POS0012 EPIDEMIOLOGY OF FIBROMYALGIA HOSPITALIZATIONS IN THE UNITED STATES

Background:

Fibromyalgia is a chronic pain syndrome that is associated with protean symptoms including musculoskeletal pain, psychiatric symptoms, cognitive dysfunction, memory difficulty, and sleep disturbance. Fibromyalgia can be a primary diagnosis, or it can be associated with other conditions. Fibromyalgia is often seen in conjunction with autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. In 1990, the American College of Rheumatology released classification criteria for fibromyalgia that included symptoms of diffuse pain and physical exam findings of at least 11 of 18 defined tender points. In 2010, the ACR updated these criteria and eliminated the requirement of tender points. In 2011, these criteria were further modified to that they could be self-administered. A previous study used the national inpatient sample to examine hospitalization data for patients with fibromyalgia from 1999-2007. 1 No studies, however, have examined this data since the new ACR criteria were established in 2010.

Objectives:

We aim to characterize the epidemiology of hospitalized patients with diagnosis of fibromyalgia.

Methods:

Hospitalized patients with a diagnosis of fibromyalgia were identified in the 2016-2018 National Inpatient Sample (NIS) using the International Classification of Diseases 10 system (ICD-10). The NIS is an all-payer inpatient database that estimates over 37 million annual U.S. hospitalizations and is maintained by the Healthcare Cost and Utilization Project. The primary outcomes were prevalence of fibromyalgia and comorbid rheumatologic conditions among hospitalized patients. Secondary outcomes included cause of admission, mortality, length of stay, and cost of care.

Results:

Of 1,351,234 patients with fibromyalgia identified, 437,145 were admitted in 2016 increasing to 461,820 in 2018. On average 59.1 years old, more likely female (1,262,735, 93.5%) and white (1,060,845, 81.3%). Patients were most likely to have Medicare (775,420, 57.5%) and were in the bottom quartile of income (402,945, 30.3%). The most common rheumatologic comorbidities were rheumatoid arthritis (142,195, 10.5%), lupus (69,980, 5.2%), and inflammatory bowel disease (38,165, 2.2%). Notably fibromyalgia was commonly associated with depression (500,420, 37.0%), obesity (379,324, 28.1%), hypothyroidism (334,585 24.7%), and congestive heart failure (213,790, 15.8%).The mortality rate was 13,605 (1.0%) patients, the average length of stay was (4.53 days), and the average cost of hospitalization ($12,522). The most common causes of admission were inflammatory syndromes and joint disorders (13.4%) of which OA (4.2%) was most common complaint, digestive complaints (12.1%) of which IBD (4.4%) was most common.

Conclusion:

The yearly number of fibromyalgia hospital discharges were greater than previously described. This may be a result of a more sensitive classification criteria. Further investigation into the etiology of this increase in fibromyalgia hospitalization diagnosis is warranted.

References:

[1]Haviland MG, Banta JE, Przekop P. Fibromyalgia: prevalence, course, and co-morbidities in hospitalized patients in the United States, 1999-2007. Clin Exp Rheumatol. 2011 Nov-Dec;29(6 Suppl 69):S79-87. Epub 2012 Jan 3. PMID: 22243553.

Disclosure of Interests:

None declared.

OP0286 CHARACTERISTICS ASSOCIATED WITH SEVERE COVID-19 OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE (COVID-19 GRA)

Background:

An increased risk of severe COVID-19 outcomes may be seen in patients with autoimmune diseases on moderate to high daily doses of glucocorticoids, as well as in those with comorbidities. However, specific information about COVID-19 outcomes in SLE is scarce.

Objectives:

To determine the characteristics associated with severe COVID-19 outcomes in a multi-national cross-sectional registry of COVID-19 patients with SLE.

Methods:

SLE adult patients from a physician-reported registry of the COVID-19 GRA were studied. Variables collected at COVID-19 diagnosis included age, sex, race/ethnicity, region, comorbidities, disease activity, time period of COVID-19 diagnosis, glucocorticoid (GC) dose, and immunomodulatory therapy. Immunomodulatory therapy was categorized as: antimalarials only, no SLE therapy, traditional immunosuppressive (IS) drug monotherapy, biologics/targeted synthetic IS drug monotherapy, and biologic and traditional IS drug combination therapy. We used an ordinal COVID-19 severity outcome defined as: not hospitalized/hospitalized without supplementary oxygen; hospitalized with non-invasive ventilation; hospitalized with mechanical ventilation/extracorporeal membrane oxygenation; and death. An ordinal logistic regression model was constructed to assess the association between demographic characteristics, comorbidities, medications, disease activity and COVID-19 severity. This assumed that the relationship between each pair of outcome groups is of the same direction and magnitude.

Results:

Of 1069 SLE patients included, 1047 (89.6%) were female, with a mean age of 44.5 (SD: 14.1) years. Patient outcomes included 815 (78.8%) not hospitalized/hospitalized without supplementary oxygen; 116 (11.2) hospitalized with non-invasive ventilation, 25 (2.4%) hospitalized with mechanical ventilation/extracorporeal membrane oxygenation and 78 (7.5%) died. In a multivariate model (n=804), increased age [OR=1.03 (1.01, 1.04)], male sex [OR =1.93 (1.21, 3.08)], COVID-19 diagnosis between June 2020 and January 2021 (OR =1.87 (1.17, 3.00)), no IS drug use [OR =2.29 (1.34, 3.91)], chronic renal disease [OR =2.34 (1.48, 3.70)], cardiovascular disease [OR =1.93 (1.34, 3.91)] and moderate/high disease activity [OR =2.24 (1.46, 3.43)] were associated with more severe COVID-19 outcomes. Compared with no use of GC, patients using GC had a higher odds of poor outcome: 0-5 mg/d, OR =1.98 (1.33, 2.96); 5-10 mg/d, OR =2.88 (1.27, 6.56); >10 mg/d, OR =2.01 (1.26, 3.21) (Table 1).

Table 1.

Characteristics associated with more severe COVID-19 outcomes in SLE. (N=804)

OR (95% CI)Age, years1.03 (1.01, 1.04)Sex, Male1.93 (1.21, 3.08)Race/Ethnicity, Non-White vs White1.47 (0.87, 2.50)RegionEuropeRef.North America0.67 (0.29, 1.54)South America0.67 (0.29, 1.54)Other1.93 (0.85, 4.39)Season, June 16th 2020-January 8th 2021 vs January-June 15th 20201.87 (1.17, 3.00)Glucocorticoids0 mg/dayRef.0-5 mg/day1.98 (1.33, 2.96)5-10 mg/day2.88 (1.27, 6.56)=>10 mg/day2.01 (1.26, 3.21)Medication CategoryAntimalarial onlyRef.No IS drugs2.29 (1.34, 3.91)Traditional IS drugs as monotherapy1.17 (0.77, 1.77)b/ts IS drugs as monotherapy1.00 (0.37, 2.71)Combination of traditional and b/ts IS1.00 (0.55, 1.82)Comorbidity BurdenNumber of Comorbidities (excluding renal and cardiovascular disease)1.39 (0.97, 1.99)Chronic renal disease2.34 (1.48, 3.70)Cardiovascular disease1.93 (1.34, 3.91)Disease Activity, Moderate/ high vs Remission/ low 2.24 (1.46, 3.43)

IS: immunosuppressive. b/ts: biologics/targeted synthetics

Conclusion:

Increased age, male sex, glucocorticoid use, chronic renal disease, cardiovascular disease and moderate/high disease activity at time of COVID-19 diagnosis were associated with more severe COVID-19 outcomes in SLE. Potential limitations include possible selection bias (physician reporting), the cross-sectional nature of the data, and the assumptions underlying the outcomes modelling.

Acknowledgements:

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR) the UK National Health Service, the National Institute for Health Research (NIHR), or the UK Department of Health, or any other organization.

Disclosure of Interests:

Manuel F. Ugarte-Gil Grant/research support from: Pfizer, Janssen, Graciela S Alarcon: None declared, Andrea Seet: None declared, Zara Izadi: None declared, Cristina Reategui Sokolova: None declared, Ann E Clarke Consultant of: AstraZeneca, BristolMyersSquibb, GlaxoSmithKline, Exagen Diagnostics, Leanna Wise: None declared, Guillermo Pons-Estel: None declared, Maria Jose Santos: None declared, Sasha Bernatsky: None declared, Lauren Mathias: None declared, Nathan Lim: None declared, Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum unrelated to this work., Grant/research support from: Amgen and Bristol-Myers Squibb, Zachary Wallace Consultant of: Viela Bio and MedPace, Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: MS, UCB, and Pfizer, Anja Strangfeld Speakers bureau: AbbVie, MSD, Roche, BMS, Pfizer, Grant/research support from: AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, Grant/research support from: Lilly, Mylan, Pfizer, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: Pfizer, Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Pfizer outside the submitted work, Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000), Milena Gianfrancesco: None declared, Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project

POS1366 THE RELATIONSHIP OF MAST CELL ACTIVATION SYNDROME AND HYPERMOBILE EHLERS-DANLOS SYNDROME IN HOSPITALIZED PATIENTS IN THE UNITED STATES

Background:

Patients with hypermobile Ehlers-Danlos syndrome (hEDS) often report symptoms of cutaneous flushing, pruritis, vomiting, diarrhea and anaphylactoid responses to environmental, food, and mechanical stimuli. There is a growing body of literature investigating the possible link between disorders of mast cell regulation including mast cell activation syndrome (MCAS) and connective tissue disorders including hEDS. The evidence for such a relationship, however, remains limited1.

Objectives:

We aimed to evaluate the association between hEDS and MCAS among hospitalized patients using a nationally representative cohort.

Methods:

Hospitalized patients with a diagnosis of hEDS or MCAS were identified in the 2016-2018 National Inpatient Sample (NIS) using the International Classification of Diseases 10 system (ICD-10). The NIS is an all-payer inpatient database that estimates over 37 million annual U.S. hospitalizations and is maintained by the Healthcare Cost and Utilization Project. The primary outcomes were prevalence of EDS and MCAS among hospitalized patients. Secondary outcomes included cause of admission, mortality, length of stay, and cost of care. Multivariate hierarchical regression analysis was using adjusting for demographics, hospital factors, and comorbid conditions.

Results:

Among 37,665 patients identified in this study, 35,115 (95.9%) patients had hEDS and 3,630 (9.6%) patients had MCAS. 1080 patients had concomitant diagnosis of hEDS (3.1%) and MCAS (29.8%), of whom 555 (51.4%) were diagnosed in 2018 compared with 100 (9.3%) patients in 2016 (P<0.001). The mean age of patients with both conditions was significantly lower than those diagnosed with hEDS (29.5 vs 36.6 years, P<0.001) or MCAS (29.5 vs 39.8 years, P<0.001) alone. Those with comorbid hEDS and MCAS were more likely female (95.8% vs 84.5%, P<0.001), had private insurance (67.6% vs 52.4%, P<0.001) and were among the highest income quartile (47.4% vs 31.9%, P<0.001). There were no significant differences in mortality or overall comorbidity burden. Patients with hEDS and MCAS had higher adjusted hospitalization charges ($64,445 vs $54,782, β=0.15, P<0.05) and longer adjusted lengths of stay (6.4 vs 4.9 days, IRR 1.35, P<0.001).

Conclusion:

Nearly 1 in 3 patients diagnosed with MCAS have comorbid diagnosis of hEDS. This association appeared to increase over time with the increasing diagnosis of MCAS. Social determinants of disease such as health insurance status and income appeared to be associated with the identification of the overlap syndrome. These findings merit further investigation into the co-occurrence of these disease entities and development of consistent clinical diagnostic criteria.

References:

[1]Kohn A, Chang C. The Relationship Between Hypermobile Ehlers-Danlos Syndrome (hEDS), Postural Orthostatic Tachycardia Syndrome (POTS), and Mast Cell Activation Syndrome (MCAS). Clin Rev Allergy Immunol. 2020;58(3):273-297. doi:10.1007/s12016-019-08755-8

Disclosure of Interests:

None declared

POS0252 IMPACT OF ANCA-ASSOCIATED VASCULITIS ON CLINICAL OUTCOMES AND RESOURCE UTILIZATION IN ELECTIVE PCI

Background:

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitides (AV) can increase risk of atherosclerosis. 1 Patients with autoimmune disease have increased rates of coronary events that are not fully explained by classic risk factors. 2 A prior study has shown that autoimmune vasculitides –including polyarteritis nodosa, hypersensitivity granulomatosis with polyangiitis, giant cell arteritis, thrombotic angiitis, Takayasu arteritis, Goodpasture syndrome, and Kawasaki disease –are associated with increased cost of care and increased 30-day readmission after percutaneous coronary intervention (PCI). 3 It is important to distinguish the cardiovascular outcomes of small–vessel ANCA-associated vasculitides from the other vasculitides included in this prior study because coronary arteritis is typically a complication of medium to large vessel vasculitis.

Objectives:

To investigate the impact of comorbid ANCA-associated small vessel vasculitis (AV) on outcomes of PCI in a nationally representative cohort.

Methods:

Patients undergoing PCI in the 2016-2018 National Inpatient Sample were selected and those with ANCA-associated vasculitis were identified using the ICD-10 classification system. The NIS is an all-payer, survey-weighted, inpatient database estimating 37 million annual U.S. hospitalizations managed by the Healthcare Cost and Utilization Project (HCUP). Primary study outcomes were prevalence of comorbid vasculitis, mortality, complications, and cost of care.

Results:

Of 1,351,670 patients undergoing PCI were identified, 410 (0.03%) had diagnosis of ANCA-vasculitis. AV patients were similar to non-AV patients in distribution of gender, race, and median household income. AV patients were older (70.9 vs 65.2 years, P<0.001) and more likely to utilize Medicare (78% vs 53%, P<0.005). AV patients were more likely to present with non-ST segment myocardial infarction (NSTEMI) (57.3% vs 41.5%, P<0.005) and less likely to present with ST-elevation myocardial infarction (NSTEMI) (18.3% vs 31.3%, P<0.05). AV patients had similar adjusted mortality (6.1% vs 2.6%, aOR: 2.1, P=0.8), cost of care ($32,985 vs $25,767, β = 0.02, P=0.7), and length of hospitalization (6.0 vs 3.9, IRR: 1.2, P=0.13).

Conclusion:

The presence of ANCA-associated vasculitis did not appear to negatively impact inpatient clinical outcomes or utilization of care among patients undergoing PCI in the United States. Cost of care was not increased, in contrast to an increase cost of care when small, medium, and large vasculitides are grouped together. The greater proportion of NSTEMI patients among those with AAV corresponds with a growing body of literature implicating inflammatory processes in the pathogenesis of certain forms of myocardial infarction meriting further investigation.

References:

[1]Misra DP, Shenoy SN. Cardiac involvement in primary systemic vasculitis and potential drug therapies to reduce cardiovascular risk. Rheumatol Int. 2017;37(1):151-167. doi:10.1007/s00296-016-3435-1.

[2]Amaya-Amaya J, Sarmiento-Monroy JC, Rojas-Villarraga A. Cardiovascular Involvement in Autoimmune Diseases. El Rosario University Press; 2013. Accessed February 1, 2021. https://www.ncbi.nlm.nih.gov/books/NBK459468/.

[3]Bailey KL, Mantha A, Sanaiha Y, Mathias L, Benharash P, Ebrahimi R. Short-Term Outcomes After Percutaneous Coronary Intervention in Patients With Autoimmune Vasculitides. J Am Coll Cardiol. 2019;74(1):159-160. doi:10.1016/j.jacc.2019.04.051.

Disclosure of Interests:

None declared

In Vitro Anti-Toxoplasma gondii and Antimicrobial Activity of Amides Derived from Cinnamic Acid

Most cinnamic acids, their esters, amides, aldehydes, and alcohols present several therapeutic actions through anti-inflammatory, antitumor, and inhibitory activity against a great variety of microorganisms. In this work, eight amines derived from cinnamic acid were synthesized and tested against host cells infected with Toxoplasma gondii and the bacteria Escherichia coli, Pseudomonas aeruginosa, Staphylococcus epidermidis, and three strains of Staphylococcus aureus. Compounds 3 and 4 showed the best result against intracellular T. gondii, presenting antiparasitic activity at low concentrations (0.38 and 0.77 mM). The antibacterial activity of these compounds was also evaluated by the agar microdilution method, and amides 2 and 5 had a minimum inhibitory concentration of 250 µg mL⁻¹ against two strains of S. aureus (ATCC 25923 and bovine strain LSA 88). These also showed synergistic action along with a variety of antibiotics, demonstrating that amines derived from cinnamic acid have potential as pharmacological agents.

Chemical Constituents of Lecythis pisonis (Lecythidaceae) – A New Saponin and Complete 1H and 13C Chemical Shift Assignments

A novel triterpenoid saponin 3- O-β-D-glucuronopyranosyl-(1→3)-2α,19α-dihydroxyolean-12-en-28-oic acid [3- O-β-D-glucuronopyranosyl-(1′→3)-arjunic acid, 1], ten known compounds [six triterpenoids: α-amyrin (2), β-amyrin (3), germanicol (4), lupeol (5), friedelin (6), friedelanol (7); four steroids -campesterol (8), stigmasterol (9), sitosterol (10), cholesterol (11)], and a long chain alcohol n-eicosan-1-ol (12) were identified in the bark of Lecythis pisonis. The structures were established by 1D and 2D NMR spectroscopy (1H and 13C-NMR, DEPTQ, 1H-1H-COSY, NOESY, HSQC and HMBC), low (CG-MS) and high resolution mass spectrometry (HR-ESI-MS), and infrared (IR) spectral data involving comparison with the literature.

Rauvolfia grandiflora (apocynaceae) extract interferes with staphylococcal density, enterotoxin production and antimicrobial activity

Staphylococci bacteria are involved in many human and animal infections and development of alternative antimicrobial drugs against pathogenic bacteria is of great interest to the pharmaceutical industry. This study investigated the in vitro effect of Rauvolfia grandiflora methanol extract (root bark fraction) (RGE) on the density of ATCC strains of Staphylococcus aureus and Staphylococcus epidermidis, and a clinical enterotoxin-producer, S. aureus bovine strain. The alkaloid, isoreserpiline, obtained from dichloromethane extract of R. grandiflora was ineffective against the strains tested. After incubation of staphylococci strains in the presence of 1.2 μg.mL(-1) RGE, a significant inhibition of cell growth was observed using both spectrophotometry and ELISA assays. Twelve drugs were evaluated for their antimicrobial effects on culture RGE-treated cells using the disk diffusion method. Penicillin resistant strains became sensitive to the drug after RGE treatment. Furthermore, enterotoxin production by RGE-treated S. aureus was evaluated using a standardized ELISA method. Although staphylococcal LSA 88 bovine strain cells remained viable after exposure to the extract, enterotoxin production was precluded in 20% after RGE treatment. Significant interference in staphylococci cell density, drug sensitivity and enterotoxin secretion was observed after treatment. The study highlights the necessity to find new methods of disease prevention and new antibiotic therapies against staphylococcal infections.

Fragmentation of plumeran indole alkaloids from Aspidosperma spruceanum by electrospray ionization tandem mass spectrometry

The fragmentation of six plumeran indole alkaloids (PIAs) previously isolated from Aspidosperma spruceanum has been investigated by electrospray ionization tandem mass spectrometry (ESI-MS/MS) in the positive ion mode. The fragmentation pathways have been established on the basis of MS/MS experiments using fragment ions generated in-source and deuterium-labeled alkaloids as precursor ions and on the basis of accurate mass measurements. Our results demonstrated that the fragmentation routes observed for the protonated PIAs are essentially derived from a pericyclic reaction and from the opening of rings D and E, followed by 1,4-hydrogen rearrangements. Product ions resulting from radical eliminations were also observed, contrary to the 'even-electron rule'. Our data reveals that some product ions from protonated PIAs provide crucial information for the characterization of the acyl substituent at N-1, the methoxyl and hydroxyl groups at the aromatic moiety, and give evidence of an ether bridge between C-18 and C-21. The data reported here were used for the dereplication of these compounds in a stem bark methanolic extract of Aspidosperma spruceanum.

Two new terpenoids from Trichilia quadrijuga (Meliaceae)

Two new terpenoids, ambrosanoli-10(14)-en-11,12-diol (1), a sesquiterpene named quadrijugol, and a pregnane steroid, 3beta,4beta-dihydroxypregnan-16-one (2), were isolated from the stem and leaves of Trichilia quadrijuga, along with eleven known compounds, spathulenol, kudtdiol, 2beta,3beta,4beta-trihydroxypregnan-16-one, bourjotinolone B, piscidinol, niloticin, dihydroniloticin, beta-sitosterol, 3-O-beta-D-glucopyranosyl-sitosterol, itesmol and stigmasterol. Structures were elucidated by spectral data analysis, mainly afforded by 1H and 3C NMR (1D and 2D NMR HMQC, HMBC, NOESY and COSY) and mass spectra.

Two New Terpenoids from Trichilia quadrijuga (Meliaceae)

Two new terpenoids, ambrosanoli-10(14)-en-11,12-diol (1), a sesquiterpene named quadrijugol, and a pregnane steroid, 3β,4β-dihydroxypregnan-16-one (2), were isolated from the stem and leaves of Trichilia quadrijuga, along with eleven known compounds, spathulenol, kudtdiol, 2β,3β,4β-trihydroxypregnan-16-one, bourjotinolone B, piscidinol, niloticin, dihydroniloticin, β-sitosterol, 3-O-β-D-glucopyranosyl-sitosterol, itesmol and stigmasterol. Structures were elucidated by spectral data analysis, mainly afforded by 1H and 13C NMR (1D and 2D NMR HMQC, HMBC, NOESY and COSY) and mass spectra.

Two fast screening methods (GC-MS and TLC-ChEI assay) for rapid evaluation of potential anticholinesterasic indole alkaloids in complex mixtures

The pharmacotherapyfor Alzheimer's disease (AD) includes the use of acetylcholinesterase inhibitors (AChEI). Recent investigations for novel AD therapeutic agents from plants suggested that Tabernaemontana genus is a promising source of novel anticholinesterasic indole alkaloids. In this work two fast screening techniques were combined in order to easily identify novel cholinesterase inhibitors (ChEI). Gas chromatography-mass spectrometry (GC-MS) of the less polar alkaloidic fractions obtained from the acid-base extraction of the stalk of T. laeta revealed thirteen monoindole alkaloids, four of them confirmed by co-injection with previously isolated alkaloids. The others were tentatively identified by mass fragmentation analysis. By gas chromatography with flame ionization detection (GC-FID) and using isatin as internal standard, affinisine and voachalotine were determined as major compounds. These fractions and fourteen previously isolated alkaloids, obtained from root bark of T. laeta and T. hystrix were investigated for acetyl (AChE) and butyrylcholinesterase (BuChE) inhibitory activities by the modified Ellman's method in thin layer chromatography(TLC-ChEI). Results showed selective inhibition of the alkaloids heyneanine and Nb-methylvoachalotine for BuChE, and 19-epi-isovoacristine for AChE, whereas olivacine, affinisine, ibogamine, affinine, conodurine and hystrixnineinhibited both enzymes. In addition to confirming that monoterpenoid indole alkaloids can be novel therapeutic agents for AD, this is the first report of the ChEI activity of olivacine, a pyridocarbazole alkaloid.

Cymosanine, a novel C19-Quassinoid from Simaba subcymosa

Cymosanine (1) and three further known quassinoids, cedronin (2), chaparrinone (3), and simarolide (4), were isolated from the root bark of Simaba subcymosa. The structures were established by spectroscopic data, mainly 1D, 2D NMR and mass spectra.

Isolation and structural elucidation of a novel rotenoid from the seeds ofClitoria fairchildiana

The seeds of Clitoria fairchildiana provided a new rotenoid, 6-hydroxy-2,3,9-trimethoxy-[1]benzopyrano[3,4-b][1]benzopyran-12(6H)-one. The structural elucidation was performed using detailed analyses of H- and 13C-NMR spectra including 2DNMR spectroscopic techniques (1H-13CHETCOR) and by comparison with spectrometric data from the literature. The anti-inflammatory activity was investigated using a capillary permeability assay.

Two new diprenylated coumarins from Flindersia brayleyana

Flindersia brayleyana F. Muell. contains the diprenylated coumarins 1 and 2, in addition to the known coumarins braylin (3) and brayleyanin (4). The structures of the new natural products were elucidated by extensive NMR analysis and mass spectra.

Derris (Lonchocarpus) urucu (Leguminosae) extract modifies the peritrophic matrix structure of Aedes aegypti (Diptera:Culicidae)

Aqueous suspension of ethanol extracts of Derris (Lonchocarpus) urucu (Leguminosae), collected in the state of Amazonas, Brazil, were tested for larvicidal activity against the mosquito Aedes aegypti (Diptera:Culicidae). The aim of this study was to observe the alterations of peritrophic matrix in Ae. aegypti larvae treated with an aqueous suspension of D. urucu extract. Different concentrations of D. urucu root extract were tested against fourth instar larvae. One hundred percent mortality was observed at 150 microg/ml (LC(50) 17.6 microg/ml) 24 h following treatment. In response to D. urucu feeding, larvae excreted a large amount of amorphous feces, while control larvae did not produce feces during the assay period. Ultrastructural studies showed tha larvae fed with 150 microg/ml of D. urucu extract for 4 h have an imperfect peritrophic matrix and extensive damage of the midgut epithelium. Data indicate a protective role for the peritrophic matrix. The structural modification of the peritrophic matrix is intrinsically associated with larval mortality.

A new isoflavone glycoside from dalbergia nigra

The new 5-hydroxy-6, 7-dimethoxy-4'-O-(6-O-D-apio-beta-D-furanosyl-beta-D-glucopyranosyl)i soflavone (1) has been isolated from Dalbergia nigra. The structure was elucidated using extensive spectroscopic analysis (1D and 2D NMR, MS, IR, UV).

Evaluation of the importance of maternal history of diabetes and of mitochondrial variation in the development of NIDDM

In 79 South Indian nuclear pedigrees ascertained via probands with NIDDM and both parents living, parental diabetic status was established through previously diagnosed NIDDM (n = 97) or oral glucose tolerance testing (n = 61). There was no significant difference between diabetes prevalence in mothers and fathers (60 vs 53 (76% vs 67%), respectively, p = 0.22). 'Age at diabetes diagnosis' survival curves did differ according to parental gender (p = 0.02) but this may reflect gender differences in health provision rather than pathophysiology. No maternal excess effects of the magnitude evident in previous studies were detected, suggesting either ethnic differences or overestimation of the maternal effect when reported histories of parental diabetes have been used. The tRNA(Leu(UUR) gene region was studied for diabetes-associated variation given the role of mutations in this gene in some pedigrees displaying maternal transmission of NIDDM. None of 142 unrelated South Indian NIDDM subjects displayed the MELAS mutation at nt3243. However, sequencing identified two variants of potential importance: (a) at nt3290 in the tRNA(Leu(UUR) gene, seen in 7/142 diabetic and 1/85 control subjects (p = 0.11), (b) at nt3316 in the ND1 gene (4/142 vs 1/85 subjects, respectively (p = 0.51)). Further studies are needed to determine the relevance of these variants to the development of NIDDM.

[Remnant portion of the tube in ectopic pregnancy: review and report of a case]

PURPOSE

After a review of the literature, to establish what the best treatment is to treat interstitial portion in ectopic gestations.

TYPE OF STUDY

Review and report of a case. SITE: Specialized Clinics Hospital of Franco da Rocha of the School of Medicine of Jundiaí.

PATIENTS

One patient of the School Hospital.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Review and clinical observation.

CONCLUSIONS

The authors present a case of an exceptional ectopic gestation with a remnant portion of the tube seen at the Hospital above, with absent contralateral ovary. They discuss the etiologic factors of the ectopic gestation with contralateral corpus luteum, and suggest the possibility of internal transmigration in the case presented. They comment on the clinical severity, as the area is highly vascularized, and they also comment of the diagnosis difficulties if gestation proceeds. They discuss the treatment for ectopic gestation in general and the possible prophylactic ways of dealing with the remnant portion of the tube in ectopic gestation. They conclude that randomized studies are needed to find out what the best treatment is for the interstitial portion during salpingectomy due to ectopic gestation.

[HELLP syndrome: review and report of a case]

PURPOSE

to review the literature for a serious disease and present a case in order to caution specialists concerning the need for early and accurate diagnosis. TYPE: literature review and retrospective study of a case.

PLACE

Hospital of Specialized Clinics of Franco da Rocha, of the Jundiaí School of Medicine.

PATIENTS

one patient admitted to the School Hospital.

RESULTS

review and clinical observation.

CONCLUSIONS

the authors conclude that publication of this case is important because despite the typical features, attending physicians had difficulties in terms of diagnosis and treatment. They describe symptoms which are characteristic of HS associated to preeclampsia and eclampsia, and they caution to the importance of patient complaints of epigastric and right hypochondrium pain. They also alert to the importance of a correct approach (clinical, US scanning, and laboratory tests) for diagnosis and early treatment.

[Chronic premature detachment of placenta]

PURPOSE OF THE STUDY

to evidence the existence of chronic premature separation of the placenta.

TYPE OF STUDY

retrospective. SITE: Hospital of the Jundiaí School of Medicine.

PATIENTS

four patients of the authors.

INTERVENTIONS

without statistical treatment because this is not a comparative study.

MEASUREMENTS AND RESULTS

chronic premature separation of the placenta, a classical asymptomatic or monosymptomatic disorder, can be detected by ultrasound and/or cardiotocography. Four cases seen among the authors' patients are presented, who were diagnosed by insidious evolution, discrete blood loss, and uterine excitability. Three of the patients were hypertensive. Diagnosis was established by amniocentesis, single or serial ultrasound, and cardiotocography. Newborns were premature, but the four of them survived.

CONCLUSIONS

the authors conclude that the obstetric treatment depends on gestational age, fetal conditions, size of the clot, and intensity of blood losses. A conservative approach may be appropriate depending on fetal-maternal conditions. However, further studies are needed to devise more adequate approaches.

[Grand multiparity: is it a high risk pregnancy?]

PURPOSE OF THE STUDY

evaluate biological and medical characteristics of the grand multipara and her offspring in the neonatal period.

TYPE OF STUDY

comparative and retrospective. SITE: Hospital of the Jundiai School of Medicine.

PATIENTS

study group--134 grand multiparas; control group--100 primiparas. All patients were admitted to the Franco da Rocha Hospital, the maternity school of the Jundiai School of Medicine.

INTERVENTION

analytical study.

MEASURES AND RESULTS

hypertension, haemorrhage, twins, premature labor, pelvic location, and anemia were the complications seen in group 1. Cesarean section was indicated in the presence of a prior cesarean section, and fetal distress was the indication followed in group 2. Post partum damage to soft tissue was more prevalent in group 1. Premature labor and perinatal mortality were more frequent in group 1.

CONCLUSION

The authors conclude that GMP were women with a high risk and, thus, they suggest adequate antenatal assistance as an important measure to decrease perinatal and maternal mortality.