Comparative Study between Paracervical Block and Non-Steroidal Anti Inflammatory Drug for Relief of Pain during Manual Vacuum Aspiration Procedure

The incidence of first trimester pregnancy loss is around 10.0-20.0% of registered pregnancies. Manual vacuum aspiration is a safe, effective and acceptable option of treatment for patients diagnosed with first trimester pregnancy loss. Main disadvantage of MVA is the pain caused by manipulation of the cervix, the uterine suction and the cervical dilatation. This study showed the way how the pain and discomfort might be reduced. This was a cross-sectional comparative study was conducted at the obstetrics and Gynecological Department of Sadar hospital, Manikganj, Bangladesh from January 2017 to December 2017. All the consecutive women admitted and diagnosed as incomplete abortion, missed abortion and anembryonic pregnancy (blighted ovum) were included in this study. Sampling technique was purposive sampling. The objective of this study was to compare the effectiveness of paracervical block anesthesia with non-steroidal anti inflammatory drug (NSAID) for relief of pain during the manual vacuum aspiration procedure for the treatment of first trimester pregnancy loss. Total 120 cases were included in this study. Assigned study population were divided into two groups like Group A and Group B. 60 of the study population were included in Group A who were given paracervical block anesthesia 3 minutes before the procedure. Another 60 study population was included in Group B who was given diclofenac 75mg intramuscular injection, 30 minutes before the procedure. Both intraoperative and postoperative pain level was evaluated by using visual analog scale ranged from (0-10 points) 30 minutes after the procedure. At the same time the satisfaction level of the study population were measured by 5 points lickert scale. Regarding clinical profile of the study population it showed no significant difference in case of mean age, mean gestational age and mean duration of the procedure between two groups. The mean intraoperative pain score in Group A was 4.0±1.3, in Group B it was 5.4±1.5 (p=0.001) which was significant. So it showed that paracervical block anesthesia significantly reduced the pain in relation to diclofenac 75mg intramuscular injection. Mean postoperative pain level 30 minutes after procedure in Group A was 2.2±0.4 and in Group B was 2.4±0.4 (p=0.343), where post-operative pain is lower in Group A than Group B. Though this difference is not statistically significant (p=0.343). In Group A 73.0% (n=44) and in Group B 43.0% (n=26) study population were agreed that the procedure was easy. Most common adverse effect was epigastric pain which was 1.7% (n=1) in Group A and 10.0% (n=7) in Group B. Paracervical block significantly reduces intraoperative pain during Manual Vacuum Aspiration (MVA) procedure in the treatment of first trimester pregnancy loss in comparison to intramuscular injection of diclofenac. In conclusion it might be mentioned that regarding paracervical block anesthesia, efficacy is higher and side effects are less. Moreover paracervical block anesthesia is cost effective.

Effect of Meconium Staining Amniotic Fluid on Fetal Outcome

Meconium-stained amniotic fluid is the passage of meconium by a fetus in utero during the antenatal period or in labour. It has for long been considered to be a bad predictor of fetal distress and meconium aspiration syndrome (MAS). The objective of this study was to find out the fetal outcome of MSAF and clear amniotic fluid. This cross- sectional comparative study was carried out in Upazilla Health Complex, Palash, Narshingdi from July 2016 to June 2017. A total of 100 pregnant women among them 50 women with MSAF and 50 women with clear liquor were studied to see the record of ANC, mode of delivery and fetal outcome by APGAR score. Study showed that among MSAF group 76.0% (n=38) had irregular ANC and 24.0% (n=12) had regular ANC whereas in clear liquor 86.0% (n=43) had regular ANC 14.0% had irregular ANC. Among MSAF (50 cases) thick meconium was in 20 cases (40.0%) and thin meconium was in 30 cases (60.0%). Regarding mode of delivery 52.0% (n=26) MSAF cases had instrumental delivery and Caesarean section compared to 24.0% (n=12) in clear liquor group. Regarding thick MSAF among 40.0% (n=20), (n=14) had low APGAR score and (n=6) had normal score at one minute and (n=9) low APGAR score and (n=11) normal score at five minutes. In clear liquor, among 100.0% (n=50), 20.0% (n=10) had low APGAR score and 80.0% (n=40) had normal score at one-minute and at five minutes 8.0% (n=4) had low APGAR score and 92.0% (n=46) had normal score. Among MSAF 26.0% (n=13) were admitted to SCBU compare to 12.0% (n=6) in clear liquor group. The mean SCBU stay was 3.1 days in MSAF whereas 1.2 days in clear liquor. Among MSAF babies 4.0% (n=2) had MAS compared to no MAS in clear liquor group. Regarding Survivalist 92.0% (n=46) were alive in MSAF whereas 100.0% all (n=50) were alive in clear liquor group.

Hematological Abnormalities and Comorbidities Are Associated With the Severity of Kidney Disease: A Hospital-Based Cross-Sectional Study in Bangladesh

Background

Abnormalities in hematology and comorbidities might have a role in chronic kidney disease (CKD) patients. However, the exact relationships between hematological parameters and the severity of CKD are not well understood. Also, the underlying mechanisms remain under investigation. The present study aimed to evaluate the association of different blood parameters and comorbidities among hospitalized CKD patients in Bangladesh.

Methods

The present study enrolled admitted CKD patients at Evercare Hospital Ltd, Dhaka, Bangladesh, from January 1, 2021, to August 1, 2021. For this study, the demographic and clinical information of the patients were collected. Then some routine blood tests for the hematological profile of CKD patients were performed. Finally, several statistical methods were performed and data interpretations were done to evaluate the role of hematological changes on CKD patients.

Results

Among 300 patients, early-stage CKD patients (ESCKDP) and advanced-stage CKD patients (ASCKDP) were 153 and 147, respectively. The decreased levels of hemoglobin (Hb) and red blood cell (RBC) in ASCKDP were observed. However, the present study found increased levels of corpuscular Hb in ASCKDP than ESCKDP. Also, the present study noticed correlations between these changes and the severity of CKD. Also, we observed a significant difference in age and body mass index between ESCKDP and ASCKDP.

Conclusions

Based on our results, lower Hb and RBC levels may use in assessing the severity and the treatment decisions of CKD patients in the hospital setting. Therefore, our findings may assist with developing a treatment protocol for hospitalized CKD patients.

Hematological abnormalities and comorbidities are associated with COVID-19 severity among hospitalized patients: Experience from Bangladesh

BACKGROUND

The hematological abnormalities are assumed to be involved in the disease progression of COVID-19. However, the actual associations between specific blood parameters and COVID-19 are not well understood. Here we aimed to assess the correlations between hematological parameters and the severity of COVID-19.

METHODS

We included COVID-19 patients who were admitted to Evercare Hospital Ltd, Dhaka, Bangladesh, between November 10, 2020, to April 12, 2021, with a confirmed case of RT-PCR test. We recorded demographic information, clinical data, and routine hematological examination results of all COVID-19 patients. We performed statistical analyses and interpretation of data to compare severe COVID-19 patients (SCP) and non-severe COVID-19 patients (NSCP).

RESULTS

The age and BMI of the admitted COVID-19 patients were 48.79±8.53 years and 25.82±3.75 kg/m2. This study included a total of 306 hospitalized COVID-19 patients. Among them, NSCP and SCP were 198 and 108, respectively. And we recorded 12 deaths from SCP. We observed the alterations of several hematological parameters between SCP and NSCP. Among them, we noticed the increased levels of C-reactive protein (CRP), d-dimer, and ferritin showed good indicative value to evaluate the severity of COVID-19. Also, there were positive correlations among these parameters. Moreover, we found correlations between the outcomes of COVID-19 patients with patient's demographics and comorbid diseases.

CONCLUSION

Based on our results, CRP, d-dimer, and ferritin levels at admission to hospitals represent simple assessment factors for COVID-19 severity and the treatment decisions at the hospital setup. These blood parameters could serve as indicators for the prognosis and severity of COVID-19. Therefore, our study findings might help to develop a treatment protocol for COVID-19 patients at the hospital setup.

Preoperative Analysis of CA-I25 and its Relation with Histopathological Study in Ovarian Tumours

Ovarian cancer (OC) is the seventh most common cancer among women in the world. Epithelial OC is the most predominant pathological subtype, with five major histotype. All five subtypes that differ in origination, pathogenesis, molecular alterations, risk factors and prognosis. The clinical presentations of ovarian tumors are variable and not specific. Most of the malignant ovarian tumor seeks medical advice at advanced stage of the disease. At that stage no effective treatment could be possible. There are several researches are going on developing a screening test for ovarian cancer. But there hasn't been much success yet. Clinical examination such as complete pelvic examination together with two investigations is used most often to screen the ovarian cancer. These investigations are transvaginal ultrasound (TVUS) and the blood test CA-125. The measurement of CA-125 level usually in combination with other modalities like bimanual pelvic examination, transvaginal ultrasonography is the proposed modality of early detection of ovarian cancer. The most promising application of this tumor marker is the screening. Therefore this cross sectional and observational study was conducted to observe the relationship of histopathological diagnosis and clinical features with serum CA-125 levels. Study conducted from January 2017 to December 2017 at Sir Salimullah Medical College& Mitford Hospital, Dhaka, Bangladesh. All admitted Gynecological patients having ovarian tumors during study period were included purposively for this study. Sample size was 50. Clinical features and preoperative findings of CA-125 level of these 50 patients were collected. Finally histopathological reports were accumulated after operative treatment. Gastrointestinal & constitutional complain, gynecologic mass and pain in abdomen were the selected symptoms. CA-125 levels were evaluated in relation with histopathological findings. The different findings were correlated with those of studies done at home and abroad. Mean age of the study population was (Mean±SD) 34.25±14.65. Histological findings among the study population showed that benign tumors were 72% (n=36) and malignant tumors were 28% (n=14). In case of benign ovarian tumors among 36 women, 94.4% (n=34) of them showed CA 125 level <35U/ml, other 5.6% (n=2) showed more than normal (>35U/ml) but range was 35-65U/ml. While 14 of the study population having histopathologically proven malignant ovarian tumor, showed the tumor marker level >35U/ml among 71.4% (n=10) and 28.6% (n=4) showed tumor marker <35U/ml. This finding was statistically significant (p=0.001). Histopathological findings revealed that there were significant increases in CA-125 levels in women with malignant serous histotype of serous cyst adenocarcinoma where range of CA-125 level were 2018.88 to 4249.63U/ml. Constitutional symptoms such as weight loss, loss of appetite, symptoms of mass effect such as urinary retention and rapidly progressing tumor were the symptoms of malignant ovarian tumors. Preoperative elevated level of CA-125 is the differentiating points of malignant serous histotype from benign ovarian tumors. This study will put forward some clues about the clinical diagnosis of ovarian tumor which may be utilized for making investigation and management plan. Also it will help for making prompt decision during pre-operative and per-operative procedures.

Scar Endometriosis - A Rare Entity: Case Series

Endometriosis is a condition where there are functional endometrial glands and stroma in sites other than uterine mucosa. It is a unique condition which is benign but has a tendency of invasion and extension locally. Scar endometriosis is a rare entity where there is presence and proliferation of endometrial gland and stroma in the scar of the previous surgery. It is estimated to be only 0.03 to 0.15% of all cases of endometriosis. Because of its deceptive nature and lack of specific diagnostic tools, scar endometriosis is often difficult to diagnose. It is also a challenge for the clinicians as this condition is difficult to treat because it is nonresponsive to hormonal treatment and excision is often the only effective treatment. Here we present two cases of scar endometriosis that we have encountered in BIRDEM general hospital, Dhaka, Bangladesh in last five years.

Induction by Misoprostol In Case of Intra Uterine Fetal Death: A Cross Sectional Study

The objective of this study was to find out the effectiveness and safety of vaginal misoprostol in delivering the dead fetus in cases of intrauterine fetal death (IUFD). This cross sectional study was undertaken among all consecutive patients admitted at the Department of Obstetrics and Gynecology, Dhaka Medical College Hospital, Dhaka, Bangladesh, from October 2012 to September 2013, were included for this study. Vaginal misoprostol was applied in 50 cases that were admitted and diagnosed as a case of IUFD. After taking informed written consent from patients 50μgm of tablet misoprostol was introduced per vaginally into the posterior fornix. Doses were repeated in every 4 hours up to effective contraction to a maximum 6 doses. Follow up was done in hourly interval. Those who did not respond, decision for other methods like oxytocin infusion or LUCS were done. Study showed 60% (n=30) patients belonged to age group of 18-24 years. Among study population 44% (n=22) of the patients belonged to 22-32 weeks of gestation, 30% (n=15) were 33-37 weeks and 26% (n=13) were 38-42 weeks. The causes of intrauterine death were unidentified among 60% (n=30) of cases. Regarding antenatal check up 54% (n=27) had no checkup, 26% (n=13) were irregular and 20% (n=10) were regular. 60% (n=30) of the patients had less Bishop Score <3. Ninety six percent (96%) (n=48) patients responded with vaginal misoprostol and only 4% (n=2) were non responder group. Most 84% (n=42) of the cases needed 2-3 doses, only 8% (n=4) cases needed single dose and 8% (n=4) cases needed 4 to 6 doses. The induction delivery interval varied from 6 to 23 hours and maximum 52% (n=26) of the patients delivered within 12 hours. Adverse effects such as uterine hyper stimulation, tachysystole were not detected. The major complications observed like postpartum hemorrhage 4% (n=2), reduced platelet count 2% (n=1), and chorioamnionitis 4% (n=2). However minor complications like nausea, shivering and mild fever also observed in few cases. Study showed successful induction of labor by misoprostol in a shorter time with significantly less side effects.

Knowledge, Attitude and Practice of Bangladeshi Women towards Breast Cancer: A Cross Sectional Study

In Bangladesh incidence rate of breast cancer was about 22.5 per 100000 females. Breast cancer has been reported as the highest prevalence rate (19.3 per 100,000) among Bangladeshi women between 15 and 44 years of age. For this prevailing situation a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Bangladesh towards breast cancer at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2013 to June 2014. All female participants attending at outpatient department of BSMMU having age more than 20 years and education at least JSC, purposively selected until the sample size achieved 500. Only applying simple cost free method like self breast examination (SBE) and clinical breast examination (CBE) one can asses her breast. Thereby awareness develops regarding her breast so any mass newly appear can be assessed by the lady herself. Early diagnosis of the breast cancer will reduce the burden of treatment cost, mortality & morbidity. Research and development strategy of the project is to enhance the awareness of the community people about breast cancer prevention. Mean age of the study population was 36.16 years. Regarding education nearly 30% (n=150) of them studied up to Junior School, 16% (n=80) respondents completed masters and above remaining in between. Regarding occupation, almost 60% (n=300) were house wife, 32% (n=160) were service holder and only 8% (n=40) of them were students. Knowledge about common female cancer 60% (n=300) were aware about the cervical cancer, 24% (n=120) mentioned breast cancer, 4% (n=20) mentioned ovarian cancer, and 12% (n=60) don't know anything regarding common women cancer. Knowledge about early symptoms of breast cancer, majority of the respondents 66% (n=330) were aware that mass in the breast is the main symptom, 2% (n=10) mentioned pain in breast, 32% (n=160) mentioned that they don't know anything regarding the early symptoms. About the cause of breast cancer 60% (n=300) mentioned that, they don't know anything regarding the cause of breast cancer, 36% (n=180) were aware that non lactation is a cause of breast cancer. About 4% (n=20) of the study population mentioned others, like due to some ones bad did cancer occur as punishment. Knowledge about risk factor of breast cancer, 65% (n=325) have no idea about the risk of breast cancer, 32% (n=160) mentioned few risk factors which have relation with breast cancer and 3% (n=15) did not mention anything. Regarding diagnosis of cancer breast 72% (n=360) mentioned they don't know anything, 16% (n=80) by doing ultra sonogram of breast, 6% (n=30) mentioned about Mammography and 6% (n=30) MRI & others. Regarding screening for prevention of breast cancer 60% (n=300) mentioned that they don't know anything regarding screening. Thirty percent (n=150) were aware that there is screening method but they are not aware specifically regarding this method and they also not aware that breast cancer is a preventable disease. 10% (n=50) were fully aware about screening method like CBE & SBE. About the cause of not seeking medical advice for prevention of Breast cancer, majority of the respondents 40% (n=200) mentioned expenditure problems, 32% (n=160) they don't have any knowledge about this type of medical advice, 8% (n=40) mentioned communication problems and 20% (n=100) others. Regarding Practice of CBE & SBE 68% (n=340) never practice CBE & SBE, 30% (n=150) occasionally practiced CBE & SBE. Only 2% (n=10) mentioned that they were regularly practicing CBE & SBE.

Surgical Management of Desmoid Tumor of the Female Pelvis: A Case Report

A 25 years married women having one child delivered vaginaly presented in the department of Obs & Gynae, Bangabandhu Sheikh Mujib Medical University, Bangladesh on April 2013 with pelvic pain and discomfort. No history of previous pelvic trauma was present. Patient examination showed a isolated mass in the right lower abdomen, right adnexa, extending to the pelvic wall upto lower end of ureter. Tumor markers were within normal limit. Intravenous pyelogram (IVP) showed mild right hydroureter and hydronephrosis with obstruction at the lower end of ureter. She was diagnosed as a case of adnexal mass with mild hydroureter & mild hydronephrosis and it was decided to operate on the patient. The surgical approach was transabdominal. On laparotomy a pseudocystic lesion 12×10cm in size was found over the right paracolic gutter and extending down into the pelvis involving the right parametrium. No abnormality was found in the uterus or tubes. The histological examination revealed a desmoid tumor of the pelvis. The patient's recovery was uneventful.

Hypothyroidism and its Effect on Menstrual Pattern and Fertility

Hypothyroidism is one of the most common endocrine disorders encountered in clinical practice. Thyroid disorder is very common among the female. The aim of this study was to evaluate the effects of hypothyroidism on menstrual pattern and sub-fertility. This cross-sectional comparative study was carried out in the Department of Obstetrics and Gynecology with collaboration of endocrine department of Bangabandhu Sheikh Mujib Medical University (BSMMU) from July 2006 to June 2008, cases were collected from the thyroid clinic of this hospital. Total study subject were 139, among them hypothyroid cases were 79 and euthyroid were 60. Among the hypothyroidism group 62.0% (n=49) had normal menstrual cycle, 21.5% (n=16) had oligomenorrhoea, 10.1% (n=8) had polymenorrhoea and 6.3% (n=6) had amenorrhoea. On the contrary in euthyroid group 86.7% (n=52) had normal menstrual cycle, 6.7% (n=4) had oligomenorrhoea, 5.0% (n=3) had polymenorrhoea and 1.7% (n=1) had amenorrhoea. Proportion of abnormal menstrual history was found to high among hypothyroid group almost 34% (n=27) compared to euthyroid group 13.4% (n=8) and the difference was statistically significant (p<0.001). The proportion of primary subfertility in hypothyroid 11.4% (n=9) whereas in euthyroid cases 1.7% (n=1) and secondary subfertility in hypothyroid 7.6% (n=6) where as in euthyroid cases 5.0% (n=3). So, sub-fertility was higher among hypothyroid group compared to euthyroid group but the difference was not statistically significant (p>0.05). Overall sub-fertility was 13.7% (n=10) and it was 6.7% (n=4) among the euthyroid group. Among total hypothyroid group 60.7% (n=48) are the overt hypothyroid and 39.20% (n=31) are the sub-clinical hypothyroid group. The effect of hypothyroidism is significant on menstrual pattern and on fertility. Hypothyroid women had more menstrual disorders and also suffering from sub-fertility.

Injury to the proximal deep medial collateral ligament

Most injuries to the medial collateral ligament (MCL) heal well after conservative treatment. We have identified a subgroup of injuries to the deep portion of the MCL which is refractory to conservative treatment and causes persistant symptoms. They usually occur in high-level football players and may require surgical repair.

We describe a consecutive series of 17 men with a mean age of 29 years (18 to 44) who were all engaged in high levels of sport. Following a minor injury to the MCL there was persistent tenderness at the site of the proximal attachment of the deep MCL. It could be precipitated by rapid external rotation at the knee by clinical testing or during sport. The mean time from injury to presentation was 23.6 weeks (10 to 79) and none of the patients had responded to conservative treatment. The surgical finding was a failure of healing of a tear of the deep MCL at its femoral origin which could be repaired. After a period of postoperative protective bracing and subsequent rehabilitation the outcome was good. All the patients returned to their sports and remained asymptomatic at a mean of 48 weeks (28 to 60) post-operatively.

Recognition of this subgroup is important since the clinical features, the course of recovery and surgical requirement differ from those of most injuries to the MCL.

Crystal arthropathy of the lumbar spine: a series of six cases and a review of the literature

There have been very few reports in the literature of gout and pseudogout of the spine. We describe six patients who presented with acute sciatica attributable to spinal stenosis with cyst formation in the facet joints. Cytopathological studies confirmed the diagnosis of crystal arthropathy in each case. Specific formation of a synovial cyst was identified pre-operatively by MRI in five patients. In the sixth, the diagnosis was made incidentally during decompressive surgery. Surgical decompression alone was undertaken in four patients. In one with an associated degenerative spondylolisthesis, an additional intertransverse fusion was performed. Another patient had previously undergone a spinal fusion adjacent to the involved spinal segment, and spinal stabilisation was undertaken as well as a decompression. In addition to standard histological examination material was sent for examination under polarised light which revealed deposition of urate or calcium pyrophosphate dihydrate crystals in all cases. It is not possible to diagnose gout and pseudogout of the spine by standard examination of a fixed specimen. However, examining dry specimens under polarised light suggests that crystal arthropathy is a significant aetiological factor in the development of symptomatic spinal stenosis associated with cyst formation in a facet joint.

Distribution of fluid within the peritoneal cavity: A cadaveric study

This study assesses the distribution of varying volumes of fluid within the peritoneal cavity of cadavers of different sizes (small < or =60 kg; medium = 60-100 kg; large > or =100 kg). The results help to predict the volumes of therapeutic solutions (e.g., adhesiolysis solutions used in the prevention of post-operative adhesion formation) that would be required to reach all the relevant spaces within the greater sac of the peritoneal cavity. Twenty-one cadavers (9 male, 12 female) were selected randomly. Midline laparotomy and bilateral subcostal incisions were made to visualize the distribution of 500 ml of water into the pelvic cavity, paracolic gutters, right subhepatic, and subphrenic spaces. A further 500 ml of water was then added and the distribution was again recorded. The results showed that 500 ml of water was found to distribute to all areas in 47.8% of cadavers, and 1,000 ml distributed to all areas in 81.0% of cadavers. One hundred percent of small cadavers achieved maximum distribution with 500 ml irrespective of gender. Seventy percent of medium cadavers achieved maximum distribution with 1,000 ml, and 75% of large cadavers achieved maximum distribution with 1,000 ml. Anatomical variation in the size of the phrenicocolic ligament was found to be an important limiting factor in the distribution of fluid to the space inferior to the left lobe of the liver and the left subphrenic space. Pre-existing intra-abdominal pathology and previous abdominal surgery also influenced the distribution of fluid within the peritoneal cavity.

The biosynthesis of acarbose and validamycin

The studies reported here have established the biosynthetic origin of the mC7N units of acarbose and validamycin from sedo-heptulose 7-phosphate, and have identified 2-epi-5-epi-valiolone as the initial cyclization product. The deoxyhexose moiety of acarbose arises from glucose with deoxythymidyl-diphospho-4-keto-6-deoxy-D-glucose (dTDP-4-keto-6-deoxy-D-glucose) as a proximate intermediate. However, despite the identical origin of the aminocyclitol moieties in acarbose and validamycin A, the pathways of their formation seem to be substantially different. Validamycin A formation involves a number of discrete ketocyclitol intermediates, 5-epi-valiolone, valienone, and validone, whereas no free intermediates have been identified on the pathway from 2-epi-5-epi-valiolone to the pseudodisaccharide moiety of acarbose. The stage is now set for unraveling the mechanism or mechanisms by which the two components of the pseudodisaccharide moieties of acarbose and validamycin are uniquely coupled to each other via a nitrogen bridge.

Synthesis of 5-epi-[6-(2)H(2)]valiolone and stereospecifically monodeuterated 5-epi-valiolones: exploring the steric course of 5-epi-valiolone dehydratase in validamycin A biosynthesis

In validamycin A biosynthesis, as well as that of acarbose, the valienamine and validamine moieties are ultimately derived from a C(7) sugar, sedoheptulose 7-phosphate, which is cyclized to 2-epi-5-epi-valiolone by a cyclase that operates via a dehydroquinate (DHQ) synthase-like mechanism. 2-epi-5-epi-Valiolone is first epimerized at C-2 to give 5-epi-valiolone and then dehydrated between C-5 and C-6 to yield valienone. To probe the dehydration mechanism of 5-epi-valiolone to valienone, stereospecifically 6alpha- and 6beta-monodeuterated 5-epi-valiolones were synthesized. The key step in the synthesis was desulfurization of the tetrabenzyl-6,6-bis(methylthio)-5-epi-valiolone and introduction of the deuterium utilizing Zn, NiCl(2), ND(4)Cl/D(2)O, and THF. Extensive studies using various combinations of protio- and deuteroreagents and solvents probed the mechanism of the reductive desulfurization, which is crucial for the preparation of stereospecifically monodeuterated 5-epi-valiolones. Incorporation experiments with the labeled precursors in the validamycin A producer strain, Streptomyces hygroscopicus var. limoneus, revealed that the dehydration of 5-epi-valiolone to valienone occurs by a syn elimination of water.

Biosynthesis of the validamycins: identification of intermediates in the biosynthesis of validamycin A by Streptomyces hygroscopicus var. limoneus

To study the biosynthesis of the pseudotrisaccharide antibiotic, validamycin A (1), a number of potential precursors of the antibiotic were synthesized in (2)H-, (3)H-, or (13)C-labeled form and fed to cultures of Streptomyces hygroscopicus var. limoneus. The resulting validamycin A from each of these feeding experiments was isolated, purified and analyzed by liquid scintillation counting, (2)H- or (13)C NMR or selective ion monitoring mass spectrometry (SIM-MS) techniques. The results demonstrate that 2-epi-5-epi-valiolone (9) is specifically incorporated into 1 and labels both cyclitol moieties. This suggests that 9 is the initial cyclization product generated from an open-chain C(7) precursor, D-sedoheptulose 7-phosphate (5), by a DHQ synthase-like cyclization mechanism. A more proximate precursor of 1 is valienone (11), which is also incorporated into both cyclitol moieties. The conversion of 9 into 11 involves first epimerization to 5-epi-valiolone (10), which is efficiently incorporated into 1, followed by dehydration, although a low level of incorporation of 2-epi-valienone (15) is also observed. Reduction of 11 affords validone (12), which is also incorporated specifically into 1, but labels only the reduced cyclitol moiety. The mode of introduction of the nitrogen atom linking the two pseudosaccharide moieties is not clear yet. 7-Tritiated valiolamine (8), valienamine (2), and validamine (3) were all not incorporated into 1, although each of these amines has been isolated from the fermentation, with 3 being most prevalent. Demonstration of in vivo formation of [7-(3)H]validamine ([7-(3)H]-3) from [7-(3)H]-12 suggests that 3 may be a pathway intermediate and that the nonincorporation of [7-(3)H]-3 into 1 is due to a lack of cellular uptake. We thus propose that 3, formed by amination of 12, and 11 condense to form a Schiff base, which is reduced to the pseudodisaccharide unit, validoxylamine A (13). Transfer of a D-glucose unit to the 4'-position of 13 then completes the biosynthesis of 1. Other possibilities for the mechanism of formation of the nitrogen bridge between the two pseudosaccharide units are also discussed.

The AcbC protein from Actinoplanes species is a C7-cyclitol synthase related to 3-dehydroquinate synthases and is involved in the biosynthesis of the alpha-glucosidase inhibitor acarbose

The putative biosynthetic gene cluster for the alpha-glucosidase inhibitor acarbose was identified in the producer Actinoplanes sp. 50/110 by cloning a DNA segment containing the conserved gene for dTDP-D-glucose 4,6-dehydratase, acbB. The two flanking genes were acbA (dTDP-D-glucose synthase) and acbC, encoding a protein with significant similarity to 3-dehydroquinate synthases (AroB proteins). The acbC gene was overexpressed heterologously in Streptomyces lividans 66, and the product was shown to be a C7-cyclitol synthase using sedo-heptulose 7-phosphate, but not ido-heptulose 7-phosphate, as its substrate. The cyclization product, 2-epi-5-epi-valiolone ((2S,3S,4S,5R)-5-(hydroxymethyl)cyclohexanon-2,3,4,5-tetrol), is a precursor of the valienamine moiety of acarbose. A possible five-step reaction mechanism is proposed for the cyclization reaction catalyzed by AcbC based on the recent analysis of the three-dimensional structure of a eukaryotic 3-dehydroquinate synthase domain (Carpenter, E. P., Hawkins, A. R., Frost, J. W., and Brown, K. A. (1998) Nature 394, 299-302).

Enantiomers of flurbiprofen can distinguish key pathophysiological steps of NSAID enteropathy in the rat

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal damage by a non-prostaglandin (PG) dependent "topical" action and by inhibiting cyclooxygenase.

AIMS

To discriminate between these two effects by studying some key pathophysiological steps in NSAID enteropathy following administration of (R)- and (S)-flurbiprofen, the racemic mixture, and an uncoupler, dinitrophenol.

METHODS

The effects of dinitrophenol, racemic, (R)-, and (S)-flurbiprofen on mitochondria were assessed in vitro and on key pathophysiological features of small intestinal damage in vivo (ultrastructure by electron microscopy, mucosal prostanoid concentrations, intestinal permeability, inflammation, and ulcer count) in rats.

RESULTS

All the drugs uncoupled mitochondrial oxidative phosphorylation in vitro, caused mitochondrial damage in vivo, and increased intestinal permeability. Dinitrophenol and (R)-flurbiprofen caused no significant decreases in mucosal prostanoid concentrations (apart from a decrease in thromboxane (TX) B2 concentrations following (R)-flurbiprofen) while racemic and (S)- flurbiprofen reduced mucosal prostanoids significantly (PGE, TXB2, and 6-keto-PGF1alpha concentrations by 73-95%). Intestinal inflammation was significantly greater following administration of (S)-flurbiprofen and racemate than with dinitrophenol and (R)-flurbiprofen. No small intestinal ulcers were found following dinitrophenol or (R)-flurbiprofen while both racemic and (S)-flurbiprofen caused numerous ulcers.

CONCLUSIONS

Dinitrophenol and (R)-flurbiprofen show similarities in their actions to uncouple mitochondrial oxidative phosphorylation in vitro, alter mitochondrial morphology in vivo, increase intestinal permeability, and cause mild inflammation without ulcers. Concurrent severe decreases in mucosal prostanoids seem to be the driving force for the development of severe inflammation and ulcers.

Comparison of indomethacin and nimesulide, a selective cyclooxygenase-2 inhibitor, on key pathophysiologic steps in the pathogenesis of nonsteroidal anti-inflammatory drug enteropathy in the rat

BACKGROUND

The predicted gastrointestinal tolerability of specific cyclooxygenase-2 inhibitors could be due to either a lack of 'topical' irritation and/or lack of effect on cyclooxygenase-1.

METHODS

Key pathophysiologic steps (in vitro and in vivo uncoupling, intestinal prostanoid levels (prostaglandin E, thromboxane B2, and 6-keto-prostaglandin F1alpha), intestinal permeability (51Cr-ethylenediaminetetraacetic acid), inflammation (faecal excretion of a granulocyte marker protein), and ulcer counts) in enteropathy induced by nonsteroidal anti-inflammatory drugs were assessed after administration of indomethacin, 10 mg/kg, and 15 (roughly equipotent), 30, and 60 mg/kg of the preferential cyclooxygenase-2 inhibitor nimesulide.

RESULTS

Indomethacin uncoupled oxidative phosphorylation at lower concentrations than nimesulide in vitro. Indomethacin was associated with electron microscopy changes suggestive of uncoupling in 60%-70% of enterocytes examined, whereas nimesulide affected 10%-30% of enterocytes, depending on the dose. Indomethacin increased intestinal permeability and caused inflammation and ulcers with 71%-96% reductions in prostanoid levels. Nimesulide at 15 mg/kg caused no damage, whereas 30 and 60 mg/kg nimesulide were associated with significant decreases in mucosal prostanoids (46%-75%), but only the 60-mg/kg dose caused a transient increase in intestinal permeability. However, at none of the doses did nimesulide cause intestinal inflammation or ulcers.

CONCLUSIONS

These results endorse the idea that selective cyclooxygenase-2 inhibitors may be associated with some gastrointestinal tolerance due to their selectivity for cyclooxygenase-2, inhibiting cyclooxygenase-1 at only very high doses, and reduced topical irritation.

Anti-malarial activities of acylated bruceolide derivatives

Several O-acylated derivatives of bruceolide (2) were synthesized and their anti-malarial activities together with selective toxicities were examined. It was found that 3,15-di-O-acetyl-(3c), 3,15-di-O-propionyl-(3d) and 15-O-propionylbruceolide (3b), as well as bruceine B (3a), exhibited potent anti-malarial activities with high selective toxicities.

Indonesian medicinal plants. XXI. Inhibitors of Na+/H+ exchanger from the bark of Erythrina variegata and the roots of Maclura cochinchinensis

Through bioassay-guided separation of the methanol extracts of Indonesian medicinal plants, three inhibitors of the Na+/H+ exchange system, erythrinin B (2), euchrenone b10 (3), and 1,3,5-trihydroxy-4-(3-methylbut-2-enyl)xanthen-9-one (4), were isolated from the bark of Erythrina variegata (Fabaceae) (for 2) and the roots of Maclura cochinchinensis (Moraceae) (for 2, 3, 4). Compounds 2, 3, and 4 significantly inhibited the Na+/H+ exchange system of arterial smooth muscle cells, with minimum inhibitory concentrations of 1.25, 1.25, and 10 micrograms/ml, respectively. Three new prenylated xanthones named isocudraniaxanthones B (5) and A (7) and isoalvaxanthone (9) were also isolated from M. cochinchinensis and the chemical structures were elucidated on the bases of their chemical and physicochemical properties.

Intestinal tolerability of nitroxybutyl-flurbiprofen in rats

BACKGROUND

Nitric oxide derivatives of non-steroidal anti-inflammatory drugs (NSAIDs) are thought to be much less ulcerogenic than their parent compounds.

AIM

To compare the effect and potency of flurbiprofen and nitroxybutyl-flurbiprofen to uncouple mitochondrial oxidative phosphorylation (an early pathogenic event in NSAID enteropathy), increase intestinal permeability (transitional stage), and cause macroscopic small intestinal damage.

METHODS

In vitro uncoupling potency was assessed using isolated coupled rat liver mitochondria and in vivo by electron microscopy of rat small intestinal mucosa (two hours after the drugs). A dose-response study with flurbiprofen (single doses of 5, 10, 20, and 40 mg/kg) and equimolar doses of nitroxybutyl-flurbiprofen was performed; assessing their effect on intestinal permeability (at 18-20 hours), with 51Cr EDTA, and the number of pointed (< 5 mm) and longitudinal (> 5 mm) small intestinal ulcers at 24 hours.

RESULTS

Flurbiprofen, but not nitroxybutyl-flurbiprofen, stimulated coupled respiration in vitro. Both drugs, however, uncoupled in vivo; in the case of nitroxybutyl-flurbiprofen possibly because hydrolysis of its ester bond released free flurbiprofen. Intestinal permeability was uniformly and equally increased with both drugs compared with controls. The number of small intestinal ulcers, pointed and longitudinal, was significantly reduced with nitroxybutyl-flurbiprofen apart from the number of longitudinal ulcers with the highest dose.

CONCLUSIONS

These studies show that nitroxybutyl-flurbiprofen is associated with significantly less macroscopic damage in the small intestine than flurbiprofen but was associated with mitochondrial damage in vivo and caused similar increases in permeability of the small intestine, suggesting that its beneficial effect is on the later pathogenic stages of the damage.

Nonsteroidal antiinflammatory drugs and uncoupling of mitochondrial oxidative phosphorylation

OBJECTIVE

There is a lack of correlation between cyclooxygenase (COX) inhibition and nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal (GI) damage; it has been suggested that mucosal damage may be initiated by a "topical" action of NSAIDs involving mitochondrial injury. We evaluated the effect of a range of NSAIDs and related compounds on mitochondrial function and assessed the differences between them in relation to their physicochemical properties.

METHODS

Stimulation of respiration, as an indicator of mitochondrial uncoupling, was measured in isolated coupled rat liver mitochondrial preparations, using an oxygen electrode.

RESULTS

Conventional NSAIDs and acidic prodrugs all had stimulatory effects on mitochondrial respiration at micromolar concentrations (0.02-2.7 microM); higher concentrations were inhibitory. The uncoupling potency was inversely correlated with drug pKa (r = -0.87, P < 0.001; n = 12). Drugs known to have good GI tolerability, including modified flurbiprofen (dimero-flurbiprofen and nitrobutyl-flurbiprofen), nabumetone (a non-acidic prodrug), and non-acidic highly selective COX-2 inhibitors, did not cause uncoupling.

CONCLUSION

The ability to uncouple mitochondrial oxidative phosphorylation is a common characteristic of antiinflammatory agents with an ionizable group. Modification or absence of an ionizable moiety reduces the effect on mitochondria and could lead to improved NSAID GI safety.

Indonesian medicinal plants. XVII. Characterization of quassinoids from the stems of Quassia indica

Four new quassinoids named samaderines X (1), Y (2) and Z (3), and indaquassin X (5), and a new C19 quassinoid glycoside, 2-O-glucosylsamaderine C (10), together with five known quassinoids, samaderines B (7), C (8), and E (4), indaquassin C (6), and simarinolide (9), were isolated form the stems of Quassia indica (Simaroubaceae), an Indonesian medicinal plant. The chemical structures of these quassinoids have been elucidated on the bases of their chemical and physiochemical properties. Samaderines X (1), Z (3), E (4), and B (7) were shown to exhibit significant growth-inhibitory activity against the cultured malarial parasite Plasmodium falciparum (a chloroquine- resistant K1 strain), and 1--8 were shown to exhibit in vitro cytotoxicity (IC50: 0.04--100 micrograms/ml) against KB cells. Samaderines X (1), B (7) and C (8), as well s indaquassin X (5), exhibited inhibitory activity in the in vitro endothelial cell-neutrophil leukocyte adhesion assay, whereas samaderines X (1) and B (7) were found to exhibit significant anti-inflammatory activity.

Indonesian Medicinal Plants. XIV. Characterization of 3'-O-Caffeoylsweroside, a new secoiridoid glucoside, and kelampayosides A and B, two new phenolic apioglucosides, from the bark of Anthocephalus chinensis (Rubiaceae)

A new secoiridoid glucoside named 3'-O-caffeoylsweroside (1), and two new phenolic apioglucosides, named kelampayoside A (4) and kelampayoside B (6), together with eleven known compounds (five iridoids and six alkaloids), were isolated from the bark of Anthocephalus chinensis (Rubiaceae), an Indonesian medicinal plant from Sumatra Island, Indonesia. The chemical structures of 1, 4 and 6 have been elucidated respectively as 3'-O-caffeoylsweroside (1), antiarol 1-O-beta-D-apiofuranosyl (1 --> 6)-beta-D-glucopyranoside (4), and antiarol 1-O-beta-D-5"-O-caffeoylapiofuransoyl (1 --> 6)-beta-D-glucopyranoside (6) on the bases of their chemical and physiochemical properties. Among fourteen constituents characterized, cadambine (13), one of the major indole alkaloid constituents of A. chinensis, was shown to exhibit moderate growth-inhibitory activity against the malarial parasite Plasmodium falciparum (a chloroquine-resistant K1 strain) cultured in human erythrocytes.

Marine natural products. XXXVI. Biologically active polyacetylenes, adociacetylenes A, B, C, and D, from an Okinawan Marine sponge of Adocia sp

Adociacetylenes A (1), B (2), C (3), and D (4) were isolated as new polyacetylenes from an Okinawan marine sponge of Adocia sp. Their chemical structures have been elucidated on the bases of their chemical and physicochemical properties. Adociacetylenes A (1), C (3), and D (4) exhibited inhibitory activity in the in vitro endothelial cell-neutrophil leukocyte adhesion assay.

Clinical implications of patients' knowledge

We evaluated the effectiveness of current strategies for educating patients in routine clinical practice in three related studies. (1) A study of overall knowledge in 100 patients with rheumatoid arthritis (RA) and osteoarthritis (OA) showed knowledge of diagnosis and treatment effects were high (86% and 83% respectively) but only a minority (37%) were well informed about side effects. (2) Patients' detailed knowledge of drug therapy was assessed in 50 RA and OA patients. Between 56%-92% knew why drugs were given, their use and their likely effects. But many patients were unaware of the main adverse reactions and also how to avoid or limit them. (3) The relationship of patient education to overall disease management was evaluated in 89 RA patients with 5-10 years disease duration using validate guidelines for specialist care. Those patients who had been give inadequate education about drug therapy had a reduced level of overall care. Although education is considered important by patients, it is often inadequate, and this is associated with a less effective overall treatment.

Taxol and its related taxoids from the needles of Taxus sumatrana

Through bioassay-guided separation of the chemical constituents of the needles of Taxus sumatrana, taxol (1), cephalomannine (2), and a new taxoid 19-hydroxy-13-oxobaccatin III (8) have been isolated together with 7-epi-10-deacetyltaxol (3), 7-epi-10-deacetylcephalomannine (4), baccatin III (5), 19-hydroxybaccatin III (6), and 10-deacetyl-13-oxobaccatin III (7). The chemical structure of 8 has been elucidated on the bases of its chemical and physicochemical properties.

Indonesian medicinal plants. VIII. Chemical structures of three new triterpenoids, bruceajavanin A, dihydrobruceajavanin A, and bruceajavanin B, and a new alkaloidal glycoside, bruceacanthinoside, from the stems of Brucea javanica (Simaroubaceae)

Three new apotirucallane-type triterpenoids named bruceajavanin A (1) dihydrobruceajavanin A (2) and bruceajavanin B (3), and a novel beta-carboline alkaloidal glycoside named bruceacanthinoside (4) were isolated from the stems of Brucea javanica (Simaroubaceae), a traditional medicine used to treat malaria in the Bengkulu area, Sumatra, Indonesia. Their chemical structures have been elucidated on the bases of their chemical and physicochemical properties. Bruceajavanin A (1), dihydrobruceajavanin A (2) and bruceacanthinoside (4) were shown to inhibit growth of the cultured malarial parasite Plasmodium falciparum K1 of a chloroquine-resistant strain.

Indonesian medicinal plants. VII. Seven new clerodane-type diterpenoids, peronemins A2, A3, B1, B2, B3, C1, and D1, from the leaves of Peronema canescens (Verbenaceae)

Seven new clerodane-type diterpenoids, named peronemins B2 (1), A2 (2), B1 (3), C1 (4), B3 (5), A3 (6), and D1 (7), were isolated from the leaves of Peronema canescens (Verbenaceae), an Indonesian medicinal plant collected in Bengkulu, Sumatera Island, Indonesia. The chemical structures of 1-7 have been elucidated on the basis of their chemical and physicochemical properties.

Antireticulin antibody in systemic sclerosis

The prevalence, immunoglobulin class, and IgG subclass of antireticulin antibody in the serum samples of 32 patients with systemic sclerosis were investigated by indirect immunofluorescence on unfixed rodent tissue. Antireticulin antibody was present in 22/32 (69%) of patients and belonged to the IgG class in 19/22 (86%), the IgA class in 13/22 (59%), and the IgM class in 6/22 (27%) of positive sera. IgG1 was the predominant subclass of IgG antireticulin antibody, occurring either alone or in association with IgG3 in 12/19 cases (63%). Thus antireticulin antibody of the IgG and IgA classes is found in most patients with systemic sclerosis. The finding of an autoantibody with reactivity for collagen-like fibres in systemic sclerosis indicates that the antibody has a potential role in the pathogenesis of the disease, and as it belongs to the IgA class this suggests that it arises in response to antigens presented to the immune system at the mucosal level.