Market access for Chinese herbal medicinal products in Europe-A ten-year review of relevant products, policies, and challenges.

BACKGROUND: With increased consumer demand in Europe for natural and efficacious health products, the use of herbal products in the market is rising. Products of Chinese herbal medicine (CHM) could greatly expand European consumer options; however, only seven herbal medicinal products (HMPs) based on CHM formulae have been registered in the European Union (EU) since 2012. PURPOSE: This study reviews the ten-year registration status of HMPs based on CHM formulae in Europe and identifies major challenges and possible solutions for pharmaceutical companies seeking market access for new HMPs. METHODS: An overview of relevant EU regulations identifies pathways to market access in EU countries for CHM products. A discussion of successful attempts to register HMPs based on CHM formulae since 2012 highlights specific challenges that applicants can expect to face. RESULTS: CHM products can enter the EU market as HMPs through the full or well-established use marketing authorization, or through the simplified registration procedure. Alternatively, some CHM products have entered the market as dietary supplements, nutritional foods, and agricultural products; however, under these categories, claims for medicinal use cannot be advertised. Since the registration of the first CHM product, Diao Xin Xue Kang (with the single component of Dioscorea nipponica rhizome), in 2012, only six other HMPs based on CHM formulae have been successfully registered. Among these, four are mono-component products. The remaining two products contain combinations of several herbal ingredients. It is more difficult to register combination products than mono-component products, due to their more complex composition and differences in registration requirements (esp. concerning establishing indications) in China and Europe. CONCLUSIONS: To promote the successful registration of CHM products in Europe, pharmaceutical companies are advised to: demonstrate full control of, and the ability to test, their supply chain and manufacturing procedures following the guidance of European competent authorities; carefully adhere to all steps of the registration process and advices from European competent authorities; take the medication habits and pharmaceutical needs of European market into consideration; and establish collaboration with European local organizations, as appropriate.

Improved route to a diphenoxide-based precursor for chemical vapour deposition of parylene AF-4.

In this work, we present the synthesis of an alternative precursor for chemical vapour deposition of parylene AF-4 to the widely used standard, octafluoro[2.2]paracyclophane. The standard precursor suffers from uncertainties in its supply chain and its synthesis is of low yield. A comparison between different reaction parameters and solvents is drawn by means of thermal, laboratory-scale and microwave-assisted reactions and quantitative nuclear magnetic resonance (qNMR) studies.

MRI/TRUS fusion vs. systematic biopsy: intra-patient comparison of diagnostic accuracy for prostate cancer using PI-RADS v2.

OBJECTIVE: To evaluate the efficacy of multiparametric magnetic resonance/transrectal ultrasound fusion (MRI/TRUS fusion) biopsy versus systematic biopsy and its association with PI-RADS v2 categories in patients with suspected prostate cancer. MATERIALS AND METHODS: 122 patients undergoing both MRI/TRUS fusion and systematic biopsy, with suspicion of prostate cancer, with suspicious findings on MRI based on PI-RADS v2, were included between April 2016 and March 2017. Comparison of tumor detection rates using each technique and combined techniques was performed for all lesions as well as those that are traditionally difficult to access (i.e., anterior lesions). RESULTS: Prostate cancer was detected in 83/122 patients (68%) with 74.6% clinically significant lesions (Gleason 3 + 4 or greater). There was a statistically significant difference in presence of clinically significant prostate cancer in PI-RADS v2 categories of 3, 4, and 5 (20%, 52% and 77%, respectively, p < 0.001). Fusion biopsy was positive in a significantly higher percentage of patients versus systematic biopsy (56% versus 48%, respectively, p < 0.05). The fusion biopsy alone was positive in 20%. Of 34 patients with anterior lesions on MRI, 44% were detected only by fusion biopsy, with a joint yield of 71%. In patients with previous negative systematic biopsies, 48.7% lesions were found by fusion biopsy with 20.5% being exclusively positive by this method. The percentage of positive cores for fusion biopsies was significantly higher than for systematic biopsies (26% vs. 12.3%, p < 0.001). CONCLUSION: The incorporation of MRI/TRUS fusion biopsy significantly improves the detection rate of prostate cancer versus systematic biopsy, particularly for anterior lesions.

Bi-layer sandwich film for antibacterial catheters.

Background: Approximately one quarter of all nosocomial infections can be attributed to the urinary tract. The infections are supposed to be mainly caused by implantations of urethral catheters and stents. A new catheter design is introduced with the aim to lower the high number of nosocomial urethral infections. In order to avoid limitations to use, the design is first applied to conventional commercially available balloon catheters. Results: The main feature of the design is a sandwich layer on both sides of the catheter wall, which is composed of a fragmented base layer of silver capped by a thin film of poly(p-xylylene). This top layer is mainly designed to release a controlled amount of Ag+ ions, which is bactericidal, but not toxic to humans. Simultaneously, the lifetime is prolonged to at least one year. The base layer is electrolessly deposited applying Tollens' reagens, the cap layer is deposited by using chemical vapor deposition. Conclusion: The three main problems of this process, electroless deposition of a fragmented silver film on the surface of an electrically insulating organic polymer, irreproducible evaporation during heating of the precursor, and exponential decrease of the layer thickness along the capillary, have been solved trough the application of a simple electrochemical reaction and two standard principles of physics: Papin's pot and the principle of Le Chatelier.

Efficacy of silver/hydrophilic poly(p-xylylene) on preventing bacterial growth and biofilm formation in urinary catheters.

Catheter associated urinary tract infections (CAUTI), caused by several strains of bacteria, are a common complication for catheterized patients. This may eventually lead to a blockage of the catheter due to the formation of a crystalline or amorphous biofilm. Inhibiting bacteria should result in a longer application time free of complaints. This issue has been investigated using an innovative type of silver-coated catheter with a semipermeable cap layer to prevent CAUTI. In this work, two different types of silver catheters were investigated, both of which were capped with poly(p-xylylene) (PPX-N) and exhibited different surface properties that completely changed their wetting conduct with water. The contact angle of conventionally deposited PPX-N is approximately 80°. After O2 plasma treatment, the contact angle drops to approximately 30°. These two systems, Ag/PPX-N and Ag/PPX-N-O2, were tested in synthetic urine at a body temperature of 37 °C. First, the optical density and the inhibition zones of both bacteria strains (Escherichia coli and Staphylococcus cohnii) were examined to confirm the antibacterial effect of these silver-coated catheters. Afterward, the efficacy of silver catheters with different treatments of biofilm formed by E. coli and S. cohnii were tested with crystal violet staining assays. To estimate the life cycles of silver/PPX-catheters, the eluted amount of silver was assessed at several time intervals by anodic stripping voltammetry. The silver catheter with hydrophilic PPX-N coating limited bacterial growth in synthetic urine and prevented biofilm formation. The authors attribute the enhanced bacteriostatic effect to increased silver ion release detected under these conditions. With this extensive preparatory analytic work, the authors studied the ability of the two different cap layers (without silver), PPX-N and oxygen plasma treated PPX-N, to control the growth of a crystalline biofilm by measuring the concentrations of the Ca2+ and Mg2+ ions after exposure of the catheters to saturated urine for 24 h. The higher concentrations of Ca2+ and Mg2+ in the precipitates on the PPX-N catheters indicates that the hydrophilic PPX-N coating is superior to the simple PPX-N coating, with regard to the formation of a crystalline biofilm. Moreover, hydrophilic PPX-N as a cap layer may promote wettability and increase silver ion release rate and thus reduce the adhesion of suspended crystals to the catheter. Reduced bacterial growth and reduced adhesion may help to prevent CAUTI.

Remission spectrometry for blood vessel detection during stereotactic biopsy of brain tumors.

Stereotactic biopsy is used to enable diagnostic confirmation of brain tumors and treatment planning. Despite being a well-established technique, it is related to significant morbidity and mortality rates mostly caused by hemorrhages due to blood vessel ruptures. This paper presents a method of vessel detection during stereotactic biopsy that can be easily implemented by integrating two side-view fibers into a conventional side-cutting biopsy needle. Tissue within the needle window is illuminated through the first fiber; the second fiber detects the remitted light. By taking the ratio of the intensities at two wavelengths with strongly differing hemoglobin absorption, blood vessels can be recognized immediately before biopsy sampling. Via ray tracing simulations and phantom experiments, the dependency of the remission ratio R = I578 /I650 on various parameters (blood oxygenation, fiber-to-vessel and inter-fiber distance, vessel diameter and orientation) was investigated for a bare-fiber probe. Up to 800-1200 µm away from the probe, a vessel can be recognized by a considerable reduction of the remission ratio from the background level. The technique was also successfully tested with a real biopsy needle probe on both optical phantoms and ex-vivo porcine brain tissue, thus showing potential to improve the safety of stereotactic biopsy. Dual-wavelength remission measurement for the detection of blood vessels during stereotactic biopsy.

Rol del PET/CT con 18FDG en patología no neoplásica / Role of 18FDG PET/CT in non-malignant diseases

La Tomografía por emisión de positrones/tomografía computada (PET/CT) se ha vuelto fundamental para la evaluación oncológica. En los últimos años se ha hecho evidente su utilidad para evaluar otras patologías inflamatorias no neoplásicas, las cuales pueden presentar aumento del metabolismo medible. El PET/CT tiene la ventaja de poder detectar enfermedades incluso cuando no tienen un correlato en las imágenes morfológicas, permitiendo además localizar de manera precisa estas alteraciones. Entre estas patologías se encuentran el estudio de fiebre de origen desconocido, enfermedades inflamatorias, enfermedades del tejido conectivo, vasculitis y también en el seguimiento y diagnóstico de algunas patologías infecciosas. Se realizará una revisión en la literatura de la utilidad del PET/CT en estas patologías complementada con casos clínicos.

Silver ions eluted from partially protected silver nanoparticles.

The most prominent character of a new type of antibacterial urological catheters is the zebra-stripe pattern of a silver film, which is plated electroless on their interior wall and capped by a very thin semipermeable layer of parylene. This design effectively controls the release rate of Ag(+) ions in artificial urine, which has been measured as function of time with optical emission spectroscopy. By evaluating the minimum inhibitory concentration against certain strains of bacteria with solutions of AgNO3 of known concentration with the method of optical density and applying this analysis to the silver-eluting catheters, it was shown that this moderation prolongs the period of their application significantly. But to act as antibacterial agent in chlorine-containing solutions, as in urine, the presence of urea is required to avoid precipitation of AgCl and to meet or even exceed the minimum inhibitory concentration of Ag(+). The quality of the silver depot layer was further determined by the deposition rate and its morphology, which revealed that the film consisted of grains with a mean size of 150 nm.

Microbiological investigation of an antibacterial sandwich layer system.

To allow medical application of an artificial bladder made of biocompatible polyurethane, a long-term stable antibacterial coating is required. Alone, the artificial bladder exhibits no defense against microorganisms. Silver coating provides long-term antibacterial protection by the continuous release of silver ions into aqueous solutions. To control and to prolong the rate of silver ion release, the deposited silver film has to be protected by an inert film of biocompatible polyparylene by means of chemical vapor deposition. In this study, an antibacterial artificial bladder surface was developed by the formation of a sandwich structure consisting of silver and a biocompatible polymer (polyparylene) as a diffusion barrier. Specifically, this study analyzed the correlation between polyparylene thickness and silver release to determine optimal concentrations to combat common bacteria in vitro. The release of silver from sandwich structures was investigated in vitro by testing different thicknesses of polyparylene (0, 190, 540, and 1000 nm) as a diffusion barrier. The best result was demonstrated with a thickness of 190 nm of polyparylene, which yielded a silver dispense rate of 650 pg/(cm(2)⋅min), which would yield bacteriozidal concentrations above 30 µg/l in the bladder volume. The authors confirmed the antibacterial effect in vitro against common urinary tract infection pathogens, namely, Escherichia coli and Staphylococcus cohnii. Inhibition of bacterial growth could be detected within 8 h. A diffusion assay with spherical silver spots showed concentric zones free of bacterial growth. Our results suggest the possible utility of silver-polyparylene coatings as antibacterial agents.

Modern European monographs for quality control of Chinese herbs.

The actual concern about the safety and efficacy of herbal drugs originating from traditional Chinese medicine (TCM) is based on observations that these medicinal plants may have a high risk potential due to insufficient definitions, problems with identity, purity and falsifications. No uniform legal status for these groups of herbal drugs currently exists in the European Union. For quality control, monographs for TCM herbs can mainly be found in the Pharmacopoeia of the Peoples Republic of China. Based on these facts the Commission of the European Pharmacopoeia decided in 2005 to establish TCM-herbal drug monographs for the most important medicinal plants imported from Far East. These new monographs had to be established and evaluated on the basis of existing monographs in the Chinese Pharmacopoeia (ChP), English edition 2005. Due to important differences in the overall features of EP and ChP, a simple adapt/adopt procedure was not feasible. Therefore, specialist groups were mandated with a corresponding working programme. Some results and actual problems related to this working programme will be presented and discussed.

Aerobic exercise with relaxation: influence on pain and psychological well-being in female migraine patients.

OBJECTIVE: The objective of this pilot study was to address the influence of an aerobic exercise program combined with relaxation on pain and psychological variables in migraine patients. DESIGN: Controlled, randomised design with half of the group receiving an intervention (aerobic exercise group) in addition to standard medical care received by all patients. SETTING/PATIENTS/OUTCOME MEASUREMENT: Thirty female migraine outpatients completed a range of psychological questionnaires measuring sensational and affective dimensions of pain, body image, depression, and quality of life. INTERVENTION: The aerobic exercise group (n = 15) participated in a 6-week, twice-weekly, indoor exercise program (45 minutes of gymnastics with music and 15 minutes of progressive muscle relaxation). RESULTS/CONCLUSION: The program led to a significant reduction of self-rated migraine pain intensity. Although there was an improvement in depression-related symptoms within the aerobic exercise group, no significant differences in psychological variables between groups were found.

Case report: severe heat stroke with multiple organ dysfunction - a novel intravascular treatment approach.

INTRODUCTION: We report the case of a patient who developed a severe post-exertional heat stroke with consecutive multiple organ dysfunction resistant to conventional antipyretic treatment, necessitating the use of a novel endovascular device to combat hyperthermia and maintain normothermia. METHODS: A 38-year-old male suffering from severe heat stroke with predominant signs and symptoms of encephalopathy requiring acute admission to an intensive care unit, was admitted to a ten-bed neurological intensive care unit of a tertiary care hospital. The patient developed consecutive multiple organ dysfunction with rhabdomyolysis, and hepatic and respiratory failure. Temperature elevation was resistant to conventional treatment measures. Aggressive intensive care treatment included forced diuresis and endovascular cooling to combat hyperthermia and maintain normothermia. RESULTS: Analyses of serum revealed elevation of proinflammatory cytokines (TNF alpha, IL-6), cytokines (IL-2R), anti-inflammatory cytokines (IL-4) and chemokines (IL-8) as well as signs of rhabdomyolysis and hepatic failure. Aggressive intensive care treatment as forced diuresis and endovascular cooling (CoolGard and CoolLine) to combat hyperthermia and maintain normothermia were used successfully to treat this severe heat stroke. CONCLUSION: In this case of severe heat stroke, presenting with multiple organ dysfunction and elevation of cytokines and chemokines, which was resistant to conventional cooling therapies, endovascular cooling may have contributed significantly to the reduction of body temperature and, possibly, avoided a fatal result.

Beta-1,3 glucan sulfate, but not beta-1,3 glucan, induces the salicylic acid signaling pathway in tobacco and Arabidopsis.

Sulfate substituents naturally occurring in biomolecules, such as oligosaccharides and polysaccharides, can play a critical role in major physiological functions in plants and animals. We show that laminarin, a beta-1,3 glucan with elicitor activity in tobacco (Nicotiana tabacum), becomes, after chemical sulfation, an inducer of the salicylic acid (SA) signaling pathway in tobacco and Arabidopsis thaliana. In tobacco cell suspensions, the oxidative burst induced by the laminarin sulfate PS3 was Ca2+ dependent but partially kinase independent, whereas laminarin triggered a strickly kinase-dependent oxidative burst. Cells treated with PS3 or laminarin remained fully responsive to a second application of laminarin or PS3, respectively, suggesting two distinct perception systems. In tobacco leaves, PS3, but not laminarin, caused electrolyte leakage and triggered scopoletin and SA accumulation. Expression of different families of Pathogenesis-Related (PR) proteins was analyzed in wild-type and mutant tobacco as well as in Arabidopsis. Laminarin induced expression of ethylene-dependent PR proteins, whereas PS3 triggered expression of ethylene- and SA-dependent PR proteins. In Arabidopsis, PS3-induced PR1 expression was also NPR1 (for nonexpressor of PR genes1) dependent. Structure-activity analysis revealed that (1) a minimum chain length is essential for biological activity of unsulfated as well as sulfated laminarin, (2) the sulfate residues are essential and cannot be replaced by other anionic groups, and (3) moderately sulfated beta-1,3 glucans are active. In tobacco, PS3 and curdlan sulfate induced immunity against Tobacco mosaic virus infection, whereas laminarin induced only a weak resistance. The results open new routes to work out new molecules suitable for crop protection.

Stability control of senna leaves and senna extracts.

Powdered senna leaves and a commercial methanolic senna leaf extract were investigated for apparent degradation pathways of known constituents. Different defined storage conditions were chosen according to the guidelines of the international conference on harmonization. Analytical fingerprinting was carried out by HPLC with photodiode array detection. Differences in degradation pathways were observed between the powdered herbal drug material and the extract, depending on storage conditions and packaging materials. Within the crude plant material sennosides were shown to be degraded to sennidine monoglycosides, while rhein 8-O-glucoside was hydrolysed to rhein by enzymatic processes. Degradation of the anthranoid compounds was not due to the same pathways in the investigated commercial extracts. Only unspecific alterations of all compounds were observed. Forced decomposition of this herbal drug preparation under high temperature caused oxidative decomposition of the sennosides to rhein 8-O-glucoside. Furthermore flavonoid glycosides decomposition were observed with an apparent increase in the content of flavone aglyca.

Investigation of the Origanum onites L. essential oil using the chorioallantoic membrane (CAM) assay.

The in vivo test on the chorioallantoic membrane of the fertilized hen's egg (CAM assay) is a current method to determine antiangiogenic, antiinflammatory activity and toxic effects of individual compounds or complex plant extracts. The method is used for testing natural compounds in small amounts for revealing various modes of action and the complex mechanisms related to angiogenesis and inflammation. Furthermore, possible side effects such as membrane irritation, toxic, and anticoagulant properties of the investigated material in question can be detected. For the evaluation, the essential oil obtained by hydrodistillation of the aerial parts of Origanum onites L., a common spice and medicinal plant, was tested for its effect in the chorioallantoic membrane (CAM) assay. The essential oil composition was revealed by means of gas chromatography-mass spectrometry (GC-MS). Eighty three components were identified, representing 99.1% of the total oil. Carvacrol, thymol, p-cymene, and gamma-terpinene were found as major components and were also individually tested in the CAM assay. Along with the monoterpenes carvacrol and thymol, their methyl ether derivatives were also examined for comparison of their physiological action. Neither the essential oil nor its components showed any pronounced antiinflammatory or antiangiogenic property in the CAM assay, at 10-250 microg/pellet. However, the irritant effect of the essential oil was linked to thymol in a dose-response fashion, up to 10 microg/pellet, where it was still showing irritation.

Essential Oil of Betula pendula Roth. Buds.

The essential oil of Betula pendula Roth. buds was obtained using both hydrodistillation and microdistillation techniques and their chemical compositions were analyzed using both gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS). Overall, more than 50 compounds were identified representing 80% and 92% for hydrodistillation and microdistillation, respectively. The main components (by hydrodistillation and microdistillation, respectively) found were alpha-copaene (12% and 10%), germacrene D (11% and 18%) and delta-cadinene (11% and 15%) in the analyzed essential oils. The microdistillation technique proved to be a useful tool and compliant alternative when compared to hydrodistillation.

Inhibition of PMN-elastase activity by semisynthetic glucan sulfates.

Proteolysis of connective tissue by enzymes such as PMN-elastase (PMNE) is a crucial step during inflammation and metastasis. Semisynthetic sulfated carbohydrates (SC) were shown to exhibit potent antiinflammatory and antimetastatic activity in vivo. The aim of the present study was to examine whether interferences with PMN-elastase may contribute to these effects. Therefore, the interactions of these compounds with PMNE were evaluated in various test systems. Besides semisynthetic alpha-1,4/1,6- and beta-1,3-glucan sulfates, UFH, a LMWH and pentosan polysulfate (PPS) were included in the study. The inhibitory activity of SC improves not only with increasing molecular weight (MW 10 - 250 kDa: 37 - 54% inhibition at 0.25 micro g/ml) and degree of sulfation (DS 0.25 - 2.0: 16 - 50% inhibition at 0.25 micro g/ml), but depends also on their genuine polysaccharide structure (IC50 beta-1,3-glucan sulfate 0.18 / alpha-1,4/1,6-glucan sulfate 0.25 / UFH 0.5 micro g/ml). Using physiological substrate assays (collagen, elastin), beta-1,3- and alpha-1,4/1,6-glucan sulfates are more active than UFH (inhibition at 1.5 micro g/ml: 41 / 32 / 12%). According to enzyme-inhibitor binding studies, SC exhibit structure dependent affinity to the enzyme (K(d) for PMNE: beta-1,3 < alpha-1,4/1,6 < UFH). Finally, SC were shown to inhibit cancer cell-mediated elastinolysis.

Chemical composition of the essential oil of Phlomis linearis Boiss. & Bal., and biological effects on the CAM-assay: a safety evaluation.

Phlomis linearis Boiss. & Bal. of the Lamiaceae family growing in central, east and southeast Anatolia is an endemic species for Turkey. The essential oil obtained from the aerial parts by hydro distillation was subsequently analyzed by GC/MS. The main components of the oil were found as beta-caryophyllene (24.2%), germacrene D (22.3%) and caryophyllene oxide (9.2%), among 49 identified compounds, representing 94.5% of the total essential oil. The overall biological activity of the essential oil (100 microg/pellet) was tested on the chorioallantoic membrane (CAM) of the fertilized hen's egg in order to examine the anti-angiogenic and anti-inflammatory activity. None of the tests showed pronounced activity, toxicity or irritation at the tested concentration.