Diabetic hyperglycemic emergencies: a systematic approach

For patients presenting with suspected diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) understanding of the etiology and pathophysiology will ensure optimal emergency management. Morbidity and mortality is most often due to the underlying precipitating cause, which may include infection, infarction/ischemia, noncompliance with insulin therapy, pregnancy, and dietary indiscretion. Current guidelines are based primarily on expert opinion and consensus statements, but more recent evidence suggests that recommendations related to arterial blood gas, insulin bolus, and IV fluid replacement should be re-evaluated. This issue presents an approach to DKA and HHS management based on current evidence, with a simplified pathway for emergency department management.

Multi-Organ System Injury from Inhalant Abuse.

We present an illustrative case of a 24-year old male who developed cardiovascular and multi-organ system toxicity after inhaling a keyboard dust cleaner containing a halogenated hydrocarbon. In the field, the patient demonstrated neurotoxic effects in addition to electrocardiographic changes concerning for toxic myocarditis. We discuss the types of hydrocarbons, methods of abuse, and toxic effects of their inhalation including "sudden sniffing death" from myocardial sensitization.

Hybridization and adaptation to introduced balloon vines in an Australian soapberry bug.

Contemporary adaptation of plant feeding insects to introduced hosts provides clear cases of ecologically based population divergence. In most cases the mechanisms permitting rapid differentiation are not well known. Here we study morphological and genetic variation associated with recent shifts by the Australian soapberry bug Leptocoris tagalicus onto two naturalized Neotropical balloon vines, Cardiospermum halicacabum and C. grandiflorum that differ in time since introduction. Our results show that these vines have much larger fruits than the native hosts (Whitewood tree -Atalaya hemiglauca- and Woolly Rambutan -Alectryon tomentosus-) and that bugs living on them have evolved significantly longer beaks and new allometries. Genetic analyses of mitochondrial haplotypes and amplified fragment length polymorphic (AFLP) markers indicate that the lineage of bugs on the annual vine C. halicacabum, the older introduction, is intermediate between the two subspecies of L. tagalicus found on native hosts. Moreover, where the annual vine and Whitewood tree co-occur, the morphology and genomic composition of the bugs are similar to those occurring in allopatry. These results show that hybridization provided the genetic elements underlying the strongly differentiated 'Halicacabum bugs'. In contrast, the bugs feeding on the recently introduced perennial balloon vine (C. grandiflorum) showed no evidence of admixture, and are genetically indistinguishable from the nearby populations on a native host.

Obligate versus rich patch opportunism: evolution and endocrine mechanisms.

Opportunistic breeding has been hypothesized to evolve in response to rare or unpredictable resource pulses. In this traditional view of opportunism, individuals invest heavily in reproduction whenever conditions are permissive for breeding, perhaps at the expense of investment in survival. We term this strategy 'obligate opportunism' (OBO). We also present an additional strategy that could account for the evolution of opportunism. High mobility may allow individuals to move between rich patches of resources that are spatially or temporally unpredictable, reducing exposure to food scarcity and taking advantage of breeding opportunities. This strategy, which we term 'rich patch exploiter' (RPE), predicts that investment in survival-enhancing processes may occur at the expense of reproduction despite high resource availability. We review examples to determine which opportunists better match predictions from the OBO strategy or the RPE strategy and then review endocrine profiles in the context of the two strategies.

Influence of genetic architecture on contemporary local evolution in the soapberry bug, Jadera haematoloma: artificial selection on beak length.

Little is known about the influence of genetic architecture on local adaptation. We investigated the genetic architecture of the rapid contemporary evolution of mouthparts, the flight polymorphism and life history traits in the soapberry bug Jadera haematoloma (Hemiptera) using laboratory selection. The mouthparts of these seed-feeding bugs have adapted in 40-50 years by decreasing in length following novel natural selection induced by a host switch to the seeds of an introduced tree with smaller fruits than those of the native host vine. Laboratory selection on beak length in both an ancestral population feeding on the native host and a derived population feeding on the introduced host reveals genetic variance allowing a rapid response (heritabilities of 0.51-0.87) to selection for either longer or shorter beaks. This selection resulted in reverse evolution by restoring long beaks in the derived population and forward evolution by re-creating short beaks in the ancestral bugs. There were strong genetic correlations (0.68-0.84) in both populations between beak lengths and the frequency of flight morphs, with short beaks associated with short wings. The results reveal a genetically interrelated set of adaptive multivariate traits including both beak length and flight morph. This suite of traits reflects host plant patchiness and seeding phenology. Weaker evidence suggests that egg mass and early egg production may be elements of the same suite. Reversible or forward evolution thus may occur in a broad set of genetically correlated multivariate traits undergoing rapid contemporary adaptation to altered local environments.

Altitudinal variation in behavioural thermoregulation: local adaptation vs. plasticity in California grasshoppers.

We investigated the adaptive significance of behavioural thermoregulation in univoltine populations of the grasshopper Melanoplus sanguinipes along an altitudinal gradient in California using laboratory tests of animals raised under different temperatures. Trials consisted of continuous body temperature measurements with semi-implanted microprobes in a test arena, and observation and simultaneous recording of behavioural responses. These responses included mobility, basking and orientation of the body axes (aspect angle) towards a radiation source. Mobility and basking are determined by the altitudinal origin of the parental generation and not by the temperature treatments. With increasing altitude, individuals tend increasingly to raise body temperatures via mobility and increased basking. In contrast, body orientation towards the radiation source is influenced by the temperature treatments but not by the altitude of origin. Individuals experiencing higher temperatures during rearing show a lower tendency to lateral flanking. We conclude that body orientation responses are not adapted locally. In contrast other components of the behavioural syndrome that increase body temperature, such as mobility and basking, are adaptive in response to local selection pressure. The thermoregulatory syndrome of these grasshoppers is an important contribution to life-history adaptations that appropriately match season lengths.

Patterns of recreational drug use at dance events in Edinburgh, Scotland.

AIMS: To describe the patterns of drug use at dance (rave) events in terms of prevalence, frequency, type of drugs used, patterns of use, access and risk-associated behaviours. DESIGN: Self-selecting participant-completed survey. SETTING: Three dance events in Edinburgh, Scotland, UK. PARTICIPANTS: One hundred and twenty-two drug users (57% males, 43% females), 90% of whom were in employment or education, with an age range of 16-47, 80% between 18 and 23 years. MEASUREMENTS: Participants who answered 'yes' to the question 'Have you used drugs for dance events in the past year' reported (i) the prevalence, types and frequency of drugs used; (ii) prevalence and contents of mixing drugs; (iii) accessing drugs; and (iv) engagement with drug-associated risk behaviours. FINDINGS: Over 80% of the participants had used ecstasy and amphetamine, over 30% cocaine and LSD; over 10% nitrites, psilocybin and ketamine and less than 5% had used crack or tranquillizers. Participants reported regular consumption of ecstasy and amphetamine (e.g. 35% used ecstasy and 25% amphetamine on a weekly basis) often taken in combination, with the occasional use of cocaine, LSD, ketamine and psilocybin. Poly- and mixing-drug behaviours were significantly more likely than monodrug usage. Drugs were accessed through friends than from any other source. Eighty-five per cent reported mixing drugs and/or alcohol, 35% driving on drugs, 36% having a bad experience on drugs; 30% unprotected sex; and 0.9% injecting drugs. Women in the sample reported higher consumption than men. CONCLUSIONS: Dance-drug use has a characteristic pattern that has implications for health promotion and criminal policy.

Genetic architecture of adaptive differentiation in evolving host races of the soapberry bug, Jadera haematoloma.

To explore genetic architecture and adaptive evolution, we conducted environmental and genetic experiments with two recently (ca. 100 generations) diverged, geographically adjacent races of the soapberry bug. One race occurs on a native host plant species, the other on an introduced host. We focused on three traits: length of the mouthparts, body size and development time. The first experiment was an environmental manipulation, comparing individuals of each population reared on one or the other host species ('cross-rearing') and estimating three evolutionary rates for each trait. The first rate, 'evolutionary path' compares ancestral-derived populations when both were reared on the introduced host. The second, 'current ecological contrast' compares populations with each reared on its natal host. The third, 'evolved tradeoff' compares the two races when reared on the native host. Differences among these rates are striking and informative. For example, development time, which appears to be relatively undifferentiated phenotypically, has actually evolved very rapidly via countergradient selection. The pattern differs for each trait, and clear developmental tradeoffs have evolved as quickly as adaptation to the new host in each. The second experiment was a two-generation 'line cross' study. With joint-scaling analyses, we compared purebred, hybrid and backcrossed individuals to describe genetic architecture. Additive genetic variance for mouthpart length was consistently large (ca. 60%), but the interaction of dominance, maternal effects and epistasis was important in the other traits. Rearing host strongly affected genetic architecture. There was no clear relationship between genetic architecture and rate of evolution. Selection has produced both additive and nonadditive differentiation between the host races with surprising speed, consistent with theoretical predictions about evolution in fitness-associated traits.

Enzyme profiles in two wing polymorphic soapberry bug populations (Jadera haematoloma: Rhopalidae).

Wing-polymorphic insects are excellent models for asking questions about trade-offs in physiology and life-history because of the existence of multiple morphs exhibiting numerous strategies living in one environment. We measured activities of select key enzymes in oxidative metabolism (citrate synthase), glycolysis (hexokinase, pyruvate kinase) and fatty acid oxidation (ß-hydroxyacyl CoA dehydrogenase, HOAD) in flying and non-flying long-winged bugs from two populations (ancestral and derived) of the wing-polymorphic soapberry bug (Jadera haematoloma). In the ancestral population, flyers had significantly greater activities of citrate synthase, hexokinase, pyruvate kinase, and HOAD than non-flyers. In contrast, in the derived population, flyers and non-flyers showed no significant differences in the activities of any of the enzymes tested. There were no significant differences in activities of citrate synthase as a function of adult age (3-20 d) for either population. Short-winged bugs in the derived population had significantly lower citrate synthase activities than either of the two derived, long-winged morphs, however, they were analogous to the ancestral long-winged non-flyer. These results suggest an evolution of alternative flight strategies between the two populations.

Relationships among climate, latitude and migration: Australian butterflies are not temperate-zone birds.

We examined the distribution of butterflies over the mostly arid and semi-arid continent of Australia and analyzed the proportion of migrant species and species diversity with respect to an array of climatic and geographic variables. On a continent-wide scale, latitude explained virtually no variance in either proportion of migrants (r 2=0.01) or species diversity (r 2=0.03) in Australian butterflies. These results are in marked contrast to those for temperate-zone birds from three continents where latitude explained between 82 and 98% of the variance in frequency of migrants and also accounted for much of the variance in bird species diversity. In eastern Australia where rainfall regimes are similar to those in temperate Europe and North and South America, latitude explains 78% of the variance in frequency of butterfly migrants. In both eastern and central Australia, latitude also accounts for relatively high proportions of the variance in species diversity. Rainfall patterns and especially soil moisture are negatively associated with migration frequency in Australian butterfly faunas, both alone and in combination with other climate variables. Where moisture levels are relatively high, as in eastern Australia, measures of temperature are associated with migration frequency, a result consistent with findings for temperate-zone birds, suggesting latitude is a surrogate for temperature. The ultimate causes of migration in temperate-zone birds and Australian butterflies are the uneven temporal, and in Australia also spatial, distribution of resources. Uneven distribution is brought about primarily by temperature in temperate regions and by erratic rainfall over much of arid Australia. As a key determinant of productivity, especially in the tropics and subtropics, aridity is likely to be an important determinant of the global distributions of migrants.

Observations on cardiovascular and neuroendocrine disturbance in the Guillain-Barré syndrome.

Cardiovascular disturbances were found to be a common feature of patients with the Guillian-Barré syndrome who were severely paralysed, requiring assisted ventilation. Glycosuria was noted in association with these disturbances, and in five patients investigated we found impaired glucose tolerance tests at the height of the paralysis. Catecholamine and 17-hydroxycorticosteroid urinary excretions were found to be high in four patients investigated when the neuropathy was most severe, and in one patient plasma cortisol levels were high with loss of diurnal variation. With recovery from paralysis cardiovascular disturbances became less marked, catecholamine and 17-hydroxycorticosteroid urinary excretions reverted to normal, glucose tolerance improved but remained abnormal in three patients during the period of observation. It is suggested that increased levels of catecholamines and cortisol contributed to the development of impaired glucose tolerance and cardiovascular disturbances.