The efficiency of 1D and 2D NMR spectroscopy along with HPLC-DAD-MS analyses in characterising the content of a dietary supplement is demonstrated. Experiments directly performed on a lyophilised sample of a commercial product gave details on the quality control of the product. The lack of the marker constituents of some of the declared plant species (Crataegus oxyacantha, Olea europea, Capsella bursa-pastoris and Fumaria officinalis) and the presence of banned adulterants, responsible for the strong antihypertensive effect of the supplement were established. The analyses proved the presence of indole alkaloids belonging to the group of Rauwolfia sp., such as ajmaline, reserpine and yohimbine. Quantitative HPLC analysis showed that the content of reserpine in the product was in the therapeutic range and therefore responsible for the collapses of the patients. (C) 2013 Elsevier B.V. All rights reserved.

Background The concurrence of acute coronary syndrome with allergy or hypersensitivity as well as with anaphylactic reactions is increasingly encountered in daily clinical practice. Mast cell activation with acute cardiovascular (CV) events is described as Kounis syndrome (KS), an 'allergic angina', progressing to 'allergic myocardial infarction' [1]. Possible triggers include drugs, foods, animal or insect bites, and even drug-eluting stents or endovascular devices [1]. Description We present three cases of 57 (1), 58 (2) and 64-year-old (3) men who were admitted to Prato hospital emergency department with thoracic pain and dyspnea. In patients 1 and 2 the symptoms recurred after taking only one pill of amoxicillin/clavulanic acid (875/125 mg) for periodontal disease. The third patient reported being treated with oral amoxicillin (1000 mg) as a preventive measure before dental treatment. He had taken a total of 5 pills and he stopped the medication a day before hospital admission because of intermittent epigastric pain. After the hospitalization, in keeping with analytical parameters (troponin I increase: 3.78 ng/ml (1); 0.14 ng/ml (3)) and electrocardiographic abnormalities (ST segment elevations (1-2)), all patients were diagnosed with unstable angina or acute myocardial infarction during anaphylaxis to antibiotic drug. An emergency coronary angiogram, performed for all patients, showed abnormal coronary arteries only in the 64-year-old man (3). All patients recovered without complications and were discharged on their third, second and sixth day of hospitalization, respectively. Discussion From an analysis of medical literature and validated databases (Micromedex®; Farmadati®) emerged that KS due to amoxicillin or amoxicillin/clavulanic acid use is a rare event in the adults [2]. In the present cases the temporal relationship between the event and drug assumption strongly suggested a role of amoxicillin in the occurrence of 'allergic angina'. The causal relationship of amoxicillin in patients 1 and 2 might be confounded by concomitant use of other drugs (atorvastatin (1); nebivolol/hydrochlorothiazide, doxazosin and tapazole (2)). Therefore the three reports were graded as 'possible' according to the objective causality assessment [3]. Conclusion The presentation of three cases of Kounis syndrome in a single hospital emergency department during about three months period (between December 2011 and February 2012), suggests that this case might not be as rare as previously believed. Clinicians should be aware of this contingency when treating patients with acute cardiovascular symptoms taking drugs known to induce allergic reactions.

Background Pelargonium sidoides (PS) is an African herbaceous, perennial plant in the geranium family. The root is the medically part used for respiratory problems [1]. The reported pharmacological activities include moderate direct antibacterial and antiviral potencies and immunomodulatory properties. An alcohol extract of PS has become popular in Germany as a treatment for different respiratory problems, including acute bronchitis, the common cold, sinusitis, pharyngitis and tonsillitis. The chemical composition of the Pelargonium sidoides consists mainly of sesquiterpenes, the most abundant, coumarin and high quantity of tannins. Case Presentation In March 2011, a 46 year-old male patient was admitted to Emergency Department (ED) of Prato for severe asthenia associated to a wide complex tachycardia sensitive to intravenous amiodarone. The patient suffered from epilepsy, oligophrenia, hypothyroidism, hypertension and congenital heart disease. He had been on well tolerated therapy with furosemide, acetylsalicylic acid, phenobarbital sodium, carbamazepine, olanzapine, valproate sodium, lansoprazole, allopurinol, canrenone, for ten years. On admission, vital signs were normal except for heart rate (108 beats per minute) and pulse oximetry (oxygen saturation level of 91%). The blood tests, performed about 15 days before, showed normal values (especially ALT, AST and bilirubin were in normal range). Just before hospital admission, the patient was treated with a remedy for a common cold: PS 30 drops three times a day, stopped after six days. In ED the routine blood tests showed increased liver enzymes: ALT: 2385 IU I-1 (normal range: 1-45) and AST: 4072 IU I-1 (normal range: 1-36). After three days, blood tests showed a decrease of ALT: 1813 IU I-1 and AST: 1251 IU I-1 and INR (International Normalized Ratio): 1.89. The patient died the 4th day, probably due to acute liver failure and respiratory distress related to the above comorbidities. The PS causality assessment was defined as 'possible' according to Naranjo algorithm. Discussion Adverse drug reactions (ADRs) related to PS are quite rare in the published clinical trials and generally, they are of mild severity and comparable to placebo. The most frequent ADRs reported, due to PS, were gastrointestinal disorders, nervous system, ear and labyrinth disorders. It is known that high concentrations of coumarins and tannins can cause liver toxicity. Recently, 15 cases of suspected hepatotoxicity induced by PS has been published, but they were evaluated as 'doubtful' by the authors [2]. It is important to remember that concomitant diseases and drug interactions may have contributed to the above adverse event. Our case underlines the importance of further studies to establish the real association between PS and liver damage.

Fennel (Foeniculum vulgare Mill.) mature fruit (commonly known as seeds) and essential oil of fennel are widely used as flavoring agents in food products such as liqueurs, bread, cheese, and an ingredient of cosmetics and pharmaceutical products. Moreover fennel infusions are the classical decoction for nursing babies to prevent flatulence and colic spasm. Traditionally in Europe and Mediterranean areas fennel is used as antispasmodic, diuretic, anti-inflammatory, analgesic, secretomotor, secretolytic, galactagogue, eye lotion, and antioxidant remedy and integrator. Topically, fennel powder is used as a poultice for snake bites. In Asian cultures fennel was ingested to speed the elimination of poisons. As one of the ancient Saxon people's nine sacred herbs, fennel was credited with the power to cure. Fennel was also valued as a magic herb: in the Middle Ages it was draped over doorways on Midsummer's Eve to protect the household from evil spirits. Recently because of estragole carcinogenicity, fennel has been charged to be dangerous for humans especially if used as decoction for babies. But this allegation do not consider the remedy is prepared as a matrix of substances, and recent researches confirm that pure estragole is inactivated by many substance contained in the decoction.

In this study HPLC-DAD-ESI-MS, HPLC-ESI-MSn and 2D NMR techniques were applied for the quality control of a herbal supplement. Several reports were received by the pharmacovigilance system by patients who fainted after consuming „)Olivis(lrquor)), a dietary supplement for the integrative treatment for hypertension. Declared components of this product are extracts from Olea europaea L., Crataegus oxyacantha L., Fumaria officinalis L., Capsella bursa-pastoris (L.) Medik. „)Olivis(lrquor)) sample was subjected, after lyophilization, to direct 2D NMR and HPLC-DAD-ESI-MS analyses to identify the marker constituents of the different Herbal Drugs. Comparison of the NMR and chromatographic profiles of the product with those of the marker compounds of the declared plant species, (such as oleuropein, protopine), showed the lack of the latter. Samples of the declared plant species were taken into consideration as well. Comparison of these samples with the commercial product revealed marked differences in their content. Further, HPLC-DAD and HPLC-ESI-MS analyses showed the presence of Rauwolfia sp. type indole alkaloids, while HPLC-ESI-MSn analyses revealed the presence of reserpine. Parallel phytochemical fractionations led to the isolation of ajmaline. Quantitation studies showed that (i) the content of reserpine in the product was in the therapeutic range and therefore responsible for the collapses of the patients; (ii) ajmaline prevailed against reserpine indicating that a Rauwolfia species other than R. serpentina was used. The present study shows the importance of extensive controls using combined analytical tools of the botanical products on the market to assure their quality and as a consequence their safety profiles.

Objectives To evaluate the type, frequency, severity and predictors of potential Drug-Drug Interactions (DDIs) in a cohort of patients undergoing radiodiagnostic procedures. Setting Eight Radiology wards located in Tuscany (Italy). Methods All participants exposed to at least two medications were included in the analysis. DDIs were grouped according to their severity as ‘minor’, ‘moderate’ or ‘major’. A logistic model was used to estimate Odds Ratios and 95% Confidence Intervals for all predictors of potential DDI. Main outcome measures Type and predictors of potential DDI in a cohort of patients undergoing radiodiagnostic procedures. Results One-thousand-and-two subjects (57.6% females; mean age: 67.3 ± 12.2) entered the analysis, and 46.1% of them incurred in a potential DDI (78.9% ‘moderate’ in severity). The combination of allopurinol and ACE-inhibitors was the most frequent (21/153) among major potential DDIs, while steroids were involved in all cases of potential DDI due to premedication. Co-morbidity, number of co-medications, advanced age and premedication use increased the risk of potential DDI; a protective role was found for positive history of allergy. When the analysis was restricted to subjects with premedication (n = 93), only 12.9% of them reported a potential DDI directly attributable to premedication drugs. Conclusions Among patients undergoing radiological examination, types and predictors of potential DDIs appeared in agreement with other kind of in-hospital populations. Premedication revealed to be a proxy predictor for potential DDIs. Considering the poor capability of the prescriber in recognizing interactions, their systematic evaluation (using an informatics tool) in patients undergoing radiological examination might be helpful in preventing the occurrence of clinically relevant DDIs.

In this study HPLC-DAD-ESI-MS, including HPLC-ESI-MSn analyses and 2D NMR techniques were applied for the quality control of a herbal supplement. Several reports were received by the pharmacovigilance system by patients who fainted after consuming the product „Olivis“, a dietary supplement as an adjunctive treatment for hypertension. Declared components of this product are extracts from Olea europea, Crataegus oxyacantha, Fumaria officinalis, Capsella bursa pastoris. „Olivis“ sample was subjected to 2D NMR and HPLC-DAD-ESI-MS analyses in order to identify the marker consituents of the different Herbal Drugs. Comparison of the NMR and chromatographic profiles of the extracts with the original product showed the lack of constituents responsible for antihypertensive activity, such as oleuropein, protopine. Since signals corresponding to polysaccharides submerged those of the other characteristic compounds, fractionation of the preparation was carried out in order to separate the bulk of saccharides. HPLC-DAD and HPLC-ESI-MS analyses of the fractions showed the presence of an alkaloid, ajmaline, as the principal constituent of this product, as well as alkaloids structurally related to ajmaline. HPLC-ESI-MSn analyses revealed a chromatographic peak identified as reserpine. Phytochemical fractionations led to the isolation of ajmaline, whereas quantitation showed that ajmaline prevailed against reserpine indicating that a Rauwolfia species other than R. serpentina was used for this product. Rauwolfia extracts have been banned but they are available via internet. The present study shows the importance of extensive controls using combined analytical tools of the botanical products on the market to assure their quality and as a consequence their safety profiles.