Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea.

BACKGROUND: The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists. METHODS: A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI). RESULTS: HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points. CONCLUSION: Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.

A case of multicentric reticulohistiocytosis.

Multicentric reticulohistiocytosis (MRH) is a rare non-Langerhans histiocytosis of unknown etiology with a predilection for joint and skin. The characteristic clinical features are papulonodular skin eruptions and inflammatory polyarthritis, sometimes progressive to arthritis mutilans, a severe destructive arthropathy. Although these manifestations can present at the same time, it is more common that one feature precedes the others. Notably, these features are similar to those found in some rheumatic diseases, such as rheumatoid arthritis or dermatomyositis, and this can lead to a misdiagnosis, especially during periods where only one feature is present. Herein, we report a female patient with polyarthralgia and subsequent skin eruptions, who was eventually diagnosed with MRH. Her symptoms seemed to resemble those of some rheumatic diseases, but several features such as affected joints and the characteristic shape of the skin lesions did not correspond to that. The histological result of infiltration of histiocytes and multinucleated giant cells in the skin ultimately facilitated the correct diagnosis. In this paper, we review MRH briefly and highlight several differential points which enable us to increase the likelihood of correctly diagnosing MRH.

Benefits of fungal-to-bacterial quorum quenching as anti-biofouling strategy in membrane bioreactors for wastewater treatment and water reuse.

This study addresses membrane biofouling in membrane bioreactors (MBRs) by exploring fungal-to-bacterial quorum quenching (QQ) strategies. While most research has been focused on bacterial-to-bacterial QQ tactics, this study identified fungal strain Vanrija sp. MS1, which is capable of degrading N-acyl-homoserine lactones (signaling molecules of Gram-negative bacteria). To determine the benefits of fungal over bacterial strains, after immobilization on fluidizing spherical beads in an MBR, MS1 significantly reduced the fouling rate by 1.8-fold compared to control MBR, decreased extracellular polymeric substance levels in the biofilm during MBR operation, and favorably changed microbial community and bacterial network, resulting in biofouling mitigation. It is noteworthy that, unlike Rhodococcus sp. BH4, MS1 enhanced QQ activity when switching from neutral to acidic conditions. These results suggest that MS1 has the potential for the effective treatment of acidic industrial wastewater sources such as semiconductor and secondary battery wastewater using MBRs.

Chromosome-level genome assembly of Korean holoparasitic plants, Orobanche coerulescens.

Orobanche coerulescens is a parasitic plant that cannot complete its life cycle without a host and is incapable of photosynthesis. The habitats of O. coerulescens span the coasts of Korea and its volcanic islands, Ulleungdo and Dokdo. Those on the volcanic islands exhibit morphological differences and have distinct hosts compared to those on the peninsula. The family of Orobanchaceae, encompassing both autotrophic and parasitic species, serves as a model for evolutionary studies of parasitic states. However, there are limited genome assemblies for the Orobanche genus. In our study, we produced approximately 100x ONT long reads to construct a chromosome-level genome of O. coerulescens. The resulting assembly has a total size of 3,648 Mb with an N50 value of 195 Mb, and 82.0% of BUSCO genes were identified as complete. Results of the repeat annotation revealed that 86.3% of the genome consisted of repeat elements, and 29,395 protein-coding genes were annotated. This chromosome-level genome will be an important biological resource for conserving biodiversity and further understanding parasitic plants.

Correlation of MR arthrographic findings and range of shoulder motions in patients with frozen shoulder.

OBJECTIVE: The purpose of this article is to correlate MRI arthrographic findings with range of shoulder motions in patients with frozen shoulder. MATERIALS AND METHODS: Shoulder MRI studies of 40 patients (22 women and 18 men; mean age, 52.8 years) with frozen shoulder were retrospectively compared with MRI studies of 40 age- and sex-matched control subjects without frozen shoulder. The thickness of the coracohumeral ligament and the capsule in axillary recess were measured retrospectively. The range of shoulder motions, including external rotation (ER), internal rotation (IR), lateral abduction, and forward flexion (FF), were prospectively evaluated by one experienced orthopedic surgeon. RESULTS: The mean (±SD) thickness of the coracohumeral ligament (4.13±1.04 vs 2.51±0.59 mm; p=0.000) and the capsule in axillary recess (3.97±1.45 vs 2.33±0.87 mm; p=0.000) were significantly greater in the patient group than in the control group. Multiple linear regression showed that only coracohumeral ligament thickness was significantly associated with ER (R2=0.418; p=0.000) and IR (R2=0.346; p=0.001), but not with lateral abduction and FF. Capsular thickness in axillary recess was not significantly correlated with any shoulder motion. CONCLUSION: Coracohumeral ligament thickness on MR arthrography correlates with the range limitation of ER and IR in patients with frozen shoulder.

Optimization of Fermentation Medium for Indole Acetic Acid Production by Pseudarthrobacter sp. NIBRBAC000502770.

Indole acetic acid (IAA) has been an important compound for plant growth and is widely known to be produced by plant growth-promoting rhizobacteria (PGPR). The isolate producing the maximum amount of IAA from the Korea shooting range soil was identified as Pseudarthrobacter sp. NIBRBAC000502770, using 16S rRNA gene sequencing. IAA production was determined in Luria-Bertani (LB) broth and optimized using different temperatures, agitation rates, L-tryptophan concentrations, carbon and nitrogen sources, and inorganic salts. The strain NIBRBAC000502770 showed better production of IAA at temperature 30 °C (29.47 mg·L-1) and at an agitation rate of 200 rpm (32.65 mg·L-1). Maltose (0.5%) was found to be the best carbon source for the strain (yielding 36.48 mg·L-1 IAA). IAA yield was 19.17 mg·L-1 and 24.73 mg·L-1 at 1% yeast extract and 1% tryptone as nitrogen sources, respectively. qRT-PCR showed the transcript levels of amiE and aldH genes, which had been predicted to encode indole-3-acetamide hydrolase and indole-3-acetaldehyde dehydrogenase, to be significantly upregulated in response to tryptophan. This study has examined that NIBRBAC000502770 has significant effects as a biological agent such as plant growth promotion, and development of optimal medium could significantly reduce the cost of mass production of microorganisms.

The complete chloroplast genome of Campanula takesimana Nakai from Dokdo Island in Korea (Campanulaceae).

Completed chloroplast genome of Campanula takesimana Nakai isolated from Dokdo island in Korea is 169,719 bp long (GC ratio is 38.8%) and has four subregions: 102,381 bp of large single-copy (37.8%) and 7,750 bp of small single-copy (32.6%) regions are separated by 29,794 bp of inverted repeat (41.3%) regions including 131 genes (87 protein-coding genes, eight rRNAs, and 36 tRNAs). Phylogenetic analyses suggested that C. takesimana from Dokdo Island form a clade with C. takesimana from Ulleungdo Island and that chloroplast genomes of the two accessions are diverged.

Granulocytic sarcoma of the spine: MRI and clinical review.

OBJECTIVE: Granulocytic sarcoma is a tumor formed by myeloid precursors at an extramedullary site. The purpose of this study was to evaluate the MRI findings and clinical manifestations in 32 cases of granulocytic sarcoma of the spine. MATERIALS AND METHODS: Thirty-two patients (21 males, 11 females; mean age, 32 years) with myeloid leukemia and spinal granulocytic sarcoma were included in this study. All of the patients underwent radiotherapy with chemotherapy, and four patients underwent surgical decompression or excisional biopsy. All 32 patients underwent MRI of the spine; 21 patients underwent follow-up MRI. RESULTS: Nine patients had spinal granulocytic sarcoma in the initial manifestation of leukemia. The other 23 diagnoses were made during a remission or relapse period. The lumbosacral and thoracic portions of the spine were commonly involved. Twenty-seven patients had multiple or contiguous multilevel involvement. According to location, spinal granulocytic sarcoma was classified as epidural in the central spinal canal, epidural along the nerve course, thickening of the nerve root itself, or prevertebral. Lesions were seen as isointense on T1-weighted images and had intermediate signal intensity with homogeneous enhancement on T2-weighted images. Nine patients had complete reduction of the tumor volume, and 12 patients had partial reduction. The median survival period was 9 months, and the 1-year survival rate was 41%. CONCLUSION: Knowledge of the imaging findings of spinal granulocytic sarcoma, which consists of multiple extramedullary masses with diffuse leukemic bone marrow infiltration, can lead to early diagnosis and appropriate treatment to reduce neurologic symptoms.

MRI features of skeletal muscle lymphoma.

OBJECTIVE: The purpose of this study was to assess the MRI findings of skeletal muscle lymphoma. MATERIALS AND METHODS: MR images of pathologically proven lymphoma of skeletal muscle in 20 patients were retrospectively reviewed for the presence or absence of individual imaging findings. Nine patients had primary muscle lymphoma, and 11 patients had muscle metastasis from systemic lymphoma. RESULTS: The initial manifestation of skeletal muscle lymphoma was a muscle mass in 15 patients (75%) and abnormal muscle signal intensity in five patients (25%). Muscle enlargement was found in all cases. Long segmental involvement with orientation of the tumor along muscle fascicles was found in 15 patients (75%). Seventeen patients (85%) had traversing vessels within involved muscles. All of the tumors had equal to slightly increased signal intensity compared with normal muscle on T1-weighted images and intermediate signal intensity compared with fat on T2-weighted images. Among the 19 patients who underwent contrast-enhanced imaging, skeletal muscle lymphoma exhibited diffuse homogeneous enhancement in 13 patients (68%), predominantly peripheral thick bandlike enhancement in four patients (21%), and marginal septal enhancement in two patients (11%). Thick irregular enhancement of both deep and superficial fascia was found in 16 patients (84%), and one patient (5%) had deep enhancement only. Subcutaneous stranding was found in 16 patients (80%) and skin thickening in four patients (20%). CONCLUSION: Skeletal muscle lymphoma has distinctive MRI features that help differentiate it from other soft-tissue tumors and tumorlike lesions.

Double trapezia sign: A new radiologic sign of scaphoid nonunion.

In scaphoid nonunion, pseudarthrosis and sclerotic change occur at the nonunion site. These changes make a distal fragment look like a trapezium on plain radiographs and we called this phenomenon the double trapezia sign. The purpose of this study was to estimate the diagnostic reliability of the double trapezia sign and its clinical and prognostic implications for the scaphoid nonunion.A retrospective review of 124 patients who underwent surgical treatment because of scaphoid nonunion between January 2007 and December 2017 was performed. Two hand surgeons and 1 musculoskeletal radiologist reviewed preoperative plain radiographs independently. Each observer evaluated the plain radiographs in 2 separate sessions at least 3 weeks apart to assess intraobserver and interobserver reliabilities of the double trapezia sign. To assess clinical and prognostic implications of the double trapezia sign, the patients were divided into the positive and nonpositive groups, and several variables such as age, sex, duration of nonunion, size of the distal fragment, avascular necrosis (AVN) of the proximal fragment, type of bone graft, healing time, and failure rate were compared between the 2 groups.The kappa values of intraobserver and interobserver reliabilities were >0.8, corresponding to almost perfect agreement. There were 58 patients in the positive group and 66 patients in the nonpositive group. The mean duration of nonunion was 38.5 months in the positive group and 12.2 months in the nonpositive group (P < .001). The size of distal fragment was 49.6% and 60.9%, respectively (P < .001). The AVN of proximal fragment was 24.1% and 54.5%, respectively (P = .001). The mean healing time was 4.1 and 6.4 months, respectively (P < .001). The failure rate was 13.8% and 27.3%, respectively (P = .066).In conclusion, the double trapezia sign is a valuable radiographic sign of scaphoid nonunion. The double trapezia sign is easily identifiable on plain radiographs and has excellent intra- and interobserver reliabilities. The positive double trapezia sign implies mid-waist nonunion, long duration of nonunion, less possibility of AVN, and favorable postoperative prognosis.

Diversity and evolution of Ty1-copia and Ty3-gypsy retroelements in the non-photosynthetic flowering plants Orobanche and Phelipanche (Orobanchaceae).

We present the first study on the diversity and evolution of Ty1-copia and Ty3-gypsy retroelements in a group of non-photosynthetic flowering plants. To this end partial sequences of the reverse transcriptase (rt) gene were obtained from 20 clones for each retroelement type from seven and six accessions of Orobanche and Phelipanche (Orobanchaceae), respectively. Overall sequence similarity is higher in Ty3-gypsy elements than in Ty1-copia elements in agreement with the results from other angiosperm groups. Higher sequence diversity and stronger phylogenetic structure, especially of Ty1-copia sequences, in Orobanche species compared to Phelipanche species support the previously suggested hypothesis (based on karyological and cytological data) that genomes of Orobanche species are more dynamic than those of Phelipanche species. No evidence was found for intraspecific differences of retroelement diversity nor for differences between pest taxa and their putative wild relatives, e.g., O. crenata and O. owerini. The occurrence of a few sequences from Phelipanche species in clades otherwise comprising sequences from Orobanche species might be due to horizontal gene transfer, but the alternative of vertical transmission cannot be rejected unambiguously.

Bone erosion is associated with reduction of circulating endothelial progenitor cells and endothelial dysfunction in rheumatoid arthritis.

OBJECTIVE: To identify factors influencing endothelial progenitor cell (EPC) counts in patients with rheumatoid arthritis (RA). METHODS: The number of circulating CD34+/ vascular endothelial growth factor receptor 2-positive EPCs was measured in 126 RA patients and 46 non-RA control patients. Endothelial function was assessed by brachial flow-mediated dilation (FMD). Serum CXCL12 concentrations were determined using an enzyme-linked immunosorbent assay. EPCs and FMD were measured at baseline and after 24 weeks of anti-tumor necrosis factor (TNF) therapy in 29 patients with active RA. RESULTS: The numbers of circulating EPCs were significantly lower in the RA patients than in the non-RA controls. In multivariate analysis, older age, reduced levels of high-density lipoprotein cholesterol, and higher bone erosion scores were independent risk factors for reduced EPC counts in RA patients. Serum CXCL12 levels correlated negatively with EPC counts, but positively with bone erosion scores. FMD was impaired in RA patients, and a decreased FMD in RA was closely associated with a higher bone erosion score and a reduced EPC count. In addition, EPC counts were restored by anti-TNF therapy, and this increase was paralleled by improvement in FMD. Interestingly, restoration of EPC counts was attenuated in patients with higher bone erosion scores than in those with lower scores, despite similar levels of improvement in disease activity. CONCLUSION: The numbers of circulating EPCs in RA patients are reduced and are inversely correlated with serum levels of CXCL12. Reduced EPC counts are closely associated not only with bone erosion, but also with endothelial dysfunction.

MR findings of the osteofibrous dysplasia.

OBJECTIVE: The aim of this study was to describe MR findings of osteofibrous dysplasia. MATERIALS AND METHODS: MR images of 24 pathologically proven osteofibrous dysplasia cases were retrospectively analyzed for a signal intensity of the lesion, presence of intralesional fat signal, internal hypointense band, multilocular appearance, cortical expansion, intramedullary extension, cystic area, cortical breakage and extraosseous extension, abnormal signal from the adjacent bone marrow and soft tissue and patterns of contrast enhancement. RESULTS: All cases of osteofibrous dysplasia exhibited intermediate signal intensity on T1-weighted images. On T2-weighted images, 20 and 4 cases exhibited heterogeneously intermediate and high signal intensity, respectively. Intralesional fat was identified in 12% of the cases. Internal low-signal bands and multilocular appearance were observed in 91%. Cortical expansion was present in 58%. Intramedullary extension was present in all cases, and an entire intramedullary replacement was observed in 33%. Cortical breakage (n = 3) and extraosseous mass formation (n = 1) were observed in cases with pathologic fractures only. A cystic area was observed in one case. Among 21 cases without a pathologic fracture, abnormal signal intensity in the surrounding bone marrow and adjacent soft tissue was observed in 43% and 48%, respectively. All cases exhibited diffuse contrast enhancement. CONCLUSION: Osteofibrous dysplasia exhibited diverse imaging features ranging from lesions confined to the cortex to more aggressive lesions with complete intramedullary involvement or perilesional marrow edema.

The neurological safety of epidural parecoxib in rats.

Epidural injection of cyclooxygenase-2 inhibitors has been suggested as a useful therapeutic modality in pain management in animal studies and clinical settings. Direct epidural administration of parecoxib, a highly selective cyclooxygenase-2 inhibitor, may have advantages over its parenteral administration regarding required dose, side effects, and efficacy. However, no animal studies have been performed to investigate the possible neurotoxicity of epidurally injected parecoxib. Therefore, the present study was performed to assess the neurotoxicity of epidurally injected parecoxib in rats. Rats (n=45) were randomly divided into three groups: normal saline group (group N, n=15), ethanol group (group E, n=15), and parecoxib group (group P, n=15). 0.3 mL of epidural parecoxib (6 mg) and the same volume of epidural ethanol or normal saline were injected into the epidural space. Neurologic assessment was performed 3, 7 and 21 days after the injection by pinch toe testing. Histologic changes were evaluated for vacuolation of the dorsal funiculus, chromatolytic changes of the motor neurons, neuritis, and meningeal inflammation. All rats in groups N and P showed normal response to pinch-toe testing and had a normal gait at each observation point. Histological examination showed no evidence suggestive of neuronal body or axonal lesions, gliosis, or myelin sheet damage in group N or P at any time. However, all rats in group E showed sensory-motor dysfunction, behavioral change, or histopathological abnormalities. No neurotoxicity on the spinal cord or abnormalities in sensorimotor function or behavior was noted in rats that received epidural parecoxib.

The effects of midazolam and sevoflurane on the GABA(A) receptors with alternatively spliced variants of the γ2 subunit.

BACKGROUND: Emergence agitation after sevoflurane anesthesia in children can be prevented by midazolam. Alternative splicing of the GABA(A) receptor changes with age. Therefore, we hypothesized that alternative splicing of the γ2 subunit affects the GABA current when applying sevoflurane and midazolam. METHODS: We performed the whole-cell patch clamp technique on human embryonic kidney 293 cells that were transfected with α1ß2γ2L or α1ß2γ2S. The concentration-response relations were recorded for midazolam and sevoflurane, and the co-application responses were measured at concentrations of 1.5 nM, 15 nM and 300 nM of midazolam and 0.5%, 2.0% and 4.0% of sevoflurane. Each GABA current was compared with that produced by 5 µM of GABA. RESULTS: The concentration-response relationships for midazolam and sevoflurane were dose-dependent without any differences between the α1ß2γ2L and α1ß2γ2S subtypes. 1.5 nM and 15 nM of midazolam did not significantly enhance the current after treatment with 0.5% sevoflurane for both subtypes. The current after treatment with 2.0% sevoflurane was enhanced by 1.5 nM midazolam for the α1ß2γ2S subtype, but not for the α1ß2γ2L subtype. In the case of 2.0% sevoflurane with 15 nM of midazolam, and 4.0% sevoflurane with 300 nM of midazolam, the GABA currents were significantly enhanced for both subtypes. CONCLUSIONS: These results show that the difference in the γ2 subunit cannot explain the emergence agitation after sevoflurane anesthesia in children in vitro. This suggests that co-application of sevoflurane and midazolam enhances the GABA current according to the alternative splicing of the γ2 subunit and the concentration of both drugs.

Imaging features of invasive lobular carcinoma: comparison with invasive ductal carcinoma.

PURPOSE: The aim of this study was to evaluate the imaging findings of invasive lobular carcinoma (ILC) compared to those of invasive ductal carcinoma (IDC). MATERIALS AND METHODS: The study included ILCs (n = 27) and IDCs (n = 85). Imaging findings were retrospectively evaluated, according to the BI-RADS lexicon. We compared the imaging findings, multiplicity, and magnetic resonance imaging (MRI) detection accuracy of ILC with those of IDC. RESULTS: At mammography, normal findings and mass lesions were more frequent with ILCs (14.8% and 59.2%, respectively) than with IDCs (1.2% and 44.7%, respectively) (P = 0.009). With ultrasonography (US), posterior acoustic shadowing was more frequently seen in ILCs (59.2%) than in IDCs (15.8%) (P < 0.001). With MRI, both ILCs and IDCs most commonly appeared as a heterogeneously enhancing, irregular mass with a spiculated border. Multifocality was more frequently associated with ILCs (40.7%) than with IDCs (14.1% 1% 0.002). However, multicentricity and bilaterality were not different between the two groups. The sensitivity and specificity of MRI for the detection of multiplicity were 91.6% and 73.3%, respectively, for ILCs and 83.3% and 80.3%, respectively, for IDCs. CONCLUSION: Normal findings, mass lesions on mammography, and posterior acoustic shadowing on US were more frequently associated with ILCs than with IDCs. Multifocality was more prevalent with ILCs than with IDCs.

A plastid gene phylogeny of the non-photosynthetic parasitic Orobanche (Orobanchaceae) and related genera.

The phylogenetic relationships of the non-photosynthetic Orobanche sensu lato (Orobanchaceae), which includes some of the economically most important parasitic weeds, remain insufficiently understood and controversial. This concerns both the phylogenetic relationships within the genus, in particular its monophyly or lack thereof, and the relationships to other holoparasitic genera such as Cistanche or Conopholis. Here we present the first comprehensive phylogenetic study of this group based on a region from the plastid genome (rps2 gene). Although substitution rates appear to be elevated compared to the photosynthetic members of Orobanchaceae, relationships among the major lineages Cistanche, Conopholis plus Epifagus, Boschniakia rossica (Cham. & Schltdl.) B. Fedtsch., B. himalaica Hook. f. & Thomson, B. hookeri Walp. plus B. strobilacea A. Gray, and Orobanche s. l. remain unresolved. Resolution within Orobanche, however, is much better. In agreement with morphological, cytological and other molecular phylogenetic evidence, five lineages, corresponding to the four traditionally recognised sections (Gymnocaulis, Myzorrhiza, Orobanche, Trionychon) and O. latisquama Reut. ex Boiss. (of sect. Orobanche), can be distinguished. A combined analysis of plastid rps2 and nuclear ITS sequences of the holoparasitic genera results in more resolved and better supported trees, although the relationships among Orobanche s. l., Cistanche, and the clade including the remaining genera is unresolved. Therefore, rps2 is a marker from the plastid genome that is well-suited to be used in combination with other already established nuclear markers for resolving generic relationships of Orobanche and related genera.

Horizontal gene transfer of a plastid gene in the non-photosynthetic flowering plants Orobanche and Phelipanche (Orobanchaceae).

Plastid sequences are among the most widely used in phylogenetic and phylogeographic studies in flowering plants, where they are usually assumed to evolve like non-recombining, uniparentally transmitted, single-copy genes. Among others, this assumption can be violated by intracellular gene transfer (IGT) within cells or by the exchange of genes across mating barriers (horizontal gene transfer, HGT). We report on HGT of a plastid region including rps2, trnL-F, and rbcL in a group of non-photosynthetic flowering plants. Species of the parasitic broomrape genus Phelipanche harbor two copies of rps2, a plastid ribosomal gene, one corresponding to the phylogenetic position of the respective species, the other being horizontally acquired from the related broomrape genus Orobanche. While the vertically transmitted copies probably reside within the plastid genome, the localization of the horizontally acquired copies is not known. With both donor and recipient being parasitic plants, a possible pathway for the exchange of genetic material is via a commonly attacked host.

Chromosomal stasis in diploids contrasts with genome restructuring in auto- and allopolyploid taxa of Hepatica (Ranunculaceae).

Polyploidization and chromosomal rearrangements are recognized as major forces in plant evolution. Their role is investigated in the disjunctly distributed northern hemisphere Hepatica (Ranunculaceae). Chromosome numbers, karyotype morphology, banding patterns, 5S and 35S rDNA localization in all known species were investigated and interpreted in a phylogenetic context established from nuclear internal transcribed spacer (ITS) and plastid matK sequences. All species had a chromosome base number of x = 7. The karyotype was symmetric and showed little variation among diploids with one locus each of 5S and 35S rDNA, except for interpopulational variation concerning 35S rDNA loci number and localization in H. asiatica. Tetraploids exhibited chromosomal changes, including asymmetry and/or loss of rDNA loci. Nuclear and plastid sequences resulted in incongruent topologies because of the positions of some tetraploid taxa. The diversification of Hepatica occurred not earlier than the Pliocene. Genome restructuring, especially involving 35S rDNA, within a few million yr or less characterizes evolution of both auto- and allopolyploids and of the diploid species H. asiatica, which is the presumptive ancestor of two other diploid species.