Blinding assessment in clinical trials of traditional Chinese medicine: Exploratory principles and protocol.

As one of the key components of clinical trials, blinding, if successfully implemented, can help to mitigate the risks of implementation bias and measurement bias, consequently improving the validity and reliability of the trial results. However, successful blinding in clinical trials of traditional Chinese medicine (TCM) is hard to achieve, and the evaluation of blinding success through blinding assessment lacks established guidelines. Taking into account the challenges associated with blinding in the TCM field, here we present a framework for assessing blinding. Further, this study proposes a blinding assessment protocol for TCM clinical trials, building upon the framework and the existing methods. An assessment report checklist and an approach for evaluating the assessment results are presented based on the proposed protocol. It is anticipated that these improvements to blinding assessment will generate greater awareness among researchers, facilitate the standardization of blinding, and augment the blinding effectiveness. The use of this blinding assessment may further advance the quality and precision of TCM clinical trials and improve the accuracy of the trial results. The blinding assessment protocol will undergo continued optimization and refinement, drawing upon expert consensus and experience derived from clinical trials. Please cite this article as: Wang XC, Liu XY, Shi KL, Meng QG, Yu YF, Wang SY, Wang J, Qu C, Lei C, Yu XP. Blinding assessment in clinical trials of traditional Chinese medicine: Exploratory principles and protocol. J Integr Med. 2023; 21(6): 528-536.

Bibliometric Analysis of Network Pharmacology in Traditional Chinese Medicine.

Aim: We evaluated the developmental process, research status, and existing challenges of network pharmacology. Moreover, we elucidated the corresponding solutions to improve and develop network pharmacology. Methods: Research data for the current study were retrieved from the Web of Science. The developmental process of network pharmacology was analyzed using HisCite, whereas cooccurrence analysis of countries, institutions, keywords, and references in literature was conducted using CiteSpace. Results: In literature, there was a trend of annual increase of studies on network pharmacology and China was found to be the country with the most published literature on network pharmacology. The main publishing research institutions were universities of traditional Chinese medicine (TCM). The keywords with more research frequency were TCM, mechanisms, molecular docking, and quercetin, among others. Conclusion: Currently, studies on network pharmacology are mainly associated with the exploration of action mechanisms of TCM. The main active ingredient in many Chinese medicines is quercetin. This ingredient may lead to deviation of research results, inability to truly analyze active ingredients, and even mislead the research direction of TCM. Such deviation may be because the database fails to reflect the content and composition changes of Chinese medicinal components. The database does not account for interactions among components, targets, and diseases, and it ignores the different pathological states of the disease. Therefore, network pharmacology should be improved from the databases and research methods.

[Priority ranking of Chinese patent medicine prescriptions for type 2 diabetes mellitus (syndrome of deficiency of both Qi and Yin): based on analytic hierarchy process (AHP)].

Clinical expertise, patient preference, and the best evidence are the three elements of evidence-based medicine. Based on high-level and high-quality evidence, qualitative and quantitative analysis of the prescribing decisions of physicians is beneficial to improving clinical efficacy. A mature methodological system is available for the retrieval, analysis, summary, evaluation, and recommendation of the evidence, but there are still few studies on physicians' prescribing decisions. How to analyze the trend of physicians' prescribing decisions based on the priority ranking in addition and subtraction of prescriptions? Analytic hierarchy process(AHP) is a method for decision making, which arranges the elements of the decision problem into overall goal, criteria, and operational sub-criteria, and uses the matrix eigenvector method to solve the problem. This study aims to analyze the priority of physicians' prescribing decisions for diabetes mellitus with deficiency of both Qi and Yin based on AHP. To be specific, a database of diabetes mellitus cases with deficiency of both Qi and Yin was established and AHP was used to yield the priority ranking of Chinese patent medicine prescriptions in specific clinical scenarios. In the selected cases of diabetes mellitus with deficiency of both Qi and Yin, Xiaoke Pills was the best prescription for the treatment of type 2 diabetes mellitus(deficiency of both Qi and Yin)(normalized=0.388), followed by Liuwei Dihuang Pills(normalized=0.269), Qishen Capsules(normalized=0.230), and Shengmai Injection(normalized=0.113). According to the analysis the available data, for type 2 diabetes mellitus(deficiency of both Qi and Yin), Xiaoke Pills was the most effective prescription in specific scenarios. When the physicians' prescribing decisions are consistent with the evidence, quantitative analysis of physicians' cognition will boost the evidence-based medical decision-making. However, the research results are also affected by the quality of literature, evidence level and priority, which are thus have some limitations. It is recommended that further small data research based on individual cases be carried out to lay a evidence-based basis for the clinical decision-making of type 2 diabetes mellitus.

A metabolomic approach to elucidate the inhibitory effects of baicalin in pulmonary fibrosis.

CONTEXT: Baicalin, a major flavonoid extracted from Scutellaria baicalensis Georgi (Lamiaceae), has been shown to exert therapeutic effects on pulmonary fibrosis (PF). OBJECTIVE: To use serum metabolomics combined with biochemical and histopathological analyses to clarify anti-PF mechanisms of baicalin on metabolic pathways and the levels of potential biomarkers. MATERIALS AND METHODS: Forty male Sprague-Dawley rats were randomly divided into the control, PF model, prednisolone acetate-treated (4.2 mg/kg/day) and baicalin-treated (25 and 100 mg/kg/day) groups. A rat model of PF was established using a tracheal injection of bleomycin, and the respective drugs were administered intragastrically for 4 weeks. Histomorphology of lung tissue was examined after H&E and Masson's trichrome staining. Biochemical indicators including SOD, MDA and HYP were measured. Serum-metabonomic analysis based on UPLC-Q-TOF/MS was used to clarify the changes in potential biomarkers among different groups of PF rats. RESULTS: Both doses of baicalin effectively alleviated bleomycin-induced pathological changes, and increased the levels of SOD (from 69.48 to 99.50 and 112.30, respectively), reduced the levels of MDA (from 10.91 to 5.0 and 7.53, respectively) and HYP (from 0.63 to 0.41 and 0.49, respectively). Forty-eight potential biomarkers associated with PF were identified. Meanwhile, the metabolic profiles and fluctuating metabolite levels were normalized or partially reversed after baicalin treatment. Furthermore, baicalin was found to improve PF potentially by the regulation of four key biomarkers involving taurine and hypotaurine metabolism, glutathione metabolism, and glycerophospholipid metabolism. CONCLUSIONS: These findings revealed the anti-fibrotic mechanisms of baicalin and it may be considered as an effective therapy for PF.

Global Research Trends of Herbal Medicine for Pain in Three Decades (1990-2019): A Bibliometric Analysis.

PURPOSE: The aim of this study was to explore the global research trends of herbal medicine for pain from 1990 to 2019, using bibliometric methods, and explore international collaborations, intellectual structure, the evolution of active topics, emerging trends, and research frontiers. METHODS: Articles on herbal medicine for pain were retrieved from WoSCC. Two information visualization softwares including CiteSpace and HistCite were used to process bibliographic catalogs. Identification of international collaborations, intellectual structure, the evolution of active topics, emerging trends, and research frontiers were performed based on results from bibliometric analysis. RESULTS: A total of 2986 original articles published between 1990 and 2019 were identified based on the inclusion criteria. The number of publications on herbal medicine for pain in WoSCC significantly increased. China ranked highest in the number of scientific outputs; however, articles with the highest citation rates were found to be from the United States. China-Japan reported the most active collaborations, whereas Kyung Hee University from South Korea was the most productive institution. Zhang Y was the most productive author, whereas research by Sherman KJ and Vane JR had the highest influence. Journal of Ethnopharmacology was the most active journal, whereas Integrative and Complementary Medicine was the most active research area. History of herbal medicine for pain research comprises three major phases of activities. The main points of focus of bibliometric analysis of herbal medicine for pain include "knee osteoarthritis", "cancer", "low back pain", etc.. Moreover, research on mechanisms of action of herbal medicine for pain remains at the forefront of this field. CONCLUSION: This paper provides a basis for future development of research on herbal medicine for pain, which may help researchers explore new directions for future research and identify new perspectives on potential collaborations in this field.

Serial Culture Is Critical for In Vitro Development of Parthenogenetic Embryos in the Golden Syrian Hamster.

Unlike oocytes of many other mammalian species, parthenogenetically activated hamster oocytes have not been reported to develop beyond the two-cell stage. This study investigated the in vitro development into blastocysts of parthenogenetic embryos of Golden Syrian hamsters. We observed that hamster oocytes could easily be artificially activated (AA) by treatment with ionomycin plus 6-dimethylaminopurine + cycloheximide + cytochalasin B as assessed by embryo cleavage in HECM-9 (63.15%) or HECM-10 (63.82%). None of the cleaved embryos developed beyond the two-cell stage when cultured in either of the two media. However, some of the embryos overcame the two-cell block and developed to the blastocyst stage (26.45%) when they were first cultured in HECM-10 for 24 hours and then in HECM-9 (serial culture media HECM-10-9) for 72 hours. Blastocyst development was further significantly (66.2%) improved when embryos were cultured in HECM-10 supplemented with ethylenediaminetetraacetic acid for 24 hours, then in HECM-9 supplemented with glucose for 72 hours (serial culture media HECM-11a-b). Hamster oocytes activated with ionomycin, ethanol, or a combination of the two treatments would develop to the blastocyst stage in serial culture media HECM-11a-b, whereas none of the spontaneously activated oocytes cleaved (0% vs. 86.93%, p < 0.05). DNA and microtubule configurations of spontaneously activated and AA oocytes were assessed by immunocytochemical staining and fluorescence microscopy. The results indicate that serial culture and the method of activation are critical for overcoming the in vitro developmental block of hamster parthenogenetic embryos. This study is the first to report blastocyst development from parthenogenetically activated hamster oocytes.

Moist exposed burn ointment for treating pressure ulcers: A multicenter randomized controlled trial.

BACKGROUND: Pressure ulcers often seriously affect the quality of life of patients. Moist Exposed Burn Ointment (MEBO) has been developed to treat patients with pressure ulcers. The present study aimed to evaluate the efficacy and safety of MEBO in the treatment of pressure ulcers in Chinese patients. METHODS: Seventy-two patients with pressure ulcers were randomly assigned to 2 groups who received a placebo or MEBO for 2 months. The primary outcomes included the wound surface area (WSA) and pressure ulcer scale for healing (PUSH) tool. The secondary outcomes included a visual analog scale (VAS), questionnaire of ulcer status, and adverse effects. RESULTS: Sixty-seven patients completed the study. After 2 months of treatment, the difference of mean change from the baseline was greater for MEBO (vs placebo) for WSA mean (SD) -6.0 (-8.8, -3.3), PUSH Tool -2.6 (-4.7, -1.5), and VAS score -2.9 (-4.4, -1.7). On the basis of the questionnaire, the pressure ulcers were "completely healed" (50.0% vs 16.7%) (P < .05) in patients after 2 months of treatment with MEBO versus placebo. No major adverse effects were found in the 2 groups. CONCLUSION: We showed that MEBO is effective and well tolerated for improving wound healing in Chinese patients with pressure ulcers.

Effects of pulsed electromagnetic fields on histomorphometry and osteocalcin in disuse osteoporosis rats.

OBJECTIVE: Bone histomorphometry and the concentration of the serum osteocalcin expression were observed in disuse osteoporosis (DOP) rats in order to explore the mechanism of pulsed electromagnetic fields in treating DOP. METHODS: Female SD rats, weighing 250 ∼ 280 g, were randomly divided into 4 groups: a control group and three experimental groups. The right hindlimbs of all the rats were immobilized by tibia-tail fixation, except for those in the INT group. The ALN group rats were given an alendronate sodium (1 mg kg-1 d-1) treatment, and the rats in the PEMF group received PEMF irradiation. Bone histomorphometry and the concentration of serum osteocalcin expression were detected in 2, 4, 8, and 12 weeks. RESULTS: Four weeks after modeling, as compared with the DOP group, the %Tb-Ar and Tb-N in the ALN group were increased, and the difference was significant (P< 0.05 or P< 0.01). At 8 weeks, as compared with the DOP group, the %Tb-Ar and Tb-N in the ALN group and the PEMF group both increased, and there was a significant difference (P< 0.05 or P< 0.01). At 12 weeks, as compared with the DOP group, the BGP serum concentration of the ALN group was reduced, and there was a statistical difference (P< 0.05). CONCLUSION: Pulse electromagnetic field with drug can prevent disuse osteoporosis by changing the bone microstructure. In the long run, PEMF improves the mechanical performance of biological structures better than alendronate sodium does. PEMF may influence the process of bone remodeling by promoting the level of osteocalcin.

Improved development by melatonin treatment after vitrification of mouse metaphase II oocytes.

The study was aimed to investigate the effect of melatonin on the development potential of mouse MII oocytes after cryopreservation. Mouse MII oocytes were subjected first to vitrification/warming and 2 h of in vitro culture (phase 1), then to parthenogenetic activation (PA) followed by in vitro culture of parthenogenetic embryos (phase 2). Different concentrations of melatonin (0, 10-9, 10-6 mol/L) were added to the medium during either phase 1, phase 2 or both phases. The fresh oocytes were used as control. When melatonin was used during both phases, 10-9 mol/L melatonin-treated group showed similar rates of cleavage and 4-cell embryo development compared with control, which were significantly higher than those of melatonin-free group, while the rates in either 10-6 mol/L melatonin-treated or melatonin-free groups were significantly lower than that in control. When 10-9 mol/L melatonin was added during either phase 1 or phase 2, both cleavage and 4-cell embryo development rates of either group were significantly lower than those of control. After oocyte vitrification/warming and PA, the ROS levels increased significantly and maternal-to-zygotic transition (MZT) related genes (Dcp1a, Dcp2, Hspa1a, Eif1ax, Pou5f1, Sox2) expression were disorganized. However, after 10-9 mol/L melatonin supplementation, the ROS levels decreased significantly compared with melatonin-free group, and the gene expressions were almost recovered to normal level of control group. These results demonstrated that 10-9 mol/L melatonin supplementation could increase the developmental potential of vitrified-warmed mouse MII oocytes, which may result from ROS scavenging activities and recovery of normal levels of the expressions of MZT-related genes.

Acupuncture for the Treatment of Oculomotor Paralysis: A Pilot Randomised Controlled Trial.

This study consisted of a single centre randomised controlled trial with two parallel arms: an acupuncture group (n = 20) with 27 affected eyes and a sham group (n = 20) with 23 affected eyes. Participants in the acupuncture group received acupuncture treatment once daily, three times weekly for four weeks. Participants assigned to the control group received sham acupuncture, the same protocol as that used for the acupuncture group but without insertion of needles into the skin. The primary outcome measure was the cervical range of motion (CROM) score. Secondary outcome measures were the palpebral fissure size, response rate, and adverse events. All 40 participants completed the study. In the comparison of acupuncture and sham acupuncture, a significant difference was observed between acupuncture and sham acupuncture in CROM score (21.37 ± 15.16 and 32.21 ± 19.54, resp.) (P < 0.05) and palpebral fissure size (7.19 ± 2.94 and 5.41 ± 2.45, resp.) (P < 0.05). Response rate was also significantly different in the acupuncture group (P < 0.05). No adverse events were reported in both groups in this study. In summary, it was demonstrated that acupuncture had a feasibility positive effect on oculomotor paralysis.

No effect of exogenous melatonin on development of cryopreserved metaphase II oocytes in mouse.

BACKGROUND: This study was conducted to investigate effect of exogenous melatonin on the development of mouse mature oocytes after cryopreservation. RESULTS: First, mouse metaphase II (MII) oocytes were vitrified in the open-pulled straws (OPS). After warming, they were cultured for 1 h in M2 medium containing melatonin at different concentrations (0, 10(-9), 10(-7), 10(-5), 10(-3) mol/L). Then the oocytes were used to detect reactive oxygen species (ROS) and glutathione (GSH) levels (fluorescence microscopy), and the developmental potential after parthenogenetic activation. The experimental results showed that the ROS level and cleavage rate in 10(-3) mol/L melatonin group was significantly lower than that in melatonin-free group (control). The GSH levels and blastocyst rates in all melatonin-treated groups were similar to that in control. Based on the above results, we detected the expression of gene Hsp90aa1, Hsf1, Hspa1b, Nrf2 and Bcl-x1 with qRT-PCR in oocytes treated with 10(-7), or 10(-3) mol/L melatonin and untreated control. After warming and culture for 1 h, the oocytes showed higher Hsp90aa1 expression in 10(-7) mol/L melatonin-treated group than in the control (P < 0.05); the Hsf1, Hsp90aa1 and Bcl-x1 expression were significantly decreased in 10(-3) mol/L melatonin-treated group when compared to the control. Based on the above results and previous research, we detected the development of vitrified-warmed oocytes treated with either 10(-7) or 0 mol/L melatonin by in vitro fertilization. No difference was observed between them. CONCLUSIONS: Our results indicate that the supplementation of melatonin (10(-9) to 10(-3) mol/L) in culture medium and incubation for 1 h did not improve the subsequent developmental potential of vitrified-warmed mouse MII oocytes, even if there were alteration in gene expression.

Activity study of a hydroxynaphthoquinone fraction from Arnebia euchroma in experimental arthritis.

Although various drugs for the treatment of rheumatoid arthritis (RA) have been used in clinics, RA is not completely curable to date. Thus, to seek new drugs for the treatment of RA has been a hotspot. Hydroxynaphthoquinones are the major anti-inflammatory active constituents in Arnebia euchroma (Royle) Johnst. The present study aims to evaluate the anti-arthritic activity of a hydroxynaphthoquinone mixture (HM) of A. euchroma (Royle) Johnst, including its anti-inflammatory and analgesic effects. The anti-arthritic efficacy of HM was examined using complete Freund's adjuvant- and bovine type II collagen-induced arthritic models. The paw edema, polyarthritis index and histopathological change were evaluated. The analgesic effect was assessed using the chemical and thermal models of nociception. Results found that HM administered prophylactically and curatively showed marked anti-arthritic activity by suppressing the paw swelling and development of inflammation, lowering the levels of TNF-α and IL-1ß and protecting cartilage and bone from damage. The protection of HM was superior to that of reference drugs such as prednisone acetate or etanercept, and showed no direct deleterious effect. Similarly, HM showed significant analgesic effects. In summary, HM possessed potent anti-arthritic activity. It could relieve inflammatory symptoms and protect against joint destruction. These findings indicate that HM would be a potential therapeutic agent for arthritic disease, which provide pharmacological evidence for its clinical application.

Cardioprotective effects of salvianolic Acid a on myocardial ischemia-reperfusion injury in vivo and in vitro.

Salvianolic acid A (SAA), one of the major active components of Danshen that is a traditional Chinese medicine, has been reported to possess protective effect in cardiac diseases and antioxidative activity. This study aims to investigate the cardioprotection of SAA in vivo and in vitro using the model of myocardial ischemia-reperfusion in rat and hydrogen peroxide (H(2)O(2))-induced H9c2 rat cardiomyoblasts apoptosis. It was found that SAA significantly limited infarct size of ischemic myocardium when given immediately prior to reperfusion. SAA also significantly suppressed cellular injury and apoptotic cell death. Additionally, the results of western blot and phospho-specific antibody microarray analysis showed that SAA could up-regulate Bcl-2 expression and increase the phosphorylation of proteins such as Akt, p42/p44 extracellular signal-related kinases (Erk1/2), and their related effectors. The phosphorylation of those points was related to suppress apoptosis. In summary, SAA possesses marked protective effect on myocardial ischemia-reperfusion injury, which is related to its ability to reduce myocardial cell apoptosis and damage induced by oxidative stress. The protection is achieved via up-regulation of Bcl-2 expression and affecting protein phosphorylation. These findings indicate that SAA may be of value in cardioprotection during myocardial ischemia-reperfusion injury, which provide pharmacological evidence for clinical application.

[A multi-centered randomized double-blinded controlled clinical study on efficacy of gulling pa'an capsule in treating Parkinson's disease].

OBJECTIVE: To objectively evaluate the clinical efficacy of Gulling Pa'an Capsule (GPC), a Chinese medicine, in treating Parkinson's disease (PD). METHODS: According to the good clinical practice (GCP) principle, a multi-centered, double-blinded, layered, randomized and grouping-controlled clinical trial was carried out from May 2002 to January 2005 on 242 PD patients. Among them, 53 patients who had never received levodopa were randomized into two groups, 28 in group A treated with GPC, and 25 in group B treated with placebo; patients who had received levodopa were assigned depending on the Hoehn & Yahr (H-Y) grade, to 4 groups, 75 and 19 of grade 1.5 -3 in group C and E, respectively, 79 and 16 of grade 4 in group D and F, respectively, patients in group C and E were treated with GPC and Levodopa, and those in group D and F treated with placebo and Levodopa for control. The treatment course was 12 weeks for all. Changes of unified Parkinson's disease rating scale (UPDRS) II/III scores in comparing with the baseline were assessed. For the groups C, D, E and F, the dosage of levodopa administered was also recorded. Meanwhile, the blood pressure, pulse rate, blood and urine routine, liver and renal functions, electrocardiogram (ECG) and adverse reactions were monitored as the indices for safety supervise. RESULTS: (1) After treatment, symptoms were markedly improved in 1 out of the 28 patients in group A and improved in 11, the markedly improving rate was 3.6% and the improving rate 39.3%; while in group B, the corresponding outcomes were 0 (0/25) and 28.0% (7/25) respectively, showing insignificant difference between the two groups. UPDRS scores, including the total, II and III scores were all significantly lowered in group A after treatment (P < 0.01, P < 0.05); while in group B, significant lowering only showed in terms of UPDRS III (P < 0.05); but the inter-group comparison of the changes in all the three items showed no significant difference. (2) The significant improving rate was 12.0% (9/75) and improving rate 48.0% (36/75) in group C, while those in group D, 12.7% (10/79) and 24.1% (19/79) respectively, the efficacy in group C was better (P < 0.05). The items of 3 UPDRS scores in groups C and D were all significantly lowered after treatment (P < 0.01), and the lowering in group C was more significant in terms of the total and II scores (P < 0.05). (3) The significant improving rate was 5.3% (1/19) and improving rate 36.8% (7/19) in group E, while in group F 0% (0/19) and 25.0% (4/16), respectively, showing insignificant difference between them; UPDRS scores lowered significantly in the two groups after treatment (P < 0.01), also showed no statistical significance in comparison (P > 0.05). (4) The dosage of Levodopa required in groups C and E was significantly reduced after treatment (P < 0.05), while in groups D and F, it was unchanged (P > 0.05); yet, the further analysis displayed that significant reduction only presented in group C (P < 0.05), not in the other three groups. CONCLUSIONS: The overall efficacy of levodopa in combined with GPC for treating PD patients of H-Y grade 1.5 -3 is significantly higher than that of levodopa alone. GPC shows obvious effects in improving patients' motor syndrome and the quality of life; as used in combining with levodopa, the dosage of levodopa required could be reduced.

[Observation on therapeutic effect of electroacupuncture at points Baliao and Huiyang (BL 35) on retention of urine induced by spinal cord injury].

OBJECTIVE: To explore a more effective therapy for retention of urine induced by spinal cord injury. METHODS: Eighty-four cases were randomly divided into a treatment group of 46 cases and a control group of 38 cases. The treatment group were treated with electroacupuncture at Baliao and Huiyang (BL 35), and the control group with electroacupuncture at acupoints routinely selected. RESULTS: The total effective rate and the cured rate were 82.6% and 43.5% in the treatment group and 63.2% and 23.7% in the control group respectively, with a very significant difference between the two groups (P < 0. 01). CONCLUSION: Electroacupuncture at Baliao and Huiyang (BL 35) has obvious therapeutic effect on retention of urine induced by spinal cord injury.

[Preliminary study on the alpha-glucosidase inhibitor from Glycyrrhiza uralensis Fisch].

OBJECTIVE: To extract and isolate alpha-glucosidase inhibitor from Glycyrrhiza uralensis Fisch. METHODS: The aqueous extract of Glycyrrhiza uralensis Fisch. was extracted by petroleum, ethyl acetate and n-butanol. In addition, the inhibitory activity against alpha-glucosidase of every fraction was determined and the inhibitory kinetics of ethyl acetate fraction was investigated. RESULTS: The inhibitory activities of four fractions were 68.93%, 83.2%, 32.17% and 10.79% respectively. Compared with the aqueous extract (69.77%), the inhibitory activity of ethyl acetate fraction was higher. Ethyl acetate fraction was shown to be a fast-binding, dose-dependent and competitive model with a Ki value of 34 microg/ml. CONCLUSION: It is hoped to obtain good alpha-glucosidase inhibitors by separating ethyl acetate fraction of aqueous extract of Glycyrrhiza uralensis Fisch further.