Viral dominance patterns in chronic hepatitis delta determine early response to interferon alpha therapy.

Chronic hepatitis D is caused by coinfection of hepatitis B and hepatitis D virus. While HDV is the dominant virus over HBV in the majority of cases, mechanisms and consequences of viral dominance are largely unknown. We aimed to investigate associations between viral dominance patterns and patients' characteristics and inflammatory features; 109 HDV-infected patients treated with PEG-IFNa-2α within the international multicentre, prospective HIDIT-2 trial were studied. Patients were classified as D- or B-dominant if the viral load of one virus exceeded that of the other virus by more than 1log10 . Otherwise, no viral dominance (ND) was described. We used Luminex-based multiplex technology to study 50 soluble immune mediators (SIM) in pretreatment samples of 105 HDV RNA-positive patients. Dominance of HDV was evident in the majority (75%) of cases. While only 7% displayed B-dominance, 17% showed nondominance. D-dominance was associated with downregulation of 4 interleukins (IL-2ra, IL-13, IL-16 and IL-18) and 5 chemokines/cytokines (CTACK (CCL27), MCP-1 (CCL2), M-CSF, TRAIL and ICAM-1) while no analyte was increased. In addition, D-dominance could be linked to a delayed HDV RNA response to pegylated interferon as patients with B-dominance or nondominance showed higher early HDV RNA responses (61% at week 12) than D-dominant patients (11%; P < .001). In conclusion, this study revealed unexpected effects of viral dominance on clinical and immunological features in chronic hepatitis delta patients. Individualizing PEG-IFNa-2α treatment duration should consider viral dominance. Overall, our findings suggest an activated but exhausted IFN system in D-dominant patients.

Cross-genotype-specific T-cell responses in acute hepatitis E virus (HEV) infection.

Hepatitis E is an inflammatory liver disease caused by infection with the hepatitis E virus (HEV). In tropical regions, HEV is highly endemic and predominantly mediated by HEV genotypes 1 and 2 with >3 million symptomatic cases per year and around 70 000 deaths. In Europe and America, the zoonotic HEV genotypes 3 and 4 have been reported with continues increasing new infections per year. So far, little is known about T-cell responses during acute HEV genotype 3 infection. Therefore, we did a comprehensive study investigating HEV-specific T-cell responses using genotypes 3- and 1-specific overlapping peptides. Additional cytokines and chemokines were measured in the plasma. In four patients, longitudinal studies were performed. Broad functional HEV-specific CD4(+) and CD8(+) T-cell responses were detectable in patients acutely infected with HEV genotype 3. Elevated of pro- and anti-inflammatory cytokine levels during acute HEV infection correlated with ALT levels. Memory HEV-specific T-cell responses were detectable up to >1.5 years upon infection. Importantly, cross-genotype HEV-specific T-cell responses (between genotypes 1 and 3) were measurable in all investigated patients. In conclusion, we could show for the first time HEV-specific T-cell responses during and after acute HEV genotype 3 infection. Our data of cross-genotype HEV-specific T-cell responses might suggest a potential role in cross-genotype-specific protection between HEV genotypes 1 and 3.

Hepatitis B core-related antigen (HBcrAg) levels in the natural history of hepatitis B virus infection in a large European cohort predominantly infected with genotypes A and D.

Hepatitis B core-related antigen (HBcrAg) has been suggested as an additional marker of hepatitis B virus (HBV) infection. HBcrAg combines the antigenic reactivity resulting from denatured hepatitis B e antigen (HBeAg), HBV core antigen and an artificial core-related protein (p22cr). In Asian patients, high levels of HBcrAg have been suggested to be an independent risk factor for hepatocellular carcinoma, while low levels could guide safe cessation of treatment with nucleos(t)ide analogues. We here studied HBcrAg levels in different phases of HBV infection in a large European cohort predominantly infected with genotypes A and D: HBeAg-positive immune tolerance (n = 30), HBeAg-positive immune clearance (IC) (n = 60), HBeAg-negative hepatitis (ENH) (n = 50), HBeAg-negative inactive/quiescent carrier phase (c) (n = 109) and acute hepatitis B (n = 8). Median HBcrAg levels were high in the immune tolerance and immune clearance phases (8.41 and 8.11 log U/mL, respectively), lower in ENH subjects (4.82 log U/mL) but only 2.00 log U/mL in ENQ subjects. Correlation between HBcrAg and HBV DNA varied among the different phases of HBV infection, while HBcrAg moderately correlated with hepatitis B surface antigen in all phases. ENQ patients had HBcrAg levels <3 log U/mL in 79%, in contrast to only 12% in the ENH group. HBcrAg levels vary significantly during the different phases of HBV infection. HBcrAg may serve as valuable marker for virus replication and reflect the transcriptional activity of intrahepatic cccDNA. In HBeAg-negative patients, HBcrAg may help to distinguish between inactive carriers (ENQ) and those with active disease (ENH).

Development and evaluation of a baseline-event-anticipation score for hepatitis delta.

Hepatitis delta is considered the most severe form of viral hepatitis, but variables associated with disease progression are poorly defined. This study aimed to identify risk factors associated with worse clinical outcome in patients with hepatitis delta and to develop a clinical score to determine their risk of experiencing liver-related morbidity or mortality. We followed 75 HBsAg-anti-HDV-positive patients with hepatitis delta for up to 16 years (median 5 years). The baseline-event-anticipation score (BEA score) was developed based on variables associated with the development of liver-related clinical complications. Age, region of origin, presence of cirrhosis, albumin, INR, hyperbilirubinemia and thrombocytopenia were all associated with the development of an event in the training cohort. The BEA score included age, sex, region of origin, bilirubin, platelets and INR. Points were allocated according to hazard ratios, and three risk groups were defined: BEA-A mild risk, BEA-B moderate risk and BEA-C high risk. Hazard ratios of BEA-B and BEA-C patients for liver-related clinical endpoints were 9.01 and 25.27 vs BEA-A with an area under curve of the receiving operating characteristic curve of 0.88. The accuracy of the BEA score was confirmed in two independent validation cohorts followed in Barcelona (n = 77) and Düsseldorf (n = 62). Delta hepatitis is associated with a very severe long-term outcome. The BEA score is easy to apply and predicts with a very high accuracy the development of liver-related complications in patients with hepatitis delta.

Course and treatment of chronic hepatitis E virus infection in lung transplant recipients.

OBJECTIVE: Persistent hepatitis E virus (HEV) infections have been described in various transplant cohorts. However, the frequency and the course of HEV infection in lung transplant recipients (Lu-Tr) are not well defined. METHODS: We retrospectively analyzed serum from 95 Lu-Tr for HEV RNA and anti-HEV immunoglobulin-G (IgG) (with the MP assay). Anti-HEV seroprevalence was compared to that of 537 healthy individuals. Prospective HEV screening was subsequently initiated in Lu-Tr. RESULTS: Elevated liver enzymes were observed in 44/95 (46.3%) patients. Anti-HEV IgG was present in 5/95 patients (5.3%), revealing a slightly higher prevalence compared to controls (2%, 11/537; P = 0.07). Chronic HEV infection with detectable viral replication was confirmed by polymerase chain reaction in 3 (3.2%) patients, all of whom demonstrated clinical and biochemical features of active liver disease (maximum alanine aminotransferase [ALTmax ] 89, 215, and 270 IU/L, respectively). One patient had died from multi-organ failure in combination with liver cirrhosis before HEV diagnosis. Two additional patients with chronic hepatitis E were identified during prospective screening (ALTmax 359 and 318 IU/L). All patients still alive commenced ribavirin therapy for 5 months, with dose adjustment (400-600 mg/day) according to renal function and hemoglobin level. Sustained resolution of HEV infection occurred in 2 patients. One patient is still under treatment, and the fourth died from graft failure considered unrelated to ribavirin therapy. CONCLUSION: Chronic hepatitis E should be considered in the differential diagnosis of elevated liver enzymes, which are commonly seen in Lu-Tr. We observed 1 case of end-stage liver cirrhosis and death in an HEV-infected subject, who was not treated with ribavirin. Given this potentially devastating consequence, ribavirin therapy of persistent HEV infection appears to be acceptably safe and effective in Lu-Tr. However, larger prospective studies are warranted.

Detection of low HCV viraemia by repeated HCV RNA testing predicts treatment failure to triple therapy with telaprevir.

BACKGROUND: Early on-treatment virological response is one of the most important predictors for sustained virological response (SVR) to treatment of chronic hepatitis C virus (HCV) genotype 1 infection with triple therapy including HCV protease inhibitors (PI). Treatment duration (24 vs. 48 weeks) is based on HCV RNA results at weeks 4 and 12 of PI therapy when HCV RNA must be 'undetectable' to allow shorter therapy. AIM: To analyse the reliability of HCV RNA measurements at key decision time points (weeks 4 and 12) and the predictive value of concordant or discordant assay results for SVR. METHODS: Weeks 4 and 12 samples of patients receiving telaprevir-containing triple therapy were initially tested with the AmpliPrep/COBAS-TaqMan_HCV-Test-v1.0 (limit of detection; LOD = 15IU/mL) and retested with the AmpliPrep/COBAS-TaqMan_HCV-Test-v2.0 (LOD = 15IU/mL) and the High_Pure/COBAS-TaqMan_HCV-Test-v2.0 (LOD = 20IU/mL). RESULTS: Concordance among the three test results in classifying samples as HCV RNA 'undetectable' or 'detectable' was only 55% at week 4, but 85% at week 12. Retesting of 'undetectable' week 4 samples with the respective other assays revealed positive HCV RNA results in 32-50%. In 30%, HCV RNA was 'undetectable' by all three tests at week 4 and all of these patients achieved SVR. In contrast, treatment failure occurred in 62% of patients with at least one 'detectable' result, including cases with one or two other 'undetectable' tests at week 4. CONCLUSIONS: A single 'undetectable' HCV RNA result at week 4 is not always associated with achieving SVR. Repeated testing in difficult-to-treat patients may identify those at risk for treatment failure.

Evolutionary history of the Afro-Madagascan Ixora species (Rubiaceae): species diversification and distribution of key morphological traits inferred from dated molecular phylogenetic trees.

BACKGROUND AND AIMS: Previous work on the pantropical genus Ixora has revealed an Afro-Madagascan clade, but as yet no study has focused in detail on the evolutionary history and morphological trends in this group. Here the evolutionary history of Afro-Madagascan Ixora spp. (a clade of approx. 80 taxa) is investigated and the phylogenetic trees compared with several key morphological traits in taxa occurring in Madagascar. METHODS: Phylogenetic relationships of Afro-Madagascan Ixora are assessed using sequence data from four plastid regions (petD, rps16, rpoB-trnC and trnL-trnF) and nuclear ribosomal external transcribed spacer (ETS) and internal transcribed spacer (ITS) regions. The phylogenetic distribution of key morphological characters is assessed. Bayesian inference (implemented in BEAST) is used to estimate the temporal origin of Ixora based on fossil evidence. KEY RESULTS: Two separate lineages of Madagascan taxa are recovered, one of which is nested in a group of East African taxa. Divergence in Ixora is estimated to have commenced during the mid Miocene, with extensive cladogenesis occurring in the Afro-Madagascan clade during the Pliocene onwards. CONCLUSIONS: Both lineages of Madagascan Ixora exhibit morphological innovations that are rare throughout the rest of the genus, including a trend towards pauciflorous inflorescences and a trend towards extreme corolla tube length, suggesting that the same ecological and selective pressures are acting upon taxa from both Madagascan lineages. Novel ecological opportunities resulting from climate-induced habitat fragmentation and corolla tube length diversification are likely to have facilitated species radiation on Madagascar.

Chronic hepatitis e in heart transplant recipients.

Chronic courses of hepatitis E virus (HEV) infections have been described in immunosuppressed patients. We aimed to study the role of HEV infections in heart transplant recipients (HTR). 274 HTR were prospectively screened for HEV infection using an anti-HEV-IgG ELISA and HEV-PCR. In addition, 137 patients undergoing cardiac surgery (non-HTR) and 537 healthy subjects were studied cross-sectionally. The anti-HEV-IgG seroprevalence was 11% in HTR, 7% in non-HTR and 2% in healthy controls (HTR vs. healthy controls p<0.0001; non-HTR vs. healthy controls p<0.01). Anti-HEV tested positive in 4.0% in control cohorts of other immunocompromised patients (n = 474). Four HTR (1.5%) were chronically infected with HEV as shown by HEV-PCR and all four patients had liver transaminases of >200 IU/L and histological or clinical evidence of advanced liver disease. In three patients ribavirin treatment was successful with a sustained biochemical and virological response while treatment failed in one cirrhotic patient after ribavirin dose reduction. Heart transplant recipients and patients undergoing cardiac surgery have an increased risk for HEV infections. Chronic hepatitis E may explain elevated liver enzymes in heart transplant recipients. Treatment of HEV infection with ribavirin is effective but the optimal dose and duration of ribavirin therapy remains to be determined.

Chronic hepatitis E in hematopoietic stem cell transplant patients in a low-endemic country?

Cases of chronic hepatitis E have been described in patients after kidney and liver transplantation. In addition, hepatitis E virus (HEV) reactivation was reported after hematopoietic stem cell transplantation (HSCT). We here evaluated if HEV infection might explain elevated liver enzymes in a well selected cohort of allogeneic HSCT patients with biochemical evidence of hepatitis (n = 52). Of note, none of the subjects tested positive for HEV RNA, including 2 HSCT patients who had been infected with HEV already before transplantation. Thus, both chronic courses of HEV infections and HEV reactivations seem to be rather rare events in HSCT patients in a non-endemic country.

Hepatitis E: an emerging infectious disease in Germany?

Increased frequencies of HEV infections have been reported in several industrialized countries. We suggest that this finding might be explained by a better awareness of the disease and not by an increased incidence. Although reported HEV infections increased more than 6-fold in Germany in recent years, the seroprevalence remained unchanged (2 %).

Dietary amino acids fed in free form or as protein do differently affect amino acid absorption in a rat everted sac model.

In the present study, the effect of free amino acid (FAA) diets on the intestinal absorption rate of methionine and leucine was studied 'ex vivo' with rats adapted for different periods of time to the diets, using the everted sac method. The adaptation period to the 21% FAA diet with an amino acid content based on casein was either, 0 (no adaptation, N-ADA), 5 (short-term adaptation, ST-ADA), or 26-33 days (long-term adaptation, LT-ADA). Within the ST-ADA and the LT-ADA groups, three different levels of methionine were included: 50%, 100% and 200% of the level normally present in casein. All diets were iso-nitrogenous and iso-caloric. After the adaptation period (0, 5, or 26-33 days), intestinal everted sacs were prepared. Methionine or leucine was added to the medium as transport substrate. The methionine absorption rate of the rats of the LT-ADA groups was higher than that of the N-ADA groups. Furthermore, adaptation to 200% dietary methionine levels caused a significantly slower leucine absorption compared to the 100%, and 50% group. Methionine absorption was similar in the 100% and 200% groups, but the absorption of methionine in the 50% group was enhanced in the distal part of the intestines. We concluded that in response diets with 21% FAAs as only amino acid source, amino acid absorption is decreased to avoid toxic effects of high levels of methionine in the circulation.

The ALSSQOL: balancing physical and nonphysical factors in assessing quality of life in ALS.

BACKGROUND: There is no generally accepted instrument for measuring quality of life (QOL) in patients with ALS. Current instruments are either too heavily weighted toward strength and physical function or useful for the evaluation of individuals but of less utility in assessing large samples. OBJECTIVE: To develop and evaluate the psychometric properties of an ALS-specific QOL instrument (the ALSSQOL) that would reflect overall QOL as assessed by the patient and would be valid and reliable across large samples. METHODS: The ALSSQOL is based on the McGill Quality of Life Questionnaire (MQOL), modified by changes in format and by adding questions on religiousness and spirituality, items derived from interviews with ALS patients, and items identified from open-ended questions administered during the MQOL. The psychometric properties of the ALSSQOL were assessed by a prospective multicenter study in which participants completed the ALSSQOL, other instruments measuring overall QOL, and instruments assessing religiousness, spirituality, and psychological distress. RESULTS: A 59-item ALSSQOL was developed; 342 patients evaluated its psychometric properties. Completion time averaged 15 minutes. Forty-six items loaded on six factors. The ALSSQOL demonstrated concurrent, convergent, and discriminant validity for the overall instrument and convergent validity for its subscales. Analysis of individual items permitted insight into variables of clinical importance. CONCLUSIONS: This new ALS-specific quality of life instrument is a practical tool for the assessment of overall quality of life in individuals with ALS and appears to be valid and useful across large samples. Validation studies of a shortened version are now under way.

Dietary amino acids fed in free form and as protein components do not differently affect postprandial plasma insulin, glucagon, growth hormone and corticosterone responses in rats.

This study examined, whether the postprandial fate of dietary amino acids from different amino acid sources is regulated by the responses of insulin, glucagon, corticosterone and growth hormone (GH). Male Wistar rats were cannulated in the vena jugularis and assigned to dietary groups. The diets contained 21% casein or the same amino acids in free form. In the free amino acid diets, methionine level was varied between the groups. The feed was supplied in two distinct meals. In previous experiments it was established that oxidative amino acid losses of the free amino acid diets and protein diets were different. After 3 weeks on those diets, it appeared that the differences in postprandial oxidative losses had been diminished. GH was measured every 12 min, from 144 min before the start of the experimental meal over the following 144 min. Insulin and corticosterone were measured six times from the start of the meal until 270 min after the meal. No differences have been observed between the hormonal responses to both meals at day 5 and at day 26. In conclusion, it has been found that the differences in the oxidative losses between protein and free amino acid meals are not mediated by the combined action of the insulin, glucagon, corticosterone and GH. Postprandial catabolism of amino acids is most probably regulated by substrate induction.

Dental implants in patients with orofacial clefts: a long-term follow-up study.

Aim of this study was to determine the success of implants that were inserted in patients with cleft of the lip, alveolus and palate (CLAP) and to identify prognosis-relevant factors. In a prospective evaluation, 75 implants inserted in combination with bone grafting at cleft sites of 45 patients were examined. The observation period extended 5.5 years in average (minimum 1.5, maximum 11.3 years). Implant success was evaluated clinically and radiographically and was compared to age- and gender-matched control groups. Statistic assessment included Kaplan-Meier survival analysis, Log rank tests and Cox regression analysis. In total, 10 implants were lost in 8 patients, resulting in an implant survival rate of 82.2% at the end of the observation period. Patient-related parameters of age, gender or type of cleft had no significant influence. The length of an implant was significantly related to an improved survival rate (P<0.01). Implant survival was less in CLAP patients when compared to implant insertions in a non-cleft control group, but improved when compared to patients with bone grafting for other indications. It is concluded that implants combined with bone grafting can offer a reliable alternative in patients with CLAP.

Potential clients' beliefs about the relative competency and caring of psychologists: implications for the profession.

To assess the extent to which the results reported by Warner and Bradley (1991) can be generalized beyond the population of undergraduate psychology students, 132 adults in the metropolitan Harrisburg area were asked to evaluate the competency and traits of clinical psychologists, licensed professional counselors, and psychiatrists. Results indicated that the general public believed counselors to be more caring than psychologists and psychiatrists. All three professional groups were perceived to be comparable in their ability to treat the least severe disorders. Licensed counselors were perceived to be most competent to treat disorders rated by the subjects as moderately severe, comparable in competence to clinical psychologists for adjustment disorders, and comparable to psychiatrists for marital problems. Psychiatrists and psychologists were considered the most competent to treat the most severe disorder, major depression. The results indicate that while clinical psychologists often were viewed as competent, they were not viewed as the single practitioner of choice for any diagnostic classification, nor were they noted to have positive character traits.

Molar fracture resistance after adhesive restoration with ceramic inlays or resin-based composites.

PURPOSE: To determine the fracture resistance of teeth, following treatment with various types of adhesive restorations. MATERIALS AND METHODS: 5 0 caries-free, extracted human molars were randomly divided into five groups consisting of 10 molars each. MOD cavities were prepared in 40 molars with a width in the facio-lingual direction of 50% of the intercuspal distances. The cavities were filled with the following materials: Cerec or IPS Empress ceramic inlays, Arabesk or Charisma F resin-based composite (RBC) restorations. The control group consisted of 10 sound, non-restored molars. All 50 teeth were loaded occlusally until fracture using a tensile testing machine. The statistical analysis included ANOVA, Kolmogorov-Smimov-test, Scheffé test, and boxplots. RESULTS: There was no significant difference (P > 0.05) between the mean values of the sound teeth (2,102 N) and the teeth with the Cerec ceramic inlays (2,139 N). However, both groups demonstrated a significant difference (P < 0.05) when compared with the teeth with IPS Empress ceramic inlays (1,459 N) and Arabesk RBC restorations (1459 N). No significant differences were found between the last two groups. Molars restored with Charisma F composite restorations (1,562 N) revealed no significant difference when compared with all other groups including controls (P > 0.05). A stabilization of molars is possible by means of an adhesive restoration in the form of an "internal splinting" regardless of the restorative material used.

[Styloid process: radiograph and craniomandibular dysfunction (CMD)]. / Processus styloideus: Röntgenbild und cranio-mandibuläre Dysfunktion (CMD).

The aim of the study was to investigate the suitability of orthopantomograms for measuring the length of the styloid process (SP), and to determine the frequency of elongated SP in patients with craniomandibular dysfunction (CMD). For 350 patients, two ortho-pantomograms were available, produced by a SIEMENS Orthophos 5 using programs P1 and P6, respectively, plus a craniomandibular function index. The SP length measurements from the orthopantomograms and the palpation findings were correlated. In 34,7% of the 700 orthopantomograms the SP was measurable. The mean length was determined to be 29.1 mm in OPT1 films on both sides. In the OPT6 films the length values were 30.1 mm on the right, and 30.4 mm on the left side. In CMD patients there was no evidence of the SP causing the complaints. Two conclusions can be made: For epidemiologic studies on the length of the styloid process, the orthopantomogram is of limited use. In CMD patients the elongated styloid process is of negligible importance as a cause of complaints.

Familial isolated parathyroid adenoma in a consanguineous family.

The 23-year-old Caucasian male propositus presented with symptomatic hypercalcemia, hypophosphatemia and normocalciuria for 2 months. His 29-year-old brother had undergone an operation for recurrent parathyroid adenoma at age 26 and 28. No other member of the family was affected. His father and mother were second-degree relatives. Laboratory studies showed primary hyperparathyroidism (pHPT), while the remaining endocrine studies and genetic testing for multiple endocrine neoplasia 1 and 2A were normal. Technetium-cardiolite scintigraphy and ultrasound scans revealed a parathyroid mass at the left lower neck. Apart from bilateral hearing loss due to gentamicin treatment as a pre-term child, the patient was in of good health. Signs or symptoms of other endocrinopathies were absent. The patient was referred for parathyroidectomy with subsequent autotransplantation of the remaining glands into his sternocleidomastoid muscle. Histological examination revealed an adenoma with oncocytic differentiation, similar to that seen in his brother. The disease may follow a recessive mode of inheritance or may be due to a dominant germ-cell mutation in one of the parents. The presented case may ultimately help in elucidating the molecular genetic basis of this rare form of pHPT.

Quality of life in ALS is maintained as physical function declines.

OBJECTIVES: To study patients with ALS to determine how physical function, quality of life (QOL), and spirituality or religiousness change over time, and what relationship these changes have to one another. METHODS: Sixty patients with ALS were studied prospectively. They were assessed at baseline, 3 months, and 6 months, using questionnaires designed to measure general quality of life (McGill Quality of Life questionnaire), religiosity (Idler Index of Religiosity), ALS-specific health-related quality of life (SIP/ALS-19), and ALS-specific function (ALS functional rating scale). RESULTS: A two-way repeated measures multivariate analysis of variance revealed that both the passage of time and the specific QOL scales used were factors in predicting patient quality of life (F[1, 59]= 9.87, p < 0.003 and F[3, 177]= 16.90, p < 0.001) Despite a progressive decline in physical function as measured by the ALS-specific function score, the general QOL and religiosity scores changed little. In contrast, the ALS-specific health-related QOL score declined in parallel with the ALS-specific function score. CONCLUSIONS: QOL in patients with ALS appears to be independent of physical function, which agrees with a previous cross-sectional study. The ALS-specific health-related QOL score is primarily a measure of physical function. QOL instruments that assess spiritual, religious, and psychological factors produce different results than those obtained using measures of physical function alone.

Combined phylogenetic analysis in the Rubiaceae-Ixoroideae: morphology, nuclear and chloroplast DNA data.

Parsimony analyses of morphology, restriction sites of the cpDNA, sequences from the nuclear, ribosomal internal transcribed spacer (ITS), and the chloroplast gene rbcL were performed to asses tribal and generic relationships in the subfamily Ixoroideae (Rubiaceae). The tribes Vanguerieae and Alberteae (Antirheoideae) are clearly part of Ixoroideae, as are some Cinchonoideae taxa. Pavetteae should exclude Ixora and allies, which should be recognized as the tribe Ixoreae. Heinsenia, representing Aulacocalyceae, is part of Gardenieae, as is Duperrea, a genus earlier placed in Pavetteae. Posoqueria and Bertiera and the taxa in the subtribe Diplosporinae should be excluded from Gardenieae. Bertiera and three Diplosporinae taxa are part of Coffeeae, while Cremaspora (Diplosporinae) is best housed in a tribe of its own, Cremasporeae. The mangrove genus Scyphiphora, recently placed in Diplosporinae, is closer to Ixoreae and tentatively included there. The combined analysis resulted in higher resolution compared to the separate analyses, exemplifying that combined analyses can remedy the incapability of one data set to resolve portions of a phylogeny. Twenty-four new rbcL sequences representing all five Ixoroideae tribes (sensu Robbrecht) are presented.