Gastric emptying during and following resolution of moderate diabetic ketoacidosis in type 1 diabetes: a case series

INTRODUCTION

To use the 'gold standard' technique of scintigraphy to quantify gastric emptying (GE) as soon as practicable during an admission with diabetic ketoacidosis (DKA) and following its resolution at least 7 days later.

RESEARCH DESIGN AND METHODS

Five patients with type 1 diabetes, age 29±12 years; Body Mass Index 23±3 kg/m2; hemoglobin A1c 11.3%±1.9%, were studied during an admission with DKA and following its resolution. Solid and liquid GE were measured using scintigraphy. Solid emptying was assessed via the percentage intragastric retention at 100 min and that of liquid by the 50% emptying time.

RESULTS

There was no difference in either solid or liquid GE at the initial study compared with the follow-up. Median (IQR) solid retention was 47±20 versus 38%±33%, respectively; p=0.31, and time to empty 50% of liquid was 37±25 min versus 35±15 min, p=0.31, at the initial and follow-up GE study, respectively.

CONCLUSIONS

GE of solids and liquids is not affected by moderate DKA, inferring that earlier reintroduction of oral intake may be appropriate.

Myocardial deformation imaging by 2D speckle tracking echocardiography for assessment of diastolic dysfunction in murine cardiopathology

Diastolic dysfunction is increasingly identified as a key, early onset subclinical condition characterizing cardiopathologies of rising prevalence, including diabetic heart disease and heart failure with preserved ejection fraction (HFpEF). Diastolic dysfunction characterization has important prognostic value in management of disease outcomes. Validated tools for in vivo monitoring of diastolic function in rodent models of diabetes are required for progress in pre-clinical cardiology studies. 2D speckle tracking echocardiography has emerged as a powerful tool for evaluating cardiac wall deformation throughout the cardiac cycle. The aim of this study was to examine the applicability of 2D speckle tracking echocardiography for comprehensive global and regional assessment of diastolic function in a pre-clinical murine model of cardio-metabolic disease. Type 2 diabetes (T2D) was induced in C57Bl/6 male mice using a high fat high sugar dietary intervention for 20 weeks. Significant impairment in left ventricle peak diastolic strain rate was evident in longitudinal, radial and circumferential planes in T2D mice. Peak diastolic velocity was similarly impaired in the longitudinal and radial planes. Regional analysis of longitudinal peak diastolic strain rate revealed that the anterior free left ventricular wall is particularly susceptible to T2D-induced diastolic dysfunction. These findings provide a significant advance on characterization of diastolic dysfunction in a pre-clinical mouse model of cardiopathology and offer a comprehensive suite of benchmark values for future pre-clinical cardiology studies.

Determinants of blood glucose concentrations following a high carbohydrate meal in type 2 diabetes: A multiple linear regression analysis

This study showed that in relatively well-controlled type 2 diabetes blood glucose levels after a high carbohydrate meal were associated positively with fasting blood glucose, but also positively with gastric emptying in the first hour and negatively with the increments in plasma glucagon-like peptide-1 (GLP-1) in the later postprandial phase.

Plasma GLP-1 Response to Oral and Intraduodenal Nutrients in Health and Type 2 Diabetes-Impact on Gastric Emptying

CONTEXT

Both gastric emptying and the secretion of glucagon-like peptide-1 (GLP-1) are major determinants of postprandial glycemia in health and type 2 diabetes (T2D). GLP-1 secretion after a meal is dependent on the entry of nutrients into the small intestine, which, in turn, slows gastric emptying.

OBJECTIVE

To define the relationship between gastric emptying and the GLP-1 response to both oral and small intestinal nutrients in subjects with and without T2D.

METHODS

We evaluated: (i) the relationship between gastric emptying (breath test) and postprandial GLP-1 levels after a mashed potato meal in 73 individuals with T2D; (ii) inter-individual variations in GLP-1 response to (a) intraduodenal glucose (4 kcal/min) during euglycemia and hyperglycemia in 11 healthy and 12 T2D, subjects, (b) intraduodenal fat (2 kcal/min) in 15 T2D subjects, and (c) intraduodenal protein (3 kcal/min) in 10 healthy subjects; and (iii) the relationship between gastric emptying (breath test) of 75 g oral glucose and the GLP-1 response to intraduodenal glucose (4 kcal/min) in 21 subjects (9 healthy, 12 T2D).

RESULTS

The GLP-1 response to the mashed potato meal was unrelated to the gastric half-emptying time (T50). The GLP-1 responses to intraduodenal glucose, fat, and protein varied substantially between individuals, but intra-individual variation to glucose was modest. The T50 of oral glucose was related directly to the GLP-1 response to intraduodenal glucose (r = 0.65, P = 0.002).

CONCLUSION

In a given individual, gastric emptying is not a determinant of the postprandial GLP-1 response. However, the intrinsic gastric emptying rate is determined in part by the responsiveness of GLP-1 to intestinal nutrients.

Effects of Sustained Treatment With Lixisenatide on Gastric Emptying and Postprandial Glucose Metabolism in Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVE

Tachyphylaxis for slowing of gastric emptying is seen with continuous exposure to glucagon-like peptide 1 (GLP-1). We therefore aimed to establish whether prolonged use of a "short-acting" GLP-1 receptor agonist, lixisenatide, achieves sustained slowing of gastric emptying and reduction in postprandial glycemia.

RESEARCH DESIGN AND METHODS

A total of 30 patients with metformin-treated type 2 diabetes underwent assessment of gastric emptying (scintigraphy) and glucose metabolism (dual tracer technique) after a 75-g glucose drink, before and after 8 weeks' treatment with lixisenatide (20 μg subcutaneously daily) or placebo, in a double-blind randomized parallel design.

RESULTS

Gastric retention of the glucose drink was markedly increased after lixisenatide versus placebo (ratio of adjusted geometric means for area under the curve [AUC] over 240 min of 2.19 [95% CI 1.82, 2.64], P < 0.001), associated with substantial reductions in the rate of systemic appearance of oral glucose (P < 0.001) and incremental AUC for blood glucose (P < 0.001). Lixisenatide suppressed both glucagon (P = 0.003) and insulin (P = 0.032), but not endogenous glucose production, over 120 min after oral glucose intake. Postprandial glucose lowering over 240 min was strongly related to the magnitude of slowing of gastric emptying by lixisenatide (r = -0.74, P = 0.002) and to the baseline rate of emptying (r = 0.52, P = 0.048) but unrelated to β-cell function (assessed by β-cell glucose sensitivity).

CONCLUSIONS

Eight weeks' treatment with lixisenatide is associated with sustained slowing of gastric emptying and marked reductions in postprandial glycemia and appearance of ingested glucose. Short-acting GLP-1 receptor agonists therefore potentially represent an effective long-term therapy for specifically targeting postprandial glucose excursions.

Title: Differentiating the effects of whey protein and guar gum preloads on postprandial glycemia in type 2 diabetes

BACKGROUND AND AIMS

Whey protein and guar gum have both been reported to reduce postprandial glycemia in health and type 2 diabetes, associated with stimulation of glucagon-like peptide-1 (GLP-1) and/or slowing of gastric emptying. Our aim was to evaluate, in type 2 diabetes, the acute effects of low dose "preloads" of whey and guar, given alone or in combination before a meal, on postprandial glycemia, insulin, GLP-1, and gastric emptying.

METHODS

21 patients with type 2 diabetes, managed by diet or metformin alone, were each studied on 4 days. They received a preload "shake" 15min before a mashed potato meal (368.5 kcal) labeled with ¹³C-octanoic-acid. The preloads comprised either (i) 17 g whey (W), (ii) 5 g guar (G), (iii) 17 g whey + 5 g guar (WG) each sweetened with 60 mg sucralose, and (iv) 60 mg sucralose alone (control; C), all dissolved in 150 mL water. Venous blood was sampled frequently for measurements of glucose, insulin, and GLP-1 concentrations. Gastric half-emptying time (T50) was calculated from breath ¹³CO₂ excretion over 240 min.

RESULTS

Postprandial blood glucose concentrations were lower with W and WG compared to C (each P < 0.0001, treatment × time interaction), and lower after G than C only at 30min. Insulin, GLP-1, and glucagon concentrations were higher after W than WG, G, or C (P < 0.05, treatment × time interaction), without differences between the latter three. Gastric emptying was slower with W (T50: 179.6 ± 6.1 min, P < 0.05) and WG (T50: 197.6 ± 9.7 min, P < 0.0001) when compared to C (T50: 162.9 ± 6.2 min), but did not differ between G (T50: 171.3 ± 7.0) and C (P > 0.99).

CONCLUSION

Both whey and whey/guar preloads reduced postprandial glycemia, associated with slowing of gastric emptying. Low dose guar was less effective as a preload for glucose-lowering and did not slow gastric emptying.

CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE

Australian and New Zealand Clinical Trials Registry, Trial ID ACTRN12615001272583, http://www.anzctr.org.au.

An empirical assessment of a single family-wide hybrid capture locus set at multiple evolutionary timescales in Asteraceae

PREMISE

Hybrid capture with high-throughput sequencing (Hyb-Seq) is a powerful tool for evolutionary studies. The applicability of an Asteraceae family-specific Hyb-Seq probe set and the outcomes of different phylogenetic analyses are investigated here.

METHODS

Hyb-Seq data from 112 Asteraceae samples were organized into groups at different taxonomic levels (tribe, genus, and species). For each group, data sets of non-paralogous loci were built and proportions of parsimony informative characters estimated. The impacts of analyzing alternative data sets, removing long branches, and type of analysis on tree resolution and inferred topologies were investigated in tribe Cichorieae.

RESULTS

Alignments of the Asteraceae family-wide Hyb-Seq locus set were parsimony informative at all taxonomic levels. Levels of resolution and topologies inferred at shallower nodes differed depending on the locus data set and the type of analysis, and were affected by the presence of long branches.

DISCUSSION

The approach used to build a Hyb-Seq locus data set influenced resolution and topologies inferred in phylogenetic analyses. Removal of long branches improved the reliability of topological inferences in maximum likelihood analyses. The Astereaceae Hyb-Seq probe set is applicable at multiple taxonomic depths, which demonstrates that probe sets do not necessarily need to be lineage-specific.

Gastric Emptying in Patients With Well-Controlled Type 2 Diabetes Compared With Young and Older Control Subjects Without Diabetes

CONTEXT

Gastric emptying is a major determinant of postprandial glycemia and is often delayed in long-standing, complicated type 2 diabetes mellitus (T2DM). However, there is little information about gastric emptying in well-controlled T2DM.

OBJECTIVE

To evaluate the rate of gastric emptying in community-based patients with relatively well-controlled T2DM compared with young and older control subjects without diabetes.

PARTICIPANTS AND DESIGN

A total of 111 patients with T2DM managed by diet (n = 52) or metformin monotherapy (n = 59) (HbA1c 6.6 ± 0.1%/49.0 ± 0.9 mmol/mol), 18 age- and body mass index (BMI)-matched older subjects without diabetes, and 15 young healthy subjects consumed a standardized mashed potato meal (368.5 kcal) containing 100 μL 13C-octanoic acid. Gastric emptying (by breath test) and blood glucose were evaluated over 240 minutes.

RESULTS

Gastric emptying was slower in the older than in the young subjects without diabetes (2.3 ± 0.1 vs 3.0 ± 0.1 kcal/min, P = 0.0008). However, relative to the age- and BMI-matched subjects without diabetes, gastric emptying (2.8 ± 0.1 kcal/min) was faster in patients with T2DM (P = 0.0005). Furthermore, gastric emptying was faster in the metformin-treated (3.0 ± 0.1 kcal/min) than in the diet-controlled (2.7 ± 0.1 kcal/min) patients with T2DM (P = 0.011), although there were no differences in age, BMI, HbA1c, or the duration of known diabetes. The increments in blood glucose (at t = 30 and 60 minutes and the incremental area under the curve during t = 0 to 120 minutes) after the meal were related directly to the rate of gastric emptying in the subjects with T2DM regardless of treatment with or without metformin (P < 0.05 each).

CONCLUSIONS

Gastric emptying is slowed with aging but otherwise is relatively more rapid in patients with well-controlled T2DM. This provides a strong rationale for slowing gastric emptying to improve postprandial glycemic control in these patients.

Longitudinal evaluation of gastric emptying in type 2 diabetes

AIMS

To evaluate the natural history of gastric emptying in type 2 diabetes.

METHODS

12 patients with type 2 diabetes (7 female; age 65.6 ± 1.2 years; duration of known diabetes 22.9 ± 1.5 years) were invited to return for repeat measurements of gastric emptying using the same dual-labelled solid and liquid meal, a mean of 14.0 ± 0.5 years after their initial study. Blood glucose levels, glycated haemoglobin, upper gastrointestinal symptoms and autonomic nerve function at baseline and follow up were also compared.

RESULTS

Gastric emptying of solids was more rapid at follow up than at baseline (period effect P < 0.05), while emptying of liquids was comparable at baseline and follow up (period effect P = 0.2). Gastric emptying of the solid component was abnormally slow (based on T100min) in 6 subjects at baseline and 1 subject at follow up. Liquid emptying was abnormally slow in 6 subjects at baseline, and 5 subjects at follow up. Two patients were insulin treated at baseline, and 6 at follow up. HbA1c was higher at follow up (P < 0.05); however, fasting blood glucose (P = 0.6), postprandial blood glucose excursions (P = 0.07), autonomic nerve function (P > 0.999), and total upper gastrointestinal symptom score (P = 0.1) did not differ.

CONCLUSIONS

In patients with long-term type 2 diabetes, gastric emptying of solids and liquids does not usually become more delayed over time, and abnormally slow gastric emptying of solids may improve.

A whey/guar "preload" improves postprandial glycaemia and glycated haemoglobin levels in type 2 diabetes: A 12-week, single-blind, randomized, placebo-controlled trial

AIMS

To evaluate the effects of 12 weeks of treatment with a whey/guar preload on gastric emptying, postprandial glycaemia and glycated haemoglobin (HbA1c) levels in people with type 2 diabetes (T2DM).

MATERIALS AND METHODS

A total of 79 people with T2DM, managed on diet or metformin (HbA1c 49 ± 0.7 mmol/mol [6.6 ± 0.1%]), were randomized, in single-blind fashion, to receive 150 mL flavoured preloads, containing either 17 g whey protein plus 5 g guar (n = 37) or flavoured placebo (n = 42), 15 minutes before two meals, each day for 12 weeks. Blood glucose and gastric emptying (breath test) were measured before and after a mashed potato meal at baseline (without preload), and after the preload at the beginning (week 1) and end (week 12) of treatment. HbA1c levels, energy intake, weight and body composition were also evaluated.

RESULTS

Gastric emptying was slower (P < 0.01) and postprandial blood glucose levels lower (P < 0.05) with the whey/guar preload compared to placebo preload, and the magnitude of reduction in glycaemia was related to the rate of gastric emptying at both week 1 (r = -0.54, P < 0.001) and week 12 (r = -0.54, P < 0.0001). At the end of treatment, there was a 1 mmol/mol [0.1%] reduction in HbA1c in the whey/guar group compared to the placebo group (49 ± 1.0 mmol/mol [6.6 ± 0.05%] vs. 50 ± 0.8 mmol/mol [6.7 ± 0.05%]; P < 0.05). There were no differences in energy intake, body weight, or lean or fat mass between the groups.

CONCLUSIONS

In patients with well-controlled T2DM, 12 weeks' treatment with a low-dose whey/guar preload, taken twice daily before meals, had sustained effects of slowing gastric emptying and reducing postprandial blood glucose, which were associated with a modest reduction in HbA1c, without causing weight gain.

Comparative effects of intraduodenal fat and glucose on the gut-incretin axis in healthy males

BACKGROUND

The interaction of nutrients with the small intestine stimulates the secretion of numerous enteroendocrine hormones that regulate postprandial metabolism. However, differences in gastrointestinal hormonal responses between the macronutrients are incompletely understood. In the present study, we compared blood glucose and plasma hormone concentrations in response to standardised intraduodenal (ID) fat and glucose infusions in healthy humans.

METHODS

In a parallel study design, 16 healthy males who received an intraduodenal fat infusion were compared with 12 healthy males who received intraduodenal glucose, both at a rate of 2kcal/min over 120min. Venous blood was sampled at frequent intervals for measurements of blood glucose, and plasma total and active glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), insulin and glucagon.

RESULTS

Plasma concentrations of the incretin hormones (both total and active GLP-1 and GIP) and glucagon were higher, and plasma insulin and blood glucose concentrations lower, during intraduodenal fat, when compared with intraduodenal glucose, infusion (treatment by time interaction: P<0.001 for each).

CONCLUSIONS

Compared with glucose, intraduodenal fat elicits substantially greater GLP-1, GIP and glucagon secretion, with minimal effects on blood glucose or plasma insulin in healthy humans. These observations are consistent with the concept that fat is a more potent stimulus of the 'gut-incretin' axis than carbohydrate.

Effective Expansion: Balance between Shrinkage and Hygroscopic Expansion

The purpose of this study was to investigate the relationship between hygroscopic expansion and polymerization shrinkage for compensation of polymerization shrinkage stresses in a restored tooth. One resin-modified glass-ionomer (RMGI) (Ketac Nano, 3M ESPE), 2 compomers (Dyract, Dentsply; Compoglass, Ivoclar), and a universal resin-based composite (Esthet•X HD, Dentsply) were tested. Volumetric change after polymerization ("total shrinkage") and during 4 wk of water storage at 37°C was measured using an optical method (n= 10). Post-gel shrinkage was measured during polymerization using a strain gauge method (n= 10). Extracted human molars with large mesio-occluso-distal slot preparations were restored with the tested restorative materials. Tooth surfaces at baseline (preparation), after restoration, and during 4 wk of 37°C water storage were scanned with an optical scanner to determine cuspal flexure (n= 8). Occlusal interface integrity was measured using dye penetration. Data were analyzed using analysis of variance and post hoc tests (significance level 0.05). All tested materials shrunk after polymerization. RMGI had the highest total shrinkage (4.65%) but lowest post-gel shrinkage (0.35%). Shrinkage values dropped significantly during storage in water but had not completely compensated polymerization shrinkage after 4 wk. All restored teeth initially exhibited inward (negative) cuspal flexure due to polymerization shrinkage. Cuspal flexure with the RMGI restoration was significantly less (-6.4 µm) than with the other materials (-12.1 to -14.1 µm). After 1 d, cuspal flexure reversed to +5.0 µm cuspal expansion with the RMGI and increased to +9.3 µm at 4 wk. After 4 wk, hygroscopic expansion compensated cuspal flexure in a compomer (Compoglass) and reduced flexure with Dyract and resin-based composite. Marginal integrity (93.7% intact restoration wall) was best for the Compoglass restorations and lowest (73.1%) for the RMGI restorations. Hygroscopic expansion was more effective in compensating shrinkage stress than would be assumed based on total shrinkage, because only post-gel shrinkage needed compensation. Effective expansion is therefore hygroscopic expansion minus post-gel shrinkage.

Evolution and variation of the nifD and hupL elements in the heterocystous cyanobacteria

In heterocystous cyanobacteria, heterocyst differentiation is accompanied by developmentally regulated DNA rearrangements that occur within the nifD and hupL genes, referred to as the nifD and hupL elements. These elements are segments of DNA that are embedded within the coding region of each gene and range from 4 to 24 kb in length. The nifD and hupL elements are independently excised from the genome during the later stages of differentiation by the site-specific recombinases, XisA and XisC, respectively, which are encoded within the elements themselves. Here we examine the variation and evolution of the nifD and hupL elements by comparing full-length nifD and hupL element sequences and by phylogenetic analysis of xisA and xisC gene sequences. There is considerable variation in the size and composition of the nifD and hupL elements, however, conserved regions are also present within representatives of each element. The data suggest that the nifD and hupL elements have undergone a complex pattern of insertions, deletions, translocations and sequence divergence over the course of evolution, but that conserved regions remain.

Mycorrhizal specificity in the fully mycoheterotrophic Hexalectris Raf. (Orchidaceae: Epidendroideae)

Mycoheterotrophic species have abandoned an autotrophic lifestyle and obtain carbon exclusively from mycorrhizal fungi. Although these species have evolved independently in many plant families, such events have occurred most often in the Orchidaceae, resulting in the highest concentration of these species in the tracheophytes. Studies of mycoheterotrophic species' mycobionts have generally revealed extreme levels of mycorrhizal specialization, suggesting that this system is ideal for studying the evolution of mycorrhizal associations. However, these studies have often investigated single or few, often unrelated, species without consideration of their phylogenetic relationships. Herein, we present the first investigation of the mycorrhizal associates of all species of a well-characterized orchid genus comprised exclusively of mycoheterotrophic species. With the employment of molecular phylogenetic methods, we identify the fungal associates of each of nine Hexalectris species from 134 individuals and 42 populations. We report that Hexalectris warnockii associates exclusively with members of the Thelephoraceae, H. brevicaulis and H. grandiflora associate with members of the Russulaceae and Sebacinaceae subgroup A, while each member of the H. spicata species complex associates primarily with unique sets of Sebacinaceae subgroup A clades. These results are consistent with other studies of mycorrhizal specificity within mycoheterotrophic plants in that they suggest strong selection within divergent lineages for unique associations with narrow clades of mycorrhizal fungi. Our results also suggest that mycorrhizal associations are a rapidly evolving characteristic in the H. spicata complex.

Patterns and causes of incongruence between plastid and nuclear Senecioneae (Asteraceae) phylogenies

One of the longstanding questions in phylogenetic systematics is how to address incongruence among phylogenies obtained from multiple markers and how to determine the causes. This study presents a detailed analysis of incongruent patterns between plastid and ITS/ETS phylogenies of Tribe Senecioneae (Asteraceae). This approach revealed widespread and strongly supported incongruence, which complicates conclusions about evolutionary relationships at all taxonomic levels. The patterns of incongruence that were resolved suggest that incomplete lineage sorting (ILS) and/or ancient hybridization are the most likely explanations. These phenomena are, however, extremely difficult to distinguish because they may result in similar phylogenetic patterns. We present a novel approach to evaluate whether ILS can be excluded as an explanation for incongruent patterns. This coalescence-based method uses molecular dating estimates of the duration of the putative ILS events to determine if invoking ILS as an explanation for incongruence would require unrealistically high effective population sizes. For four of the incongruent patterns identified within the Senecioneae, this approach indicates that ILS cannot be invoked to explain the observed incongruence. Alternatively, these patterns are more realistically explained by ancient hybridization events.

Excision of the nifD element in the heterocystous cyanobacteria

Heterocyst differentiation in cyanobacteria is accompanied by developmentally regulated DNA rearrangements that occur within the nifD, fdxN, and hupL genes. These genetic elements are excised from the genome by site-specific recombination during the latter stages of differentiation. The nifD element is excised by the recombinase, XisA, located within the element. Our objective was to examine the XisA-mediated excision of the nifD element. To accomplish this, we observed the ability of XisA to excise substrate plasmids that contained the flanking regions of the nifD element in an E. coli host. Using PCR directed mutagenesis, nucleotides in the nifD element flanking regions in substrate plasmids were altered and the effect on recombination was determined. Results indicate that only certain nucleotides within and surrounding the direct repeats are involved in excision. In some nucleotide positions, the presence of a purine versus a pyrimidine greatly affected recombination. Our results also indicated that the site of excision and branch migration occurs in a 6 bp region within the direct repeats.

Stem diversity, cauline domatia, and the evolution of ant-plant associations in Piper sect. Macrostachys (Piperaceae)

Plants possess a variety of structures that harbor ant nests, and the morphology of these domatia determines the nature of ant-plant mutualisms in a given plant species. In this study, we report on the differences in anatomy between myrmecophytes of Piper, which are regularly excavated by an obligate ant mutualist (Pheidole bicornis) and nonmyrmecophytes of Piper, which consistently have solid stems. Stems of excavated plant species lacked outward evidence of modification; however, striking anatomical differences were apparent between hollow-stemmed species before excavation and the remainder of the solid-stemmed species studied. Prior to excavation by ants, stems of myrmecophytes were characterized by strongly heterogeneous piths in which a large, central area had relatively large cells lacking intracellular crystals with a periphery of smaller cells containing numerous crystals. The domatium excavated by the ants was restricted to the large-celled region. This is the first report of the absence of crystals in ant-excavated portions of stems of myrmecophytes. Cauline domatia became lined with 3-8 cell layers of suberized wound tissue, which may have an impact on nutrient absorption by Piper myrmecophytes.

Characterization of a 4 kb variant of the nifD element in Anabaena sp. strain ATCC 33047

Heterocyst differentiation in some cyanobacteria is accompanied by a programmed DNA rearrangement within the nitrogen fixation gene nifD. The nifD element is excised from within nifD during the latter stages of heterocyst differentiation by site-specific recombination. There is considerable variation in those nifD elements examined thus far, with Nostoc sp. Strain PCC 7120 and Anabaena variabilis having 11 kb elements, and Nostoc punctiforme having a 24 kb element. Here we characterize a 4 kb nifD element in Anabaena sp. Strain ATCC 33047, and compare it with the other sequenced nifD elements. While there is considerable variation in both the size (ranging from 4 kb to 24 kb) and composition of the nifD elements examined thus far, there are regions that are conserved in all. These conserved regions include the flanking 3' and 5' regions, the xisA gene, and a small open reading frame known as ORF2 in Nostoc sp. Strain PCC 7120.

The evolutionary history of nitrogen fixation, as assessed by NifD

The evolutionary history of nitrogen fixation has been vigorously debated for almost two decades. Previous phylogenetic analyses of nitrogen fixation genes (nif) have shown support for either evolution by vertical descent or lateral transfer, depending on the specific nif gene examined and the method of analyses used. The debate centers on the placement and monophyly of the cyanobacteria, proteobacteria, and Gram-positive bacteria (actinobacteria and firmicutes). Some analyses place the cyanobacteria and actinobacteria within the proteobacteria, which suggests that the nif genes have been laterally transferred since this topology is incongruent with ribosomal phylogenies, the standard marker for comparison. Other nif analyses resolve and support the monophyly of the cyanobacteria, proteobacteria, and actinobacteria, supporting vertical descent. We have revisited these conflicting scenarios by analyzing nifD from an increased number of cyanobacteria, proteobacteria, and Gram-positive bacteria. Parsimony analyses of amino acid sequences and maximum likelihood analysis of nucleic acid sequences support the monophyly of the cyanobacteria and actinobacteria but not the proteobacteria, lending support for vertical descent. However, distance analysis of nucleic acid sequences placed the actinobacteria within the proteobacteria, supporting lateral transfer. We discuss evidence for both vertical descent and lateral transfer of nitrogen fixation.

Molecular phylogeny of the heterocystous cyanobacteria (subsections IV and V) based on nifD

The heterocystous cyanobacteria are currently placed in subsections IV and V, which are distinguished by cellular division in one plane (false branching) and in more than one plane (true branching), respectively. Published phylogenies of 16S rRNA gene sequence data support the monophyly of the heterocystous cyanobacteria, with members of subsection V embedded within subsection IV. It has been postulated that members of subsection V arose from within subsection IV. Therefore, phylogenetic analysis of nucleotide sequences of the nitrogen-fixation gene nifD from representatives of subsections IV and V was performed by using maximum-likelihood criteria. The heterocystous cyanobacteria are supported as being monophyletic, with the non-heterocystous cyanobacteria as their closest relative. However, neither subsection IV nor subsection V is monophyletic, with representatives of both subsections intermixed in two sister clades. Analysis of nifD does not support recognition of two distinct subsections.

Molecular phylogeny of Subtribe Artemisiinae (Asteraceae), including Artemisia and its allied and segregate genera

BACKGROUND

Subtribe Artemisiinae of Tribe Anthemideae (Asteraceae) is composed of 18 largely Asian genera that include the sagebrushes and mugworts. The subtribe includes the large cosmopolitan, wind-pollinated genus Artemisia, as well as several smaller genera and Seriphidium, that altogether comprise the Artemisia-group. Circumscription and taxonomic boundaries of Artemisia and the placements of these small segregate genera is currently unresolved.

RESULTS

We constructed a molecular phylogeny for the subtribe using the internal transcribed spacers (ITS) of nuclear ribosomal DNA analyzed with parsimony, likelihood, and Bayesian criteria. The resulting tree is comprised of three major clades that correspond to the radiate genera (e.g., Arctanthemum and Dendranthema), and two clades of Artemisia species. All three clades have allied and segregate genera embedded within each.

CONCLUSIONS

The data support a broad concept of Artemisia s.l. that includes Neopallasia, Crossostephium, Filifolium, Seriphidium, and Sphaeromeria. However, the phylogeny excludes Elachanthemum, Kaschgaria, and Stilnolepis from the Artemisia-group. Additionally, the monophyly of the four subgenera of Artemisia is also not supported, with the exception of subg. Dracunculus. Homogamous, discoid capitula appear to have arisen in parallel four to seven times, with the loss of ray florets. Thus capitular morphology is not a reliable taxonomic character, which traditionally has been one of the defining characters.

Systematic relationships in Lathyrus sect. Lathyrus (Fabaceae) based on amplified fragment length polymorphism (AFLP) data

Amplified fragment length polymorphisms (AFLP) were utilized to examine systematic relationships in Lathyrus L. sect. Lathyrus (Fabaceae). In addition to a parsimony-based phylogenetic tree, AFLP-based trees were constructed using Dice, Jaccard, and mean character difference coefficients to produce distance-based trees using the UPGMA and neighbor-joining methods. All trees clearly show a close relationship among accessions of the same species, confirming the monophyly of the species examined. All analyses indicate that species of the section Lathyrus are distinct from species of other sections. These findings confirm the monophyly of the section and contradict proposals to split it. They do not support the segregation of L. gorgoni in the section Gorgonia. Within the section Lathyrus, several relationships are present but are only weakly supported. The use of AFLP data to resolve systematic relationships in the genus Lathyrus is further demonstrated.Key words: Lathyrus, Fabaceae, systematics, AFLP.

Molecular differentiation of the heterocystous cyanobacteria, Nostoc and Anabaena, based on complete NifD sequences

The segregation of Nostoc and Anabaena into separate genera has been debated for some time. The nitrogen fixation gene nifD was completely sequenced from representatives of these genera and analyzed phylogenetically, by using the representatives of other genera of the heterocystous cyanobacteria as outgroups. We were clearly able to differentiate between Nostoc and Anabaena in all analyses used. Our data suggest that Nostoc and Anabaena should remain as separate genera.

Molecular phylogeny and biogeography of tribe anthemideae (Asteraceae), based on chloroplast gene ndhF

Anthemideae (Asteraceae) is primarily a north temperate, Old World tribe of 109 genera and approximately 1740 species. We sequenced a 1200-bp portion of chloroplast gene ndhF for representative genera and subtribes and constructed a phylogeny for the tribe. There is support for monophyly of subtribes Chrysantheminae and Gonosperminae and for portions of some subtribes. However, our molecular phylogeny differs significantly from traditional classifications and from previously published morphological phylogenies of the tribe. Many South African genera from several different subtribes form a basal grade, indicating multiple, relictual lineages. Eurasian genera form a recently derived clade that includes the Mediterranean genera of the Iberian Peninsula and North Africa. There is little resolution or support for the placement of eastern Asian genera. Apparently, the tribe originated in the Southern Hemisphere, presumably in Africa, with the Eurasian and Mediterranean members being derived from a common ancestor.

The experiences of postpartum hospital stay and returning home among Thai mothers in Australia

OBJECTIVE

To describe the experience of postpartum care among Thai women in Melbourne, Australia.

DESIGN

Ethnographic interviews and participant observation with women in relation to postpartum care and practices.

SETTING

Melbourne Metropolitan Area, Victoria, Australia.

PARTICIPANTS

26 Thai born women who gave birth in Australia.

FINDINGS

The Thai women had varying views about the length of time they should spend in hospital and the care they received. Ten of the twelve women who had had a caesarean birth stayed in hospital for six or more days, consistent with the hospital practice. However, most of those who had had a vaginal delivery opted to go home earlier than the standard hospital practice of four days stay. This was because they were unhappy about specific hospital practices, the hospital environment, or because there are several Thai confinement customs, which, traditionally, a new mother must observe in order to maintain good health and avoid future ill health and which they were not able to follow in hospital. Nevertheless, most women were satisfied with their postpartum care. Most women were aware of the Thai cultural beliefs and practices. However, they showed varying ways of coping with the hospital environment in relation to their varying social situations.

IMPLICATIONS FOR PRACTICE

Thai women are diverse in their needs, perceptions and experience of postpartum care. Therefore, it is appropriate neither to stereotype all Thai women as requiring to follow traditional confinement practices nor to require them to adjust to standard hospital practices. Rather an environment of caring concern whereby each woman's individual needs can be solicited, understood and, where possible, attended to as required. The challenge is in achieving this.

Phylogenetic analysis of Artemisia section Tridentatae (Asteraceae) based on sequences from the internal transcribed spacers (ITS) of nuclear ribosomal DNA

Artemisia sect. Tridentatae is composed of 11 species of xerophytic shrubs, which dominate much of western North America. Sequences of the internal transcribed spacers (ITS) of nuclear ribosomal DNA were used to construct a phylogeny, examine circumscription of the section, resolve interspecific relationships, and test competing hypotheses on the origin of the section. The data support the monophyly of sect. Tridentatae, with the exclusion of A. bigelovii and A. palmeri-two historically, anomolous species. However, the ITS data provide insufficient variation to fully resolve interspecific relationships or to support major lineages within the Tridentata clade. Nuclear and chloroplast DNA phylogenies are discordant, which may be a result of interspecific gene flow and subsequent chloroplast capture, particularly related to the placement of A. filifolia and A. californica, in addition to A. bigelovii. Furthermore, the ITS data are in conflict with cpDNA data, providing equivocal evidence for competing hypotheses on the Old World vs. New World origin for the section and do not provide support for definitive subgeneric placement.

Evolution of spore release mechanisms in the saprolegniaceae (Oomycetes): evidence from a phylogenetic analysis of internal transcribed spacer sequences

Classical studies on spore release within the Saprolegniaceae (Oomycetes) led to the proposition that different mechanisms of sporangial emptying represent steps in an evolutionary transition series. We have reevaluated this idea in a phylogenetic framework using internal transcribed spacer sequences of four genera. These data were compared with the response to osmotic stress exhibited by each taxon. Saprolegnia emerges as the most basal genus, sister to Achlya, Thraustotheca, and Dictyuchus. Achlya and Thraustotheca are most closely related, while Dictyuchus appears to have evolved along a separate evolutionary lineage. The resulting phylogenetic framework is consistent with the idea that the mechanism of sporangial emptying exhibited by Saprolegnia represents the plesiomorphic condition from which the other mechanisms were derived independently. These alternative mechanisms of spore release may have resulted from a small number of mutations that inhibited axonemal development and altered the temporal and spatial expression of lytic enzymes that degrade the sporangial wall. Copyright 1998 Academic Press.

Radiation exposure during cardiology fellowship training

We report catheterization laboratory personnel dose per case during parallel use of two laboratories from different manufacturers. Initially, four working positions were monitored. Review of the data from the first 140 cases showed a wide range of dose per case. Measurements were then limited to diagnostic coronary angiography cases in which a cardiology fellow was the primary operator. On a per case basis, the dose was higher when a fellow was in the laboratory with pulsed progressive fluoroscopy or was in fellowship year one. The increased dose for first year fellows was more related to increased fluoroscopy time than to cine angiography time. This study emphasizes the importance of close supervision of cardiology fellows early in their training to limit dose to patients and personnel, and it underlines the importance of each catheterization laboratory routinely having the actual personnel dose per case measured.

Usefulness of positive troponin-T and negative creatine kinase levels in identifying high-risk patients with unstable angina pectoris

Troponin-T was measured in patients with chest pain and negative creatine phosphokinase-MB isoenzymes. Patients with elevated troponin-T had a significantly greater risk of cardiac events over the next 6 months than patients with normal troponin-T.

Early and late quantitative angiographic results of vein graft lesions treated by excimer laser with adjunctive balloon angioplasty

BACKGROUND

Percutaneous excimer laser coronary angioplasty (PELCA) has been approved for treatment of diseased saphenous vein bypass grafts. However, detailed and complete quantitative angiographic analysis of immediate procedural and late follow-up results has not been performed.

METHODS AND RESULTS

PELCA using the CVX-300 excimer laser system was performed in 125 bypass lesions (mean graft age, 96 +/- 53 months; range, 2 to 240 months) in 106 consecutive patients at eight centers. Quantitative analyses of the procedural and follow-up angiograms were done with the Cardiac Measurement System. Stand-alone PELCA was done in 21 lesions (17%). Lesions were located at the ostium (20%), body (67%), or distal anastomosis (13%). The graft reference diameter was 3.26 +/- 0.79 mm (mean +/- SD). Minimal lumen diameter increased from 1.09 +/- 0.52 mm before treatment to 1.61 +/- 0.69 mm after laser and 2.18 +/- 0.63 mm after adjunctive balloon dilation (P < .001) but had declined at follow-up to 1.40 +/- 1.17 mm. Dissections were evident in 45% of lesions after laser treatment (types A and B, 27%; types C through F, 18%), including 7% occlusions. Angiographic success (< or = 50% diameter stenosis [% DS]) was 54% after laser and 91% after adjunctive PTCA, with an overall clinical success rate of 89%. In-hospital complications were death, 0.9%; myocardial infarction (Q-wave and non-Q-wave), 4.5%; and bypass surgery, 0.9%. Independent predictors of % DS after laser were reference diameter, lesion length, and minimal lumen diameter before laser. At angiographic follow-up in 83% of eligible patients, the restenosis rate per lesion (DS > 50%) was 52%, including 23 occlusions (24%). The only independent predictor of increased % DS at follow-up was lesion symmetry. Logistic regression indicated that smaller reference diameter was an independent predictor of late occlusion. Overall 1-year mortality was 8.6%. Actuarial event-free survival (freedom from death, myocardial infarction, bypass surgery, or target vessel percutaneous transluminal coronary angioplasty) was 48.2% at 1 year.

CONCLUSIONS

Excimer laser angioplasty with adjunctive balloon angioplasty can be safely and successfully performed in diseased, old saphenous vein bypass graft lesions considered at high risk for reintervention. The extent of laser ablation remains limited by the diameter and effectiveness of the catheters. Late restenosis and, in particular, total occlusion mitigate the early benefits of the procedure. Other approaches such as the routine use of additional anticoagulation (eg, warfarin) should be considered to reduce the risk of late occlusions and restenosis after laser angioplasty of bypass grafts.

High-finesse interferometers

A detailed plan for the construction and use of a nonconfocal cavity used as a high-finesse interferometer is presented. The interferometer has a free spectral range of l5 GHz, with a finesse of over 30,000.

Excimer laser coronary angioplasty for failed PTCA

Specific indications for excimer laser coronary angioplasty (ELCA) are yet undefined. We report two specific applications of ELCA when percutaneous transluminal coronary angioplasty (PTCA) failed: (1) to facilitate balloon crossing a long rigid stenosis that could not be crossed after the lesion was wired, and (2) to overcome prominent elastic recoil of the stenosis after PTCA.

PTCA of gastroepiploic bypass

A technique for percutaneous transluminal coronary angioplasty (PTCA) of gastroepiploic bypass is described using standard PTCA devices. Severe spasm of gastroepiploic bypass occurred. Modification of guide catheter position is suggested to avoid inducing gastroepiploic bypass spasm.

Gas exchange responses of two Eucalyptus species to salinity and waterlogging

The effects of salinity and waterlogging on stomatal conductance, net photosynthesis and transpiration of 3-month-old Eucalyptus camaldulensis Dehnh. and Eucalyptus lesouefii Maiden seedlings were studied under greenhouse conditions. Under non-saline conditions, waterlogging induced stomatal closure in both species. However, the stomata of E. camaldulensis reopened after five weeks, when adventitious roots were produced. Relative to that of controls, height growth of waterlogged seedlings was greater in E. camaldulensis than in E. lesouefii, as were rates of photosynthesis and transpiration. In a freely drained medium, high salinity reduced rates of seedling height growth and photosynthesis, relative to those in controls, less in E. lesouefii than in E. camaldulensis. In both species, height growth, stomatal conductance and photosynthetic rate were lowest under conditions of saline waterlogging.

Snare loop technique for removal of broken steerable PTCA wire

Two cases are described of percutaneous removal of trapped, broken steerable PTCA guidewire. One case described breakage of a guidewire inside the ascending aorta leaving a free end, which is retrieved using the snare loop technique. The second case described retrieval of an intact yet unwound wire through the guiding catheter using a snare loop wire.

Observer variation in the angiocardiographic diagnosis of mitral valve prolapse

The purpose of this study was to assess the reliability of the angiocardiographic diagnosis of mitral valve prolapse by measuring agreement between observers using defined diagnostic criteria. Sixty high-quality left ventriculograms, selected to include many that showed possible mitral valve prolapse, were reviewed by three angiocardiographers. Disagreement between observers as to positivity occurred in 26 percent and 30 percent of the cases on two reviews, and disagreement as to specific scallop involvement occurred in 68 percent and 78 percent of the cases. A specific observer agreed with himself in interpretation of positive 78 to 82 percent of the time and in the interpretation of specific scallop involvement 55 to 90 percent of the time. These results indicate that in the absence of generally agreed upon quantitative angiocardiographic criteria for the diagnosis of mitral valve prolapse, there is considerable variability among observers in the interpretation of mitral valve prolapse by angiocardiographic studies.

Cyanosis in a patient with combined ostium primum and secundum atial septal defects and anomalous inferior vena cava with azygos continuation. Case report and surgical considerations

A case is described of combined ostium primum and ostium secundum atrial septal defects and azygos connection of the inferior vena cava plus cyanosis. Emphasis is made to recognize the functional mechanism of cyanosis and to demonstrate the anatomic site of hepatic venous drainage so that an appropriate corrective operative procedure can be planned. A gratifying result was achieved in this case after closure of the atrial septal defects.

True and false aneurysms of the left ventricle following myocardial infarction

Anterolateral myocardial infarction resulted in the formation of both true and false aneurysms in a 75 year old man in whom severe congestive heart failure subsequently developed as the false aneurysm became progressively larger. Left ventriculography detected and quantified both aneurysms, and demonstrated reasonable function of the remaining volume-overloaded left ventricle. Resection of both aneurysms was accomplished with marked relief of symptoms. The literature on false aneurysm is reviewed, and the dilemma posed by the need to recognize false aneurysms before they become symptomatic or rupture is discussed.

Left ventricular aneurysm. Preoperative hemodynamics, chamber volume, and results of aneurysmectomy

Angiocardiographic characteristics of the residual contracting left ventricle (LV) have been examined in 16 patients with anterolateral ventricular aneurysms (VA). In each patient a contractile section (CS) of the LV was clearly demarcated from the remaining aneurysmal section (AS). Using a double hemispheroid model, volumes of CS and AS were separately estimated by a modified area-length method. The volume of CS plus AS agreed closely with the volume of total LV estimated by the conventional area-length method. End-diastolic volume (EDV) of total LV ranged from 79 to 312ml/72. Aneurysmal section volume ranged from 8 to 264 ml/m2. End-diastolic volume of the contractile section ranged from 52 to 159 ml/m2 (mean, 100+/-8 (se); normal, 78+/-6). Contractile section ejection fraction (EF) showed a wide range, from 15% to 79% (mean 40%+/-17% SD). Nine patients underwent resection of VA. Three of six operated patients with CS EF less than 44% died; no survivor in this group has improved by more than one functional class (New York Heart Association classification). Three operated patients had CS EF greater than 45%; all survived and are improved, two having moved from class IV to class I. These data suggest that the EF of the contracting residual LV may be an important predictor of the outcome of resection of VA.