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Kumar S, Praveen BM, Sudhakara A, Sherugar P, Yashoda MP. Extraction of diosgenin using different techniques from fenugreek seeds- A review. Steroids 2024; 214:109543. [PMID: 39647804 DOI: 10.1016/j.steroids.2024.109543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 11/29/2024] [Accepted: 11/29/2024] [Indexed: 12/10/2024]
Abstract
Diosgenin, falls under the category of steroidal saponin present in fenugreek seeds (Trigonella foenum-graecum) in the amount of 0.2-09%. This compound possesses certain pharmacological characteristics like anti-inflammatory, anti-cancer, anti-oxidant etc., that render it a desirable component in the medicinal and nutraceutical industries. Various methods such as, conventional solvent extraction, green extraction methods like Soxhlet extraction, microwave-assisted extraction (MAE), maceration methods, ultrasound-assisted extraction (UAE) and supercritical fluid extraction methods are employed to extract diosgenin from fenugreek seeds. Fundamentals such as solvent choice, pre-treatment techniques, and optimization parameters, affect the diosgenin extraction process. Furthermore, the quantification of diosgenin is governed by analytical methods(chromatography and spectroscopy), underscoring the significance of standardizing diosgenin levels to set the stage for upcoming pharmacological research. However there have been very negligible resources which focuses on conventional and novel techniques for extraction of diosgenin from Fenugreek seeds. This review aims to provide combined insights into the diverse methodologies employed for diosgenin extraction from fenugreek seeds and their implications in pharmaceutical research.
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Affiliation(s)
- Sharavan Kumar
- Department of Chemistry, Institute of Engineering and Technology, Srinivas University, Mangaluru 574146, Karnataka, India
| | - B M Praveen
- Department of Chemistry, Institute of Engineering and Technology, Srinivas University, Mangaluru 574146, Karnataka, India.
| | - Aralihalli Sudhakara
- Department of Chemistry, Rajarajeswari College of Engineering, Bengaluru 560074, Karnataka, India
| | - Prajwal Sherugar
- Centre for Nano and Material Sciences, Jain University, Jain Global Campus, Kanakapura, Ramanagaram, Bangalore 562112, India
| | - M P Yashoda
- Department of Chemistry, Manipal Institute fo Technology, Manipal Academy of Higher Education, Manipal 576104, India
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Stanković MM, Ristivojević PM, Ivković ĐD, Milutinović MG, Terzić JN, Stefanović OD. A comprehensive study on Geranium robertianum L. antibacterial potential. J Appl Microbiol 2024; 135:lxae106. [PMID: 38658191 DOI: 10.1093/jambio/lxae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/23/2024] [Accepted: 04/23/2024] [Indexed: 04/26/2024]
Abstract
AIMS The research aimed to optimize the ultrasound-assisted extraction of secondary metabolites and the antibacterial activity of the plant species Geranium robertianum. The phytochemical profiles of the optimized extracts, as well as their antibacterial and synergistic activity with an antibiotic and their potential mechanisms of action and cytotoxicity, were examined. METHODS AND RESULTS Response Surface Methodology was used to optimize extraction conditions. Optimized ethanol and acetone extracts were tested via microdilution, checkerboard, time-kill kinetics, and cell membrane permeability methods. The extracts displayed broad antibacterial activity with minimum inhibitory concentrations ranging from 1.25 to 20 mg ml-1. In addition, the extract synergistically reacted with gentamicin against gentamicin-resistant strains of Escherichia coli and Staphylococcus aureus, enhancing the efficacy of the antibiotic up to 32-fold. The extracts demonstrated strain-dependent bactericidal activity in a 24-h time interval. They increase the permeability of the cell membrane, thus disrupting its normal functioning. The cytotoxic concentration (CC50) on human keratinocytes was 1771.24 ± 5.78 µg ml-1 for ethanol extract, and 958.01 ± 6.14 µg ml-1 for acetone extract. Kaempferol, ellagic acid, quercetin, and rutin were recognized as the main components in both extracts. CONCLUSIONS The findings of this study indicate that the extracts of G. robertianum can be considered as potential natural antibacterial agents in the control of microorganisms.
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Affiliation(s)
- Marina M Stanković
- University of Kragujevac, Faculty of Science, Department of Biology and Ecology, Radoja Domanovića 12, 34000 Kragujevac, Serbia
| | - Petar M Ristivojević
- University of Belgrade, Faculty of Chemistry, Chair of Analytical Chemistry, Studentski trg 12-16, 11158 Belgrade, Serbia
| | - Đurđa D Ivković
- Innovation Centre of Faculty of Chemistry Ltd., Studentski trg 12-16, 11158 Belgrade, Serbia
| | - Milena G Milutinović
- University of Kragujevac, Faculty of Science, Department of Biology and Ecology, Radoja Domanovića 12, 34000 Kragujevac, Serbia
| | - Jelena N Terzić
- University of Kragujevac, Faculty of Science, Department of Biology and Ecology, Radoja Domanovića 12, 34000 Kragujevac, Serbia
| | - Olgica D Stefanović
- University of Kragujevac, Faculty of Science, Department of Biology and Ecology, Radoja Domanovića 12, 34000 Kragujevac, Serbia
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Stefanowicz-Hajduk J, Graczyk P, Hering A, Gucwa M, Nowak A, Hałasa R. An In Vitro Study on the Cytotoxic, Antioxidant, and Antimicrobial Properties of Yamogenin-A Plant Steroidal Saponin and Evaluation of Its Mechanism of Action in Gastric Cancer Cells. Int J Mol Sci 2024; 25:4627. [PMID: 38731847 PMCID: PMC11083171 DOI: 10.3390/ijms25094627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Yamogenin is a steroidal saponin occurring in plant species such as Asparagus officinalis, Dioscorea collettii, Trigonella foenum-graecum, and Agave sp. In this study, we evaluated in vitro cytotoxic, antioxidant, and antimicrobial properties of yamogenin. The cytotoxic activity was estimated on human colon cancer HCT116, gastric cancer AGS, squamous carcinoma UM-SCC-6 cells, and human normal fibroblasts with MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. The amount of apoptotic and dead AGS cells after treatment with yamogenin was estimated with flow cytometry. Also, in yamogenin-treated AGS cells we investigated the reactive oxygen species (ROS) production, mitochondrial membrane depolarization, activity level of caspase-8 and -9, and gene expression at mRNA level with flow cytometry, luminometry, and RT-PCR, respectively. The antioxidant properties of yamogenin were assessed with DPPH (2,2-diphenyl-1-picrylhydrazyl) and ABTS (2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) assays. The antimicrobial potential of the compound was estimated on Staphylococcus aureus, Bacillus cereus, Klebsiella pneumoniae, Escherichia coli, Salmonella enterica, Helicobacter pylori, Campylobacter coli, Campylobacter jejuni, Listeria monocytogenes, Lactobacillus paracasei, and Lactobacillus acidophilus bacteria strains. Yamogenin showed the strongest cytotoxic effect on AGS cells (IC50 18.50 ± 1.24 µg/mL) among the tested cell lines. This effect was significantly stronger in combinations of yamogenin with oxaliplatin or capecitabine than for the single compounds. Furthermore, yamogenin induced ROS production, depolarized mitochondrial membrane, and increased the activity level of caspase-8 and -9 in AGS cells. RT-PCR analysis revealed that this sapogenin strongly up-regulated TNFRSF25 expression at the mRNA level. These results indicate that yamogenin induced cell death via the extrinsic and intrinsic way of apoptosis. Antioxidant study showed that yamogenin had moderate in vitro potential (IC50 704.7 ± 5.9 µg/mL in DPPH and 631.09 ± 3.51 µg/mL in ABTS assay) as well as the inhibition of protein denaturation properties (with IC50 1421.92 ± 6.06 µg/mL). Antimicrobial test revealed a weak effect of yamogenin on bacteria strains, the strongest one being against S. aureus (with MIC value of 350 µg/mL). In conclusion, yamogenin may be a potential candidate for the treatment and prevention of gastric cancers.
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Affiliation(s)
- Justyna Stefanowicz-Hajduk
- Department of Biology and Pharmaceutical Botany, Medical University of Gdańsk, 80-416 Gdańsk, Poland; (P.G.); (A.H.); (M.G.)
| | - Piotr Graczyk
- Department of Biology and Pharmaceutical Botany, Medical University of Gdańsk, 80-416 Gdańsk, Poland; (P.G.); (A.H.); (M.G.)
| | - Anna Hering
- Department of Biology and Pharmaceutical Botany, Medical University of Gdańsk, 80-416 Gdańsk, Poland; (P.G.); (A.H.); (M.G.)
| | - Magdalena Gucwa
- Department of Biology and Pharmaceutical Botany, Medical University of Gdańsk, 80-416 Gdańsk, Poland; (P.G.); (A.H.); (M.G.)
| | - Anna Nowak
- Department of Cosmetic and Pharmaceutical Chemistry, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland;
| | - Rafał Hałasa
- Department of Pharmaceutical Microbiology, Medical University of Gdańsk, 80-416 Gdańsk, Poland;
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Rudrapal M, Rakshit G, Singh RP, Garse S, Khan J, Chakraborty S. Dietary Polyphenols: Review on Chemistry/Sources, Bioavailability/Metabolism, Antioxidant Effects, and Their Role in Disease Management. Antioxidants (Basel) 2024; 13:429. [PMID: 38671877 PMCID: PMC11047380 DOI: 10.3390/antiox13040429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Polyphenols, as secondary metabolites ubiquitous in plant sources, have emerged as pivotal bioactive compounds with far-reaching implications for human health. Plant polyphenols exhibit direct or indirect associations with biomolecules capable of modulating diverse physiological pathways. Due to their inherent abundance and structural diversity, polyphenols have garnered substantial attention from both the scientific and clinical communities. The review begins by providing an in-depth analysis of the chemical intricacies of polyphenols, shedding light on their structural diversity and the implications of such diversity on their biological activities. Subsequently, an exploration of the dietary origins of polyphenols elucidates the natural plant-based sources that contribute to their global availability. The discussion extends to the bioavailability and metabolism of polyphenols within the human body, unraveling the complex journey from ingestion to systemic effects. A central focus of the review is dedicated to unravelling the antioxidant effects of polyphenols, highlighting their role in combating oxidative stress and associated health conditions. The comprehensive analysis encompasses their impact on diverse health concerns such as hypertension, allergies, aging, and chronic diseases like heart stroke and diabetes. Insights into the global beneficial effects of polyphenols further underscore their potential as preventive and therapeutic agents. This review article critically examines the multifaceted aspects of dietary polyphenols, encompassing their chemistry, dietary origins, bioavailability/metabolism dynamics, and profound antioxidant effects. The synthesis of information presented herein aims to provide a valuable resource for researchers, clinicians, and health enthusiasts, fostering a deeper understanding of the intricate relationship between polyphenols and human health.
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Affiliation(s)
- Mithun Rudrapal
- Department of Pharmaceutical Sciences, School of Biotechnology and Pharmaceutical Sciences, Vignan’s Foundation for Science, Technology & Research (Deemed to be University), Guntur 522213, India
| | - Gourav Rakshit
- Department of Pharmaceutical Sciences & Technology, Birla Institute of Technology, Ranchi 835215, India; (G.R.); (R.P.S.); (S.C.)
| | - Ravi Pratap Singh
- Department of Pharmaceutical Sciences & Technology, Birla Institute of Technology, Ranchi 835215, India; (G.R.); (R.P.S.); (S.C.)
| | - Samiksha Garse
- School of Biotechnology and Bioinformatics, D Y Patil Deemed to be University, Navi Mumbai 400614, India;
| | - Johra Khan
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, Majmaah University, Al Majmaah 11952, Saudi Arabia;
| | - Soumi Chakraborty
- Department of Pharmaceutical Sciences & Technology, Birla Institute of Technology, Ranchi 835215, India; (G.R.); (R.P.S.); (S.C.)
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The neuroprotective and antidiabetic effects of trigonelline: A review of signaling pathways and molecular mechanisms. Biochimie 2023; 206:93-104. [PMID: 36257493 DOI: 10.1016/j.biochi.2022.10.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/07/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
The global epidemic of diabetes has brought heavy pressure on public health. New effective anti-diabetes strategies are urgently needed. Trigonelline is the main component of fenugreek, which has been proved to have a good therapeutic effect on diabetes and diabetic complications. Trigonelline achieves amelioration of diabetes, the mechanisms of which include the modulation of insulin secretion, a reduction in oxidative stress, and the improvement of glucose tolerance and insulin resistance. Besides, trigonelline has been reported to be a neuroprotective agent against many neurologic diseases including Alzheimer's disease, Parkinson's disease, stroke, and depression. Concerning the potential therapeutic effects of trigonelline, comprehensive clinical trials are warranted to evaluate this valuable molecule.
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Salinas-Arellano ED, Castro-Dionicio IY, Jeyaraj JG, Mirtallo Ezzone NP, Carcache de Blanco EJ. Phytochemical Profiles and Biological Studies of Selected Botanical Dietary Supplements Used in the United States. PROGRESS IN THE CHEMISTRY OF ORGANIC NATURAL PRODUCTS 2023; 122:1-162. [PMID: 37392311 DOI: 10.1007/978-3-031-26768-0_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/03/2023]
Abstract
Based on their current wide bioavailability, botanical dietary supplements have become an important component of the United States healthcare system, although most of these products have limited scientific evidence for their use. The most recent American Botanical Council Market Report estimated for 2020 a 17.3% increase in sales of these products when compared to 2019, for a total sales volume of $11,261 billion. The use of botanical dietary supplements products in the United States is guided by the Dietary Supplement Health and Education Act (DSHEA) from 1994, enacted by the U.S. Congress with the aim of providing more information to consumers and to facilitate access to a larger number of botanical dietary supplements available on the market than previously. Botanical dietary supplements may be formulated for and use only using crude plant samples (e.g., plant parts such as the bark, leaves, or roots) that can be processed by grinding into a dried powder. Plant parts can also be extracted with hot water to form an "herbal tea." Other preparations of botanical dietary supplements include capsules, essential oils, gummies, powders, tablets, and tinctures. Overall, botanical dietary supplements contain bioactive secondary metabolites with diverse chemotypes that typically are found at low concentration levels. These bioactive constituents usually occur in combination with inactive molecules that may induce synergy and potentiation of the effects observed when botanical dietary supplements are taken in their different forms. Most of the botanical dietary supplements available on the U.S. market have been used previously as herbal remedies or as part of traditional medicine systems from around the world. Their prior use in these systems also provides a certain level of assurance in regard to lower toxicity levels. This chapter will focus on the importance and diversity of the chemical features of bioactive secondary metabolites found in botanical dietary supplements that are responsible for their applications. Many of the active principles of botanical dietary substances are phenolics and isoprenoids, but glycosides and some alkaloids are also present. Biological studies on the active constituents of selected botanical dietary supplements will be discussed. Thus, the present chapter should be of interest for both members of the natural products scientific community, who may be performing development studies of the products available, as well as for healthcare professionals who are directly involved in the analysis of botanical interactions and evaluation of the suitability of botanical dietary supplements for human consumption.
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Affiliation(s)
- Eric D Salinas-Arellano
- Medicinal Chemistry and Pharmacognosy, College of Pharmacy, The Ohio State University, 500 West 12th Avenue, Columbus, OH, 43210, USA
| | - Ines Y Castro-Dionicio
- Medicinal Chemistry and Pharmacognosy, College of Pharmacy, The Ohio State University, 500 West 12th Avenue, Columbus, OH, 43210, USA
| | - Jonathan G Jeyaraj
- Medicinal Chemistry and Pharmacognosy, College of Pharmacy, The Ohio State University, 500 West 12th Avenue, Columbus, OH, 43210, USA
| | - Nathan P Mirtallo Ezzone
- Medicinal Chemistry and Pharmacognosy, College of Pharmacy, The Ohio State University, 500 West 12th Avenue, Columbus, OH, 43210, USA
| | - Esperanza J Carcache de Blanco
- Medicinal Chemistry and Pharmacognosy, College of Pharmacy, The Ohio State University, 500 West 12th Avenue, Columbus, OH, 43210, USA.
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Yamogenin-Induced Cell Cycle Arrest, Oxidative Stress, and Apoptosis in Human Ovarian Cancer Cell Line. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27238181. [PMID: 36500274 PMCID: PMC9740764 DOI: 10.3390/molecules27238181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022]
Abstract
Steroidal saponins are a group of compounds with complex structures and biological activities. They have anti-inflammatory, antimicrobial, fungicidal, and antitumor properties. Yamogenin is one of the spirostane saponins and occurs in Trigonella foenum-graecum, Asparagus officinalis, and Dioscorea collettii. It is a stereoisomer of diosgenin-a well-known compound whose activity and mechanisms of action in cancer cells are determined. However, the antitumor effect of yamogenin is still little known, and the mechanism of action has not been determined. In this study, we evaluated the effect of yamogenin on human ovarian cancer SKOV-3 cells in vitro by determining the cellular factors that trigger cell death. The viability of the cells was assessed with a Real-Time xCELLigence system and the cell cycle arrest with flow cytometry. The activity of initiator and executioner caspases (-8, -9, and -3/7) was estimated with luminometry and flow cytometry, respectively. The mitochondrial membrane depolarization, the level of oxidative stress, and DNA damage in the yamogenin-treated cells were also evaluated by flow cytometry. Genes expression analysis at the mRNA level was conducted with Real-Time PCR. Bid activation and chromatin condensation were estimated with fluorescent microscopy. The obtained results indicate that yamogenin has cytotoxic activity in SKOV-3 cells with an IC50 value of 23.90 ± 1.48 µg/mL and strongly inhibits the cell cycle in the sub-G1 phase. The compound also triggers cell death with a significant decrease in mitochondrial membrane potential, an increase in the level of oxidative stress (over two times higher in comparison to the control), and activation of caspase-8, -9, -3/7, as well as Bid. The results of genes expression indicate that the Tumor Necrosis Factor (TNF) Receptor Superfamily Members (TNF, TNFRSF10, TNFRSF10B, TNFRSF1B, and TNFRSF25), Fas Associated via Death Domain (FADD), and Death Effector Domain Containing 2 (DEDD2) were significantly upregulated and their relative expression was at least two times higher than in the control. Our work shows that yamogenin induces apoptosis in ovarian cancer cells, and both the extrinsic and mitochondrial-intrinsic pathways are involved in this process.
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Semwal P, Painuli S, Abu-Izneid T, Rauf A, Sharma A, Daştan SD, Kumar M, Alshehri MM, Taheri Y, Das R, Mitra S, Emran TB, Sharifi-Rad J, Calina D, Cho WC. Diosgenin: An Updated Pharmacological Review and Therapeutic Perspectives. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:1035441. [PMID: 35677108 PMCID: PMC9168095 DOI: 10.1155/2022/1035441] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 05/09/2022] [Indexed: 02/07/2023]
Abstract
Plants including Rhizoma polgonati, Smilax china, and Trigonella foenum-graecum contain a lot of diosgenin, a steroidal sapogenin. This bioactive phytochemical has shown high potential and interest in the treatment of various disorders such as cancer, diabetes, arthritis, asthma, and cardiovascular disease, in addition to being an important starting material for the preparation of several steroidal drugs in the pharmaceutical industry. This review aims to provide an overview of the in vitro, in vivo, and clinical studies reporting the diosgenin's pharmacological effects and to discuss the safety issues. Preclinical studies have shown promising effects on cancer, neuroprotection, atherosclerosis, asthma, bone health, and other pathologies. Clinical investigations have demonstrated diosgenin's nontoxic nature and promising benefits on cognitive function and menopause. However, further well-designed clinical trials are needed to address the other effects seen in preclinical studies, as well as a better knowledge of the diosgenin's safety profile.
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Affiliation(s)
- Prabhakar Semwal
- 1Department of Biotechnology, Graphic Era University, Dehradun, 248002 Uttarakhand, India
| | - Sakshi Painuli
- 1Department of Biotechnology, Graphic Era University, Dehradun, 248002 Uttarakhand, India
| | - Tareq Abu-Izneid
- 2Pharmaceutical Sciences Department, College of Pharmacy, Al Ain University, Al Ain 64141, UAE
| | - Abdur Rauf
- 3Department of Chemistry, University of Swabi, Swabi, Anbar-23561, K.P .K, Pakistan
| | - Anshu Sharma
- 4Department of Food Science and Technology, Dr. Y.S. Parmar University of Horticulture and Forestry, Nauni, 173230, India
| | - Sevgi Durna Daştan
- 5Department of Biology, Faculty of Science, Sivas Cumhuriyet University, 58140 Sivas, Turkey
- 6Beekeeping Development Application and Research Center, Sivas Cumhuriyet University, 58140 Sivas, Turkey
| | - Manoj Kumar
- 7Chemical and Biochemical Processing Division, ICAR-Central Institute for Research on Cotton Technology, Mumbai 400019, India
| | - Mohammed M. Alshehri
- 8Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Yasaman Taheri
- 9Phytochemistry Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rajib Das
- 10Department of Pharmacy, Faculty of Pharmacy, University of Dhaka, Dhaka 1000, Bangladesh
| | - Saikat Mitra
- 10Department of Pharmacy, Faculty of Pharmacy, University of Dhaka, Dhaka 1000, Bangladesh
| | - Talha Bin Emran
- 11Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh
- 12Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh
| | - Javad Sharifi-Rad
- 9Phytochemistry Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- 13Facultad de Medicina, Universidad del Azuay, Cuenca, Ecuador
| | - Daniela Calina
- 14Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - William C. Cho
- 15Department of Clinical Oncology, Queen Elizabeth Hospital, Kowloon, Hong Kong
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