Acute lead poisoning: a diagnostic challenge in the emergency department.

Acute abdominal pain is a common presentation to the emergency department (ED). Ruling out life-threatening causes and giving pain relief are the most important tasks in ED. We describe a 32-year-old man who presented to ED with abdominal pain and vomiting which was unrelieved by usual doses of analgesic. Extensive investigations revealed no significant abnormalities. On further probing, he admitted taking traditional medications for infertility. The toxicological panel revealed a high blood lead level, leading to a diagnosis of acute lead toxicity. Chelation therapy with D-penicillamine was initiated and the patient's abdominal pain resolved within 4 days.

A simple and effective method to discern the true commercial Chinese cordyceps from counterfeits.

The Chinese cordyceps, a complex of the fungus Ophiocordyceps sinensis and its species-specific host insects, is also called "DongChongXiaCao" in Chinese. Habitat degradation in recent decades and excessive harvesting by humans has intensified its scarcity and increased the prices of natural populations. Some counterfeits are traded as natural Chinese cordyceps for profit, causing confusion in the marketplace. To promote the safe use of Chinese cordyceps and related products, a duplex PCR method for specifically identifying raw Chinese cordyceps and its primary products was successfully established. Chinese cordyceps could be precisely identified by detecting an internal transcribed spacer amplicon from O. sinensis and a cytochrome oxidase c subunit 1 amplicon from the host species, at a limit of detection as low as 32 pg. Eleven commercial samples were purchased and successfully tested to further verify that the developed duplex PCR method could be reliably used to identify Chinese cordyceps. It provides a new simple way to discern true commercial Chinese cordyceps from counterfeits in the marketplace. This is an important step toward achieving an authentication method for this Chinese medicine. The methodology and the developmental strategy can be used to authenticate other traditional Chinese medicinal materials.

VERIFICATION OF AUTHENTICITY OF GINKGO BILOBA L. LEAF EXTRACT AND ITS PRODUCTS PRESENT ON THE CROATIAN MARKET BY ANALYSIS OF QUANTITY AND RATIO OF GINKGO FLAVONE GLYCOSIDES (QUERCETIN, KAEMPFEROL AND ISORHAMNETIN) TO TERPENE TRILACTONES TO THE EFFECT OF UNMASKING COUNTERFEIT DRUGS ENDANGERING PATIENT HEALTH.

Ginkgo biloba L. is the eldest plant growing on the Earth; preparations made of its leaves and seeds represent an integral part of the Chinese medicine for over a millennium. The plant species was first discovered by Linnaeus in 1771, its name thereby originating from the Latin words bis (two) and lobus (lobe), which duly illustrate the specific shape of its leaf. Contemporary Ginkgo biloba L. plant based pharmaceuticals mostly comprise extracts recovered from leaves harvested during fall, when the concentration of active components reaches its peak. Recent investigations have managed to establish the chemical composition of the plant leaf, together with the mechanisms underlying its beneficial effects on rheological profile of the blood and acceleration of its flow. High price of these preparations and their vast popularity have soon become an incentive for counterfeiting Ginkgo biloba L. extracts and the release of bogus drugs comprising cheaper extracts coming from other plants. Namely, modern Ginkgo biloba L.-based medicinal products and food supplements comprise extracts recovered from the plant leaf that get to be standardized according to its key pharmacological active components, most often flavone glycosides (represented in the share of 22%-27%) and terpene trilactones (represented in the share of 6%-7%). The flavonoids that predominate such preparations and are most relevant from the pharmacological standpoint are quercetin, kaempferol and isorhamnetin, their total amount and mutual ratios, thereby being an unquestionable indicator of the extract authenticity. Therefore, most of the analyses aiming at verifying the authenticity of a given Ginkgo biloba L.-based product boil down to the analysis of these parameters. Counterfeiting involves partial or full replacement of the Ginkgo biloba L. extract (GBE) with a cheaper plant extract of a similar composition, the latter occasionally being enriched with an additional amount of flavonoids, most often quercetin, not originating from the Ginkgo biloba L. plant. The aim of this study was to verify the authenticity and quality of Ginkgo biloba L.-based products circulating on the Croatian market. To that effect, 10 samples of products produced by various manufacturers were analyzed in a certified laboratory. The parameters based on which the authenticity of the preparations was assessed were the shares of aglycones of typical ginkgo flavone glycosides, that is to say, quercetin, kaempferol and isorhamnetin, and mutual ratios of the established quantities of quercetin to kaempferol as the key clues to unmasking Ginkgo extracts counterfeiting. The amount of ginkgo flavone glycosides was established using high performance liquid chromatography. The analysis proved 80% of the samples analyzed to be conformant to the label statements as regards the total amount of flavone glycosides and their mutual ratios. In 20% of the samples, the ratio of quercetin to kaempferol deviated from normal values; on top of that, the presence of the phytoestrogen genistein, one of the components typically comprised by the Sophora japonica L. plant, was also proven, documenting counterfeiting of the GBE and its replacement by the Sophora japonica L. extracts in the samples under consideration. Due to the untrue label statements descriptive of these products, the information on the presence of pharmacologically active genistein was neglected to be mentioned despite its unfavorable health impact that can be expected in some consumer groups. The results of this study indicated the frequency of counterfeiting the Ginkgo biloba L.-based products found on the Croatian market to be deemed substantial. Therefore, a more rigorous and more thorough control of these products and sanctioning of irresponsible manufacturers and distributers is proposed, so as to contribute to a higher market representation of high-quality products, as well as to avoid health risks and downsize the rate of their counterfeiting.

Identification of Ligustici Rhizoma et Radix and its adulterants based on their chemical constituents by UHPLC-Q/TOF-MS combined with data mining.

Ligustici Rhizoma et Radix (LR), known as Gaoben (GB) in Chinese, has been used in traditional Chinese medicine for more than 2000 years. However, the varieties of LR are not well characterized at present, and traditional recognition methods have encountered increasing difficulties. This research attempts to distinguish different varieties of LR and its adulterants based on their chemical composition. A total of 61 representative samples were collected, and their varieties were confirmed by combining expert opinion with DNA molecular technology. All of the samples were characterized by an UHPLC-Q/TOF-MS method. The marker components that may contribute to variety discrimination were discerned by a data mining method, and they were then hypothesized, analyzed, and identified. A cluster analysis was performed by partial least squares (PLS) based on their MS signals. Furthermore, a feature extraction to find out the characteristic components, and a correspondence analysis to illustrate the corresponding relationship between the varieties and their components, were developed. As a result, 71 components were identified, of which 27 components were unambiguously identified by comparison with standards. The cluster analysis shows that varieties of LR and its adulterant samples exhibited a certain classification trend, with butylphthalide, senkyunolide I, senkyunolide A, ferulic acid, (Z)-ligustilide, bergapten, levistilide A, vanillic acid, isochlorogenic acid C and isochlorogenic acid A as characteristic chemical components. The varieties and their components showed a modest correlation. In conclusion, our study verified the possibility of discriminating the varieties of LR according to their chemical compositions. This research provides a new reference for the recognition of LR and its adulterants.

Chemical Analysis of Counterfeit Hepatitis C Drug Found in Japan.

In January 2017, counterfeits of the hepatitis C drug 'HARVONI® Combination Tablets' (HARVONI®) were found at a pharmacy chain through unlicensed suppliers in Japan. A total of five lots of counterfeit HARVONI® (samples 1-5) bottles were found, and the ingredients of the bottles were all in tablet form. Among them, two differently shaped tablets were present in two of the bottles (categorized as samples 2A, 2B, 4A, and 4B). We analyzed the total of seven samples by high-resolution LC-MS, GC-MS and NMR. In samples 2A, 3 and 4B, sofosbuvir, the active component of another hepatitis C drug, SOVALDI® Tablets 400 mg (SOVALDI®), was detected. In sample 4A, sofosbuvir and ledipasvir, the active components of HARVONI®, were found. A direct comparison of the four samples and genuine products showed that three samples (2A, 3, 4B) are apparently SOVALDI® and that sample 2A is HARVONI®. In samples 1 and 5, several vitamins but none of the active compounds usually found in HARVONI® (i.e., sofosbuvir and ledipasvir) were detected. Our additional investigation indicates that these two samples are likely to be a commercial vitamin supplement distributed in Japan. Sample 2B, looked entirely different from HARVONI® and contained several herbal constitutents (such as ephedrine and glycyrrhizin) that are used in Japanese Kampo formulations. A further analysis indicated that sample 2B is likely to be a Kampo extract tablet of Shoseiryuto which is distributed in Japan. Considering this case, it is important to be vigilant to prevent a recurrence of distribution of counterfeit drugs.

St. John's Wort versus Counterfeit St. John's Wort: An HPTLC Study.

Hypericum perforatum L. is the most commonly used herb for treating depression. Due to the popularity of this botanical, there is a potential for economically driven adulteration of St. John's wort (SJW) products. The goal of this study was to investigate SJW ingredients suspected to be adulterated based on simple preliminary HPTLC tests. Commercial samples were analyzed by HPTLC following the United States Pharmacopeia (USP) monograph methodology, with additional visualization under white light. A number of these samples presented odd methanolic solution colors and unconventional HPTLC fingerprints, suggesting the presence of other species and/or extraneous polar additives. To achieve identification and separation of the polar additives, a new reversed-phase HPTLC method was developed. The adulterants were identified as synthetic dyes in the amounts of 0.51 to 1.36% by weight. Identities of the dyes were confirmed by scanning densitometry and HPTLC-MS. A modified USP method with additional detection mode permitted the identification of eight SJW samples adulterated with dyes and six others with flavonoid fingerprints different from those specified by USP from a total of 37 samples of dry extracts, finished products, and bulk raw herb. A decision flowchart is proposed to guide the detection of adulteration of SJW in a systematic fashion.

Highly sensitive on-site detection of drugs adulterated in botanical dietary supplements using thin layer chromatography combined with dynamic surface enhanced Raman spectroscopy.

The phenomenon of botanical dietary supplements (BDS) doped with illegal adulterants has become a serious problem all over the world, which could cause great threat to human's health. Therefore, it is of great value to identify BDS. Herein, we put forward a highly sensitive method for on-site detection of antitussive and antiasthmatic drugs adulterated in BDS using thin layer chromatography (TLC) combined with dynamic surface enhanced Raman spectroscopy (DSERS). Adulterants in BDS were separated on a TLC plate and located under UV illumination. Then DSERS detection was performed using a portable Raman spectrometer with 50% glycerol silver colloid serving as DSERS active substrate. Here, the effects of different solvents on detection efficacy were evaluated using phenformin hydrochloride (PHE) as a probe. It was shown that 50% glycerol resulted in higher SERS enhancement and relatively higher stability. Moreover, practical application of this novel TLC-DSERS method was demonstrated with rapid analysis of real BDS samples and one sample adulterated with benproperine phosphate (BEN) was found. Furthermore, the obtained result was verified by ultra performance liquid chromatography-quadrupole time of flight mass spectrometry (UPLC-QTOF/MS). The sensitivity of the TLC-DSERS technique is 1-2 orders of magnitude higher than that of TLC-SERS technique. The results turned out that this combined method would have good prospects for on-site and sensitive detection of adulterated BDS.

Qualitative and quantitative analysis of PDE-5 inhibitors in counterfeit medicines and dietary supplements by HPLC-UV using sildenafil as a sole reference.

Due to their popularity, medicinal products containing the phophodiesterase type 5 enzyme (PDE-5) inhibitors sildenafil, vardenafil and tadalafil are often subject to counterfeiting. In addition, illicit herbal dietary supplements adulterated with these substances or their analogs have appeared on the market offering an easy and anonymous sale. This paper describes an analytical method for qualitative and quantitative screening of sildenafil, vardenafil, tadalafil and 11 of their designer analogs in illegal erectile dysfunction products by high-performance liquid chromatography with UV detection (HPLC-UV). Sildenafil served as a single external standard for both identification and quantification of all analytes. Relative retentions and reference UV spectra were used for qualitative, and correction factors for quantitative analyses, respectively. The separation was performed on a Kinetex C18 reverse-phased column at 25°C using gradient elution. Mobile phase A consisted of 200mM ammonium acetate solution while mobile phase B was a 1:1 (v/v) mixture of methanol and acetonitrile with a flow rate of 0.5ml/min and injection volume of 5µl. Detection wavelength was set to 290nm. The method was validated in accordance with the appropriate guideline of the International Conference on Harmonization (ICH) in terms of specificity, selectivity, precision, linearity, limit of quantitation, limit of detection, accuracy, robustness and stability, and was successfully applied to the analysis of natural dietary supplements and herbal remedies with an indication for enhanced male sexual potency. The proposed method offers a cheap and simple alternative to LC-MS screening used by control laboratories for routine analysis of suspicious products.

Identification and quantitation of the ingredients in a counterfeit Vietnamese herbal medicine against rheumatic diseases.

Counterfeit and/or illegally manufactured drugs and herbal medicines are becoming an increasing problem throughout the world. Internet sales simplify distribution and payment of these falsified drugs. Here we report on a Vietnamese herbal medicine, which was advertised for treatment of rheumatic disease from a religious Vietnamese healer. By means of NMR and LC/MS we found 863mg acetaminophen, 262mg sulfamethoxazole, 42mg indomethacin and less than 1% trimethoprim in a sachet of 2.617g powder content, in addition to some cinnamon bark and phosphate.

Dose-to-dose variations with single packages of counterfeit medicines and adulterated dietary supplements as a potential source of false negatives and inaccurate health risk assessments.

In this report, we show three examples of how the variability in dose units in single packages of counterfeit medicines and adulterated dietary supplements may contribute to a false negative screening result and inaccurate health risk assessments. We describe a counterfeit Viagra 100mg blister pack and a box of an instant coffee both containing dose units with and without an active pharmaceutical ingredient (API). We also describe a purportedly herbal slimming product with capsules that mutually differed in API and impurities. The adulterated dietary supplements contained sibutramine, benzyl-sibutramine, N-desmethyl-sibutramine (DMS), N,N-didesmethyl-sibutramine (DDMS) and several other related impurities. Counterfeit medicines and adulterated dietary supplements are a health risk because their quality is unreliable. Health risks are even greater when such unreliability extends to fundamental differences between dose units in one package. Because dose-to-dose variability for these products is unpredictable, the confidence interval of a sample size is unknown. Consequently, the analyses of a selection of dose units may not be representative for the package. In the worst case, counterfeit or unauthorised medicines are not recognised as such or a health risk is not identified. In order to reduce erroneous results particular care should be taken when analysing a composite of dose units, when finding no API in a dietary supplement and when finding conformity in a suspect counterfeit medicine.

A strategy for the identification of plants in illegal pharmaceutical preparations and food supplements using chromatographic fingerprints.

The detection of regulated and forbidden herbs in pharmaceutical preparations and nutritional supplements is a growing problem for laboratories charged with the analysis of illegal pharmaceutical preparations and counterfeit medicines. This article presents a feasibility study of the use of chromatographic fingerprints for the detection of plants in pharmaceutical preparations. Fingerprints were developed for three non-regulated common herbal products--Rhamnus purshiana, Passiflora incarnata L. and Crataegus monogyna--and this was done by combining three different types of detection: diode-array detection, evaporative light scattering detection and mass spectrometry. It is shown that these plants could be detected in respective triturations of the dry extracts with lactose and three different herbal matrices as well as in commercial preparations purchased on the open market.

NMR spectrometry isotopic fingerprinting: a tool for the manufacturer for tracking active pharmaceutical ingredients from starting materials to final medicines.

In the frame of increasingly stringent quality assessment required by the regulators, the pharmaceutical industry has to face increasingly sophisticated counterfeiting practices. Counterfeits based on deliberate copying of processes or on the infringement of current patents for generic medicines are not straightforward to detect, unless the molecular probe is the active molecule itself. In this context, impurity profiling is limited. A tool based on the determination of intramolecular isotopic profiles has been developed to provide manufacturers of APIs (Active Pharmaceutical Ingredients) with a new solution to meet this double requirement. Stable isotope analyses by NMR gives direct access to site-specific isotope content at natural abundance. In this report, it is shown how both ²H and ¹³C NMR spectrometry can provide complementary and valuable information that could be applied to link APIs to their manufacturing source. Isotopic ¹³C NMR offers additional benefits over ²H NMR in using robust adiabatic polarization transfer methods, leading to a tremendous reduction in experimental time. Two approaches are illustrated. Firstly, the use of ²H and single pulse ¹³C NMR spectra obtained on 20 commercial ibuprofen samples from different origins show that this combined strategy leads to (i) a unique intramolecular isotope identification and (ii) a preliminary classification of the samples according to the synthetic pathways of the main industrial processes. An approach employing polarization transfer methods applied to 11 commercial naproxen samples, for which ²H and single pulse ¹³C NMR spectra are not exploitable and/or are not accessible in reasonable time. The relative and partial intramolecular ¹³C distribution obtained on naproxen by applying this methodology is sufficiently informative to allow the same conclusions as for ibuprofen. The additional benefits that these approaches should bring to API manufacturers are discussed.

DNA based identification of medicinal materials in Chinese patent medicines.

Chinese patent medicines (CPM) are highly processed and easy to use Traditional Chinese Medicine (TCM). The market for CPM in China alone is tens of billions US dollars annually and some of the CPM are also used as dietary supplements for health augmentation in the western countries. But concerns continue to be raised about the legality, safety and efficacy of many popular CPM. Here we report a pioneer work of applying molecular biotechnology to the identification of CPM, particularly well refined oral liquids and injections. What's more, this PCR based method can also be developed to an easy to use and cost-effective visual chip by taking advantage of G-quadruplex based Hybridization Chain Reaction. This study demonstrates that DNA identification of specific Medicinal materials is an efficient and cost-effective way to audit highly processed CPM and will assist in monitoring their quality and legality.

[Identification of Dens Draconis and Os Draconis by XRD method].

OBJECTIVE: To establish an XRD method for evaluating the quality of Os Draconis and Dens Draconis and applying in judgement of the counterfeit. METHODS: Dens Draconis, Os Draconis and the counterfeit of Os Draconis were analyzed by XRD. Their diffraction patterns were clustered analysis and evaluated their similarity degree. RESULTS: Established the analytical method of Dens Draconis and Os Draconis basing the features fingerprint information of the 10 common peaks by XRD pattern. Obtained the XRD pattern of the counterfeit of Os Draconis. The similarity degree of separate sources of Dens Draconis was high,while the similarity degree of separate sources of Os Draconis was significant different from each other. CONCLUSION: This method can be used for identification and evaluation of Os Draconis and Dens Draconis. It also can be used for identification the counterfeit of Os Draconis effectively.

[Counterfeiting of eye drops?: a laboratory study of antibiotic eye drops purchased in two African countries]. / Counterfeiting von Augentropfen? : Eine Untersuchung von Antibiotikapräparaten aus 2 Ländern Afrikas.

INTRODUCTION: Counterfeit drugs are often ineffective and are considered a problem with an immense risk potential especially in the treatment of infectious diseases. Emerging and developing countries are particularly affected. Little is known about the extent of counterfeit antibiotic drugs used in eye care. In the present study we investigated antibiotic eye drops purchased in two African countries with respect to the active substance and its concentration in the sample. METHODS: A total of 33 antibiotic eye drops purchased in Kenya and the Democratic Republic of Congo were tested. The bottles were labeled to contain one of the following substances: the quinolones ciprofloxacin, levofloxacin and ofloxacin and the aminoglycosides gentamicin and tobramycin. Imported quality products as well as cheaper generic drugs were tested. Fluoroquinolones were determined by high pressure liquid chromatography (HPLC) and quantified by fluorescence measurement and aminoglycosides were tested by using a fluorescence polarization immunoassay. RESULTS: All samples were found to contain the declared drug. Nine samples (27%) showed an under-concentration by 10% or less and ten (30%) showed an increased concentration of 10% or more than indicated on the label. 75% of the original drugs but only 12% of the generic drugs had measured concentrations within the standard advisory ranges of ± 5% from the nominal value. CONCLUSION: Our results provide no evidence for significant criminal counterfeiting of eye drops in the studied countries. The frequent deviation from the stated concentration in the generic samples is cause for concern and justifies further investigation.

Characterization and identification of suspected counterfeit miltefosine capsules.

Recently, it was revealed that generic miltefosine capsules for the treatment of visceral leishmaniasis, a fatal parasitic disease, were possibly counterfeit products. Here we report on the methods to characterize and identify miltefosine in pharmaceutical products and the procedures that were used to assess the quality of these suspected counterfeit products. Characterization and identification of miltefosine were done with liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS), Fourier transform infrared (FT-IR) spectroscopy and near-infrared (NIR) spectroscopy. Moreover, a simple, rapid and inexpensive colorimetric test was developed and evaluated for the detection of miltefosine in pharmaceutical products that can be used in the field. The complementary analytical techniques presented here were able to determine qualitatively or (semi-)quantitatively the presence or absence of miltefosine in pharmaceutical preparations and could identify suspected counterfeit miltefosine capsules. This finding of a suspected counterfeit drug intended to treat a neglected disease in a resource-poor country emphasizes the urgent need to develop more simple inexpensive assays to evaluate drug quality for use in the field.

Rapid detection and identification of counterfeit and [corrected] adulterated products of synthetic phosphodiesterase type-5 inhibitors with an atmospheric solids analysis probe.

The market success of the three approved synthetic phosphodiesterase type-5 (PDE-5) inhibitors for the treatment of erectile dysfunction has led to an explosion in counterfeit versions of these drugs. In parallel a large market has developed for herbal products claimed to be natural alternatives to these synthetic drugs. The herbal products are heavily advertised on the internet and are freely available to purchase without prescription. Furthermore, adulteration of these supposed natural medicines is a very common and serious phenomenon. Recent reports have shown that the adulteration has extended to the analogues of the three approved synthetic PDE-5 inhibitors. An Atmospheric Solids Analysis Probe (ASAP) was used for the direct analysis of the counterfeit pharmaceuticals and herbal products. Using the ASAP combined with time-of-flight mass spectrometry (TOF MS) it was possible to detect fraudulent counterfeit tablets. The physical appearance of the pills resembled the pills from the original manufacturer but contained the wrong active pharmaceutical ingredient (API). Detecting adulteration for five herbal supplements marketed as natural alternatives to PDE-5 inhibitors was also possible using the ASAP. Three types of adulteration were found in the five samples: adulteration with tadalafil or sildenafil, mixed adulteration (tadalafil and sildenafil), and adulteration with analogues of these drugs.