Clinical trial designs of new medicinal products for treating schizophrenia: discussion of EMA's Guideline and a Better Long Term Trial Design

Background and Objectives: Schizophrenia is a severe chronic disease. Endpoint variables lack objectivity and the diagnostic criteria have evolved with time. In order to guide the development of new drugs, European Medicines Agency (EMA) issued a guideline on the clinical investigation of medicinal products for the treatment of schizophrenia. Methods: Authors reviewed and discussed the efficacy trial part of the Guideline. Results: The Guideline divides clinical efficacy trials into short-term trials and long-term trials. The short-term three-arm trial is recommended to replace the short-term two-arm active-controlled non-inferiority trial because the latter has sensitivity issues. The Guideline ultimately makes that three-arm trial a superiority trial. The Guideline discusses four types of long-term trial designs. The randomized withdrawal trial design has some disadvantages. Long-term two-arm active-controlled non-inferiority trial is not recommended due to the sensitivity issue. Extension of the short-term trial is only suitable for extension of the short-term two-arm active-controlled superiority trial. The Guideline suggests that a hybrid design of a randomized withdrawal trial incorporated into a long-term parallel trial might be optimal. However, such a design has some disadvantages and might be too complex to be carried out. Authors suggest instead a three-group long-term trial design, which could provide comparison between test drug and active comparator along with comparison between the test drug and placebo. This alternative could arguably be much easier to carry out compared with the hybrid design. Conclusions: The three-group long-term design merits further discussion and evaluation.

Anise Myrtle (Syzygium anisatum) Oils

Syzygium anisatum (formerly Backhousia anisata and Anetholea anisata) is an Australian rainforest tree with leaves that produce an essential oil (EO) that has the characteristic aroma of aniseed. It is referred to as aniseed myrtle or anise myrtle in the trade and the fresh and dried leaves of this plant are used as a herb in culinary applications. The EO is extracted by steam distillation of the leaves and the major aromatic volatile compound is anethole. The EO has broad spectrum antimicrobial activity but is more effective against bacteria than fungi. Indigenous Australians have used anise myrtle for its medicinal values and in recent times it has been used as a flavoring agent by the food and beverage industry. This chapter covers the use of anise myrtle EO in food and agricultural applications, botanical aspects, and chemical composition.

Lemon Myrtle (Backhousia citriodora) Oils

Lemon myrtle has been traditionally used by indigenous Australians for cooking and healing. More recently, lemon myrtle leaves are used as a dry or fresh herb in food applications and the essential oil (EO) used as a flavoring agent in food and beverages. The leaf of the lemon myrtle (Backhousia citriodora) is steam distilled to produce the EO. Lemon myrtle EO is known for its characteristic lemon flavor and the major chemical component contributing to the aroma is citral. The EO has broad spectrum antimicrobial activity and is very effective against fungi and has increased the potential of using the EO in food preservation and treatment of postharvest diseases in fruits. This chapter covers the use of lemon myrtle EO in food and agriculture applications, general usage, botanical aspects, and chemical composition.

Study on the inhibitory effects of native medicinal plants on growth and aflatoxin production by toxigenic Aspergilli isolated from rainbow trout feed

In the present study, natural occurrence of fungi and aflatoxin B1 (AFB1) in pellet feed and feed ingredients used for rainbow trout was investigated with emphasis to Aspergillus section Flavi members and medicinal plants inhibitory to Aspergillus growth and/or AF production. The feed samples were cultured on the standard isolation media including dichloran rosebengal chloramphenicol agar (DRCA) and Aspergillus flavus/parasiticus agar (AFPA) for 2 weeks at 28 °C. Identification of fungal isolates was implemented based on the macro- and microscopic morphological criteria. AFs were detected using high performance liquid chromatography (HPLC). Based on the results obtained, a total of 109 fungal isolates were identified of which Aspergillus was the prominent genus (57.0%), followed by Penicillium (12.84%), Absidia (11.01%) and Pseudallscheria (10.10%). The most frequent Aspergillus species was A. flavus (60.66%) isolated from all the feed ingredients as well as pellet feed. Among 37 A. flavus isolates, 19 (51.35%) were able to produce AFB1 on yeast extract-sucrose (YES) broth in the range of 10.2 to 612.8 [tg/g fungal dry weight. HPLC analyses of trout feed showed that pellet feed and all feed ingredients tested except gluten were contaminated with different levels of AFB1 in the range of 1.83 to 67.35 lig/kg. In order to finding natural inhibitors of fungal growth and/or AF production, essential oils (EOs) and extracts of 49 medicinal plants were studied against an aflatoxin-producing A. parasiticus using a microbioassay technique. The EOs was analyzed by gas chromatography/mass spectrometry (GC/MS). Based on the results obtained, Achillea millefolium sub sp. elborsensis, Ferula gummosa, Mentha spicata, Azadirachta indica, Conium maculatum and Artemisia dracunculus remarkably inhibited A. parasiticus growth without affecting AF production by the fungus. Besides of Thymus vulgaris and Citrus aurantifolia, the EO of Foeniculum vulgare significantly inhibited both fungal growth (-70.0%) and AFs B1 and G1 (-99.0%) production. The EO of Carum carvi and ethyl acetate extract of Platycladus orientalis suppressed AFs B1 and G1 by more than 90.0%, without any obvious effect on fungal growth. The IC50 values of bioactive plants for AFs B1 and G1 were determined in the ranges of 90.6 to 576.2 and 2.8 to 61.9 µg/ml, respectively. Overall, results of the present study indicate the importance of AF contamination of trout feed as a risk factor for fish farming and thus, an urgent necessity for constant monitoring of trout feed for any unacceptable levels of AF contamination. Likewise, antifungal activities of bioactive plants introduced here would be an important contribution to explain the use of these plants as effective antimicrobial candidates to protect feeds from toxigenic fungus growth and subsequent AF contamination.

Utilização de plantas medicinais no tratamento de feridas : perfil do stryphnodendron barbatiman

Introdução – O recurso à utilização de plantas com fins terapêuticos, é uma das mais antigas formas de prática medicinal da humanidade, sobretudo por parte da população de países menos desenvolvidos, que ainda hoje, segundo a Organização Mundial de Saúde, recorre, em muitas situações, à utilização das plantas medicinais como a única forma de acesso aos cuidados básicos de saúde. Porém, e apesar do advento da medicina moderna, que se correndo do avanço da biotecnologia, por meio da qual as plantas, consideradas medicinais, podem ter seu potencial terapêutico aprovado pela ciência para fins medicamentosos, uma parte significativa da comercialização de plantas medicinais continua a não ser feita em farmácias ou lojas de produtos naturais, mas sim comercializadas em feiras livres, pelos chamados raizeiros. Partindo deste enquadramento, os objetivos centrais desta investigação foram: identificar quais as espécies de plantas medicinais mais indicadas por comerciantes, raizeiros, no tratamento de feridas e que são comercializadas nas mais importantes feiras livres da cidade de Maceió, e caracterizar a fonte de conhecimento desses raizeiros, em relação às mesmas. Métodos – Realizou-se um estudo que seguiu os pressupostos de uma pesquisa de natureza qualitativa, de matriz transversal, com recurso a uma amostra não probabilística, acidental e por conveniência constituída por 26 raizeiros, na sua maioria pertencentes ao do grupo etário dos 37-52 anos (46,14%), que desenvolvem a atividade comercial de plantas medicinais como sua única e/ou principal atividade produtiva (76,90%), e em que 50% são do sexo feminino. Como instrumento de recolha de dados recorreu-se à entrevista, a partir de convites efectuados pela autora do estudo na sequência da realização de visitas às principais feiras livres da cidade de Maceió-AL. Resultados – Os dados recolhidos pela totalidade das entrevistas permitiram constatar que o barbatimão (Stryphnodendron barbatiman) é a planta mais frequentemente indicada para o tratamento em feridas, logo seguida da Aroeira (MyracrodruonurundeuvaLâmina), e da Sambacaitá (Hyptis pectinata). As menos recomendadas são a Garra do Diabo (Harpagophytum procubens); a Jatobá (Hymenae acourbaril L.) e a Babosa (Aloe arborescens). A maioria dos raizeiros afirmaram também que recomendavam a “casca” e a “entre casca” como a forma farmacêutica mais eficaz. Em relação à aprendizagem/ conhecimento sobre a utilização medicinal do barbatimão (Stryphnodendron barbatiman): 69,3% dos raizeiros entrevistados afirmaram ter aprendido com familiares; 19,2 com amigos e 11,5% através de conversas com outros comerciantes do mesmo ramo de negócio. Cem por cento dos entrevistados afirmaram que o Stryphnodendron barbatiman, independetemente de ser a planta mais recomendada pelos raizeiros, é a planta mais procurada pela população e, que segundo a mesma, é a que apresenta um melhor resultado. Apenas 50% dos entrevistados refere que o barbatimão é armazenado seco e ensacado, e quanto questionados sobre a validade do mesmo, 69,3% dos raizeiros afirmaram que esse prazo é indeterminado. Quanto à duração da “terapia” pelo barbatimão, 100% dos raizeiros entrevistados, afirmaram que deve permanecer durante o tempo que o paciente ou o profissional de saúde que estiver acompanhando o caso, julgar necessário. Conclusões – Os resultados deste estudo vêm confirmar que o recurso à utilização de plantas com fins terapêuticos no tratamento de feridas, por parte da população brasileira, continua sendo muito usual, sendo o barbatimão (Stryphnodendron barbatimam) o mais indicado e conhecido pela cultura popular. Nesse sentido é relevante que, por um lado, o profissional de enfermagem, procure entender a utilização dessa planta medicinal, popularmente utilizada, com afirmativa de êxito, no tratamento de feridas, e por outro, entendemos ser necessária a realização de estudos multidisciplinares que permitam a ampliação e a profundidade dos conhecimentos das plantas medicinais, como agem, quais são os seus efeitos tóxicos e colaterais, e quais as suas verdadeiras indicações terapêuticas. Palavras-chave: Plantas Medicinais, Ferimentos e lesões, Tratamento, Enfermagem, Raizeiros.

Extraction and detection of mycotoxins in medicinal and aromatic plants: a case study with Aloysia citrodora P.

Plants frequently suffer contaminations by toxigenic fungi, and their mycotoxins can be produced throughout growth, harvest, drying and storage periods. The objective of this work was to validate a method for detection of toxins in medicinal and aromatic plants, through a fast and highly sensitive method, optimizing the joint co-extraction of aflatoxins (AF: AFB1, AFB2, AFG1 and AFG2) and ochratoxin A (OTA) by using Aloysia citrodora P. (lemon verbena) as a case study. For optimization purposes, samples were spiked (n=3) with standard solutions of a mix of the four AFs and OTA at 10 ng/g for AFB1, AFG1 and OTA, and at 6 ng/g of AFB2 and AFG2. Several extraction procedures were tested: i) ultrasound-assisted extraction in sodium chloride and methanol/water (80:20, v/v) [(OTA+AFs)1]; ii) maceration in methanol/1% NaHCO3 (70:30, v/v) [(OTA+AFs)2]; iii) maceration in methanol/1% NaHCO3 (70:30, v/v) (OTA1); and iv) maceration in sodium chloride and methanol/water (80:20, v/v) (AF1). AF and OTA were purified using the mycotoxin-specific immunoaffinity columns AflaTest WB and OchraTest WB (VICAM), respectively. Separation was performed with a Merck Chromolith Performance C18 column (100 x 4.6 mm) by reverse-phase HPLC coupled to a fluorescence detector (FLD) and a photochemical derivatization system (for AF). The recoveries obtained from the spiked samples showed that the single-extraction methods (OTA1 and AF1) performed better than co-extraction methods. For in-house validation of the selected methods OTA1 and AF1, recovery and precision were determined (n=6). The recovery of OTA for method OTA1 was 81%, and intermediate precision (RSDint) was 1.1%. The recoveries of AFB1, AFB2, AFG1 and AFG2 ranged from 64% to 110% for method AF1, with RSDint lower than 5%. Methods OTA1 and AF1 showed precision and recoveries within the legislated values and were found to be suitable for the extraction of OTA and AF for the matrix under study.

Use of aromatic and medicinal plants, drugs and herbal products in Bragança city

Herbal therapy is characterized by the use of aromatic and medicinal plants (AMP) in different pharmaceutical forms for therapeutic purposes. The present study aims to characterize the use of AMP, drugs and herbal products in Bragança city. For this, a cross-sectional study was conducted through application of a questionnaire to 404 subjects of both gender and aged between 18 and 89 years. AMP were therapeutically used by 53.7% mainly due “to be natural” (43.9%) while 33.8% use drugs and/ or herbal products mainly “because it is good for health” (53.5%). The AMP most used were Cidreira (n=149) and Camomila (n=117) and concerning drugs and/ or herbal products Valdispert® (n=48) and Daflon® 500 (n=41) were the most reported. Overall, the reported uses of AMP, drugs and herbal products were correct, according to the reported in literature. The use of AMP is motivated by self-knowledge (55.4%) while drugs and/ or herbal products are used mostly by medical prescription (44.1%). AMP were obtained by own cultivation (44.1%) and drug and/ or herbal products in pharmacies (89.0%). Of all users, about 90% not combined these products with conventional drugs and it was identified just one potential occurrence of drug interactions related with the use of Hipericão. The occurrence of adverse effects was noted after the use of AMP Sene (11.8%), Hipericão (9.1%) and Ginkgo Biloba (8.3%). The use of these products is a common practice among the residents of Bragança city, which use a wide diversity of AMP and plant-based products.

Consultoría para el Hospital general del Instituto Salvadoreño del Seguro Social (ISSS) sobre la generación de oxígeno medicinal por el método de adsorción por balanceo de presión.

Aquellos gases que por sus características específicas son utilizados para consumo humano y aplicaciones medicinales en instituciones de salud, son denominados gases medicinales. Éstos han sido utilizados en medicina como agentes anestésicos o analgésicos; en la actualidad se puede afirmar que el empleo de gases medicinales es indispensable para la medicina moderna, ya sea en cumplimiento de sus antiguas funciones o utilizados como medios de reemplazo, así como agentes estimuladores de funciones fisiológicas. El oxígeno es el gas más utilizado y de mayor relevancia para los hospitales del mundo. Fue aplicado en 1777 y en 1780 se demostró su importancia en la medicina al ser aplicados en pacientes cuya capacidad respiratoria se veía disminuida. En la actualidad ya es considerado como medicamento en cierta cantidad de mezcla controlada. Los gases líquidos en el ámbito hospitalario han adquirido una alta demanda debido al crecimiento tanto tecnológico como de la sociedad, haciendo que su consumo sea cada vez mayor. Considerando que algunas aplicaciones de estos gases cumplen funciones de apoyo vital, implica que las instalaciones de gases medicinales sean consideradas como críticas y reciban tratamiento a través de personas profesionales que atiendan a sus características funcionales: cálculos en cuanto a capacidad y dosis, instalación, manejo, control y mantenimiento. La Bioingeniería es la ciencia idónea para este tipo de actividades ya que en las mismas deben integrarse conocimientos médicos y tecnológicos con conceptos físicos y químicos, todo bajo una óptica ingenieril. El oxígeno para aplicaciones médicas puede ser obtenido por dos métodos: el PSA (fluctuaciones de presión) y el criogénico. En ambos casos se toma aire ambiente mediante dispositivos y procesos adecuados con el fin de obtener oxígeno medicinal. Ambos métodos son capaces de proporcionar oxígeno medicinal a la concentración de pureza necesaria en aplicaciones médicas, tomando en cuenta la diferencia en costos entre ambos, el presente estudio evalúa la factibilidad para generar oxígeno medicinal por el método de adsorción por balanceo de presión (PSA) para el Hospital General del Instituto Salvadoreño del Seguro Social con el fin de brindar alternativas que mejoren continuamente la atención a los derechohabientes.

Reliability of graphite furnace atomic absorption spectrometry as alternative method for trace analysis of arsenic in natural medicinal products

Purpose: To evaluate the comparative efficiency of graphite furnace atomic absorption spectrometry (GFAAS) and hydride generation atomic absorption spectrometry (HGAAS) for trace analysis of arsenic (As) in natural herbal products (NHPs). Method: Arsenic analysis in natural herbal products and standard reference material was conducted using atomic absorption spectrometry (AAS), namely, hydride generation AAS (HGAAS) and graphite furnace (GFAAS). The samples were digested with HNO3–H2O2 in a ratio of 4:1 using microwaveassisted acid digestion. The methods were validated with the aid of the standard reference material 1515 Apple Leaves (SRM) from NIST Results: Mean recovery of three different samples of NHPs, using HGAAS and GFAAS, ranged from 89.3 - 91.4 %, and 91.7 - 93.0 %, respectively. The difference between the two methods was insignificant. A (P= 0.5), B (P=0.4) and C (P=0.88) Relative standard deviation (RSD) RSD, i.e., precision was 2.5 - 6.5 % and 2.3 - 6.7 % using HGAAS and GFAAS techniques, respectively. Recovery of arsenic in SRM was 98 and 102 % by GFAAS and HGAAS, respectively. Conclusion: GFAAS demonstrates acceptable levels of precision and accuracy. Both techniques possess comparable accuracy and repeatability. Thus, the two methods are recommended as an alternative approach for trace analysis of arsenic in natural herbal products.

Artisanal extraction and traditional knowledge associated with medicinal use of Crabwood Oil (Carapa guianensis Aublet.) in a peri-urban Várzea environment in the Amazon Estuary.

Varzea forests of the Amazon estuary contain species of importance to riverine communities. For example, the oil extracted from the seeds of crabwood trees is traditionally used to combat various illnesses and as such artisanal extraction processes have been maintained. The objectives of this study were to (1) describe the process involved in artisanal extraction of crabwood oil in the Fazendinha ProtectedArea, in the state ofAmap´a; (2) characterise the processes of knowledge transfer associated with the extraction and use of crabwood oil within a peri-urban riverine community; and (3) discern medicinal uses of the oil.The data were obtained using semistructured interviews with 13 community members involved in crabwood oil extraction and via direct observation.The process of oil extraction is divided into four stages: seed collection; cooking and resting of the seeds; shelling of the seeds and dough preparation; and oil collection. Oil extraction is carried out within the home for personal use, with surplus marketed within the community. More than 90% of the members of the community involved in extraction of crabwood oil highlighted the use of the oil to combat inflammation of the throat. Knowledge transfer occurs via oral transmission and through direct observation.

Potencial de uso da erva medicinal Cybopogon citratus no controle de fitopatógenos do feijoeiro e plantas daninhas em áreas irrigadas.

Para avaliar a erva medicinal Cymbopogon citratus (capim-limao) no controle de fitopatogenos e de plantas daninhas em feijoeiro, foram instalados experimentos utilizando diferentes subprodutos da planta. O oleo essencial de C. citratus a 10% obtido de folhas inibiu totalmente o crescimento micelial de Fusarium solani f. sp phaseoli, Sclerotinia sclerotiorum e Rhizoctonia solani, ao passo que Sclerotium rolfsii apresentou-se menos sensivel, apesar da substancia reduzir significativamente o diametro medio das colonias do fungo. Tambem o oleo de C. citratus a 10% promoveu inibicao total da germinacao de sementes de Digitaria horizontalis (capim-colchao), Sorghum halepense (capim-massambara), Bidens pilosa (picao-preto), Euphorbia heterophylla (amendoim-bravo, leiteiro) e Raphanus raphanistrum (nabica). O oleo inibiu parcialmente a germinacao de Echinochloa crusgalli (capim-arroz) e nao afetou a germinacao de Portulaca oleracea (beldroega). Em casa de vegetacao, o oleo de folhas a 10% afetou a emergencia do feijoeiro, enquanto o po (folha seca moida) incrementou a emergencia para 97% contra 75% e 88% em solos infestados com R. solani e F. solani, respectivamente. Em condicoes de campo, observou-se reducao da incidencia de F. solani e R. solani nas parcelas tratadas com suspensao aquosa de oleo de C. citratus a 1% e 5% no sulco de plantio e em tratamento de sementes a 0,5%. A analise da producao nao evidenciou diferencas significativas entre os tratamentos. Para verificar o efeito da combinacao do uso de C. citratus e da reducao de doses dos herbicidas, foram ultilizados os herbicidas pos-emergentes fomesafen e fenoxaprop-etil nas doses usadas pelo produtor (0,619 l ia/ha de cada produto) e a 80% destas doses. As especies de plantas daninhas predominantes foram: P. oleracea, Eleusine indica (capim-pe-de-galinha) e Amaranthus deflexus (caruru).

Synthesis of profluorescent isoindoline nitroxides via palladium-catalysed Heck alkenylation

The synthesis of a new structural class of isoindoline nitroxides (aminoxyls), accessible via the palladium-catalysed Heck reaction, is presented. Reaction of the aryl bromoamine, 5-bromo-1,1,3,3-tetramethylisoindoline (4) or dibromoamine, 5,6-dibromo-1,1,3,3-tetramethylisoindoline (5) or the analogous bromonitroxides 6 and 7 with methyl acrylate gives the acrylate substituted tetramethylisoindoline amines 8 and 10 and nitroxides 12 and 14. Similarly, the reaction of the aryl bromides and dibromides 4–7 with methyl 4-vinylbenzoate gives the carboxystyryl substituted tetramethylisoindoline amines 9 and 11 and the analogous nitroxides 13 and 15. The carboxystyryl tetramethylisoindoline nitroxides demonstrate strongly suppressed fluorescence, which is revealed upon removal of the free radical by reduction or radical coupling.