen. nov.Magna, the Latin for “large”, refers to the unusually large size reached by at least some specimens of this lambeosaurine; paulia honors Mr. Paul Haaga for his outstanding support to the research and public programs of the Natural History Museum of Los Angeles County and its Dinosaur Institute.As for the only known species.Magnapaulia laticaudus Morris, 1981 urn:lsid:zoobank.org:act:FD9EDA56-7E2C-4F7D-A567-3BB1C4360C8EMagnapaulia laticaudus is characterized by the following unique combination of characters: downturned rostroventral process of the maxilla , the ventral margin of which forms a 18-degree angle with the alveolar margin of the element at its mid-length; tear-shaped external naris with length/width ratio between 1.85 and 2.85, being rostrocaudally longer than in Hypacrosaurus altispinus but shorter than in Lambeosaurus spp., Corythosaurus spp., and H. stebingeri, and mediolaterally wider than in Parasaurolophus walkeri (condition shared with Velafrons coahuilensis and convergent in Olorotitan arharensis); and greatly elongated neural spines (at least four times the depth of their respective centra) of dorsal, sacral, and proximal caudal vertebrae .Lambeosaurine hadrosaurid possessing the following autapomorphies: longest haemal arches of proximal caudal vertebrae being at least four times longer than the depth of their respective centra, and the base of prezygapophyses in caudal vertebrae merging to form a bowl-shaped surface, which, in the proximal-most caudals, is continuous dorsally with a deep sulcus on the cranial surface of the neural spine. In addition, LACM 17715, consisting of left premaxilla, left maxilla, left jugal, partial atlas, three partial and two nearly complete cranial to middle cervical vertebrae, one nearly complete caudal cervical vertebra, two cervical postzygapophyseal processes, two nearly complete cranial-most dorsal vertebrae, two cranial dorsal neural arches, two partial cranial dorsal vertebrae, three cranial dorsal centra, one fragment of cranial neural arch, two fragments of middle to caudal dorsal vertebrae, two caudal dorsal neural arches, one caudal dorsal centrum, partial sacrum composed of four co-ossified vertebrae , two pairs of co-ossified sacral centra, one caudal sacral vertebra lacking the centrum, one sacral centrum, one sacral neural spine, six fragmentary sacral ribs, two caudal neural arches, partial right sternum, left coracoid, right scapula, right humerus, left ischium, complete left femur and fragmentary femur, proximal end of left tibia, and a nearly complete left metatarsal III . MeasureMagnapaulia laticaudus of the above specimens is based on 1) presence of lambeosaurine characters (see description below) in the appendicular elements  that are also found in the type specimen, in combination with 2) the specimens were found associated with the type specimen within locality LACM 7253. These two reasons together suggest that the most parsimonious interpretation is that these lambeosaurine remains belong to the same taxon. The alternative choice would be to name two distinct taxa from the same locality, because the type LACM 17715 is diagnostic on its own, and so is LACM 17705. However, we think that the first choice of considering a single taxon is the most conservative, simpler explanation given the anatomical data at hand.LACM 17698 , 17699 (tooth), 17700 (tooth), 17702 , 17703 (left ischium), 17704 , 17705 , 17706 (left tibia), 17707 , 17708 (ischium), 17709 , 17710 , 17711 (left tibia), 17712 , 17713 (dentary fragment), 17716 , 17717 , 20873 , 20874 , 20875 , 20876 (left tibia), 20883 , 20884 (dentary and pubic fragments), and 20885 . Measurements of selected specimens are given in Magnapaulia laticaudus were found in late Campanian strata of the El Gallo Formation, near the western coastline of the state of Baja California Norte, northwestern Mexico . In particular, the external naris is exposed laterally as an elongated tear-shaped depression entirely confined between the dorsomedial and ventrolateral processes . The laterodorsal surface of the rostrolateral corner of the premaxilla is limited by a sharp rim that bounds laterally the rostral region of the external naris. As the rostrolateral corner of the premaxilla narrows mediolaterally and merges with the rostral oral border, that sharp edge gradually disappears rostrally and the external naris becomes continuous with the rostromedial portion of the oral margin.Caudally, the rostrolateral corner of the premaxilla is continuous with the long lateral process . This prThe maxilla is rostrocaudally elongate and shows a subtriangular lateral profile . The eleMagnapaulia laticaudus is remarkable in being ventrally deflected , Angulomastacator daviesiOlorotitan arharensisShuangmiaosaurus gilmoreiAs preserved, the rostral third of the maxilla is relatively shallow and triangular in lateral view, so that the rostrodorsal region of the maxilla forms a 25-degree angle with the ventral alveolar margin along that same region of the bone. However, the area adjacent and rostral to the dorsal process is abraded, which likely contributes to the apparent shallow profile of the rostrodorsal region of the maxilla. As in all lambeosaurines, there is no rostromedial process medially offset from the rostral body of the maxilla, but instead a ventrally slopping shelf that would support and underlie the caudoventral process of the premaxilla . This preflected  more so Pararhabdodon and Tsintaosaurus; see Magnapaulia laticaudus, as in other lambeosaurines, opens on the dorsal surface just medial to the articular surface for the lacrimal and jugal, along the premaxilla-maxilla contact, and is not exposed laterally when the maxilla is articulated in the skull.The base of the dorsal process is approximately centered on the mid-length of the maxilla. Only the caudoventral extent of the articular surface for the jugal is preserved, whereas that for the lacrimal is missing. However, enough is preserved to indicate that the jugal articular surface is as in all other hadrosaurids  . The latThe medial surface of the maxilla is flat and consists mostly of the dental parapet . A longiThere are 41 tooth positions, of which only the seven most rostral alveoli did not preserve teeth . The alvTsintaosaurus spinorhinus , Hypacrosaurus altispinus  and Parasaurolophus spp. . Although incomplete, the lacrimal process and the ventral corner of the rostral process are much expanded dorsally and ventrally. The medial articular surface of the rostral process is medially recessed and bounded caudally by a very prominent and thick vertical ridge  and ventral edges of the rostral process, nearly the entire postorbital process, the dorsal margin of the caudal constriction, and the quadratojugal process . As presal ridge . Along iMagnapaulia laticaudus shows a proportionately deep orbital constriction, comparable in depth to that of Amurosaurus riabininiM. laticaudus are parallel to each other and nearly straight rostral to the base of the postorbital process and the rostroventral edge of the jugal flange, respectively  and its dorsoventral depth at mid-length of the dental battery is over 3.5. The preserved edentulous portion the dentary is not deflected more than 15 degrees relative to the ventral margin of the rostral series of alveoli , Hypacrosaurus altispinus , Lambeosaurus lambei , or Charonosaurus jiayinensis  originates at a similar level than in M. laticaudus.The dentary is represented by a partial element missing the caudal and rostral-most extents of the dental battery along with the rostral edentulous region, all teeth, the caudolateral wall below the coronoid process, and the dorsal expansion of the latter process . The den alveoli . It is, On the lingual side of the dentary the dental parapet is missing, exposing a total of 39 alveoli . HoweverMagnapaulia laticaudus shows several other characters that are always present in hadrosaurids, such as a substantial lateral offset of the coronoid process from the dental battery, the caudal extension of the dental battery beyond the caudal margin of the coronoid process, and an rostrocaudally straight dorsal alveolar margin that is parallel to the lateral wall of the dentary . The dentary occlusal plane shows a maximum of three teeth arranged mediolaterally . There aSeveral maxillary teeth are preserved in situ in the maxilla of LACM 17715; thus, only part of their enameled labial sides is exposed . The occThese elements are characterized by deeply opisthocoelous centra, wide and extensive neural arches, and large and elongate postzygapophyseal processes . In contCervical ribs are triradiate elements. In the few preserved ribs, the capitulum is over twice as long as the tuberculum and projects laterodorsally and slightly cranially from the craniodorsal region of the rib to articulate with the diapophysis of the centrum. In contrast, the tuberculum extends a short distance laterally and slightly ventrally to meet the parapophysis of the cervical centrum. The shaft of cervical ribs is mediolaterally compressed, with convex lateral and concave medial surfaces, and wedges caudally to a sharp point.The morphology of the most cranial dorsal vertebrae , Olorotitan arharensis , Lambeosaurus lambei (ROM 1218), or Corythosaurus intermedius , the cranial extension of the craniodorsal region of the scapula bearing the coracoid facet is moderate; the ratio between the distance from the coracoid articulation and the cranial end of the acromial process, and the height between this and the ventral apex of the glenoid facet is 0.4. The glenoid facet is both narrower and longer than the coracoid facet. It is subrectangular in articular view and expanded ventrally. The ventromedial corner of the glenoid facet ends in a prominent apex  and Hypacrosaurus altispinus . The glenoid is more extensive than the scapular facet. Specifically, the lateral margin of the scapular facet is approximately 75% of the length of the lateral margin of the glenoid facet. Both the glenoid and scapular facets are D-shaped in their articular views , C. casuarius , Hypacrosaurus altispinus , Olorotitan arharensis , Parasaurolophus walkeri , and Tsintaosaurus spinorhinus . The maximum lateral expansion of the deltopectoral crest occurs across its distal fourth and is slightly over 1.8 times the minimum diameter of the shaft. The medial surface of the deltopectoral crest is gently concave transversely. The cranial margin of the crest gradually thickens toward the angular and prominent laterodistal corner. On the caudal surface of the proximal region of the humerus, the caudal tuberosity for the latissimus dorsi muscle forms a large and prominent rugosity in some specimens, like LACM 17716  condyle is wider and more distally prominent than the radial condyle. The intercondylar surface is depressed in both the cranial and caudal sides of the distal end of the humerus; however, the depression is longer and deeper on the caudal side. The lateral and medial surfaces of the ulnar and radial condyles, respectively, are flattened and slightly concave, particularly that of the ulnar condyle.Magnapaulia laticaudus is represented by a nearly complete right exemplar missing the postacetabular process . Similarly deep or deeper iliac plates are found in other lambeosaurines like Gilmoreosaurus mongoliensisThe pubic process constitutes the cranioventral corner of the iliac plate and the cranial border of the acetabular margin. Like in all hadrosaurids, this process is triangular, relatively short, and ends cranioventrally in a well-defined apex. A prominent and thick ridge borders the lateral surface of the ventral margin of the process. At the other end of the arcuate acetabular margin of the ilium lies the ischiac process. As in all hadrosaurids and some basal hadrosauroids like Only the proximal-most region of the postacetabular process is preserved. The dorsal and ventral margins of this portion of the process are nearly parallel, and oriented caudally and slightly dorsally. The maximum depth of that region of the postacetabular process occurs proximally and is slightly less than half the depth of the central iliac plate. The postacetabular process is slightly inclined medially in relation to the parasagittal orientation of the central plate of the ilium .M. laticaudus is further expanded than its ventrodistal region , Parasaurolophus cyrtocristatus , and Tsintaosaurus spinorhinus  and Lambeosaurus  the dorsodistal margin of the prepubic process ranges from more rounded to straight and ventrally inclined; the proximal constriction is shallower and proportionately more elongate craniocaudally, and the entire dorsal margin of the prepubic process shows a widely arcuate, shallower concave profile.The pubis is composed of a large, sheet-like and cranially directed prepubic processs, and a proximal acetabular region containing the iliac process dorsally and the ischiac and postpubic processes ventrally . As in ol region . Within The iliac process is tetrahedral and mediolaterally expanded dorsally, as typically seen in other hadrosaurids Magnapaulia laticaudus consists of a robust proximal region and a long shaft ending distally in a well developed foot-like process  or Parasaurolophus cyrtocristatus . The distal articular surface of the iliac process is greatly expanded mediolaterally and twice as long as it is wide  as well as in non-hadrosaurid iguanodontians . Except in LACM 17715 (see below), the acetabular border of the ischium is dorsoventrally narrow, comprising one third of the total dorsoventral breadth of the cranial margin of the proximal region of the ischium. When completely preserved, the acetabular margin of the iliac process forms a 105-degree angle with the lateral margin of the distal articular surface.The ischium of  process . In the  process . The ili is wide . Most of is wide . This acCorythosaurus intermedius , the pubic process contains an oblique flange that borders laterally a flat triangular facet. In general, this facet is rarely readily observable, if preserved at all, in hadrosaurid ischia. The facet faces craniodorsally and forms a 140-degree angle with the vertical cranial margin of the pubic peduncle.The pubic process is very deep, mediolaterally compressed, and displays a subsquared lateral profile . The proCaudal and slightly ventral to the pubic peduncle, the bone surface is deeply concave and shows a large obturator foramen. This foramen is bounded by a rugose bony rim, the caudal extent of which is thicker and projected caudally. The caudomedial margin of this rim shows a sharp ridge that extends caudodorsally into the medial surface of the proximal segment of the ischiac shaft. The lateral surface of the proximal region of the ischium shows a thick, low longitudinal ridge just above the obturator foramen . This riMagnapaulia laticaudus, such as LACM 20874  and Hypacrosaurus altispinus , but it is unlike the relatively slender and longer distal processes of Parasaurolophus cyrtocristatus  and Tsintaosaurus spinorhinus . The ventral edge of the distal end of the ischium is sharply defined and shows a strongly concave lateral profile.The ischiac shaft of entrally . This moAmurosaurus riabininiThe femur is proportionately slender, due to its relatively elongate shaft . SpecifiM. laticaudus is proportionately slender; for example, the total length of LACM 17711 is 10 times greater that the mid-shaft diameter. At the proximal end, the two caudolateral condyles are mediolaterally short, craniocaudally wide, and laterally directed. The cnemial crest is very thick and extensive, and its proximomedial corner is slightly curved caudally. The mediolateral breadth of the distal end of the tibia is three times that of the mid-shaft diameter.The tibia  is compoThe fibula  is long This is a robust but proportionately elongate element . It is 6Magnapaulia laticaudus is partially known from various patches with impressions and natural casts of the scales , C. intermedius , Lambeosaurus lambei , L. magnicristatus , and Hypacrosaurus altispinus , and saurolophines Brachylophosaurus canadensis , Gryposaurus notabilis , Edmontosaurus annectens , E. regalis , and Saurolophus angustirostris . Large osteoderm-like structures of similar size, morphology , and distribution in the skin as those observed in M. laticaudus are also known in some lambeosaurines like Corythosaurus sp. , C. casuarius , and L. lambei .The external morphology of the skin of e scales . Accordie scales , arrow. Magnapaulia laticaudus was recovered as the sister taxon to the only other known lambeosaurine from México , Velafrons coahuilensis. Both taxa form a clade of southern North American lambeosaurines and this phylogenetic placement supports removal of the Baja California lambeosaurine from the genus Lambeosaurus. The clade is unambiguously supported by an ilium with a supraacetabular crest that extends ventrally more than 25% but less than half the depth of the central iliac plate . An ambiguous synapomorphy  also unites V. coahuilensis and M. laticaudus: triangular external naris gradually closing caudodorsally and with a length/width ratio between 1.85 and 2.85 (convergent in Olorotitan arharensis). Although the external nares of Lambeosaurus spp., Corythosaurus spp., and Hypacrosaurus stebingeri show a similar contour than those of M. laticaudus and V. coahuilensis, their length/width ratio are greater than 2.85  . MagnapaMagnapaulia-Velafrons clade was inferred to be the sister clade to a more speciose monophyletic group of helmet-crested forms that included Hypacrosaurus spp., Olorotitan arahrensis, Corythosaurus spp., and Lambeosaurus spp. One unambiguous synapomorphy supported this sister relationship: an angle between the dentary proximal-most edentulous slope and the tooth row of 150 degrees or greater (reversed to a lower than 150-degree angle in H. stebingeri).Additionally, the Sahaliyania, Tsintaosaurus, Pararhabdodon, Jaxartosaurus, and Aralosaurus, support inclusion of M. laticaudus in the clade integrated by Hypacrosaurus spp., Olorotitan arharensis, Corythosaurus spp., Lambeosaurus spp., and the Charonosaurus-Parasaurolophus spp. subclade: the oral margin of the premaxilla being slightly deflected ventrally and dorsoventrally thicker toward the sagittal plane of the snout; elongation of the medial process of the premaxilla to meet the lateral process and form the caudal margin of the external naris; and absence of premaxillary accessory fossae.Three ambiguous synapomorphies, the distribution of which are variably known in Magnapaulia laticaudus shares various synapomorphies with the clade including all lambeosaurines except the more basal forms Tsintaosaurus, Pararhabdodon, Jaxartosaurus, and Aralosaurus: faint secondary ridges on the enameled surfaces of dentary tooth crowns; a triangular and craniocaudally abbreviated craniodorsal region of the maxilla; a large maxillary foramen opening on the craniodorsal surface of the maxilla, along the premaxilla-maxilla contact; absence of craniodorsal medial process of the maxilla and presence of craniodorsally-sloping shelf underlying the premaxilla; absence of premaxillary foramen; given the morphology and extent of the premaxilla, possibly the nasal folded and rotated caudodorsally; a coracoid ventral process with a depth/proximal width ratio between 0.65 and 0.80; and the distal blade of the prepubic process of the pubis with a more expanded dorsal region. These synapomorphies are, however, ambiguous since their distribution in all or some of the four basal lambeosaurines noted above are variably unknown.At a more inclusive level, Magnapaulia laticaudusAmurosaurus-Sahaliyania clade does not form a sister relationship with the Hypacrosaurus clade, but was recovered as the sister clade to the major monophyletic group including all lambeosaurines except Tsintaosaurus, Pararhabdodon, Jaxartosaurus, and Aralosaurus.The topology recovered in the present analysis differs in two important aspects from the tree derived from the only other previous cladistic study that included Olorotitan arharensis, deeply nested here among the helmet-crested lambeosaurines as the sister species to Hypacrosaurus altispinus. In the phylogeny by Prieto-Márquez O. arharensis was positioned as a relatively basal taxon outside the clade including all lambeosaurines to the exclusion of Tsintaosaurus, Pararhabdodon, Jaxartosaurus, and Aralosaurus. However, the phylogenetic position inferred here for O. arharensis is more congruent with recent analyses, in which this species appeared forming a polytomy with the genera Hypacrosaurus and CorythosaurusCorythosaurus casuarius-Hypacrosaurus spp. clade Hypacrosaurus altispinus and Olorotitan arharensis are unambiguously united based on the presence in both taxa of a straight, nearly vertical cranial margin of the rostral process of the jugal  exclharensis  and S3, Magnapaulia laticaudus, the only other lambeosaurine taxa erected so far from Mexico is Velafrons coahuilensis, from the late Campanian Cerro del Pueblo Formation outcropping near the town of Rincón Colorado, state of Coahuila M. laticaudus and V. coahuilensis share a similar morphology of the external naris, they notably differ in the orientation of the rostroventral process of the maxilla  and probably the largest individuals of Kritosaurus navajoviusAnasazisaurus horneriM. laticaudus set this animal's dimensions below the 14.7 m reported for Shantungosaurus giganteusOverall, the above estimates position Magnapaulia laticaudus leads to a revised diagnosis, phylogenetic position, and biogeographic hypothesis of this taxon. The possession of the autapomorphic elongate haemal arches of proximal caudal vertebrae (being at least four times longer than the depth of their respective centra) and the base of prezygapophyses in caudal vertebrae merging to form a bowl-shaped surface, coupled with the diagnostic combination of pendant cranioventral process of the maxilla, tear-shaped external naris with length/width ratio between 1.85 and 2.85, and neural spines of dorsal, sacral, and proximal caudal vertebrae being at least four times the depth of their respective centra, argues against previous referral of this species to Lambeosaurus and supports the erection of a new genus.A detailed comparative osteology of the available cranial, appendicular, and axial elements of Magnapaulia laticaudus was parsimoniously inferred to be the sister taxon to Velafrons coahuilensis, also from the late Campanian of México. Both species represent a unique clade of southern North American lambeosaurines, which, according to the results of Dispersal-Vicariance analysis, split from the northern forms via vicariance, prior to the middle-late Campanian (∼75 mya), from a common ancestor that lived in both the northern and southern regions of the continent.Magnapaulia laticaudus were based on first hand examination of the holotype and referred materials of this species housed at the LACM in Los Angeles  and the Instituto de Geología at the Universidad Autónoma Nacional de México (México DF)  .Magnapaulia laticaudus and the other lambeosaurine species for which this premaxillary region is preserved. In this method, the shape outlines of the external nares of 30 lambeosaurine specimens were represented by continuous curves and parameterized by their square-root velocity functions. For each shape, the square-root velocity function maps each point on the curve to a vector in R2. This function is automatically invariant to translation and is further made invariant to scale by normalizing its magnitude. We analyzed the shapes of curves as elements of an infinite-dimensional, nonlinear manifold equipped with a well-defined Riemannian  metric. Here the geometrical differences between shapes were studied under invariances to rigid rotations, translations, uniform scaling, and reparameterizations of curves. The shape differences were then quantified elastically by computing geodesics (shortest paths) on the shape space, which is an infinite-dimensional sphere where geodesics were analytically specified The morphology of the external naris in the premaxilla of lambeosaurine hadrosaurids was analyzed using its boundary representation by applying the square-root elastic framework for shape analysis of curves described by Joshi et al. Magnapaulia laticaudus within Lambeosaurinae was inferred via maximum parsimony analysis. We used the character matrix of Prieto-Márquez M. laticaudus, the present analysis included 30 hadrosauroid species, consisting of 22 Hadrosauridae (of which 19 species belong to Lambeosaurinae) and eight non-hadrosaurid Hadrosauroidea, which provide a thorough representation of the known diversity of hadrosaurids. The non-hadrosauroid iguanodontian Iguanodon bernissartensis was selected as outgroup taxon to hadrosauroids. The character coding of Olorotitan arharensis was updated following to the revised descriptions and character coding provided by Godefroit et al. The phylogenetic position of Finally, we implemented Dispersal-Vicariance Analysis or DIVA  to the rThe electronic version of this document does not represent a published work according to the International Code of Zoological Nomenclature (ICZN), and hence the nomenclatural acts contained in the electronic version are not available under that Code from the electronic edition. Therefore, a separate edition of this document was produced by a method that assures numerous identical and durable copies, and those copies were simultaneously obtainable (from the publication date noted on the first page of this article) for the purpose of providing a public and permanent scientific record, in accordance with Article 8.1 of the Code. The separate print-only edition is available on request from PLoS by sending a request to PLoS ONE, 1160 Battery Street, Suite 100, San Francisco, CA 94111, USA along with a check for $10 (to cover printing and postage) payable to “Public Library of Science”.ZooBank, the proposed online registration system for the ICZN. The ZooBank LSIDs (Life Science Identifiers) can be resolved and the associated information viewed through any standard web browser by appending the LSID to the prefix “http://zoobank.org/”. The LSID for this publication is: urn:lsid:zoobank.org:pub:B71CDFFA-9B8D-4A77-B068-A11D444D5171. The article is deposited in the PubMedCentral and LOCKSS digital archives.In addition, this published work and the nomenclatural acts it contains have been registered in Supporting Information S1List of hadrosaurid materials recovered from Upper Cretaceous strata of Baja California.(XLS)Click here for additional data file.Supporting Information S2Magnapaulia laticaudus and Olorotitan ararhensis for the 255 morphological characters included in the phylogenetic analysis.Character state codings for (XLS)Click here for additional data file.Supporting Information S3Olorotitan ararhensis for 18 of the 255 morphological characters included in the phylogenetic analysis.Revised codings for (XLS)Click here for additional data file.


Psoas abscess in cases of tuberculosis originates from the primary lesion in the lower dorsal or the lumbar spine. From the spinal origin of the Psoas muscle, this abscess tracks down its sheath and may be palpable in the iliac fossa, in the lumbar triangle, in the upper part of thigh below the inguinal ligament. We present a rare case, where patient presented with thigh swelling, which on first look gave an impression of a malignant origin. But subsequent investigation revealed it to be one of tuberculous origin, and that to, tracking down of a Psoas abscess. According to best of our knowledge, there has been no reported case of a Psoas abscess tracking down to the thigh and knee and mimicking a tumour. Mycobacterium tuberculosis[Ilio-Psoas abscess is an important disease with subtle and often nonspecific presentation that frequently provides a diagnostic challenge. Before the discovery of modern antitubercular treatment, Ilio-Psoas abscess was characteristically a well recognised complication of tuberculosis of the spine. However with the decreasing prevalence of tuberculosis, iliopsoas abscess is becoming uncommon in the developed countries. However with increasing incidence of HIV infection, a recent surge of tuberculosis has been noted, especially with multi-drug resistant rculosis.Mycobacterium tuberculosis.In this communication, we report the first case of tuberculous ilio-psoas abscess, to the best of our knowledge, masquerading as massive tumor of thigh in an immunocompetent host, caused by multi-drug-resistant A 52 year old male patient was referred to our institute as a massive tumor of right thigh  for furtPhysical examination revealed normal vital signs. The right thigh was massively swollen and was non tender and was not associated with any inflammation. The patient looked ill and underweight, but there was no lymph node enlargement or clubbing. Chest and cardiovascular examination was unremarkable. Abdominal examination revealed soft, non-tender abdomen and no organomegaly. Palpation of lumbar spine revealed tenderness .Laboratory investigations revealed normal full blood count, liver enzymes, electrolytes, urea and creatinine. ESR was 85 and HIV serology was negative. X-rays of the chest, pelvis and thigh was normal. X-rays of the lumbar spine  revealedMycobacterium tuberculosis resistant to isoniazid, and rifampicin, but sensitive to ethambutol, pyrazinamide, streptomycin, capreomycin, ofloxacin and amikacin. He was started on pyrazinamide, ethambutol, streptomycin, ofloxacin and amikacin. Isoniazid and rifampicin were discontinued. The abscess was then drained under ultrasound guidance and 650 ml of purulent fluid was obtained. Streptomycin was locally instilled and the drain was kept in place for seven days. A period of 18 months of therapy was completed. At the end of the treatment course, the swelling resolved completely, the patient improved clinically, gained weight and was walking normally.The abscess was aspirated under ultrasound guidance. Ziehl- Neelsen stain of the aspirate was positive for acid-fast bacilli. Culture of the aspirate revealed The clinical presentation of iliopsoas abscess is often variable and non-specific . The claAlong with usual laboratory and routine radiographs, Magnetic resonance imaging should be done for definitive diagnosis because of better discrimination of soft tissues and the ability to visualize the abscess wall and the surrounding structures without the need of a intravenous contrast medium . UltrasoTreatment involves the use of appropriate antitubercular drugs along with drainage of the abscess. Depending on the results of the abscess fluid culture and sensitivity, adjustments should be made. Drainage of the abscess can be done under ultrasound or computed tomography guidance. Tuberculosis is considered as medical disease and is usually well controlled by antitubercular drugs. Indications for surgery  for ilioThis is the first case of its kind, where ilio-psoas abscess presented as massive swelling of the thigh, mimicking as a soft tissue tumor. It is prudent that this condition is recognised and managed promptly. Early management and drainage of the abscess reduces the morbidity and mortality.


Sir,Naso-gastric tube (NGT) is usually indicated for enteral feeding or aspiration of intestinal secretions or stomach wash in cases of suspected poisoning. But before using this tube for any procedure, it is imperative to check and confirm the correct position of the distal end of the tube. Because, occasionally the tube may inadvertently enter the airway instead of the gastrointestinal tract. One can 2in situ. While doing preoperative assessment, hoarseness of voice was noticed in both the cases. It was found to be acute in onset. As we could not get any other reason other than possibility of NGT in trachea, NGT was removed without confirmation of position in first case. As soon as the tube was taken out, patient regained normal voice. With previous experience, it was planned to confirm position of NGT with the help of direct laryngoscopy in second case. After explaining the procedure to the patient, direct laryngoscopy was done and it was found that the tube was entering into the larynx instead of oesophagus. The tube was taken out following confirmation of wrong positioning. NGT was repositioned in oesophagus under direct laryngoscopy and guiding with the help of Magill’s forcep after intubation, in both the cases.A 28-year-old male with perforation peritonitis and a 40-year-old female with intestinal obstruction were scheduled for emergency exploratory laprotomy, with NGT (16 no size) Hoarseness is usually caused by a problem in the vocal cords. During phonation, the vocal cords meet in midline and as air leave the lungs; they vibrate producing sound . AnythinAlthough awake, healthy persons have protective airway reflexes that prevent entry of any FB into the trachea, but general debility and weakness lead to partial suppression of the laryngeal reflexes. Galley s2 detector.[There are various methods to ascertain the position of the tube in the stomach, like aspirating 2 mls of stomach content with a syringe and pour on litmus paper (turn blue litmus paper red), injecting 5 ml of air into the tube (whooshing sound over the epigastrium with stethoscope), X-ray chest and upper abdomen, pH testing of feeding tube aspirates, capnograph, calorimetric COin situ having acute onset hoarseness of voice, one must reconfirm exact position of Naso-gastric tube, with any of the above mentioned technique before starting procedure to avoid fatal consequences.We, therefore, recommend that any case of Naso-gastric tube


Sarcoidosis is a multi-system granulomatous disease of unclear etiology with variable presentation. The common sites of involvement include the lungs and the lymphnodes, though many other organs including liver, spleen, skin, eyes, and even the heart can get involved. The pathological hallmark of this disease is a non-caseating granuloma.The prevalence of cardiac involvement in patients with systemic sarcoidosis ranges from 3.7 to 54.9% depending on the population studied (asymptomatic or symptomatic), imaging techniques used and criteria used for diagnosis. Though c Even when the diagnosis is confirmed, the treatment of cardiac sarcoidosis poses a lot of challenges to the clinician. Though, atrioventricular block, the most common manifestation of cardiac sarcoidosis, may reverse with steroid and/or immunosuppressive therapy, the recurrence rate is very high and pacemaker implantation is almost always needed. The manaAtrial arrhythmias are uncommonly seen in cardiac sarcoidosis. Here agaWith increasing recognition of role of inflammation in cardiac arrhythmias, cardiac sarcoidosis provides an important interlink. As our understanding of inflammatory diseases affecting the heart like tuberculosis and sarcoidosis grows, more research on the inflammatory markers to guide therapy and on agents targeting inflammation for treatment of cardiac arrhythmias in these diseases is the need of the hour.


Various studies have reported discordant profiles of health-related quality of life (HRQOL) after stroke. The aims of this study, the first of its kind, were to determine the real impact of stroke on HRQOL across diverse cultures; and to compare HRQOL between stroke patients and healthy adults, and across stroke severity strata.100 stroke patients and 100 apparently healthy adults (AHAs) in Nigeria; as well as 103 stroke and 50 AHAs in Germany participated. Stroke severity was measured using the National Institute of Health Stroke Scale, Stroke Levity Scale and modified Rankin scale. HRQOL was evaluated using the HRQOL In Stroke Patients (HRQOLISP) measure, a holistic multiculturally-validated measure with seven therapeutically-relevant domains distributed into two spheres.Domains within the spiritual sphere were considered more important by stroke patients. In both countries, stroke patients significantly (0.00001 < p < 0.004) had worse HRQOL than AHAs in all domains within the physical sphere. This was not so for the spiritual sphere. Consistently, stroke severity correlated significantly with all domains in the physical sphere unlike the spiritual sphere. In diverse cultures, the correlation coefficients between HRQOL and all indices of stroke severity revealed a decremental trend from the physical domain  to the spiritual domain .Consistently, stroke elicited a decremental response across domains, with domains in the spiritual sphere being relatively stroke-resilient. The potential utility of the relatively preserved spiritual sphere in facilitating stroke rehabilitation requires evaluation in diverse cultures. Stroke, a leading cause of disability , is usuaEnormous variations have been reported in the profile of HRQOL in stroke patients . FurtherThus, the true impact of stroke on global and dimensional HRQOL remains unknown. This inconsistency is most probably due to considerable variations in the rigor of the methods used and the inadequacies of both qualitative and quantitative HRQOL assessment measures . None ofFurthermore, very few of the previous studies compared HRQOL in stroke patients with healthy controls while there is no international study using the same protocol and instrument to unravel the consistent impact of stroke on HRQOL across cultures. While some of the reported wide variations in post-stroke HRQOL may be due to cultural differences, it is pertinent to ascertain which aspects of post-stroke HRQOL are stable or consistently impaired across cultures. This necessitates the cross-cultural comparison of HRQOL.The aims of this study were to assess the impact of stroke on HRQOL in diverse cultures using a holistic measure (the HRQOL In Stroke Patients [HRQOLISP] questionnaire); and to compare HRQOL between stroke patients and healthy adults and across stroke severity strata. The HRQOLISP is a holistic multiculturally-validated measure based on an integrative concept of human life: the seed of life model (SOLM). The SOLM was derived from extensive literature research, multidisciplinary consultations, and discussion with stroke patients ,9,11. ItThe SOLM ,9,11 is The study was conducted between 2002 and 2004 at the University College Hospital, in Ibadan a major city in Nigeria; and from 2004 to 2005 at the Median Klinik, and the Evangelisches Geriatrisches Zentrum in Berlin, a major city in Germany. Nigeria is a low-income African country while Germany is a high-income European country. Ethical approvals were obtained from the ethical committees of the University of Ibadan/University College Hospital, Ibadan and Charité Universitätsmedizin, Berlin.A multicenter international design was employed with stroke as the exposure variable and HRQOL as the outcome variable. Hospital-based medical records of stroke patients were reviewed to obtain retrospective data about stroke.Self-reported medical histories of adult volunteers were reviewed to ascertain that they were healthy . In Ibadan, healthy clients of the geriatric clinic who visited the clinic regularly for medical screening were recruited. In Berlin, healthy hospital workers and clients of the Sport Gesundheit Park were included. Thus, a reference group of apparently healthy adults (AHAs) ,15 with Consecutive stroke patients encountered within the study period who fulfilled the inclusion criteria and gave consent were included. To improve the generalizability of the findings and because the impact of stroke on HRQOL may persist for life  : 'physiMoreover Principal Component Analysis of the seven domains showed two principal components which explained 79% of the total variance. Component 1  had an Eigenvalue of 4.42, while component 2  had an Eigenvalue of 1.14.Furthermore, internal consistency reliability and single factor analysis of the spheres yielded the following results. The spiritual sphere   and Stroke levity scale (SLS). The SLS correlates significantly to the NIHSS  and can be applied in illiterate populations . The modThe HRQOLISP was applied to consecutive patients or their reliable proxies. To ensure honest responses to personal questions, the preferred mode of administration was self-completion by the respondents. However, if the patient or proxy was unable to read and write, it was applied by face-to-face interview conducted by the same investigator in both countries. To assess the effect of mode of administration on responses, a subset of five respondents had the questionnaire administered to them by the interviewer after they had completed the questionnaire by themselves.The hypothesis tested in the data analysis was that 'despite cultural and religious differences, patients suffering from stroke, which is primarily a physical ailment, would have their spiritual functioning preserved relative to their physical functioning.' Specifically, 'across diverse cultures, the severity of stroke should correlate significantly with domains measuring the physical aspects of quality of life rather than domains assessing the spiritual components of quality of life.'Socio-demographic data collected from the patients, including age, gender and occupation, were collated and summarized. Differences between stroke patients and AHAs were analyzed using student's t-test for continuous variables and chi-square for categorical variables. HRQOLISP and SLS scores were generated with previously described methods . HRQOLISThe socio-demographic and clinical characteristics of the participants are summarized in Table Analysis of relevant items in the SLS and HRQOLISP revealed aphasia in 31% in Ibadan and 38% in Berlin; sexual dysfunction in 45% in Ibadan and 80% in Berlin; and post stroke emotional disorder in 75% in Ibadan and 68% in Berlin.In the subset of five respondents who had the questionnaire administered to them by two methods, there was strong correlation between the HRQOL scores obtained by interview and self-administration .In both Ibadan and Berlin, all domains were rated at least moderatelyimportant by AHAs and stroke patients. Domains in the spiritual sphere were accorded higher importance rating by stroke patients than by AHAs in both cities. The mean HRQOLISP scores for the AHAs were similar in the physical sphere in Berlin and Ibadan, but higher in the spiritual sphere in Ibadan than Berlin Tables  and 3. CIn both countries, in contrast to domains within the spiritual sphere, stroke severity correlated significantly with all domains in the physical sphere Table . FurtherThe study of HRQOL involves the assessment of multiple subjective realities in constant flux ,7. AlthoIdeally, to measure the true impact of stroke on HRQOL, a prospective cohort of patients at high risk of stroke would be recruited and their HRQOL would be measured just before and after stroke. The difference in HRQOL so derived would be ascribed to the stroke event. However such a study which is not cost-efficient, would require the recruitment of very large number of patients which may eventually yield very few stroke patients resulting in poorly generalizable results as in the Framingham study  .Therefore, the realistic design for measuring the impact of stroke on HRQOL is to compare the HRQOL in stroke patients with normative data from a healthy reference group. This assumes that the HRQOL of the stroke patient before the stroke is approximately the HRQOL of the healthy population.This design revealed that stroke consistently resulted in worse HRQOL scores in all domains in both countries Tables  and 2B. Thus, in comparison to AHAs, impairment of physical, psycho-emotional, cognitive and eco-social domains appears to be a consistent finding in stroke ,4,18,25.Consistently, the spiritual sphere was relatively stroke-resistant Tables  and 2B. Furthermore, domains in the spiritual sphere were considered more important by stroke patients. This was so, even in Berlin, where religious beliefs were less intense than in Ibadan. This high rating of the spiritual sphere is probably due to its documented pivotal role in the re-establishment of continuity of self ,21,29,30In both cities, in clear contrast to the domains in the spiritual sphere, all domains in the physical sphere correlated significantly to all measures of stroke severity Table . Thus, sAdditionally, in Ibadan and Berlin, a decremental trend in the correlation coefficients of stroke severity to HRQOL was consistently demonstrated across domains going from the outermost to the innermost domain. The strongest correlation was found to the physical domain while the weakest was to the spiritual domain Table  and 3B. Taken together, these findings have implications for evidence-based rehabilitation service planning and health resource allocation  ,6,7,13. Nevertheless, due to the documented ,7,29,30 This is the first study of HRQOL in stroke patients to use a holistic well-validated measure in a transnational multicultural setting comparing a low-income African country to an industrialized high-income European country. In these contrasting settings, the same protocol was applied including the establishment of normative groups of AHAs. This comparison group was well-matched for age and gender in Ibadan, and age in Berlin. The incomplete matching of the comparison group for gender in Berlin was controlled for in the analysis using ANCOVA. Furthermore, subgroup analysis comparing male stroke patients to male AHAs and female stroke patients to female AHAs yielded similar results with mean differences in HRQOL being substantially greater in the physical sphere.The consistent observation of the dualistic impact of stroke on HRQOL and its decremental response across domains are unique and novel. Prospective multicultural transnational studies are required to explore this pattern and unravel the dynamic interplay between the physical and spiritual spheres of HRQOL. As illustrated in Figure Consistently, in diverse cultural settings with different religious and ethnic identities, stroke had a dualistic impact on HRQOL. It elicited a decremental response across domains, with domains in the spiritual sphere being relatively stroke-resistant. While the more affected physical sphere should be the primary target for restorative therapy, the relatively preserved spiritual sphere could help to promote coping. In this respect, the preserved spiritual sphere could serve as a trigger for revitalizing other aspects of HRQOL.In diverse cultures, therapeutic exploitation of these personal resources might facilitate adaptive processes and even promote the impact of restorative interventions for the physical sphere. However, the potential of the spiritual sphere to reduce the biographical impact of stroke is likely to be modified by its post-ictal salience in a given cultural and personal context. Prospective studies are warranted to exploit the dynamics of this novel paradigm. This may serve as a model for other chronic neurologic conditions with potential biographic impact.HRQOL: Health related quality of life; HRQOLISP: Health related quality of life in stroke patients questionnaire; SLS: stroke levity scale; SOLM: seed of life model; NIHSS: National institute of health stroke scale; mRS: modified Rankin scale; AHA: Apparently healthy adults; SEC: socioeconomic classThe author declares that they have no competing interests.MOO conceived and designed the study. He collected and analysed the data and drafted the manuscript.Dr. Mayowa Ojo OWOLABI,MBBS, MWACP, FMCP, Dr. med.-magna cum laude (Berlin), Cert. Epid. & Glob. Health (Dundee)Senior Lecturer and Consultant Neurologist, Department of Medicine,University College Hospital, Ibadan. Nigeria.Pioneering Regional Vice President ,World Federation for Neurorehabilitation.mayowaowolabi@yahoo.comEmail address: Telephone Number: +234 802 077 5595+234 807 849 6775Health-Related Quality Of Life In Stroke Patients (HRQOLISP) questionnaire-original international version. The file contains the complete HRQOLISP instrument.Click here for fileHealth-Related Quality Of Life In Stroke Patients (HRQOLISP) questionnaire-German version. The file contains the complete German version of the HRQOLISP instrument.Click here for file


The present paper reviews pediatric posttraumatic stress disorder, emphasizing the relational basis of the disorder and highlighting the missing link between juvenile delinquency and trauma. The first part of the paper defines trauma and the diagnostic criteria for PTSD, noting child-specific features. The second part reviews the literature emphasizing the relational and attachment relevant nature of trauma. The third part explores psychological mechanisms for how attachment relations could affect trauma responses. Attachment relations (1) shape core schemas of the world, others, and the self and (2) foster emotional engagement or disengagement, both of which have been associated with traumatic responses. The most empirically supported pediatric trauma treatment, trauma-focused cognitive behavioral therapy (TF-CBT), acknowledges the attachment figure's influence and includes treating and training the parent and conjoint child-parent discussion. The next section reviews the noteworthy link between juvenile delinquency and trauma history. More awareness of trauma and PTSD in children and adolescents is recommended to effectively address juvenile delinquency. The review ends with a few helpful points for practicing pediatricians regarding childhood trauma. Trauma and PTSD in children occur in the context of the ongoing parent-child relation, and this lens may offer insights to the correlations which previous studies have uncovered, integrating the findings and adding a fuller contour to the picture of pediatric PTSD. This paper aims to review and integrate an understanding of PTSD in children and adolescents in an attachment context and organizes the article in several sections: defining PTSD in children; a review of parental influences on pediatric PTSD; psychological mechanisms for how attachment relations affect trauma responses; the link between PTSD and juvenile delinquency; a few take-away points for pediatricians.Trauma is a profound experience of the loss of security and welfare evoking feelings of fear, helplessness, horror, and possibly disorganized agitation in children . The desThe latest DSM-IV-TR outlines the diagnostic criteria for PTSD following the occurrence of a traumatic event, including symptoms for longer than one month of 1) reliving the trauma, (2) avoiding associations related to the trauma, and (3) increased arousal resulting in “clinically significant distress or impairment in social, occupational, or other important areas of functioning” [ relivingChildren may suffer from trauma in many significant ways including developmental delays; numerous social, behavioral, and academic difficulties; somatic complaints; lower self-esteem; attachment issues . Thus, PTo more deeply understand the nature of post traumatic stress disorder (PTSD), including the impact of the etiological event of the trauma and the manifestation and trajectory of its symptoms, some scholars have turned to the influence of attachment figures and attachment styles on PTSD. This focus occurs in the larger context of the growing interest in emotions and their social function in the psychological sciences  and psycOther pools of research which suggest the influence of parents on pediatric PTSD include papers on the interpersonal aspects of trauma and PTSD , the effMuch of the highlighted literature is guided by the primacy of the parent-child relationship and the strong influence of parent variables and behaviors on child outcomes. Research in developmental , 18 and What psychological mechanisms may explain how attachment relations affect traumatic responses? It is interesting that both literature in trauma and that in attachment relations discuss the role of (1) core schemas and (2) emotional engagement as relevant psychological mechanisms. First, if attachment relations shape core schemas, and PTSD is caused by negative schemas of the self and world formed through trauma, then it is plausible that attachment figures can play a role in influencing PTSD. Schemas are a conceptual framework based on life experiences that help the individual organize information and interpret and adapt to the environment. Trauma can cause damage either by negatively changing one's positive schemas of one's self as competent and the world as safe or by priming existing knowledge of one's self as incompetent and the world as dangerous . Though Attachment theory founder Bowlby  conceiveAccording to developmental psychologist Jean Piaget, who is commonly known for introducing and popularizing the term schema, childhood was a time of rapid schema development. Thus, behaviors by attachment figures (as well as childhood trauma) should have a stronger impact during this time in schema formation, providing the foundational schema which can be further tweaked. Following the line of thought of the core schema theory, attachment figures that strengthen the child's schemas of the self as competent and the world as safe can play a role in mitigating the negative effects of trauma and the likelihood of PTSD. Second, if emotional engagement with the trauma facilitates trauma resolution, then the healthy attachment relationship, which can elicit strong feelings of engagement and comfort, should help process trauma feelings and mitigate PTSD. Conversely, trauma occurring in the context of an unhealthy attachment relationship which hinders emotional engagement with the trauma should increase PTSD. Research points to early emotional engagement with the trauma as crucial for trauma processing and recovery and emotional withholding, avoidance, or disassociation as linked to PTSD severity –30. IndeAttachment relations can play a critical role in emotional engagement with the trauma. First, it is within the context of the attachment relation that infants first learn about emotional engagement, as both the receiver and giver of it, developing styles of engagement  based on patterns of the attachment figure's sensitivity, responsiveness, timeliness, and availability . For theAinsworth  found thAttachment theory holds that this attachment style, though first shaped by the attachment figure, extends beyond the primary relation and is correlated with later responses and psychopathology . On the Second, attachment figures can help children emotionally engage with and process the relevant trauma. Though attachment style is relevant throughout the lifespan, the facilitation of emotional engagement by attachment figures like parents is especially pertinent for children facing childhood trauma; attachment theory holds that attachment behaviors are most visible during early childhood and during times of distress and uncertainty , both ofThe most empirically supported pediatric trauma treatment, trauma-focused cognitive behavioral therapy (TF-CBT), incorporates all of the previously discussed aspects, aiming to support positive core schemas and correct maladaptive ones, foster emotional engagement, and strengthen the parent child bond . This trThe complexity of trauma situations and degree and nature of parent involvement in the trauma, from less involved, witness, victim similar to the child, enabler, or perpetrator, will affect the parent-child dynamic, parent and child symptomatology, and healing of the trauma. As discussed in the literature review, relational traumas are more influential, and thus, traumas in which parents are involved in a more negative light will likely be more challenging. However, as discussed above, TF-CBT provides a general method for addressing childhood trauma, and with the assumption that the involved caregiver is not a current threat to the child, it utilizes the strength of the parent-child attachment dynamic in facilitating cognitive and emotional trauma processing for healing. While TF-CBT is empirically supported , it is lAs an anxiety disorder, one may imagine PTSD to be a source of strife for the victim and perhaps close a circle of contacts. However, rather than being a quietly contained disorder, the violence and chaos experienced by the victim through trauma may manifest as outward acts of aggression, delinquency, and conduct disorder; conduct disorder behaviors and the like may be considered as symptoms of PTSD, rather than isolated problems. Ryan and Testa's  finding In youth with conduct disorder, Reebye et al.  found PTThe environmental factors conducive to juvenile delinquency such as parental psychopathology, drug use, and criminal activity; neighborhoods with criminal subculture, low participation, and frequent mobility among residents; poor school conditions with chaotic environments  are alsoThus, children in the previously mentioned negative environments who have also experienced trauma are at greatest risk for juvenile offending, and care should be taken to view aggressive actions in context of trauma history and environment rather than as merely innately malicious acts. Individual risk factors associated with juvenile delinquency such as low social conformity, drug use, low self-esteem, antisocial attitudes, noncompliance, and poor school achievement  are all Tarolla et al.  describeThe child's advocates include the family, teachers, pediatrician, and mental health care specialists such as social workers, therapists, psychologists, and psychiatrists, and in light of the previous research, measures taken by these members to resolve trauma are in themselves a preventative measure against juvenile delinquency. Though mental health care specialists will be responsible for the formal psychological assessment and treatment, pediatricians aware of trauma symptoms and treatment will have a more comprehensive understanding of the patient and can also effectively make referrals if needed. Based on this paper, a few take-away points regarding childhood trauma for pediatricians include the chaotic environmental factors conducive to both trauma and juvenile delinquency described in the previous section; the earlier described DSM-IV criteria for PTSD, noting child-specific features; the fact that trauma can affect the child without the child meeting full PTSD criteria and that these effects may subtly or explicitly affect the child's functioning and development, manifesting as developmental delays, behavioral or academic difficulties, or somatic complaints and may also resemble symptoms traditionally associated with ADHD, conduct disorder, or juvenile delinquency (see  for a fuUnderstanding trauma history and strengthening attachment relations will be a critical piece in addressing and healing delinquent children and adolescents.


The axillary approach to brachial plexus blockade provides satisfactory anaesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the four main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or ultrasound guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable, and the paper summarizes the current position with particular reference to ultrasound guidance. The axillary approach to brachial plexus was first demonstrated in 1884 by William Halsted when he injected cocaine under direct vision . It was The brachial plexus supplies the nerve supply to the upper limb and is formed by the ventral rami of the lower four cervical nerves and the first thoracic nerve. It consists of roots, trunks, divisions, and cords. The roots are arranged between the scalenus anterior and medius muscles, and they combine in the posterior triangle to form three trunks: upper, middle, and lower. On approaching the clavicle, each of the three trunks divides into an anterior and posterior division to supply the flexor and extensor compartments of the arm, respectively. Anterior divisions of the upper and middle trunk unite to form the lateral cord, anterior division of the lower trunk continues as the medial cord, and posterior divisions of all the three trunks assemble to from the posterior cord. The three cords enter the axilla at the apex and are arranged, according to the names, around the second and third parts of the axillary artery. In relation to the first part of the artery, however, the lateral and posterior cords are lateral, and the medial cord lies posterior to the artery.At the lateral border of the pectoralis minor muscle, the cords divide into terminal nerves of the brachial plexus: musculocutaneous, median, ulnar, radial, axillary, medial cutaneous nerve of arm (MCNA), and medial cutaneous nerve of forearm (MCNF), which along with the intercosto-brachial nerve (ICB) provide the sensory and motor supply to the whole upper extremity . The corAt the level of axilla, the median, radial, and ulnar nerves lie within the neurovascular bundle, whereas the median cutaneous nerve of the arm and forearm may lie either inside or outside the sheath. The musculocutaneous nerve always lies outside the sheath , because it leaves the lateral cord before the cords enter the axilla. Within the fascia, in relation to the axillary artery, the nerves are arranged as follows: (1) median-lateral and anterior, (2) ulnar-medial and anterior, and (3) radial-medial and posterior. The musculocutaneous nerve appears lateral and posterior to the artery.The best approach to brachial plexus is determined by the sensory and motor innervations of the surgical site concerned and the potential adverse effects of each. Hence, for shoulder and proximal humeral procedures, an interscalene block is performed, which reliably blocks C5-C6 nerve roots and proximal branches such as the suprascapular nerve. A supraclavicular approach provides the most widespread surgical anaesthesia for the whole arm, whilst an infraclavicular approach often provides a pattern similar to the axillary approach.An axillary approach provides good surgical anaesthesia for the elbow, forearm, and hand and also cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve. The axillary approach to the brachial plexus is considered the safest of the four approaches because of reduced risk to surrounding structures such as the risk of phrenic nerve blockade and/or pneumothorax, but the general risks of accidental intravascular and intraneural injection still exists.surgical anaesthesia for elbow, forearm, and hand procedures,cutaneous anesthesia for superficial procedures of the inner arm, for example, brachiobasilic fistula formation,chronic pain treatment.peripheral nerve stimulation,ultrasound guided. The use of a nerve stimulator for peripheral nerve blockade provided a definite advantage over traditional paraesthesia or transarterial techniques of the 1980s and became the most favoured modality used for peripheral block performance until the advent of ultrasound guidance. A multi-injection technique using a nerve stimulator was found to be associated with a higher success rate , as tradIn 1981, Abramowitz and Cohen described the first use of Doppler ultrasound to identify the axillary artery, thereby aiding the performance of axillary plexus block for upper limb surgery . But it The arm is abducted to 90 degrees and the elbow flexed to 90 degrees. The axilla is prepared aseptically and a high-frequency linear probe scans in a transverse plane at the lateral border of pectoralis major muscle. The pulsating axillary artery is visualized, and the transducer moved to locate the individual nerves around the artery. Easing the pressure off the transducer usually reveals the position of the axillary vein. The nerves at this level have a honeycomb appearance, but their locations relative to the artery are variable. The median nerve usually lies around 9–12 o'clock position, the ulnar nerve often in the corresponding 2 o'clock position, and radial at the 5 o'clock position in relation to the artery  Figure . The musAfter positioning of the probe, we recommend infiltration of local anaesthetic distal to the probe, subcutaneously, to cover the injection site and to block the intercostobrachial nerve. A short-bevelled 5 cm needle can then be inserted either in-plane or out-of-plane  relative−1and Mepivacaine 1% provide effective nerve blockade for 2.5–3 hours and are ideal for shorter duration procedures [The choice of local anaesthetic is determined by the duration of sensory analgesia desired. Lidocaine 1.5–2% with adrenaline 5 mcg·mLocedures , 23. Forocedures . When usocedures .2of Mepivacaine has been shown to effective for individual nerves of axillary block, which translates into 0.7–1 mL of local anaesthetic for individual nerves [In the past, it was necessary to use large volumes of local anaesthetic to achieve acceptable success rates for peripheral regional anaesthetic techniques. Recent studies have shown that volume of local anaesthetic can be significantly reduced when axillary blocks are performed under ultrasound guidance , 23, 26.l nerves . HoweverAxillary nerve block is a safe and effective regional anaesthetic technique suitable for a wide variety of procedures, for both inpatient and outpatient care –32. Ultr


Hepatoid carcinoma of the ovary (HCO) was first reported in 1987 in 5 cases of malignant ovarian tumors which were similar to hepatocarcinoma in the histological analysis. We report the first case in the literature of a patient diagnosed with HCO treated using HIPEC after extensive cytoreductive surgery, and we discuss the value of this therapeutical option in patients with HCO. Hepatoid carcinoma of the ovary (HCO) was first reported in 1987 by Ishikura and Scully , current2). The patient was discharged on the sixth postoperative day without any adverse event. The histological analysis revealed the presence of hepatoid ovarian carcinoma (2). Currently, she has metastasis in the L2 vertebra treated with radiotherapy, without any signs of peritoneal relapse, 28 months after surgery.A 57-year-old female with no relevant medical history was referred to our unit with clinical symptoms consisting in abdominal discomfort and distension, nauseas, vomiting, and weight loss. On physical exploration, there was a palpable mass in the hypogastrium with high volume of ascites. Laboratory tests showed a high serum AFP level  and high serum CA125 level . A subsequent pelvic and abdominal computerized tomography (CT) scan demonstrated the presence of a large pelvic mass, ascites, and omental cake, suggesting ovarian neoplasia with peritoneal dissemination (IIIC-stage) . One gasarcinoma  with botHCO was first reported by Ishikura and Scully in 1987, after discovering 5 cases of malignant ovarian tumors which were similar to hepatocarcinoma in the histological analysis [In the histological analysis of this type of tumors, diffuse infiltration of the ovarian parenchyma is usually found due to a columnar neoplasia composed of polygonal cells with eosinophilic cytoplasms, forming structures which look like the histological image that appears in well-differentiated hepatocarcinoma . In immuIn the genital area, 75% of cases were reported in the ovary. The absence of lesions in the liver parenchyma, upon diagnosis or during followup, would support the diagnosis of the primary ovarian origin of the neoplasia. The simultaneous presence of an ovarian and hepatic lesion at the time of diagnosis makes it very difficult to distinguish between primary ovarian or hepatic origin, although ovarian metastases of hepatocarcinoma are very uncommon [The precise origin of the tumor cell is controversial. HCO has sometimes been classified within the group of primary ovarian tumors, in the “miscellaneous” section. The association of this carcinoma with areas of papillary serous carcinoma or areas of adenocarcinoma, in addition to its elevated Ca.125 marker, lends support to its epithelial origin .The therapeutic protocol published by Sugarbaker, initially for gastrointestinal tumors with peritoneal dissemination, proposes maximal surgical cytoreduction, which would eliminate macroscopic disease, accompanied by the administration of hyperthermic intraoperative intraperitoneal chemotherapy (with platins and taxanes in the case of the ovary) which would eradicate microscopic disease, the cause of relapses detected during followup . Ideal cTo conclude, the use of peritonectomy procedures and the use of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) are a therapeutic weapon which has demonstrated its utility in peritoneal dissemination in gastrointestinal and gynecological tumors. Ovarian carcinoma has been postulated as a firm candidate for this therapy and hepatoid carcinoma of the ovary could also benefit from this.


Over the past forty years the availability of coagulation factor replacement therapy has greatly contributed to the improved care of people with hemophilia. Following the blood-borne viral infections in the late 1970s and early 1980, caused by coagulation factor concentrates manufactured using non-virally inactivated pooled plasma, the need for safer treatment became crucial to the hemophilia community. The introduction of virus inactivated plasma-derived coagulation factors and then of recombinant products has revolutionized the care of these people. These therapeutic weapons have improved their quality of life and that of their families and permitted home treatment, i.e., factor replacement therapy at regular intervals in order to prevent both bleeding and the resultant joint damage (i.e. primary prophylaxis). Accordingly, a near normal lifestyle and life-expectancy have been achieved. The main current problem in hemophilia is the onset of alloantibodies inactivating the infused coagulation factor, even though immune tolerance regimens based on long-term daily injections of large dosages of coagulation factors are able to eradicate inhibitors in approximately two-thirds of affected patients. In addition availability of products that bypass the intrinsic coagulation defects have dramatically improved the management of this complication. The major challenges of current treatment regimens, such the short half life of hemophilia therapeutics with need for frequent intravenous injections, encourage the current efforts to produce coagulation factors with more prolonged bioavailability. Finally, intensive research is devoted to gene transfer therapy, the only way to ultimately obtain cure in hemophilia. Hemophilia A and B are X chromosome-linked bleeding disorders included among the rare diseases and caused by mutations in the factor VIII (FVIII) and factor IX (FIX) genes . Both fath century, described a family with males who died from bleeding after trivial injury [Hemophilia was recognized in ancient times. The Talmud, a collection of Jewish rabbinical writings from the second century AD, stated that male babies should not be circumcised provided two brothers had already died owing to excessive bleeding from the procedure. The Arabic physician Albucasis, who lived in the 12l injury . The firl injury ." He clel injury . Hemophil injury . Her eigl injury .anti-hemophilic globulin. In 1944, Pavlosky from Buenos Aires, showed that blood from one hemophiliac could correct the coagulation defect of another hemophiliac and vice-versa. He had stumbled upon two patients with a deficiency in different proteins - factor VIII and factor IX [The bleeding tendency of hemophilia was originally believed to be due to a fragility of blood vessels. In the 1930s defective platelets were thought to be the most likely cause. Then, in 1937, Patek and Taylor from Harvard found that they could correct the coagulation defect by adding a substance extracted from plasma. This was called In the 1950s and early 1960s, hemophiliacs could be only treated with whole blood or fresh plasma. Unfortunately, there is not enough FVIII or FIX proteins in these blood products to stop severe bleeding. Thus most people with severe hemophilia died in childhood or in early adulthood, hemorrhages after surgery or trauma or in vital organs  being the most common causes of death . In 1964This optimistic perception of hemophilia changed dramatically in the early 1980s, at a time when 60-70% of people with severe disease became infected with the human immunodeficiency virus (HIV) that had contaminated coagulation factor concentrates. Almost all treated hemophiliacs were also infected with the hepatitis C virus (HCV) , transmitted by factor concentrates manufactured from plasma pooled from thousands of donors . As a coAlthough the safety of plasma-derived factors has dramatically improved in the last 25 years, the fear related to the possible transmission by blood or its derivates of new or unknown pathogens has prompted the hemophilia caregivers of western countries to treat previously untreated hemophilic babies mainly with recombinant products . In paraThe availability for replacement therapy of high-quality factor concentrates was important not only for reducing the likelihood of death from hemorrhage but also for the broad implementation of prophylactic treatment regimens in order to prevent bleeding and resultant joint damage, ultimately allowing patients to maintain a near normal lifestyle . This, tIn this favorable context, the most challenging complication of therapy has become the development of inhibitory alloantibodies against FVIII or FIX. These inhibitors, that develop in approximately 25-30% of severe hemophilia A patients and in only 3-5% of those with hemophilia B, render replacement therapies ineffective, limit patient access to a safe and effective standard of care and predispose them to an increased risk of morbidity and mortality . The intDespite intensive research in the field of inhibitor development, the mechanism of this complication still remains only partially understood. Patient-related, non-modifiable risk factors as well as environmental modifiable risk factors have been identified ,27. Debahttp://www.clinicaltrials.gov, study NCT 01064284; EUDRACT n. 2009-011186-88). SIPPET is an investigator-driven, prospective, randomized, open-label clinical trial comparing inhibitor frequency in PUPs or minimally treated patients first exposed to plasma-derived VWF/FVIII concentrates or recombinant FVIII [Unfortunately, no randomized clinical trial is currently available to provide definite evidence on whether or not a difference in immunogenicity does indeed exist between plasma-derived and recombinant FVIII. For this reason, the Survey of Inhibitors in Plasma-Product Exposed Toddlers (SIPPET) has recently started , a method meant eradicate inhibitors through the long-term daily treatment of patients with large doses of coagulation factors. ITI is the only proven therapy for inhibitors, but puts enormous challenges on patients and the community in terms of venous access and economic burden (up to 1 million Euros), so that it is prohibitive for many countries. After several in vitro studies showed a decrease in inhibitor activity against FVIII complexed with VWF (VWF/FVIII) compared with that against recombinant FVIII ,40, a nuWith the widespread adoption of primary prophylaxis programs and the implementation of ITI regimens requiring intensive and regular infusion of factor concentrates, the route of administration of replacement therapy has become a crucial issue. Although peripheral venipuncture is the first choice, central venous access devices (CVADs) are often necessary in very young children with poor venous access. Totally implantable catheters (ports) should be preferred over external CVADs because the risk of complications, especially infections and thrombosis, is smaller . TransieWhile primary prophylaxis remains the gold standard for preserving joint function in babies with severe hemophilia , there iWhile reaching more advanced age, persons with hemophilia are developing medical and surgical conditions, such as cardiovascular diseases and cancers, that were previously uncommon ,18,51-53In the last decade the ultimate goal of the investigators has been the search of the definitive cure of hemophilia, i.e. the correction through gene transfer of the underlying DNA defect . FollowiIn the last two decades the forementioned advances on the efficacy and safety of the treatment of hemophiliacs have been obtained and implemented quasi exclusively in western countries. Thus, the first goal for the next future is to obtain wider treatment availability. There are a number of emerging and densely populated countries, such as India and China, where the level of hemophilia care is far from being satisfactory. For these countries, which are rapidly developing a high level of technological competence, it is probably more appropriate to foster DNA technology with the goal to produce recombinant factors and develop gene transfer rather than programmes based on plasma fractionation. On the other hand, the industrial production of plasma-derived factors should continue and expand, to meet the increasing needs and demands of those countries  that are rapidly improving their programmes of health care delivery to persons with hemophilia and that cannot afford the higher cost of recombinant factors. Although the extension of programmes of hemophilia care to developing countries is the main goal for the immediate future, there are also a number of objectives for high-income countries. First of all, to maintain the current excellent levels of treatment that risks to be jeopardized owing to the global economic crisis. It must be emphasized that the costs of hemophilia are truly a tiny part of the whole budget for health care in any country, and that cost effectiveness of hemophilia care is well proven. In addition, richer countries should support the needs of factor replacement therapy of low-income countries of Africa, where an adequate production of plasma-derived or recombinant factor concentrates cannot be foreseen for the next future.(OBI-1) and tested in a phase II trial in hemophilia A patients with inhibitors [From a research point of view, which advances in the treatment are likely to be realized in the next ten years? The most likely progress in this field is the availability of FVIII and FIX molecules with longer half-lives. This would be a significant step forward, considering that in countries that can afford primary prophylaxis the main obstacles to its widespread adoption are problems related to venous access. Several pharmaceutical companies are currently developing factors with longer half-life to obviate frequent administration, and/or reduced antigenicity/immunogenicity to minimize inhibitor development -70. The hibitors . This prhibitors . HoweverIn the past three decades, hemophilia has moved from the status of a neglected and often fatal hereditary hemorrhagic disorder to that of a defined group of well-characterized molecular entities. There is little doubt at the moment that, among the most prevalent monogenic disorders , hemophilia enjoys the most efficacious and safe treatment. Indeed, after the dramatic events of widespread blood-borne virus transmission in the 1970s–1980s, there has been a strong drive towards a continuous improvement in the efficacy and safety of replacement therapy and towards the cure of the disease through gene therapy. To maintain this high level of health care and research two elements are essential. First, there is a need of international collaboration in clinical research on hemophilia. Indeed, very few of the aforementioned cogent unsolved questions can be tackled by studies done in single, albeit large, hemophilia centers. The adequacy of the sample size is essential also for a rare disease such hemophilia and this goal can be achieved only through collaborative multicenter studies. Secondly, it is necessary to maintain a high interest and expertise in the field of hemophilia, especially among newer generations of physicians, who appear to be attracted by the more appealing thrombotic side of hemostasis .PMM has received speaker fees from Baxter, Bayer, Biotest, Grifols, Kedrion, Novo Nordisk, Pfizer and consultantship fees from Bayer. MF declares no conflict of interest.MF wrote the first draft of the manuscript after detailed planning with PMM, who revised substantially all the drafts. Both authors read and approved the final manuscript.


Introducing the Cardiovascular, metabolic and lipoprotein translation section of journal of translational medicine. Journal of Translational Medicine has focused on all areas of translational medicine derived from human experimentation to facilitate the communication between basic and clinical science. As the obesity, diabetes and cardiovascular disease epidemic continues to rise, especially with industrialization of developing countries [The ountries , there iountries  related Indeed the thrust to discover novel pathways for therapeutics within the cardiometabolic arena is accelerating rapidly with the continued advent of technologies in genomics , biologiJournal of Translational Medicine, which is devoted to the rapid publication of research papers within these fields.However, groups performing cardiometabolic and lipoprotein-based multi-disciplinary, translational research between the T1 and T2 phases often struggle to find an appropriate target journal to publish their findings because of the mixed content of basic and clinical research. This mismatch often delays publication of important findings due to the combination of multiple submissions to basic science and clinical journals. In order to increase the speed at which discoveries move from the lab into the clinic, ultimately improving the health of populations, fast and efficient communication is essential to keep up with these moving targets. Therefore, we here introduce the section of Cardiovascular, metabolic and lipoprotein translation within the This section aims to speed mechanistic understanding, development of novel diagnostics and potential therapeutic targets within cardiovascular, metabolic diseases and lipoprotein diseases. We are open to experiments involving cellular models, animal models, observational studies and clinical trials that are distinguished for their novelty in approach, design or indication, timeliness, and unique ability to translate laboratory concepts from the bench to the bedside. Highest priority will be given to those manuscripts which are specifically focused on cardiovascular, metabolic and lipid disorders which enrich understanding of disease mechanism, novel therapeutics and state-of-the-art scientific technique.We invite your group to consider publishing your findings within this exciting new section which will be overseen by a talented group of Editorial Board members within cardiovascular medicine, lipoprotein biology, endocrinology, metabolism, animal biology, basic science and human genomics.


Hirudo sp., has been particularly informative. These leeches express well-defined behaviors and autonomic movements which are amenable to investigation at the circuit and neuronal levels. In this review, we discuss some of the best understood of these movements and the circuits which underlie them, focusing on swimming, crawling and heartbeat. We also discuss the rudiments of decision-making: the selection between generally mutually exclusive behaviors at the neuronal level.In the study of the neural circuits underlying behavior and autonomic functions, the stereotyped and accessible nervous system of medicinal leeches,  The study of the neuronal basis of movement, both behavioral and autonomic, is often stymied by an inability to move between cellular, network, system and behavioral levels and an inability to disambiguate the role of sensory feedback and centrally generated commands . While mWhen sufficiently motivated by sensory input that either suggests a potential meal or indicates a disturbance, leeches will initiate targeted locomotion in the form of swimming or crawling ,10. GentLeeches swim with a dorsoventral, approximately sinusoidal, undulatory traveling wave with a wavelength of approximately one body length . SwimminSwimming can be experimentally elicited, either as an escape mechanism or for directed locomotion. A moderate touch or a more significant, higher-intensity contact can initiate swimming in sufficiently deep water. When the leech is hungry, either pressure or light-dark waves in water will elicit from the leech targeted locomotion toward the apparent source ,17. AlteThe central pattern generator (CPG) circuit that produces the swimming motor pattern in leeches is composed of complex segmental oscillators which rely heavily on intersegmental connectivity to generate a robust motor pattern. Midbody ganglia contain a bilateral, triphasic oscillator composed predominantly of bilaterally paired interneurons with significant interganglion connectivity Figure . The conNeurons of the CPG receive indirect input from sensory neurons, as well as direct input from trigger, command and gating neurons and synapse onto both inhibitory and excitatory motor neurons. Furthermore, there are significant asymmetric connections between the swim oscillators in neighboring ganglia that help maintain an intersegmental phase lag along the longitudinal (front-to-rear) axis of the animal Figure , althougAlthough an isolated nerve cord can express a fictive swimming motor pattern, some characteristics of the pattern in the intact animal are altered by sensory feedback. In particular, intersegmental coordination is affected by the stretch receptors in the longitudinal muscles ,23. CertThe second primary mode of locomotion that leeches exhibit is crawling in various forms. In the best studied form, the leech plants its posterior sucker, extends its body with a wave of circular muscle contraction from anterior to posterior, then plants its anterior sucker, releases the posterior sucker, shortens its body with a front-to-rear wave  and finally anchors its posterior sucker. To achieve this elongation and shortening, the circular muscles and longitudinal muscles within each segment contract in antiphase. In air, each cycle or "step" typically moves a leech two-thirds to three-fourths of its length, and it typically takes 3 to 10 seconds in intact animals -31. As wMany of the same sensory inputs that initiate swimming can initiate crawling. In addition to physical or electrophysiological stimulation, neuromodulators can initiate fictive crawling, even in the absence of the head brain or tail brain, which are otherwise required . DopaminThe crawling CPG is less well understood than other behavioral circuits in leeches. The relative activity patterns of many motor neurons involved in crawling have been described  and seveLeeches constantly make choices about how to respond to external stimuli and internal drives (such as hunger). It is these behavioral choices that we consider decision-making, despite the simplicity of the leech's nervous system. No matter how complex, a decision may be broken down into elemental choices, and the role of context in the form of sensory environment, internal state and experience influences each of these choices . We nextWhen a leech is touched at its front end, it reliably shortens, even if it was swimming at the time. Swimming and shortening are incompatible behaviors, and although the circuitry for shortening is not well-understood, it is possible to determine how swimming is inhibited once the "decision" to shorten has been made. The most powerful command neuron for swimming, cell 204, is strongly inhibited by stimuli that elicit shortening, but two swim trigger neurons, Tr1 and swim exciter 1 (SE1), are excited. These observations in turn suggest that cell 204 is dedicated to swimming but that the trigger neurons are multifunctional.et al. . Le. Le38]. The heartbeat CPG can be conceptualized as two timing networks: a beat-timing network comprising the first four pairs of HNs (two oscillator pairs and two coordinating pairs) and an unidentified switch-timing network which governs the activity of the switch interneurons. The two timing networks converge on the switch interneurons, and, together with the HN(6), HN(7), HN(15) and HN(16) HNs, they make up the heartbeat CPG. The output of the CPG is configured into two coordination states of the HEs by the alternating activity states of the two switch interneurons.The medicinal leech is a fantastic organism in which to study the neural systems and circuits underlying behavior and autonomic movement. Even with our rich collective understanding of rhythmic motor pattern generation garnered from these and other animals, we have a great deal more yet to learn. Uncovering the details of centrally generated neural patterns and how they specifically interact with sensory feedback, and with one another, to produce adaptable, behaviorally meaningful motor patterns is an important goal of research in the medicinal leech. For example, a more complete picture of the circuit responsible for crawling is within reach, as is a better understanding of the contribution of individual neural properties of the constituent neurons of all of these circuits. Moreover, we are just beginning to exploit the full potential of the leech for the investigation of behavioral choice as well as the context dependence of these choices. We hope that this review provides readers with an appreciation of the depth of investigation leeches afford, as well as motivation and a foundation for future study.CPG: central pattern generator; HE: heart exciter motor neuron; HN: heart interneurons; DE: dorsal longitudinal excitatory motor neuron; DI: dorsal longitudinal inhibitory motor neuron; VE: ventral longitudinal excitatory motor neuron; VI: ventral longitudinal inhibitory motor neuron.The authors declare that they have no competing interests.DGL drafted the introduction, swimming, crawling, conclusion and abstract sections. RLC drafted the decision-making and heartbeat sections. Both authors reviewed and revised the entire manuscript, and both read and approved the final manuscript.