key: cord-291279-8rfx9qde authors: li, zhuman; han, chuangchuang; huang, huihong; guo, zhijun; xu, feng title: novel coronavirus pneumonia treatment with traditional chinese medicine: response philosophy in another culture date: 2020-07-10 journal: front public health doi: 10.3389/fpubh.2020.00385 sha: doc_id: 291279 cord_uid: 8rfx9qde nan in late 2019, novel coronavirus (sars-cov-2) caused pneumonia in wuhan was spread to the whole country and was identified by world health organization (who) as "public health emergencies of international concern" (1-4). on the morning of march 12, 2020 beijing time, who officially identified it as a pandemic 1 . up to june 15, 2020, the novel coronavirus disease (covid-19) has swept over 200 countries and territories, resulting in more than 7.6 million confirmed cases and over 0.42 million confirmed deaths 2 . the novel coronavirus-caused pneumonia has a powerful infectious force for some population groups, and up to now no specific drugs could cure it (5, 6) . since the novel pneumonia outbreak, china national health committee issued seven editions of diagnosis and medical treatment plan 3 . more than 40,000 medical staffs including traditional chinese medicine (tcm) doctors from all over the country were called up to wuhan, and other cities in hubei provinces to treat patients 4 . the epidemic situation displays a good trend after severe prevention and control in china 5 . in the 7th edition of diagnosis and medical treatment plan issued by national health commission (nhc) of china, many tcm remedies are recommended for covid-19 patients in medical observation period. huo xiang zheng qi capsule is recommended for patients when there is clinical manifestation of "fatigue accompanied by gastrointestinal discomfort"; and jin hua qing gan granule, lian hua qing wen capsule, and shu feng jie du capsule are recommended for patients when fatigue with fever occur. according to a news release from the national administration of tcm, the integration of traditional chinese and western medical treatment can achieve satisfactory results for resolution of symptoms of covid-19 6 . in the medicine field of china, there is always a dispute between the modern medicine and the traditional medicine for a long time. the pros and cons of debate have its own perspective and opinion. we are pleased to see that in the face of severe epidemic situation, there are mixed teams of modern medicine doctors and tcm doctors. the majority of covid-19 patients in china have been treated with integrated chinese and modern medicine. hundreds of herbal remedies have been used throughout the country (7). the chinese government and academic experts in herbal medicine have recommended incorporating tcm into conventional treatment methods so as to generate synergistic effect by the combinational therapy of chinese and western medicine (7) . unfortunately, the experience of tcm in the treatment of epidemic situation has not been widely recognized and used for reference in the western occident developed countries. the lack of high-quality scientific evidence may be one of important reason that would lead to reject. another fundamental reason is that the whole theory system of tcm is not acknowledged by western-trained audience. it might be due to different culture, more specifically, different treatment philosophy. tcm has its strong material base from single monomeric compounds to chinese herb extracts in covid-19 treatment. psychosocial pharmacological effect probably plays an important role in the traditional medicine (8) . so what is the exactly treatment philosophy in tcm culture to the novel coronavirus disease? chinese public in general are always long taught that tcm is a national quintessence with an ancient historical origin. in addition to tcm, peking opera, martial arts, and calligraphy are well-known as the "four quintessence of china" both at home and abroad. national quintessence itself is more related with culture and social custom than with natural science. tcm has been played an indispensable role in the prevention and treatment of epidemic diseases in history. during the sars epidemic in 2003, the intervention of tcm has also achieved therapeutic effect (9, 10) . in the broad and profound tcm theory system, the present covid-19 is just one of common epidemics. even covid-19 is brand new emerging severe infectious disease caused by a brand new coronavirus and no specific drug is used to cure in modern medicine, tcm still has confidence to fight the epidemic. in tcm culture perspective, covid-19 is an epidemic disease caused by an epidemic evil with dampness and heat, which is called li-qi in chinese (11) . after li-qi invades the human body, it enters the lung first to make the lung-qi (vital essence of lung, which is in charge of breath function) stagnate, then lead abnormal breath movement, phlegm-heat accumulation and block, and finally bring out the dead yin and the dead yang (12) . according to tcm treatment philosophy, dampness should be eliminated first, and then heat be cleared away. after heat and phlegm are cleared away, the body is restored to normal function at last (13) . there seems to be something in common between virus and li-qi. both think that there is an external cause of disease. modern medicine refer it virus, they usually hope to find specific drug to cure the disease. however, tcm does not know microbiology and could not capture the virus entity, they could only focus on li-qi-induced symptom with herbal remedies. the aim of tcm treatment is simple, so long as tcm remedies provide effective way to regulate functional disorders of the human body. therefore, tcm remedies are used to detoxify poisonous dampness and heat, to strengthen body to resist pathogenic factor, to adjust the harmony of the internal relationship of the human body. that is to say, when tcm doctors treat this kind of disease, they do not have to make the cause clear to start. it is of importance to solve the symptoms for most patients. a small, non-randomized, single center retrospective observational study reported a shorter average duration of viral shedding and faster resolution of radiological pneumonia in hospitalized covid-19 patients prescribed jin hua qing gan granules for more than 2 days as compared with those receiving conventional care (14) . the potential efficacy of this herbal medicine for covid-19 treatment should be further investigated in adequately powered randomized controlled trials. the understanding and description of tcm is based on the ancient macro understanding of nature and the use of speculative philosophy such as yin-yang. in the course of history, since tcm started and developed without synchronizing with modern chemistry, biology and physics, it had to takes the road of philosophical thinking. however, by the aid of advanced science, modern medicine embarks another road of development. it can be said that tcm and modern medicine are two trees growing up in the soil of two different cultures. although high-quality clinical trial evidence is lacking at present, the efficacy of tcm remedy on symptom improvement cannot be ignored. to treat covid-19, tcm and modern medicine should complement each other and cooperate with each other since tcm can contribute as an alternative measure. zl, ch, hh, zg, and fx were responsible for the design of this work and interpretation of finding and drafting the work. fx approved the final version to be published and is accountable for all aspects of the work to ensure its accuracy and integrity. all authors contributed to the article and approved the submitted version. a novel coronavirus outbreak of global health concern clinical features of patients infected with 2019 novel coronavirus in wuhan a novel coronavirus from patients with pneumonia in china a familiar cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster discovering drugs to treat coronavirus disease 2019 (covid-19) clinical medication response under new major infectious disease: off-label use and compassionate use traditional chinese medicine contributes to the treatment of covid-19 patients psychological, social, and behavioral factors that influence drug efficacy: a noteworthy research subject in clinical pharmacology is traditional chinese medicine useful in the treatment of sars? effect of glucocorticoid with traditional chinese medicine in severe acute respiratory syndrome (sars) consideration of traditional chinese medicine in treatment of highly pathogenic human coronaviruses sars-cov-2 and sars-cov. chin trad herb drugs analysis and thinking on traditional chinese medicine in preventing and treating severe cases of novel coronavirus pneumonia traditional chinese medicine theory and clinical study on novel coronavirus pneumonia (ncp) infection effect of jinhua qinggan granules on novel coronavirus pneumonia in patients the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 li, han, huang, guo and xu. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-259731-kiccsa89 authors: chen, wei-chieh; chuang, hsiao-mei; huang, jin-long; hung, siu-wan; tsai, chia-i; fu, pin-kuei title: adjuvant therapy with traditional chinese medicine in a heart failure patient complicated by hospital-acquired pneumonia: a case report date: 2019-02-27 journal: complement ther med doi: 10.1016/j.ctim.2019.01.008 sha: doc_id: 259731 cord_uid: kiccsa89 objective: we report a case of congestive heart failure complicated by hospital-acquired pneumonia that was successfully treated with traditional chinese medicine (tcm) and antibiotics. clinical features and outcome: a 33-year-old man with a history of heart failure developed pneumonia during hospitalization. after the standard antibiotic therapy for 3 days, he continued to experience persistent fever and progressive cough with purulent sputum. broad spectrum antibiotics did not relieve the fever or the purulent sputum; therefore, the patient requested tcm for integrated therapy, and was subsequently treated with a regiment of “clearing heat and damp excreting” decoction according to tcm theory. after three days of tcm combination therapy, the pneumonia patches significantly improved on chest x-ray. his sputum was obviously decreased in amount and the fever was complete remission in the 5(th) day of tcm adjuvant therapy. conclusion: integrated therapy with a “clearing heat and damp excreting” decoction may have improved hospital-acquired pneumonia in a patient comorbid with congestive heart failure. the anti-pyretic, anti-inflammatory, antitussive and diuretic effects of tcm may be responsible for the observed improvement. further experimental studies are warranted to confirm the efficacy and mechanism of tcm action in the treatment of pneumonia. pneumonia is one of the most common infectious diseases causing significant morbidity and mortality in adults even in the modern medical care system. 1 according to the world health organization statistics, pneumonia was the 4th leading cause of death, causing 3.0 million deaths worldwide in 2016. 2 as the 3 rd leading cause of death in 2016, 3 the social-economic burden of pneumonia in taiwan is significant. pneumonia is classified as community acquired (cap) or hospital acquired (hap) according to the acquisitionsite. 4 the prognosis of hap patients is unfavorable, especially for those with comorbidities such as chronic obstructive pulmonary disease, immunocompromised status, and congestive heart failure (chf). 5 the standard treatment for hap includes antimicrobial therapy and supportive care. antibiotics can attenuate the infectious process. however, with the widespread overuse and misuse of antibiotics, multiple-drug-resistant pathogens give rise to pneumonia that is difficult to treat. 6 the morality rate for hap (27.7%) is greater than that of cap and is especially high in those patients with multiple comorbidities. 7, 8 xu et al conducted a prospective, multi-center, double-blind, parallel, randomized controlled trial to evaluate integrated therapy consisting of traditional chinese medicine (tcm) and antibiotics in elderly patients with pneumonia. 9 their findings indicate that tcm combination therapy is safe and effective in ameliorating expectoration and promoting the absorption of pneumonia lesions. 9 here, we report a hap patient comorbid with chf who was treated with tcm adjuvant therapy. the patient exhibited rapid, significant improvement in symptoms and image findings. on december 6, 2016, a 33-year-old man presented with fever offand-on up to 39.6°c, chills, and cough with purulent sputum. he had been discharged from a rehabilitation ward 1-2 days before this admission. his medical history included acute myocardial infarction complicated by cardiogenic shock over the previous year, and his present left ventricular ejection fraction (lvef) was reduced to 28%. serial laboratory examinations showed no leukocytosis but neutrophil dominance (83.1%) and an elevated c-reactive protein (c-rp) level of 7.62 mg/dl. sputum and blood culture analysis were performed on december 6, yielding negative findings. thoracic radiography revealed a bilateral perihilar alveolar pattern,a dilated azygos vein, and diffuse pulmonary consolidations with air bronchograms in bilateral lower lung fields (fig. 1) . accordingly, hap accompanied by pulmonary edema was diagnosed. empiric intravenous antibiotic treatment with piperacillin/tazobactam 4.5 g every 8 h was promptly initiated on december 6, 2016.nevertheless, the patient continued to experience fever and progressive cough with purulent sputum during antibiotic treatment. he asked for tcm combination therapy, which was started on december 9, 2016 (the 3 rd hospital day). the diagnosis according to the tmc theory was "exterior evil inward invasion" and "accumulation of phlegm and heat in the lung" in a yang-deficiency constitution. the "clearing heat and damp excreting" decoction was prescribed three times a day as shown in table 1 . after a 3-day course of treatment, the pneumonia lesions significantly improved on chest x-ray (fig. 1) . the sputum clearly decreased in volume, and the fever had completely abated by day 5 of tcm adjuvant therapy (fig. 2) . the patient's report of cough decreased. he also felt much better and more energetic. we report a hap patient comorbid with chf who experienced rapid and significant improvement in symptoms and image findings following treatment with tcm adjuvant therapy. because the bacterial cultures from sputum and blood were all negative, we believe that the antipyretic, anti-inflammatory, and antitussive effects of the tcm regiment acted against the persistent inflammation in this patient. the integration of tcm and western medicine has been shown effective for treating patients with pneumonia in a previous clinical trial and an animal study of the anti-inflammatory effects of tcm. 9,10 ma-xing-gan-shi-tang (mxgst) is an old tcm formula consisting of four ingredients: herbaephedrae (ma huang), semen armeniacae (xing ren), gypsum fibrosum (shi gao), and radix glycyrrhizae (gan cao). 11 this formula has been used to treat patient with common-cold-related fever and bronchial asthma for several centuries. in a rat model of bronchial asthma, mzgst was shown to exertanti-tussive and anti-pyretic effects through promoting airway smooth muscle relaxation and inhibiting neutrophil recruitment in the airway. 11 in an animal study, treatment of lipopolysaccharide-induced lung injury with mxgst resulted in decreased inflammation and a hyperpermeability reaction in lungs through regulation of the toll-like receptor 4, src, and nf-κb pathways. 12 in this case, we chose herbaephedrae (ma huang), gypsum fibrosum (shi gao) and radix glycyrrhizae (gan cao) as the major components of our mixture because of their antipyretic and anti-asthmatic effects. 13 we added yu xing cao (houttuyniacordata), huang qin (radix scutellariae), mu dan pi (cortex mountan), sang bai pi (cortex mori), and gua lou shi (fructus trichosanthis) to increase the antipyretic and antiinflammatory effects. we added ting li zi (semenlepidii) and fu ling (poria cocos) to improve the edema status of this patient and huang qin (scutellariae radix) and mu dan pi (moutan cortex) to ameliorate lung inflammation, based on the results of previous investigations. 14 the main component of moutan cortex is paeonol, which is reported to have anti-inflammatory effect and anti-pyretic effects against lipopolysaccharide-induced acute lung injury. 15, 16 yu xing cao (houttuyniacordata) was chosen as a key herb for the treatment of severe acute respiratory syndrome and exhibits anti-inflammatory effects according to multiple studies. 17, 18, 19 lianqiao (fructus forsythiae) was confirmed by studies to have antibacterial, antivirus, antioxidant, and anti-inflammatory effects. 20 fu ling (poriacocos) has anti-inflammatory and diuretic effects, which are reported to improve cardiac function in chf rats via the avp-v2r-aqp2 axis. 21, 22 fuzi (radix aconiti lateralis preparata) is proven to have cardiotonic action and reverse the dysfunction in chf processing. 23, 24 although the pharmacological mechanisms underlying the actions of gua lou shi (fructustrichosanthis), sang bai pi (cortex mori), and tinɡ li zi (semen lepidii) remain unclear, their functions in dealing with phlegm retention are abundantly documented in the "compendium of materia medica" (bencaogangmu), an ancient tcm herbal text book. the role of tcm in this case was not to act as antibiotics to kill pathogens. in fact, the patient had been treated with antibiotics and all the culture reports showed negative results. therefore, tcm was prescribed to help patient with "clearing heat and damp excreting" and have some diuretic effects to improve pulmonary congestion. we suggest that tcm was helpful for the edema and sputum in this case for two reasons: first, after the administration of standard antibiotic therapy, the fever and the progressive cough with purulent sputum persisted. tcm was an extra intervention administered during the fever period. second, because the bacterial cultures of sputum and blood were all negative before and after antibiotic treatment, the intermittent fever due to inflammatory reaction was highly suspicious after exclusion of other comment causes of fever, such as tumor fever and endocrine disorders. the "clearing heat and damp excreting" decoction we use was proven to have anti-inflammatory effects in a previous clinical trial and animal study. we suggest that the decreased time to fever abatement was caused by the improvement of lung inflammation after tcm adjuvant therapy. adjuvant therapy with a "clearing heat and damp excreting" decoction may improve hap in a patient comorbid with chf. these effects may be exerted through the anti-pyretic, anti-inflammatory, antitussive and diuretic effects of tcm. further investigations are warranted to confirm the efficacy and mechanism of tcm treatments for pneumonia. the institutional review board (irb) of the taichung veterans general hospital approved this case report with a reference number ce17307a on december 5, 2017. the organized irb operates according to the good clinical practice and applicable laws and regulations. management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of america and the the top 10 causes of death taiwan's leading causes of death in epidemiology and outcomes of health-care-associated pneumonia: results from a large us database of culture-positive pneumonia use of severity scoring and stratification factors in clinical trials of hospital-acquired and ventilator-associated pneumonia optimising antibiotic usage to treat bacterial infections ventilatorassociated pneumonia: current status and future recommendations risk factors for hospital-acquired pneumonia outside the intensive care unit: a case-control study evaluation on clinical efficacy of fuzheng jiedu huayu decoction combined with antibiotics in the treatment of pneumonia in the elderly -a multi-center, double-blind, parallel, randomized controlled trial comparison of the ameliorative effects of qingfei tongluo formula and azithromycin on mycoplasma pneumoniae pneumonia the effects of ma-xing-gan-shi-tang on respiratory resistance and airway leukocyte infiltration in asthmatic guinea pigs posttreatment with ma-xing-shi-gan-tang, a chinese medicine formula, ameliorates lipopolysaccharide-induced lung microvessel hyperpermeability and inflammatory reaction in rat antipyretic and anti-asthmatic activities of traditional chinese herb-pairs, ephedra and gypsum heat-processed scutellariae radix enhances anti-inflammatory effect against lipopolysaccharide-induced acute lung injury in mice via nf-kappa b signaling moutan cortex radicis improves lipopolysaccharide-induced acute lung injury in rats through anti-inflammation evaluation of lps-induced acute lung injury attenuation in rats by aminothiazole-paeonol derivatives anti-inflammatory effect of houttuynia cordata injection immunomodulatory and anti-sars activities of houttuynia cordata houttuynia cordata, a novel and selective cox-2 inhibitor with anti-inflammatory activity improvement of intestinal absorption of forsythoside a in weeping forsythia extract by various absorption enhancers based on tight junctions bioactivity-guided isolation of anti-inflammatory triterpenoids from the sclerotia of poria cocos using lps-stimulated raw264.7 cells sclederma of poria cocos exerts its diuretic effect via suppression of renal aquaporin-2 expression in rats with chronic heart failure a review on phytochemistry and pharmacological activities of the processed lateral root of aconitum carmichaelii debeaux effects of active components of fuzi and gancao compatibility on bax, bcl-2, and caspase-3 in chronic heart failure rats the authors declare that they have no conflict of interest. key: cord-279875-jxnszm5k authors: wang, wan-ying; xie, ying; zhou, hua; liu, liang title: contribution of traditional chinese medicine to the treatment of covid-19 date: 2020-07-07 journal: phytomedicine doi: 10.1016/j.phymed.2020.153279 sha: doc_id: 279875 cord_uid: jxnszm5k covid-19 as an epidemic disease has spread across the planet since december 2019. the somber situation reminds each country to take actions in preventing the spreading of the virus. china as one of the early affected countries has been fighting against the novel coronavirus with the achievements of nearly 80,000 cured confirmed patients. traditional chinese medicine (tcm) has made contributions to the treatment of covid-19 because of its efficacy and comprehensive therapeutic theory. in this commentary, the advantage, aetiology and mechanism of tcm therapy were discussed in the aspect of its functions in reducing the harms brought by covid-19 to human beings. the rapid spreading of the 2019 novel coronavirus (sars-cov-2) has resulted in an outbreak of coronavirus disease 2019 in over 200 countries globally. as of the world health organization (who) situation report on may 24, 2020, there were 5,204,508 confirmed cases all over the world, among them, 84,525 cases in china and 5,119,983 cases in locations outside china. (world health organization, 2020) the extensive attention to such an epidemic disease originated from several patients with severe pneumonia in wuhan, china in january 2020. although the situation in china has almost reached steady since march, the number of confirmed cases outside china has boosted in other regions, with 2,338,124 confirmed cases in americas and 2,006,984 confirmed cases in europe. (fig.1) . the unique features of covid-19 are the fast transmission, difficulty to cure and a lack of proper methods of preventing its infection. common clinical features of confirmed patients are fever and cough. (guan et al., 2020) the diagnosis is confirmed by their clinical, laboratory, and radiological features and then further divided into mild, severe and critically ill according to their symptoms. (li and de clercq, 2020) however, covid-19 has killed more people than the combined number of cases with sars and mers. (mahase, 2020) in china, traditional chinese medicine (tcm) is concurrently playing an important role in the treatment of covid-19, integrated with modern imaging system, first-aid facility and ordinary chemical therapy. (yang, 2020) the national percentage of treating confirmed cases of covid-19 patients with tcm-integrated therapy is over 90% with the support from over 4900 tcm practitioners all over china. each mobile cabin hospital is equipped with 2-3 tcm experts and a team of 12 national tcm masters are accompanied with severe patients in wuhan.(liu，ruiche, 2020) currently, the national treatment guidance of covid-19 (7 th edition) (general office of the national health commission, 2020) and more than 20 provinces and regions have released modified treatment guidance inclining tcm integration according to their geographical and weather conditions, which is an unique methodology in tcm therapy based on the perspective of harmonization between environment and human body. each guidance has emphasized in detail that tcm therapy should be integrated with chemical therapy and tcm practitioners should be involved in the consultation system with no exception. the advantages of tcm-integrated therapy based on the clinical data from the tcm practitioners treating patients in wuhan, the dominant advantages of tcm-integrated therapy include shortening rehabilitation period and decreasing the transferring rate from the mild to severe or critically ill cases. (yang, 2020) in a clinical experiment (first batch of clinical data involving tcm treatment) of 52 confirmed cases, of which 34 cases were treated with tcm-integrated therapy with chemical. it was reported that the length of treatment of covid-19 patients would be 5.15 days in tcm-integrated treatment group, which is 2 days shorter than that in chemical drugs therapy. tcm-integrated therapy could also increase around 30% clinical cure rate. the rate of mild patients transferred to severe patients of tcm-integrated treatment is 29% less than that of group treated by chemical drugs only. (wu, 2020) as reported from prof. tong, the total effective rate of qingfeipaidu formula could reach 97.78% in a statistics of 1261 covid-19 patients and no patients transferred to severe or critically ill cases. (zhao, 2020) for those severe covid-19 patients, tcm-integrated therapy could shorten the duration of virus nucleic acid test from positive to negative, which means the patients could be discharged from hospital 2 days earlier. technically, the clinical indexes including oxyhemoglobin saturation, lymphocyte percentage and lactate dehydrogenase are all improved substantially when patients are treated with tcm-integrated therapy. (wang, 2020) in addition, the combinational tcm formulae could also help alleviate the adverse drug reactions induced by anti-virus drugs and corticosteroids, especially in gastrointestinal and hepatic related systems. therefore, an early and full-dimensional intervention of tcm therapy could achieve a better outcome of the treatment. since covid-19 could be infected through droplet from human to human in a diverse age range, this disease could be included as "pestilence" in tcm theory. january is the coldest month over a year and the rainfall of wuhan in january is nearly 5 times of the mean rainfall during the same period in the past 20 years.(weatheronline) low fever, dry cough, debilitation, whole-body sore, nausea, diarrhea and diarrhea are common symptoms of covid-19 patients which correlate with "cold and damp" symptoms in tcm theory. therefore, a qualitative definition of covid-19 in tcm theory is a "cold and damp" (chen and nakamura, 2004; jia and gao, 2003) using a different idea from the microbiology-oriented knowledge of the aetiology of the disease or the mechanism of novel drugs, tcm emphasizes on the relief of symptoms so as to cure infected patients and control the spreading of epidemics. covid-19 was defined as a self-limited disease and severe immune injury is one of the characterized pathological features of reported cases. the enhancement of patients' immunity is therefore a crucial contributor of their recovery (stebbing et al., 2020) , which highly correlates with tcm theory. the mechanism of tcm-integrated therapy starts from the diagnosis of the disease. the criteria of confirming covid-19 cases is unified according to their serum samples and ct images from mild patients to critically ill cases.(general office of the national health commission, 2020) however, over 20% of the patients might have at least one coexisting disease with covid-19. (guan et al., 2020) patients are then further classified by their personal symptoms with high specificity treated with tcm-integrated therapy. in this way, tcm patent medicine or tcm combinational formulae could be prescribed to corresponding patients with different symptoms. locally in the organs, invigorating the circulation of blood in lung is the main issue but the balance between lung, spleen and organs in the gastrointestinal system is also emphasized in tcm theory. according to the national guidance of covid-19 treatment, a number of tcm patent medicine were recommended during medical observation period including jinhuaqinggan granules were found to be associated with multiple signaling pathways treating covid-19 through in silico analysis, such as tnf signaling pathway, mapk signaling pathway, t cell receptor signaling pathway and so on. lianhuaqingwen granules could significantly relieve clinical symptoms in covid-19 patients by inhibiting the release of inflammatory mediators so as to regulate the immune response of virus infection. (ding et al., 2017; dong et al., 2014; similarly, shufengjiedu capsule could also ameliorate upper respiratory tract infection via the erk pathway and modulate anti-inflammatory and immunomodulation activity. tao et al., 2017) for those severe covid-19 patients, the holistic perspective of tcm could be responsible inhibit ifn-γ, nf-κb and nlrp3 signaling pathways so as to reduce the inflammatory response. (paoletti et al., 2013; zhang et al., 2017) . these reports provided the scientific ground of integrating tcm therapy from the aspects of their compositions' potential targeting proteins and signaling pathways in the treatment of covid-19. there are still no effective countermeasures to defeat covid-19 from the understanding of the pathology to the development of drugs or vaccines. currently, the number of newly confirmed covid-19 patients is largely decreasing and the number of cured patients is increasing in china attributing to the effective therapeutic regimen which cannot ignore the integration of tcm therapy. in the future, more clinical cases of covid-19 could be concluded in the statistics to decipher the pathology of the disease. meanwhile, the mechanism of existing or novel drugs for covid-19 treatment could be further evaluated. the clinical experience of treating covid-19 could hopefully be adopted as a reference by other affected countries, especially the tcm-integrated therapy to address current crisis. acknowledgement: this research was funded by the science and technology development situation report -125) (world health organization, 2020) effect of xiao-chai-hu decoction with different doses of bupleurum on body temperature and content of il-1β, il-6, tnf-α in serum induced by lps among fever rat models potential natural compounds for preventing 2019-ncov infection statistical evidence for the usefulness of chinese medicine in the treatment of sars chinese history of epidemic prevention. guangxi science and technology press therapeutic potentials of baicalin and its aglycone, baicalein against inflammatory disorders the chinese prescription lianhuaqingwen capsule exerts anti-influenza activity through the inhibition of viral propagation and impacts immune function effect of lianhuaqingwen capsules on airway inflammation in patients with acute exacerbation of chronic obstructive pulmonary disease protective effects of saikoside on rats with alcoholic liver disease novel coronavirus pneumonia diagnosis and treatment plan clinical characteristics of coronavirus disease 2019 in china efficacy and safety of lianhuaqingwen capsules, a repurposed chinese herb is traditional chinese medicine useful in the treatment of sars? on the basis of syndrome differentiation considering the rapid treatment of covid-19 by qingfeipaidu decoction anti-inflammatory effects of shufengjiedu capsule for upper respiratory infection via the erk pathway study on network pharmacology of jinhua qinggan granule in the treatment of covid-19 all the mobile cabin hospitals in wuhan are equipped with tcm experts the cytokine storm of severe influenza and development of immunomodulatory therapy xiaochaihu decoction attenuates the vicious circle between the oxidative stress and the alp inactivation through lps-catecholamines interactions in gut, liver and brain during cci4+ethanol-induced mouse hcc the infiltration and apoptosis of eosinophilicand the 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characteristics of lymphocyte subsets and cytokines in peripheral blood of 123 hospitalized patients with 2019 novel coronavirus pneumonia (ncp) fighting covid-19 by feeling the pulse. people's dly the treatment strategies of chinese medicine and the participation rate of chinese medicine treatment in each province and the curative effect of new coronavirus pneumonia world health organization, 2020. coronavirus disease (covid-19) situation report -125 traditional chinese medicine has a definite effect on mild cases and can also assist in the treatment of severe cases of covid-19 treatise on acute epidemic febrile diseases inhibitory effects of flavonoids extracted from licorice on lipopolysaccharide-induced acute pulmonary inflammation in mice feiyan no.1" prescription used in many designated treatment hospitals in guangdong tcm widely used in covid-19 patient treatment, yielding good results pathological findings of covid-19 associated with acute respiratory distress syndrome combining tcm,western medicine effective against virus clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study glycyrrhizin administration ameliorates streptococcus aureus-induced acute lung injury protective effect of amygdalin on lps-induced acute lung injury by inhibiting nf-κb and nlrp3 signaling pathways academician tong xiaolin: the total effective rate of qingfeipaidu formula was 97%, none transfer from mild to severe cases compilation of information on treatment drugs for covid-19 key: cord-273556-rvo0vyk3 authors: zhang, kui; tian, maolu; zeng, yang; wang, linwen; luo, sha; xia, wei; zhang, xiangyan; zha, yan title: the combined therapy of a traditional chinese medicine formula and western medicine for a critically ill case infected with covid-19 date: 2020-06-09 journal: complement ther med doi: 10.1016/j.ctim.2020.102473 sha: doc_id: 273556 cord_uid: rvo0vyk3 objective: presentation of a case illustrating the benefits of traditional chinese medicine (tcm) for treatment of coronavirus disease 2019 (covid-19) in critically ill patients. clinical features and outcome: a 58-year-old woman presented with cough, fever, dizziness, chest tightness, polypnea and poor appetite. she was admitted to guizhou provincial people’s hospital, and diagnosed with critically ill type of covid-19 in february, 2020. according to the patient's symptoms and signs, the tcm syndrome differentiation was qi deficiency, dampness-stasis and toxin accumulation. then she received the combined therapy of a modified chinese herbal formula and western medicine. during a twelve-day period of treatment, her respiratory distress and appetite quickly improved. abnormal laboratory indicators were resumed in time and lung lesions in ct scan largely absorbed. no side effects associated with this chinese herbal formula were found. before discharge, two consecutive nasopharyngeal swabs were shown to be negative for severe acute respiratory coronavirus 2 (sars-cov-2). conclusions: our case report suggests that collaborative treatments with traditional chinese medicine prove beneficial in the management of covid-19 in critically ill patients. in order to give optimal care for this covid-19 crisis for the whole world, chinese medicine practitioners and western medical doctors should work together in frontline. coronavirus disease 2019 (covid-19) caused by severe acute respiratory coronavirus 2 (sars-cov-2) is a newly recognised illness that has spread rapidly throughout wuhan (hubei province) to other provinces in china and around the world. the clinical spectrum of covid-19 ranges from mild to critically ill cases, and the mortality of critically ill patients with covid-19 is very high. until now, no specific treatment has been recommended for severe coronavirus infection except for meticulous supportive care. for western medicine, the fundamental pathophysiology of this severe viral pneumonia is massive alveolar damage and severe acute respiratory distress syndrome(ards). from the perspective of traditional chinese medicine(tcm), its pathogenesis is characterized by "dampness, heat, toxin, stasis, closure and prostration". here, we report 1 critically ill case, who was infected by covid-19, obtained good results after the combined therapy of our tcm formula and western medicine. tcm syndrome differentiation, the detailed therapeutic formula and management were described through analysis of the patient's clinical course. we also introduced how the health care system in china has both chinese medicine practitioners(cmp) and western medical doctors to work together in frontline to give optimal care for this covid-19 crisis for the whole world. j o u r n a l p r e -p r o o f on february 6, 2020, a 58-year-old woman was admitted to guizhou provincial people's hospital, with a 7-day history of productive cough and subjective fever, and a 3-day history of dizziness, chest tightness, polypnea and poor appetite. she disclosed that she had returned to guiyang, china on january 18 after traveling to visit family in wuhan, china. sputum specimen obtained from the patient tested positive for sars-cov-2 on real-time reverse transcription-polymerase-chain-reaction (rt-pcr) assays. the woman was immediately isolated in the negative pressure wards of intensive care unit. the physical examination revealed a body temperature of 38.4°c, blood pressure of 77/52 mm hg, pulse of 83 beats per minute, respiratory rate of 23 breaths per minute, and oxygen saturation of 96% while the patient was breathing pure oxygen(fraction of inspired oxygen,fio2:100%). lung auscultation revealed rhonchi, and bedside chest radiography was performed, which was reported as showing that the textures of both lungs were thickened and blurred with patchy shadows of increased density( figure 1 ). laboratory results on hospital day 1 (illness day 7) reflected lymphopenia, decreased level of serum albumin, severely elevated inflammatory factors, mild hyperbilirubinemia, abnormal lactate dehydrogenase, and electrolyte disturbance (table 1 ). this patient suffered from thyroid disease 4 years ago, and the gland had been surgically removed. after that, she has hypothyroidism, and has taken levothyroxine sodium for a long time. moreover, she has a history of sinus bradycardia with paroxysmal atrial premature (basic heart rate:50 to 65 beats per minute) for more than one year and has been taking aspirin. according to the fifth version of guideline of the covid-19 diagnosis and treatment in china, the patient was diagnosed as covid-19 (critically ill type). after admission, the patient was immediately given high flow oxygen by a noninvasive ventilator to correct respiratory failure. moreover, vasoactive drug hydroxylamine was given to raise blood pressure. she was also treated empirically with non-specific antiviral western medicines including lopinavir/litonavir and arbidol. moxifloxacin (0·4 g once daily, intravenously) was used to prevent secondary infection. given the serious shortness of breath and hypoxaemia, methylprednisolone (initial dose 80mg once daily, intravenously) was administered to attentuate lung inflammation [1] . shenfu injection was discontinued due to the patient's anaphylaxis. it has been known that covid-19 belongs to yi bing (epidemic disease) in traditional chinese medicine, and its lesions are mainly in the lung [2] . tongue diagnose was carried out by a fixed senior chinese medicine practitioner (cmp). due to wearing heavy protective equipments, cmp did not examine the patient's pulse and did not take the tongue photos. the pathogenesis of tcm is characterized by "dampness, heat, toxin, stasis, closure and prostration". according to the patient's symptoms and signs, the tcm syndrome differentiation was qi deficiency, dampness-stasis and toxin accumulation. in addition to guideline-based covid-19 management, this patient was in time treated with our tcm formula. the therapeutic principles were to strengthen the body resistance and eliminate pathogenic factors. the specific method is to supplement qi, remove dampness-stasis and toxin. the tcm formula included sangbaipi (cortex mori) 20g, huajuhong (exocarpium citri grandis) 15g, huangqi (radix astragali) 40g, taizishen 6g. this formula was decocted in water, one dose a day and 100ml three times daily. with the above combined therapy of chinese herbs and western medicine, the patient's dyspnea was gradually improved, and fio2 needed gradually decreased to 70% on hospital day 2, 50% on hospital day 3, 45% on hospital day 4, 40% on hospital day 5, and 30% on hospital day 6. her temperature returned to normal on hospital day 3. methylprednisolone was reduced by 20 mg per day and discontinued on hospital day 4. from hospital day 7, the patient only needed supplemental oxygen through nasal cannula at 2 to 3 liters per minute, and her oxygen saturation values improved to 95 to 98%. from the morning of hospital day 11, the patient's blood pressure returned to normal(117/73mmhg), and hydroxylamine was discontinued. compared with chest computed tomographic (ct) scan on hospital day 6, a seconed chest ct scan on hospital day 10 showed patchy shadows and ground glass opacity were obviously absorbed( figure 2 ). the laboratory examinations on hospital day 11 showed all abnormal indicators had returned to normal (table 1) . two consecutive nasopharyngeal swabs were found to be negative for sars-cov-2 on rt-pcr assays, her appetite improved, and she was asymptomatic aside from occasional dry cough. according to the fifth version of guideline of the covid-19 diagnosis and treatment in china, the patient had met discharge criteria, and was discharged on february 17, 2020 (illness day 18, hospital day 12). the sars-cov-2 infection can lead to acute resolved or fatal pneumonia. currently, the main source of infection is covid-19 patients. the route of human-to-human transmission of sars-cov-2 is mainly through respiratory droplets and contacts [3] . although the number of cases has increased rapidly around the world, information, especially treatment information about critically ill patients with sars-cov-2 infection is scarce. as previously reported, older patients with a history of underlying diseases are at increased risk of becoming critically ill or dying if they have sars-cov-2 infection [4, 5] . since no specialised medication to treat covid-19 has been identified at this time, the mainstay of treatment has been supportive care. tcm has accumulated abundant clinical experiences and effective formulas on the prevention and treatment of epidemic diseases in the past thousands of years. tcm also worked very well clinically in the treatment of severe acute respiratory syndrome [6] . therefore, the chinese government has highly valued tcm in this campaign to contain and eradiate sars-cov-2. health we report on a 58-year-old critically ill patient with confirmed covid-19, characterised by type 1 acute respiratory failure and septic shock. in addition to western medicine and symptomatic support, we found that timely administration of appropriate tcm formula might significantly improve the prognosis of critically ill patients, according to the specific tcm syndrome differentiation of the patients. although our patient has endocrine and cardiac co-morbidities, her respiratory distress was quickly improved by the combined therapy of tcm formula and western medicine. the need for invasive ventilator or even extracorporeal membrane oxygenation was avoided. her abnormal laboratory indicators had been resumed in time and lung lesions in ct scan also been largely resolved. compared with other studies of critically ill patients, both the dose and duration of methylprednisolone treatment were reduced [7, 8] . we did not use immunoglobulin in this patient. the patient's total hospital stay was 11 days, shorter than reported days [7] . moreover, tcm treatment did not cause any adverse event. fei zhou et al. reported shortening of viral shedding duration after lopinavir/ritonavir treatment was not observed in their study [9] . young et al. observed that the decline in viral load as indicated by the cycle threshold value from nasopharyngeal swabs appeared similar between those treated and not treated with lopinavir-ritonavir [10] . but in our case, the combination of lopinavir/ritonavir and tcm treatment seemed to enhance the efficacy of each other and avoid side effects such as diarrhea. recently, a randomized controlled study showed no statistically significant benefits for remdesivir treatment beyond those of standard of care treatment [11] . but this trial did not attain the predetermined sample size because the outbreak of covid-19 was brought under control in china. future studies of remdesivir, including in combination with tcm treatment in those with severe covid-19 are needed to better understand their potential synergistic effectiveness. it has been known that proper tcm formulae are quite effective for severe stroke, refractory lichen planus pigmentosus-inversus, and so on [12, 13] . now. it seems that traditional chinese medicine also has a good effect on severe covid-19, at least in our case it is. in our tcm formula, huangqi (radix astragali), taizishen (radix pseudostellariae) and nanshashen (radix jinyinhua (lonicera), improving symptoms in this patient. a good prognosis has been obtained through the above treatments in this case, no side effects associated with our tcm formula been found. moreover, this formula is much cheaper than some antiviral western drugs with uncertain curative effects. numerous data have showed that the early intervention of tcm has positive effects on shortening hospital stay and ameliorating symptoms, reducing the development of mild and moderate case to severe case and the mortality rate, improving the cure rate and the on the use of corticosteroids for 2019-ncov pneumonia efficacy and safety of integrated traditional chinese and western medicine for corona virus disease 2019 (covid-19): a systematic review and meta-analysis early transmission dynamics in wuhan, china,of novel coronavirus-infected pneumonia epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study risk factors for severity and mortality in adult covid-19 inpatients in wuhan chinese herbal medicine for severe acute respiratory syndrome: a systematic review and meta-analysis clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore remdesivir in adults with severe covid-19: a randomised, double-blind, placebo-controlled, multicentre trial integrative medicine treatment for severe stroke-a case report combination therapy of acitretin capsule and chinese herbs for patients with lichen planus pigmentosus-inversus analysis report on traditional chinese medicine effectiveness in covid-19 patients in hunan province research progress of traditional chinese and western medicine on key: cord-296195-m2wwlvgx authors: chen, chung-jen; michaelis, martin; hsu, hseng-kuang; tsai, chin-chuan; yang, kunder d.; wu, yang-chang; cinatl, jindrich; doerr, hans wilhelm title: toona sinensis roem tender leaf extract inhibits sars coronavirus replication date: 2008-10-30 journal: j ethnopharmacol doi: 10.1016/j.jep.2008.07.048 sha: doc_id: 296195 cord_uid: m2wwlvgx aim of the study: severe acute respiratory syndrome (sars) is a life-threatening disease caused by the sars coronavirus (sars-cov). the development of new antiviral agents for sars-cov is an important issue. we tried to find potential resource from traditional chinese medicine (tcm) for development of new drugs against sars-cov. materials and methods: our team recruited the potential tcm formulae (also known as kampo) from two tcm books, shang-han lun (discussion of cold-induced disorders) and wen-bing tiau-bein (differential management of febrile diseases). several herbs, which were believed to be beneficial for sars by experienced tcm doctors were also recruited. in addition, a vegetable polular in taiwan, china and malaysia, the tender leaf of toona sinensis roem (also known as cedrela sinensis, belongs to the family meliacceae) was also recruited under the suggestion of botanic experts. these tcm products and plant extrats were then tested for the effectiveness against sars-cov in vitro. results: only tsl-1, the extract from tender leaf of toona sinensis roem was found to have an evident effect against sars-cov with selectivity index 12∼17. conclusion: this paper reports for the first time that extract from a vegetable, the tender leaf of toona sinensis roem, can inhibit sars-cov in vitro. thererfore, the tender leaf of toona sinensis roem may be an important resource agninst sars-cov. severe acute respiratory syndrome (sars) is a life-threatening disease caused by the sars coronavirus (sars-cov) (drosen et al., 2003) . the overall mortality rate is around 10%. therefore, the development of new antiviral agents for sars-cov is an important issue. in 2003, cinatl et al. firstly reported the discovery of glycyrrhizin to inhibit replication of sars-cov, which suggested that traditional herbs might be a potential resource for development of new drugs against sars-cov (cinatl et al., 2003a) . a lot of herbs used in traditional chinese medicine (tcm) may be of great treasure. the reason is tcm has been well organized and associated with thousands years of history in clinical practice. among a lot of tcm books, two of those, named as shang-han lun (discussion of cold-induced disorders) (zhang, 220) and wen-bing tiau-bein (differential management of febrile diseases) (wu, 1811) , described some sars like diseases and therapies. therefore, our team recruited the potential tcm formulae (also known as kampo) from these two books. several herbs, which were believed to be beneficial for sars by experienced tcm doctors were also recruited. in addition, a vegetable in taiwan, china and malaysia, the tender leaf of toona sinensis roem (also known as cedrela sinensis, belongs to the family meliacceae) (fig. 1) was also recruited under the suggestion of botanic experts. these tcm products and plant extracts were then tested for the effectiveness against sars-cov in vitro. tcm formulae included ger-gan-hwang-lein-hwang-chin tang, san-hwang-sei-sin-tang and mar-sing-ther-gang-tang, ger-gan-hwang-lein-hwang-chin tang, san-hwang-sei-sin-tang, huang-lein-zhei-du-tang, mar-sing-ther-gang-tang (the above developed around 196-219ac in han dynasty), pu-zhi-siau-du-yien (developed around 1180-1251 ac in song dynasty), yin-chiau-san, sang-zhiu yien (developed around 1800-1820 ac in ching dynasty), chu-gen tang, san-hwang sei-sin-ther-gau-yin (new developed). herbs included yin-sing, lei-gong-teng, green tea, hong-jing tein, hwang-lein and phyllanthus urinaria. s1, s2, s3 and s4 are four fractions from phyllanthus urinaria, which has been used for treatment of hepatitis b. green tea powder is produced by ten ren tea co., ltd, taipei, taiwan. green tea extract is produced by chang gung biotechnology, taipei, taiwan. it contains 86.19% of egcg and 12.13% of egc. toona sinensis roem, also known as cedrela sinensis a. juss, is a famous plant in china. it has been cultivated for more than 2300 years. according to the "tu-zing-bern-tsau" (atlas-bible of natural herb) published in the song dynasty around the 11th century, the leaf of toona sinensis roem had been described as "having sweet smell, and to be eatable". it was introduced from southern china to taiwan in 1915. the tender leaf used in this experiment was collected from toona sinensis roem grown in tuku, yunlin county at the west side of taiwan (chang et al., 2002; wang et al., 2008) (fig. 2) . tsl-1 is a fraction of crude extract from the tender leaf of toona sinensis roem prepared according to previous report (wang et al., 2008) . in brief, 100 g of tender leaves yield approximately 5-6 g of tsl-1 powder. moreover, tsl-1 treated with nanometer-manufacturing technique (to make the particle less than nanometer) was designed as tsl-1nm. in the antiviral assay against sars-cov, they were dissolved in distilled water and then diluted in mem supplemented with 2% fbs. the antiviral assays systems consisted of two systems. the first system was the screening test using hcov 229e. it was performed at taiwan as previously reported (hsieh et al., 2004) . in brief, mrc-5 cells, firstly treated with trypsin, and then were seeded onto 96-well plates with a concentration of 1× 100,000 cells/ml and a volume of 70 ul per well. after incubation at 37 • c with 5% co 2 for 24 h, 20 ul of hcov (strain 229e) virus was added and incubated for another 2 h. 10 ul of tested substances were then added to culture wells in triplicate in different concentrations. actinomycin d was used as a positive control and 0.1% dmso was used as negative control respectively. after incubation at 37 • c with 5% co 2 for 4 days, the mtt test was carried out to determine the level of cell viability. the tcm products and extracts were tested at the concentration of 5 ug/ml or 20 ug/ml in the first study and at 50 ug/ml and 200 ug/ml in the second study. the antiviral activity against sars-cov strain ffm1 was done as previously described (cinatl et al., 2003a) . this assay was performed in a p3 laboratory. in brief, sars-cov was cultured in 96-well microplates on confluent layers of vero cells. cytopathogenicity induced by the sars-cov 72 h after infection was visually scored. selectivity index (si) was counted as the ratio of cc50 to ec50. cc50 denotes the concentration of the tested extract that reduced cell viability to 50%. ec 50 denotes the concentration of the tested extract needed to inhibit the cytopathic effect to 50% of the control value. the cytotoxicity of the drugs was determined with an mmt cell-proliferative kit i (roche, mannheim, germany). african green monkey kidney cell lines vero (ccl-81) was obtained from atcc (manassas, va, usa). vero cells were grown at 37 • c in mem supplemented with 10% fetal bovine serum (fbs) containing 100 iu/ml of penicillin and 100 g/ml of streptomycin. sars-cov strain ffm 1 (drosen et al., 2003) was prepared by infecting vero cells cultures. supernatants from infected cultures were collected 2 days post infection and aliquots were stored at −80 • c. virus titres were determined by 50% tissue culture infective dose (tcid 50 ) in confluent cells in 96-well microtiter plates as described (cinatl et al., 2003a (cinatl et al., , 2005 . confluent cell cultures were infected with sars coronavirus strain ffm1 for 1 h in 96-well microplates. after adsorption period, cells were washed with pbs and incubated in mem supplemented with 2% fbs. cytopathogenic effect (cpe) was assessed visually 72 h after infection. virus yield reduction assay was performed as described before (cinatl et al., 2003b (cinatl et al., , 2005 . confluent cell layers grown in 12.5 cm 2 cell culture flasks were infected with sars-cov strain ffm 1. after 1 h incubation period, cells were washed four times with pbs and incubated (37 • c) in mem supplemented with 2% fbs. after 72 h cultures and supernatants were freezethawed and viral titres were determined by the 50% tissue culture infective dose in confluent vero cells on 96-well microtiter plates. the inhibitory effects were expressed as effective concentrations of compounds required to inhibit infectious virus titres by 50% (ec 50 ). cell proliferation was assessed using the 3-(4,5dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (mtt) dye reduction assay (mosmann, 1983) as described previously (michaelis et al., 2004) . vero cells were seeded onto 96-well microtitre plates, grown to confluency, and incubated with culture medium containing tcm or herb extracts. incubation time was analogous to that used for virus experiments. after incubation mtt (1 mg/ml) was added and after an additional 4 h cells were lysed in a buffer containing 20% (w/v) sds and 50% n,n-dimethylformamide adjusted to ph 4.5. absorbance at 570 nm was determined for each well using a 96-well multiscanner. after subtracting background absorbance, results are expressed as cell number compared to control cells that were maintained in the presence of solvent. cc 50 was determined as concentration that decreases cell viability by 50%. in the first study against hcov 229e, 12 potential tcm products and extracts were tested. they were three tcm formulae, ger-gan-hwang-lein-hwang-chin tang, san-hwang-sei-sin-tang and mar-sing-ther-gang-tang as well as nine herb extracts including yin-sing, lei-gong-teng, green tea powder, green tea extract, s1, s2, s3, s4 and hong-jing tein. all showed no antiviral activity at the concentration of either 5 ug/ml or 20 ug/ml (data not shown). therefore, they were not further tested with sars-cov. in the second study against hcov 229e, eight potential tcm products and extracts were tested. they were six tcm formulae including ger-gan-hwang-lein-hwang-chin tang, san-hwang-sei-sin-tang, mar-sing-ther-gang-tang, yin-chiau-san, chu-gen tang, and san-hwang sei-sin-ther-gau-yin as well as two herb extracts from hong-jing-tein and hwang-lein. among these tcm in the third study, five tcm formulae included yin-chiau-san, pu-zhi-siau-du-yien, ger-gern-hwang-lein, sang-zhiu-yien and huang-lein-zhei-du-tang as well as toona sinensis roem tender leaf extract tsl-1 and tsl-1nm were tested against sars-cov. none of tcm formulae had evident effect against sars-cov. however, both tsl-1 and tsl-1nm showed evident effect against sars-cov. the si of tsl-1 was greater than 12 in regular condition and 17 after boiling of tsl-1. the si of tsl-1nm was greater than 7 in regular condition and greater than 13 after boiling of tsl-1nm (table 1) . the mean si was around 15 in tsl-1 and 10 in tsl-1nm. many potential agents against sars-cov in vitro have been identified (cinatl et al., 2005) . however, a major concern is the safety and experience in practical application in human beings. much different from a lot of previously identified components or drugs against sars-cov, the tender leaf of toona sinensis roem has been used as a popular vegetable by chinese people in both mainland china and taiwan with high level of safety. however, few studies were done regarding its scientific basis till the end of 20th century. in 2002, it has been reported that the crude extract of toona sinensis roem leaf can induce apoptosis of a549 lung cancer cells (chang et al., 2002) . the effect to improve lipolysis of differentiated 3t3-l1 adipocyte was also noted (yang et al., 2003) . in addition, the aqueous extract of toona sinensis roem can exert antiproliferative action and growth inhibition on hl-60 cells through apoptosis induction (yang et al., 2006) . recently, toona sinensis roem leaf extract was proved to alleviate hyperglycemia via altering adipose glucose transporter 4 (wang et al., 2008) . however, the potential of toona sinensis roem for inhibition of sars-cov has not been reported so far. to our knowledge, this is the first report to show extract from the tender leaf of toona sinensis roem against sars-cov. it is promising to find a new natural resource against sars-cov. however, the key compound in toona sinensis roem to inhibit sars-cov is still unclear. recently, many compounds have been purified from the leaves of toona sinensis. they include methyl gallate, gallic acid, kaempferol, quercetin, quercitrin, rutin, kaempferol-d-glucoside, (+)-catechin, (−)-epicatechin, betasitosterol, stigmasterol, beta-sitosteryl-glucoside, stigmasterolglucoside, phytol and toosendanin (chia, 2007) . one of those compounds, quercetin, has been reported to have antiviral activity against hiv-luc/sars, with a selective index of 40 (yi et al., 2005) . however, the key component in toona sinensis inhibiting sars-cov still needs further investigations in the future. in conclusion, this paper reports for the first time that extract from a vegetable, the tender leaf of toona sinensis roem, can inhibit sars-cov in vitro. therefore, the tender leaf of toona sinensis roem may be an important resource against sars-cov. extract from the leaves of toona sinensis roemor exerts potent antiproliferative effect on human lung cancer cells components of toona sinensis: review glycyrrhizin, an active component of liquorice roots, and replication of sarsassociated coronavirus treatment of sars with human interferons development of antiviral therapy for severe acute respiratory syndrome identification of a novel coronavirus in patients with severe acute respiratory syndrome 2-substituted banzoxazinone analogues as anti-human coronavirus (anti-hcov) and icam-1 expression inhibition agents increased human cytomegalovirus replication in fibroblasts after treatment with therapeutical plasma concentrations of valproic acid rapid colorimetric assay for cellular growth and survival: application to proliferation and cytotoxicity assays toona sinensis roem (meliaceae) leaf extract alleviates hyperglycemia via altering adipose glucose transporter 4 wen-bing tiau-bein (differential management of febrile diseases) (in classic chinese) enhancement of glucose uptake in 3t3-l1 adipocytes by toona sinensis leaf extract toona sinensis extracts induces apoptosis via reactive oxygen species in human premyelocytic leukemia cells small molecules blocking the entry of severe acute respiratory syndrome coronavirus into host cells shang-han lun (discussion of cold-induced disorders) (in classic chinese) this study is supported by a grant from the national science council of taiwan, roc (nsc 92-2751-b-182a-006-y) and chang gung memorial hospital, taiwan (bmrp743). the authors are thankful to miss ming-chi yang for her technical assistance. we thank wu-chang chung phd, the director of r&d department of sun ten phytotech co., ltd. taiwan, to provide extracts from five formula of tcm. we also thank dr. chung-hwa hsu to provide chu-gen-tang, a new developed formula of tcm and dr. sheng-teng huang to provide three fractions of phyllanthus urinaria. this article is written in memorial of dr. yong-hsiang lin, our colleague of department of internal medicine, chang gung memorial hospital, kaohsiung medical center, devoted his young life upon the war against sars in may, 2003 at kaohsiung, taiwan. we thank a million for dr. lin's mother to encourage us to do our best to find new agents against sars-cov. key: cord-350066-xwf7u4n5 authors: zhang, baozhen; zhang, kai; tang, qilin; sun, kaihang; han, zhenzhen title: acupuncture for breathlessness in covid-19: a protocol for systematic review and meta-analysis date: 2020-07-02 journal: medicine (baltimore) doi: 10.1097/md.0000000000020701 sha: doc_id: 350066 cord_uid: xwf7u4n5 background: at present, accumulative attention has been paid to coronavirus disease 2019 (covid-19) due to its global prevalence. acupuncture may play a beneficial role in patients with breathlessness in covid-19. this study is designed to determine the efficacy and safety of acupuncture for breathlessness in covid-19. methods: randomized controlled trials (rct) will be searched from 7 electronic databases, with the last search update being 30 june 2020. studies by registers of clinical trials will be additionally searched. two investigators will independently select studies, extract data and evaluate study quality. finally, a meta-analysis will be used to evaluate the pooled intervention effect if possible. results: our present findings will indicate the application of acupuncture as an adjunctive treatment for dyspnea in covid-19, which will be published in a peer-reviewed journal. conclusion: our study will provide a reference foundation for clinical optimization of treatment. prospero registration number: crd42020182323. coronaviruses (covs) is a type of enveloped positive-sense rna virus that is diversely found in humans and wildlife. [1] human coronaviruses (hcovs) have been proven to be non-essential pathogens for a long period, which can result in "common cold" in other healthy population. [1, 2] nevertheless, two highly pathogenic hcovs from animal reservoirs have led to worldwide pandemics with striking morbidity and mortality, including severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov). [2] at present, a new strain called the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus has become another outbreak. the coronavirus disease 2019 (covid19) was recognized in wuhan, china in december, 2019, causing increasing morbidity and mortality ever since. [2] the ongoing covid-19 pandemic is an exceptional challenge for the health systems throughout the world. through the continuous accumulation of research data, the biological, epidemiological, and clinical characteristics of covid -19 have been gradually improved. international attention has been paid to covid-19 due to the quickly increasing number of diagnosed patients along with subsequently rising secondary outbreaks in various global regions. hopefully, the rapid in-depth sequencing of viral genomes has enabled the development and research of diagnostic tests, as well as the initiation of vaccine and therapeutics research. [3] however, so far, no effective vaccine or causative therapy is available. [3] existing studies have readily confirmed the interpersonal transmission of sars-cov-2, [3, 4] with an incubation period varying from 1 to 14 days (median: 5-6 days), which could be 24 days under extreme conditions. [3, 5] additionally, patients with covid-19 have a higher proportion of men, the elderly, patients with hypertension and/or diabetes. [6] there are also investigations concerning the risk factors as well as clinical outcomes in admission and intensive care unit. in an early study of patients with covid-19 in china and italian, older men, patients with smoking and cardiometabolic diseases were associated with poor prognosis. [7] in general, the clinical presentation of covid-19 includes myalgias, fatigue dry cough and fever, as well as less common ones (including abdominal pain, breathlessness, headache diarrhea and sore throat). [3, 8] a recent descriptive study found that there were 56.7% men among elderly diagnosed covid-19 patients were male, and common symptoms included fatigue (23.3%), dyspnea (30.0%), cough (56.7%), and fever (78.3%). [8] in general, older population are more vulnerable to covid-19 infection, and their mortality rate is higher, which deserves more attention. [8] the covid-19 pandemic has triggered prevalent research interest in therapeutic and preventive interventions. however, due to the lack of specific antiviral therapeutics and vaccine, adjuvant therapy has become the major therapeutic strategy for covid-19, along with the administration of corticosteroids, antivirals, broad-spectrum antibiotics and convalescent plasma. [9] at present, diverse trials have been launched, such as tocilizumab, losartan, hydroxychloroquine, remdesivir as well as convalescent plasma. [10] traditional chinese medicine (tcm) plays an important role in the prevention and treatment of various infectious diseases. to be specific, the application of tcm has also obtained significant therapeutic efficacy during the sars epidemic in 2003. [11] the combination of tcm and western medicines could relieve symptoms, enhance life quality, absorb lung infiltration, while attenuate the corticosteroid dosage among sars patients. [11] similarly, recent clinical practice has also revealed the significant therapeutic effect of tcm in covid-19. [12] china has issued guidelines for the diagnosis and treatment of covid-19, recommending the use of conventional treatment methods plus tcm. [9, 13] in the current chinese medical system, licensed practitioners of tcm are allowed to prescribe western medicines after a formal course of study. [14] therefore, the participation of tcm practitioners in the treatment of covid-19 is legal and supported by the government. during the entire treatment period of covid-19, chinese medical staff volunteered to join the designated hospitals in hubei province, [12] who comprehensively adopted acupuncture, chinese patent medicine, decoction and other characteristic therapies of tcm, shedding novel light on the control and prevention of covid-19. [12] in total, 303 ongoing clinical trials concerning the assessment of the therapeutic safety and efficacy for covid-19 patients have been launched in china by march 1, 2020, 50 of which focus on tcm, including 14 clinical trials aimed at evaluating the efficacy of tcm combined with western medicine. [15] at present, there are various types of evidence for tcm treatment of covid-19, [9, 13, 15] as shown in figure 1 . acupuncture, a main component of tcm, has been widely adopted to treat respiratory diseases in clinical practice, [16, 17] whose efficacy has been assessed by a number of randomized controlled trials (rtcs). [18] breathlessness is one of the prevalent symptoms in covid-19 patients. [8, 19] acupuncture may play a role in the prevention, treatment and rehabilitation of the covid-19 and relieve the symptoms caused by covid19 . acupuncture has been demonstrated to effectively relieving common symptoms in supportive and palliative care, including anxiety disorders, nausea, insomnia, leukopenia, fatigue as well as vomiting, [20] [21] [22] [23] [24] [25] which might also effectively treat abdominal pain and abdominal distension. [26, 27] coyle et al have proposed that acupuncture is an effective therapeutic approach for copdassociated breathlessness. [28] possible related symptoms of covid-19 treated with acupuncture is shown as figure 2 . the recent systematic review and meta-analysis show that acupuncture can relieve breathlessness in subjects with advanced diseases. [16] therefore, in this meta-analysis review, our goal is to systematically review the efficacy of acupuncture in relieving breathlessness, subsequently improving the physiological function and quality of life of patients with covid-19 combined with dyspnea. the study will be conducted in accordance with the preferred reporting items for systematic review and meta-analysis protocols (prisma-p). [29] 2.1. inclusion criteria 2.1.1. study type. randomized controlled trials (rcts) will be included in the review, without restriction on language or publication date. patients with breathlessness due to labconfirmed covid-19 will be included, regardless of age, race, sex. diagnosis of covid-19 is based on the international or chinese diagnostic criteria for covid-19. [3, 30, 31] 2.1.3. types of interventions. acupuncture will be performed in the treatment group, combined with other treatments, including routine therapy and so on. [9] patients in the control group will receive other therapeutic approaches other than acupuncture, including routine therapy, placebo, etc. 2.1.4. types of outcomes. the primary outcomes include the changes on any subjective measurement of breathlessness severity made on a validated rating scale from baseline to endpoint, including visual analogue scale, numerical rating scale and the borg scale. [32, 33] secondary outcomes include the assessment of quality of life activities using any validated questionnaire. in addition, anxiety will be evaluated by any validated scale. the safety of treatment will be assessed by the incidence and degree of adverse events. [34] [35] [36] 2.3. data collection and analysis 2.3.1. selection of studies. after searching studies, 2 investigators will review titles and abstracts, or full text if necessary. all investigators will reach agreement on the identification of study inclusion after evaluating their eligibility, and we will also record reasons why studies are eliminated. the selection process is summarized using prisma flow diagram. details of the selection procedure for studies are shown in a prisma flow chart (fig. 3) . any inconsistency is resolved by discussing with a third investigator. two investigators will extract relevant data independently, including study design, general information, characteristics of patients, comparison interventions, and outcomes. for articles with incomplete or uncertain data, the authors will be contacted for complete data. and the study will be further excluded without adequate information. if there is any dispute in the data extraction process, it will be submitted to a third researcher for processing. two investigators will independently evaluate the bias risks among enrolled researches according to the cochrane collaboration. [37] discrepancy will be resolved by discussion and judgment by an arbiter. the following seven aspects in all rcts will be evaluated: outcome assessment blinding, participants and personnel blind-ing, selective outcome reporting, allocation concealment, inadequate outcome data, generation of random sequences as well as other potential sources of bias. [37] the bias risk in each aspect will be assessed and divided into 3 levels: low risk, high risk, and unclear risk. 3) software will be used for statistical analysis if a meta-analysis is allowed. risk ratio will be calculated for dichotomous data. the intervention effect will be shown as the mean difference for continuous outcomes. additionally, 95% confidence intervals will be calculated. 2.3.5. heterogeneity evaluation. after stratifying the study according to the therapeutic duration and region, the chi-square test will be utilized to evaluate the heterogeneity and depressive symptoms. i 2 statistic will be utilized for quantification of heterogeneity degree, where i 2 >50% indicates the significant heterogeneity. [37] [38] [39] [40] 2.3.6. publication bias. the publication bias will be evaluated by funnel plots by determining whether there are 10 or more studies with the same outcome. in the case of asymmetric funnel plot, subgroup analysis or sensitivity analysis will be performed to investigate possible causes. [37, 41] 2.3.7. data synthesis. revman 5.3 software will be utilized for statistical analysis. the fixed-effects model will be employed to analyze data in the case of insignificant heterogeneity (i 2 < 50%). in the case of heterogeneity (i 2 ≥ 50%), subgroup analysis will be further conducted to decrease the clinical heterogeneity by taking into consideration of possible factors. if the heterogeneity is still significant, the random-effect model or qualitative description will be used. 2.3.8. sensitivity analysis. sensitivity analysis will be conducted by sequential omission of single study at a time, followed by simultaneously excluding 2 studies for identification of factors making the most contribution to heterogeneity. assessment of evidence quality. the grading of recommendations assessment, development and evaluation (grade) evaluation method of evidence quality will be used to evaluate the primary and secondary results of this study. the evidence quality will be categorized into high, moderate, low or very low according to five parameters (publication bias, indirectness, inconsistency, imprecision, and study limitations). since this study does not involve the patient privacy, ethical approval is not required. our research results will be shared and shown through conference reports and peer-reviewed journals. the pathogenesis and clinical symptoms related to severe respiratory disease were described many years ago in tcm texts. [42] there are many studies on current application of tcm in covid-19, [42, 43] such as the clinical outcome, pathogenesis and the current application of tcm on covid-19. the strength of our review includes the following 3 points. first, it is the first systematic review concerning the safety and effectiveness of acupuncture for breathlessness in covid-19. second, only rcts are included in our systematic review, which are more likely to provide unbiased information than other study designs. third, the comprehensive search strategy renders in-depth searching lists as well as trial registries associated with acupuncture and covid-19. however, the intrinsic methodological challenges among these enrolled trials will limit our systematic review. as a manipulated intervention, it is difficult to implement the blindness of therapeutic modes on acupuncturists. [44] [45] [46] [47] [48] acupuncture therapy could be further categorized into manipulation and needling instrument. in addition, there might be great variation on acupuncture therapy in these enrolled studies. although the above problem might be resolved and the consistency of interventions might be ensured by subgroup analysis, the comparability of enrolled researches will be decreased and the difficulty in meta-analysis will be increased. coronaviruses: an overview of their replication and pathogenesis coronavirus infections-more than just the common cold covid-19-new insights on a rapidly changing epidemic a novel coronavirus outbreak of global health concern presumed asymptomatic carrier transmission of covid-19 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention clinical characteristics of older patients infected with covid-19: a descriptive study a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version) discovering drugs to treat coronavirus disease 2019 (covid-19) chinese herbs combined with western medicine for severe acute respiratory syndrome (sars) traditional chinese medicine for covid-19 treatment is traditional chinese medicine useful in the treatment of covid-19? the dilemma and hope of traditional chinese medicine practitioners in china traditional chinese medicine in the treatment of patients infected with 2019-new coronavirus (sars-cov-2): a review and perspective acupuncture for breathlessness in advanced diseases: a systematic review and meta-analysis acupuncture for breathlessness in advanced diseases: methodological issues acupuncture: theory, efficacy, and practice characteristics,symptom management and outcomes of 101 patients with covid-19 referred for hospital palliative care the effectiveness of acupuncture in prevention and treatment of postoperative nausea and vomiting-a systematic review and meta-analysis effects of acupuncture on cancer-related fatigue: a meta-analysis interventions for sleep problems during pregnancy: a systematic review medicine (2020) 99:27 www.md-journal acupuncture for insomnia after stroke: a systematic review and meta-analysis acupuncture and electroacupuncture for anxiety disorders: a systematic review of the clinical research association of acupuncture and acupressure with improved cancer pain acupuncture for acute pancreatitis: a systematic review and meta-analysis efficacy and safety of acupuncture as an adjuvant treatment for acute pancreatitis: a protocol of systematic review and meta-analysis acupuncture therapies for chronic obstructive pulmonary disease: a systematic review of randomized, controlled trials preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015: elaboration and explanation national health commission of the people's republic of china.< guideline on diagnosis and treatment of covid-19 current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease 2019 (covid-19) measurement of feelings using visual analogue scales psychophysical bases of perceived exertion acupuncture for stable angina pectoris: a few noteworthy additions letter to the editor regarding "acupunctureinduced cranial epidural abscess: case report and review of the literature the efficacy and safety of xuebijing injection as an adjunctive treatment for acute pancreatitis: protocol for a systematic review and meta-analysis of randomized controlled trials cochrane handbook for systematic reviews of interventions version 5.1.0 [updated is nigella sativa supplementation effective for asthma? is endoscopic retrograde cholangiopancreatography safe during pregnancy? water exchange versus air insufflation for colonoscopy: methodological issues of the meta-analysis are a cause for concern xuebijing combined with ulinastation for sepsis:a few noteworthy additions traditional chinese medicine for novel coronavirus pneumonia treatment: main force or supplement traditional chinese medicine for treatment of coronavirus disease 2019: a review acupuncture on aromatase inhibitor-induced arthralgia in patients with breast cancer acupuncture for reduction of symptom burden in multiple myeloma patients undergoing autologous hematopoietic stem cell transplantation: a randomized sham-controlled trial. respond to author is acupuncture effective for knee osteoarthritis? comment on a recent trial traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the chinese healthcare system non-pharmacologic treatments for symptoms of diabetic peripheral neuropathy: a systematic review-methodological issues are a matter for concern key: cord-310210-f2wb3er0 authors: xie, runsheng; xia, yun; chen, yaolong; li, hui; shang, hongcai; kuang, xinying; xia, linjun; guo, yi title: the right extension statement for traditional chinese medicine: development, recommendations, and explanation date: 2020-09-02 journal: pharmacol res doi: 10.1016/j.phrs.2020.105178 sha: doc_id: 310210 cord_uid: f2wb3er0 nowadays, the number of traditional chinese medicine (tcm) guidelines is constantly increasing, but its reporting quality is still disappointing. one of the main reasons is that there is a lack of suitable reporting standard to guide it. low-quality reports impede the presentation of the guidelines’ content even if the guidelines are well projected and developed, thereby hindering the user’s integration and evaluation of guidelines and even misleading clinical decisions [1,2]. in response to this long-standing problem, the reporting items for practice guidelines in healthcare (right) working group has organized a group of tcm clinical experts, methodologists, and epidemiology, through a multi-staged development process, including systematic review, reporting quality evaluation and online delphi expert consensus, developed the right extension statement for tcm (right-tcm). the right-tcm extends two sections of the right statement, includes basic information and recommendations section. seven strong recommendation sub-items were added on the basis of right statement and formed the right-tcm finally. the group hopes that the right-tcm can assist tcm guideline developers in reporting guidelines, support journal editors and peer reviewers when considering tcm guideline reports, and help health care practitioners understand and implement a tcm guideline. this article will introduce its background, development, recommendations and explanation as follows. nowadays, the number of traditional chinese medicine (tcm) guidelines is constantly increasing, but its reporting quality is still disappointing. one of the main reasons is that there is a lack of suitable reporting standard to guide it. low-quality reports impede the presentation of the guidelines' content even if the guidelines are well projected and developed, thereby hindering the user's integration and evaluation of guidelines and even misleading clinical decisions [1, 2] . in response to this long-standing problem, the reporting items for practice guidelines in healthcare reporting quality is a significant part of the study of clinical guidelines. high-quality reports can fully explain the guideline development process and provide useful and clear recommendations for readers. to solve the reporting problem of guidelines, researchers from different countries studied extensively and presented relevant reporting standards. in 1993, a nine-item reporting standard was developed for the summary of clinical practice guidelines (cpgs), which is the first time to provide a template and basis for how to systematically and normatively report the information about the development and content of guidelines [3] . in 2003, the conference on guideline standardization (cogs) working group was established to develop a reporting standard for cpgs [4] . the cogs standard consists of 18 items that cover the entire process of guideline development, but it is limited to the clinical field and has not been updated since 2003. since the launch of appraisal of guidelines j o u r n a l p r e -p r o o f for research and evaluation ii (agree ii) in 2009, agree ii has been widely used in the quality evaluation of guidelines [5] [6] [7] . although it is stated in the statement that it can also be used as a reporting standard, researchers still generally use it as a quality evaluation tool. in 2016, the international right working group developed the right statement as a reporting tool for practice guidelines [8] . based on the world health organization guidelines and the items of the cogs and agree ii, this international reporting tool was developed in strict accordance with existing framework and the enhancing the quality and transparency of health research (equator) network approach. consisting of 22 items across 7 domains, the right statement has been widely applied to clinical practice, public health and health policy guidelines [9] [10] [11] . however, we found the right statement checklist does not fully applicable to the traditional chinese medicine guidelines and hard to reflect its major characteristics [12] . tcm is one of the oldest medical systems in the world and its theoretical system has unique characteristics of chinese culture and philosophy and has accumulated rich clinical experience [13] . for example, tcm is characterized by the concept of organic wholeness and treatment based on syndrome differentiation. its guidelines also reflect its distinctive characteristics and chinese traditional cultural characteristics. these factors may be ignored in the process of developing and reporting guidelines [14] . the reporting standard of the tcm guidelines should reflect the characteristics of chinese medicine itself. this idea was also endorsed by the right working group, and a multidisciplinary expert was organized to develop the extended version. the equator network approach was used as the methodological guidance for this research [15] , which included in the following three steps: (1) establishment of research working group, (2) systematic review of the literature and items establishment, (3) expert consensus and items selection. the grading of recommendations assessment, development and evaluation (grade) grid rules were used to reach decisions when the consensus is elusive (additional file 4) [16, 17] . more details of material and methods is presented in additional file 5. literature search and reporting quality evaluation. the diagram of the screening process is shown in fig. 1 . after screened for potentially eligible cpgs, a total of 539 tcm cpgs were eventually included (additional file 6). our previous research results showed that the reporting quality of these 539 tcm cpgs was improving, but the overall quality remained suboptimal [12] . there were some difficulties we encountered during the evaluation of the tcm guidelines when using the right statement. for example, in the background section, tcm have their own unique historical evolution. in terms of epidemiology, there is a lack of statistics on the basic epidemiology of the health problem of tcm. in terms of recommendations, there is a lack of reporting content concerning principle-method-recipe-medicines of tcm. in terms of evidence, there is no uniform reporting standard for the quality of evidence of ancient classic theoretical chinese medical case and famous experts experience. for these aspects, the existing right statement items are not well applicable for tcm. after extracting the information of these 539 tcm guidelines, the contents of 10 items were found not included in the right statement checklist. these items are reported to varying degrees in the tcm guidelines (fig. 2) . among of them, items 8, 9 and 10 j o u r n a l p r e -p r o o f (traditional chinese medicine decoction, traditional chinese patent medicine and acupuncture) are the contents often mentioned in interventions section of tcm guidelines. as shown in fig. 3 , the specific reporting content of these three items were further analyzed. after discussion in the face-to-face meeting, the core working group determined 24 initial sub-items based on the results of describe the acupuncture points, major points, matching points, and their addition and subtraction information. besides, other 16 weak recommendation sub-items were not included, but these items could be served as a reference for future research (table 1) . the present paper describes a multi-staged development process of the right-tcm, including one of the purposes of a systematic evaluation is to reduce random errors and systematic errors as much as possible through comprehensive searches and rigorous review and to provide near-real scientific evidence for decision makers [18, 19] . we have comprehensively collected the published cpgs for tcm and tried to use existing tools for evaluation. to begin with, we evaluated the reporting quality of tcm guidelines. the results show that the reporting quality of the tcm guidelines is poor, and the existing right statement cannot be fully suitable for the tcm guidelines. there is a requirement to develop an extension of the right statement to reflect the unique characteristics of tcm. in addition, we conducted a comprehensive analysis of the data from the tcm guidelines and condensed the data into initial items. we also used a brainstorming method to supplement the initial items, and we supplemented new items with such discussions to prevent omissions. moreover, we used the delphi method and grade grid rules in the consensus process. all the participating experts did not know each other, and they answered the questions raised without meeting each other and without discussion. this back-to-back anonymity has advantages and can avoid other influencing factors [20, 21] . finally, a total of 7 strongly recommended sub-items are determined as extension items into the right-tcm. for item 1 (s1 in the checklist of the right-tcm), it is recommended that a clinical guideline for tcm could be identified by the title. this item is useful for rapid judgment, screening and classification for the tcm guidelines. for item 6 (s2 in the checklist of the right-tcm), it is recommended to describe the principle and method of tcm treatment in the recommendations section. these general principles and basic methods for treating diseases are based on the unique concept of holism and syndrome differentiation and have guiding significance for the specific j o u r n a l p r e -p r o o f treatment measures in traditional chinese medicine [22] . for item 7 (s3 in the checklist of the right-tcm), it is recommended to describe whether to treat disease based on the syndrome differentiation of tcm. syndrome differentiation is an important basic concept of tcm [23] [24] [25] . it is the process of applying "principle-method-recipe-medicines" to clinical practice. for item 8 (s4 in the checklist of the right-tcm), it is recommended to provide clear and accurate description of tcm decoction in the intervention. tcm decoction refers to a method consisting of herbs with relatively specific processing methods and usage. the decoction is the main prescription of tcm, so it is necessary to make a detailed report on the tcm decoction [26, 27] . for item 8-5 (s4-1 in the checklist of the right-tcm), it is recommended to describe the administration route and frequency of tcm decoction. the administration route and frequency are also one of the ways to influence the efficacy of the medicine. the traditional administration route of tcm is mainly based on internal and external use (oral and dermatological drugs) [28, 29] . in addition, there are many administration routes such as inhalation, sublingual administration, mucosal surface administration, rectal administration [30] . currently, only 4% and 0.3% of the guidelines describe the route and frequency of administration, respectively. for item 10 (s5 in the checklist of the right-tcm), it is recommended to provide clear and accurate description of the acupuncture in the intervention. acupuncture is an important component of tcm interventions. acupuncture has been increasingly used as an integrative or complementary therapy and it is well-tolerated with little risk of serious adverse effects [31] [32] [33] [34] . for item 10-1 (s5-1in the checklist of the right-tcm), it is recommended to describe the acupuncture points, major points, matching points, and their addition and subtraction information. the acupoint is the area that the qi in meridian flows into the body surface and is the area where the needle is stabbed [35] . with the rapid development in recent years, tcm has been widely used in different area, and its guidelines and handbooks have also played an important role in public health emergency of international concern (pheic) [36] . such as part of "tcm classification therapy to improve curative efficacy" in the "handbook of covid-19 prevention and treatment" [37] . for pheic, the procedures and methodological requirements of the rapid advice guideline should be adopted [38] [39] [40] . however, the current right-tcm reporting items for the rapid advice guideline has yet to be developed, which may be a possible research direction in the future. although this study reflects the scalability of the right statement, there are some limitations need to attention. in the current study, we only study the standardized reports of the most commonly tcm interventions, such as tcm decoction, traditional chinese patent medicine and acupuncture. interventions of tcm also included moxibustion, massage and cupping, etc. therefore, we will revise the checklist in the future based on user feedback and evaluation results. in summary, seven strong recommendation sub-items were added on the basis of right statement and formed the right-tcm finally. we hope that the right-tcm can assist tcm guideline developers in reporting guidelines and improving the reporting quality, help the target audience understand and implement a guideline. fig. 1 the diagram of the screening process excluded practice guidelines developed by specialty societies: the need for a critical appraisal the scandal of poor epidemiological research more informative abstracts of articles describing clinical practice guidelines standardized reporting of clinical practice guidelines: a proposal from the conference on guideline standardization agree ii: advancing guideline development, reporting and evaluation in health care quality and reporting of guidelines on the diagnosis and management of dystonia development and validation of a tool to assess the quality of clinical practice guideline recommendations a reporting tool for practice guidelines in health care: the right statement reporting quality evaluation of clinical practice guidelines published in journals of mainland china in 2016 practice guidelines on migrants' health: assessment of their quality and reporting a quality evaluation of guidelines on five different viruses causing public health emergencies of international concern using the right statement to evaluate the reporting quality of clinical practice guidelines in traditional chinese medicine consort extension for chinese herbal medicine formulas 2017: recommendations, explanation, and elaboration (traditional chinese version) clinical practice guidelines in china guidance for developers of health research reporting guidelines grade guidelines: a new series of the journal of clinical epidemiology use of grade grid to reach decisions on clinical practice guidelines when consensus is elusive cochrane handbook for systematic reviews of interventions version 5.1.0. the cochrane collaboration david sackett and the birth of evidence based medicine: how to practice and teach ebm a delphi study to identify performance indicators for emergency medicine essential key messages about diagnosis, imaging, and self-care for people with low back pain: a modified delphi study of consumer and expert opinions a research on syndrome element differentiation based on phenomenology and mathematical method the basic theory, diagnostic, and therapeutic system of traditional chinese medicine and the challenges they bring to statistics study on tcm syndrome differentiation of primary liver cancer based on the analysis of latent structural model a large-scale, multi-center urine biomarkers identification of coronary heart disease in tcm syndrome differentiation application evaluation of clinical practice guidelines for traditional chinese medicine: a clinical analysis based on the analytic hierarchy process wendan decoction (traditional chinese medicine) for schizophrenia gut microbiota, a new frontier to understand traditional chinese medicines the rise of traditional chinese medicine and its materia medica: a comparison of the frequency and safety of materials and species used in europe and china inhaled insulin-intrapulmonary, intranasal, and other routes of administration: mechanisms of action non-pharmacological treatments for pain relief: tens and acupuncture acupuncture in hospice settings: a qualitative exploration of patients' experiences clinical efficacy of acupuncture on rheumatoid arthritis and associated mechanisms: a systemic review acupuncture for pain observation on clinical therapeutic effect of acupuncture treatment on functional dyspepsia based on syndrome differentiation the clinical benefits of chinese patent medicines the authors wish to express their gratitude to the following people who participated in the research and consensus process of the report specification: hao chen (nanjing university of chinese medicine theory. background section 3 describe the basis for diagnosing the disease based on biomedical theory and/or traditional chinese medicine theory.weak recommendation 4 describe the knowledge of disease pathogenesis in traditional chinese medicine theory.weak recommendation 5describe the specific reasons for using traditional chinese medicine to treat the disease.weak recommendation 6describe the principle and method of treatment for traditional chinese medicine in the recommendations. extension of right 13a item (recommendation section) 7describe whether to treat disease based on the syndrome differentiation of traditional chinese medicine. 8provide clear and accurate description of traditional chinese medicine decoction in the intervention. describe the name and provenance of traditional chinese medicine decoction. describe the herbal names, herbal addition and subtraction, dosage of traditional chinese medicine decoction.weak recommendation describe the composition principle, basis and interpretation of traditional chinese medicine decoction.no recommendation describe the decocting method of traditional chinese medicine decoction.weak recommendation describe the administration route (e.g., oral, topical), frequency of traditional chinese medicine decoction. describe the duration of treatment of traditional chinese medicine decoction.weak recommendation 9provide clear and accurate description of traditional chinese patent medicine in interventions.weak recommendation 9-1describe the product name (e.g., the trade name), provenance and manufacturer of traditional chinese patent medicine.no recommendation 9-2 describe the dosage of traditional chinese patent medicine.weak recommendation 9-3describe the administration route (e.g., oral, topical), frequency of traditional chinese patent medicine.weak recommendation 9-4describe the duration of treatment of traditional chinese patent medicines.weak recommendation provide clear and accurate description of the acupuncture in the intervention. describe the acupuncture points, major points, matching points, and their addition and subtraction information. 10-2 describe the specific information of the needling instrument used in the acupuncture process.weak recommendation 10-3describe the needling manipulation, needling depth and needling retention time of treatment required for acupuncture.weak recommendation describe the frequency of treatment required for acupuncture.weak recommendation describe the duration of treatment required for acupuncture.weak recommendation key: cord-336330-5m0fhoki authors: wong, r.w.k.; hägg, u.; samaranayake, l.; yuen, m.k.z.; seneviratne, c.j.; kao, r. title: antimicrobial activity of chinese medicine herbs against common bacteria in oral biofilm. a pilot study date: 2010-04-24 journal: int j oral maxillofac surg doi: 10.1016/j.ijom.2010.02.024 sha: doc_id: 336330 cord_uid: 5m0fhoki twenty traditional chinese medicines (tcm) were evaluated for their antimicrobial activity against four common oral bacteria. tcms were tested for sensitivity against streptococcus mitis, streptococcus sanguis, streptococcus mutans and porphyromonas gingivalis. aliquots of suspension of each bacterial species were inoculated onto a horse blood agar plate with tcms soaked separately on 6 mm paper disks. the plates were incubated for 48 h anaerobically and the mean diameters of growth inhibition of three different areas obtained. 0.2% (w/v) chlorhexidine was used as a positive control. broth microdilution assay was used to determine minimum inhibitory concentration and minimum bactericidal concentration. fructus armeniaca mume was effective against all four bacteria. thirteen tcms demonstrated antimicrobial activity against porphyromonas gingivalis, including cortex magnoliae officinalis, cortex phellodendri, flos caryophylli, flos lonicerae japonicae, fructus armeniaca mume, fructus forsythiae suspensae, herba cum radice violae yedoensitis, herba menthae haplocalycis, pericarpium granati, radix et rhizoma rhei, radix gentianae, ramulus cinnamomi cassia and rhizoma cimicifugae. cortex phellodendri showed antimicrobial activity against streptococcus mutans, while radix et rhizoma rhei was effective against streptococcus mitis and streptococcus sanguis. fructus armeniaca mume had inhibitory effects against streptococcus mitis, streptococcus sanguis, streptococcus mutans and porphyromonas gingivalis in vitro. the oral cavity contains a variety of bacteria that may cause dental caries, periodontal disease, postoperative infections after surgery or trauma or superinfections in immunocompromised patients. as new infections and bacterial resistance are con-stantly emerging, the search for novel drugs or chemicals to combat oral infection is always warranted. oral bacteria usually aggregate to form a biofilm or plaque on tooth surfaces. plaque formation involves initial colonization and multiplication by pioneer species, followed by secondary colonization by other species and finally becoming a climax community 1 . the 'pioneer species' of plaque are streptococcus oralis, streptococcus mitis and streptococcus sanguis. specific bacteria are also closely related to specific dental diseases, for example, streptococcus mutans and porphyromonas gingivalis are associated with dental caries and periodontal disease, respectively 11 . traditional chinese medicines (tcm) have been used in china to treat infectious diseases for more than 4000 years. in the past decade, many new pathogenic microorganisms emerged and there were alterations to existing infections, such as severe acute respiratory syndrome (sars), which was difficult to control and caused significant mortality. there is an urgent need to screen for natural products to identify a bank of antimicrobial materials that may be used against these infections, either alone or in combination. the use of natural products may decrease the opportunity for the development of drug resistance in microorganisms as they are surrounded by a group of antimicrobial chemicals acting together. in the oral cavity, a number of pathogenic organisms cause caries and periodontal diseases. oral bacteria provide a good starting point for investigating the antimicrobial activities of tcm because the oral cavity is a strategic place for the development of infective disease and in vivo and clinical studies are easy to carry out. unlike western medicine, tcm works as a formula of herbs that is tailored to the individual patient and their specific condition. they are designed using one or two main ingredients that target the illness, with the addition of many other ingredients to adjust the formula to suit the patient's condition 4 . the advantage of using several tcms together can also be considered a disadvantage because the treatment does not consist of a single drug. some tcm formulae have been used effectively. one example is realgar-indigo naturalis for the treatment for promyelocytic leukaemia; a recent clinical trial showed a complete remission rate of 97% 8 . the mechanism of action has recently been investigated at the molecular, cellular and organism levels 14 . tcms possess a variety of biological properties and can be developed to produce many effective drugs. certain tcms have antibacterial properties 16 . few studies have been performed to screen these tcms to see whether they are effective against bacteria forming an oral biofilm. all tcms consist of natural products, some of which are cheap and easy to obtain, although others come from endangered animal and plant species. if any tcms are effective in inhibiting the bacteria commonly found in the oral biofilm, they might reduce the oral biofilm and aid in the prevention of dental caries and periodontal disease. they could have an extensive impact on the prevention of oral disease and improve oral health. existing antimicrobial mouth rinses, such as chlorhexidine and listerine 1 , are inedible and may be harmful if ingested. there is a need to search for less harmful agents that can produce a similar antimicrobial effect. chlorhexidine gluconate is one of the most common conventional oral antimicrobial agents. it is effective against a broad spectrum of bacteria, yet it is artificial and inedible. owing to overuse of antimicrobial agents, some bacteria start to develop resistance towards them. it is therefore necessary to develop new antimicrobial agents to replace or enrich the existing choice of oral antimicrobial agents. the potential advantage of using tcm rather than artificial oral antimicrobial agents is that they are natural substances and some are edible. it may also allow the combination of different tcm rather than a single oral antimicrobial agent, which lowers the chance of cross-resistance in bacteria. further research is needed to confirm this. a number of tcm herbs are already used in oral healthcare products, such as toothpaste, to improve oral health, which shows that tcm has great potential to be developed as a product for day-to-day use. in this study, the authors investigate the antimicrobial activity of some tcms that have been used to treat symptoms related to infection (e.g. fever, inflammation, cough) on several bacteria found in the oral biofilm to identify potential agents to control oral infections and diseases. type cultures of s. mitis (atcc 15914), s. sanguis (atcc 10556), s. mutans (atcc 35668) and p. gingivalis (atcc 33277) from the oral bioscience laboratories of the faculty of dentistry, the university of hong kong, were used in the study 16 . frozen isolates were thawed and their identity reconfirmed using standard methodology. they were inoculated onto horse blood agar (hba) and incubated for 3 days at 37 8c. the bacteria cultures were harvested and suspended in phosphate buffered saline at a concentration of 1 â 10 6 cells/ml (0.5 macfarland standard units) for sensitivity studies. identification and preparation of tcm extracts tcm were purchased from local chinese medicine store and were identified mor-phologically, histologically and chemically using standard chinese herbal identification procedures 3 . voucher specimens including the identification and classification of all the tcms to be tested were stored in the hard tissue laboratory, university of hong kong. tcm extracts were prepared using standard protocols for aqueous extraction 5 . briefly, 4 ml distilled water was added to 10 g of tcm powder. the mixture was boiled under stirring on a hot plate for 4 h. distilled water was added occasionally to prevent drying. at the end of boiling, distilled water was added to make up the volume of the mixture to 4 ml. the mixture was cooled, centrifuged and filtered. this produced 2.5 g/ml of one tcm extract. the 20 tcm drugs chosen for the study were cortex magnoliae officinalis (hou po), cortex phellodendri (huang bai), flos caryophylli (ding xiang), flos chrysanthemi morifolii (ju hua), flos lonicerae japonicae (jin yin hua), fructus armeniaca mume (wu mei), fructus forsythiae suspensae (lian qiao), herba cum radice asari (xi xin), herba cum radice houttuyniae cordatae (yu xing cao), herba cum radice violae yedoensitis (zi hua di ding), herba ephedrae (ma huang), herba portulacae oleraceae (ma chi xian), herba menthae haplocalycis (bo he), pericarpium granati (shi liu pi), radix et rhizoma rhei (da huang), radix gentianae (long dan cao), radix isatidis (ban lan gan), ramulus cinnamomi cassia (gui zhi), rhizoma cimicifugae (sheng ma) and semen raphani (lai fu zi). chlorhexidine gluconate, a common oral antiseptic, at a concentration of 0.2% (w/v) was used as a positive control for all experiments. the standard agar diffusion assay for sensitivity testing 9,10 was performed according to a standard protocol designed by samaranayake et al. 12 . briefly, 20 ml aliquots of suspension of each bacterial species were inoculated on an hba plate using a glass rod, then 6 mm diameter paper disks soaked in 10 ml of each of the tcm extracts at a concentration of 2.5 g/ml were placed concentrically on the hba plate. disks soaked in 10 ml of 0.2% (w/v) chlorhexidine were used as positive controls and were also placed in the hba plates. the hba plates were incubated for 48 h anaerobically at 37 8c. naked eye measurements of the growth inhibition zone, if any, were evaluated using calibrated computer software. the diameters of growth inhibition in three different areas were measured and the mean diameter of growth inhibition was calculated for each organism. the experiment was repeated on three separate occasions. the tcms, rhizoma coptidis and galla chinensis, which showed potent antimicrobial activity against the four tested bacteria in the agar diffusion assay screening test, were selected for minimum inhibitory concentration (mic) determination using the standard broth microdilution assay 2,6,7 . in brief, bacteria were cultured anaerobically in hba for 3-7 days at 37 8c. the bacterial cultures were harvested and suspended in an appropriate medium (depending on the species) at a concentration of 1 â 10 6 cells/ml (0.5 macfarland standard units). broth microdilution assay was performed in polystyrene, 96well microtiter plates as previously described 13 . each plate included a positive control (bacteria without the drug) and negative control (medium only) and serial two-fold dilution of the drug. p. gingivalis suspensions were prepared in 'p. gingivalis broth' whereas other bacterial species were prepared in brain heart infusion broth. bacterial inoculums were prepared as described previously and 100 ml of 1 â 10 6 cells/ml bacterial suspensions were added to each well. subsequently, microtiter plates were incubated for 48 h at 37 8c in an anaerobic chamber. visual inspection was used to determine the mic. after mic determination, 20 ml of suspension from each well was inoculated in blood agar plates for 48 h for observation. the lowest drug concentration that yielded no growth was documented as minimum bactericidal concentration (mbc). for p. gingivalis all the procedures took the slow growth of the organism into account. tcms that passed all three tests are classified as tcms that have an inhibitory effect towards specific bacteria. those that showed only a weak inhibitory effect in one or two tests, but not all, are classified as partially effective in the inhibition of specific bacteria. the inhibition zone measured for chlorhexidine against s. mitis was 7.4 mm compared with those of radix et rhizoma rhei (da huang) and fructus armeniaca mume (wu mei) which were 4.4 mm and 11.3 mm, respectively (table 1 ; figs. 1 and 5) . the average inhibition zone diameter measured for chlorhexidine against s. sanguis was 9.1 mm, compared with 3.6 mm and 11.7 mm for radix et rhizoma rhei (da huang) and fructus armeniaca mume (wu mei), respectively (table 1 ; figs. 2 and 5). radix et rhizoma rhei (da huang) demonstrated a comparable effect to chlorhexidine against s. mitis, while fructus armeniaca mume (wu mei) showed signs of a stronger effect than chlorhexidine (9.1 mm) against s. mitis and s. sanguis. two of 20 tcm extracts tested demonstrated consistent antimicrobial activity with zones of growth against s. mutans. for the remaining tcms, cortex phellodendri (ding xiang), flos chrysanthemi morifolii (ju hua), flos lonicerae japonicae (jin yin hua), herba cum radice houttuyniae cordatae (yu xing cao) and herba ephedrae (ma huang) showed weak antimicrobial effects against s. sanguis. while flos chrysanthemi morifolii (ju hua) and herba ephedrae (ma huang) demonstrated weak antimicrobial effects against p. gingivalis (table 1) . data were analyzed with statistical analysis computer software (spss 15.0 for windows # , chicago, usa). a one-way anova was used to compare the effects of different tcms. differences were considered significant when the p-value was less than 0.05. all the tcm results that were shown to be effective against individual bacteria in this experiment proved to be significant (table 1) . the mic values for fructus armeniaca mume (wu mei) against s. mutans, s. mitis and s. sanguis were 0.0781 g/ml. the mic value against p. gingivalis was 0.0003 g/ ml ( table 2 ). the mbc values for fructus armeniaca mume (wu mei) against s. mutans and s. mitis were 0.1563 g/ml. its mbc value against s. sanguis was 0.0781 g/ml and 0.0003 g/ml against p. gingivalis (table 2 ). in this study, 20 tcm extracts were evaluated for their antimicrobial activities against four common bacterial species present in the oral cavity, which are important in biofilm formation (s. mitis, s. sanguis), as a cause of dental caries (s. mutans) or as a cause of periodontal disease (p. gingivalis). this research showed that some tcm are active against oral bacteria. this is one of the first studies to show this possible association. further research is needed to substantiate this and to evaluate the principles of tcm when applied to antibacterial treatment. fructus armeniaca mume (wu mei) was shown to be very effective against all four bacteria; this study is one of the first to show its effects specifically on oral bacteria. fructus armeniaca mume (wu mei), also known as prunus mume or japanese apricot, is a common fruit in asia, which is eaten in its raw form and used as a herbal medicine after it has been cooked and aged. as a tcm, fructus armeniaca mume (wu mei) is taken internally to relieve cough and used externally for the removal of warts and corns. 15 its antibacterial effect on some bacteria is known, but no research has been carried out on its action against oral bacteria. it has low toxicity compared with inedible oral antiseptic mouth rinses (e.g. chlorhexidine), costs little and is widely available. if it is effective in inhibiting the bacteria commonly found in the oral biofilm, it may be a safe agent for the effective reduction of the oral biofilm and the prevention of dental caries and periodontal disease. the authors compared the antimicrobial activity of tcms with one effective oral antiseptic, chlorhexidine. the authors showed that they have comparable effects. this research is the first study that investigates tcms specifically on oral bacteria. tcms are promising agents in the development of new antibacterials for oral microorganisms. this study is a key step in the discovery of new drugs/treatments using tcm. further research is needed to identify the active components related to the antibacterial action, to determine the range of action, and to investigate the mechanisms involved. the antibacterial actions include the mic and mbc. it is also necessary to test the antibacterial action on other oral bacteria and fungi. tcm extracts that are less effective against oral bacteria, have potential for further investigation because the active components inside the extracts may only present in very low concentration, so although they may be very effective, the overall antibacterial effect of the extracts is small. further research will focus on four strategies. the active components in the antimicrobial action of fructus armeniaca mume should be identified and the mechanisms investigated. it contains a number of acids (e.g. citric acid, malic acid, oxalic acid, succinic acid, fumaric acid, tartaric acid, picric acid); these might create a low ph environment that may account for its antibacterial effect. several herbs that have an antibacterial action can be combined. this may allow more effective control of microorganisms, and it may be possible to combat the newly emerging resistant microorganisms. tcm with similar properties to fructus armeniaca mume should be screened for their antimicrobial actions. in vivo and clinical studies should be carried out to optimize the clinical use of fructus armeniaca mume in mouth rinses, toothpaste, chewing gum and other oral products. in this study, fructus armeniaca mume was found active against all four oral bacteria. this result is unexpected as fructus armeniaca mume is used for cough suppression in tcm. this shows that only investigating herbs with strong suggestions of antimicrobial action is not enough as some important sources of antibicrobial action may be missed. in conclusion, fructus armeniaca mume had inhibitory effects on s. mitis, s. sanguis, s. mutans and p. gingivalis in vitro. it is possible that its acidic content accounts for its wide antibacterial spectrum. this study was supported by the university research grant no.: 10207346.15633. 08003.323.01, the university of hong kong. the author(s) declare that they have no competing interests. not required. my performed tcm collection, method development, validation, result analysis and manuscript drafting. cs performed mic and mbc data collection. rw and uh participated in the design of the study, selection of tcm for testing and manuscript drafting. rw, uh and ls conceived the idea of the study and participated in its design and coordination. all authors approved the final manuscript. effect of two antimicrobial agents on early in situ biofilm formation gooeliñ ska o, muszyñ ski z. antimicrobial activity of viola tricolor herb lamer-zarawska e. screening for antimycotic properties of 56 traditional chinese drugs trends in alternative medicine use in the united states coptidis rhizoma inhibits growth and proteases of oral bacteria in vitro antimicrobial activities of bakuchiol against oral microorganisms antibacterial therapy: in vitro testing, pharmaco-dynamics, pharmacology, new agents long term follow-up confirms the benefit of all-trans retinoic acid and arsenic trioxide as front line therapy for newly diagnosed acute promyelocytic leukaemia antimicrobial flavonids from the stem bark of erythrina burtii antimicrobial and cytotoxic constituents from seeds of annona squamosa essential microbiology for dentistry in vitro method to study antifungal perfusion in candida biofilms the inhibitory effects of naringin on the growth of periodontal pathogens in vitro dissection of mechanisms of chinese medicinal formula realgar-indigo naturalis as an effective treatment for promyelocytic leukemic shanghai: shanghai scientific technology publisher chinese materia medica (chemistry, pharmacy + application) address: ricky w.k. wong faculty of dentistry the university of hong kong philip dental hospital 34 hospital road hong kong china tel acknowledgement. the authors thank ms. j. yau on her technical assistance. key: cord-282699-tuas2tgd authors: liu, wei-hong; guo, sheng-nan; wang, fang; hao, yang title: understanding of guidance for acupuncture and moxibustion interventions on covid-19 (second edition) issued by caam date: 2020-03-17 journal: world j acupunct moxibustion doi: 10.1016/j.wjam.2020.03.005 sha: doc_id: 282699 cord_uid: tuas2tgd at present, the situation of global fight against covid-19 is serious. who (world health organization)-china joint mission fully confirms the success of “china's model” against covid-19 in the report. in fact, one particular power in “china's model” is acupuncture and moxibustion of traditional chinese medicine. to better apply “non-pharmaceutic measures”—the external technique of traditional chinese medicine, in the article, the main content of guidance for acupuncture and moxibustion interventions on covid-19 (second edition) issued by china association of acupuncture–moxibution is introduced and the discussion is stressed on the selection of moxibustion device and the duration of its exertion. novel coronavirus pneumonia was renamed by world health organization (who) to be "2019 coronavirus disease" recently. it is the infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and it is a kind of atypical pneumonia. on 1 december 2019, the first case of covid-19 was confirmed in the city of wuhan, hebei province, china and the virus that started the pneumonia outbreak spreads in the country. the major source of infection is the patients with covid-19 and asymptomatic sars-cov-2 carriers seem also a potential source of infection. it is mainly transmitted by respiratory droplets, contact, digestive tract and aerosol transmission. this disease is characterized as highly contagious and is susceptible to humans of all ages. on 8 january, 2020, the first case of covid-19 was confirmed in thailand, which is the earliest confirmed case outside china [1] . on 20 january, the first confirmed case was identified in the republic of korea [2] . since then, a number of cases were confirmed in singapore, italy, iran, the united states, russia, etc. thus far, this disease has spreaded globally. on 31 january 2020, who declared this epidemic outbreak a public health emergency of international concern (pheic) [3] . on * corresponding author. 2 march 2020, tedros adhanom ghebreyesus, the director-general of who, pointed in the opening remarks at the media that outside china, a total of 8739 cases of covid-19 have been reported to who from 61 countries, with 127 deaths [4] . the epidemics in the republic of korea, italy, iran and japan are of greatest concerns. the fight against covid-19 gets more serious globally. from 16 to 24, february 2020, 25 international and chinese experts of the who-china joint mission traveled to beijing, hubei, guangdong and sichuan, china to investigate the fight against the epidemic. on the second day after the end of investigation, dr. bruce aylward, the head of the international expert panel of the who-china joint mission, the senior adviser to the who's director-general, stated at the press briefing at who headquarters in geneva, that faced with the unknown pathogen, china has taken ambitious, flexible and aggressive efforts in responding to the epidemic. in the report, who-china joint mission has confirmed that china has played a crucial role in protecting the international society, buying precious time for countries to adopt active prevention and control measures and providing them with worthwhile experiences. the report also points out specifically the high effective role of non-pharmaceutic measures [5] . the report said that china, as the country with the greatest knowledge on covid-19, should further enhance the systematic and real-time sharing of epidemiologic data, clinical results and experience to inform the global response. with regard to "non-pharmaceutic measures" proposed in the report of who-china joint mission, besides active surveillance, timely detection, voluntary quarantine and rigorous tracing, actually, there is still a mysterious power, that is various kinds of external therapeutic approaches of traditional chinese medicine (tcm). by the time for the authors submitting the manuscript, it is known that many therapeutic methods of tcm, e.g. chinese herbal decoction, acupuncture, moxibusiton, acupoint plaster, auricular acupuncture and cupping have adopted in the treatment of covid-19. in the regions where tcm therapeutic methods were highly utilized, the curative rate was increased, the number of severe case decreased and the hospital discharge rate improved remarkably [6] . the utilization of tcm therapeutic interventions block effectively the continuous spreading of covid-19 in china. in response to the chinese government's call upon the solidarity in the fight against covid-19 and to better apply the external techniques of tcm to the prevention, treatment and rehabilitation of covid-19, china association of acupuncture-moxibustion (caam) developed and issued guidance for acupuncture and moxibustion intervention on covid-19 (second edition) (hereinafter guidance ) [7] . the main content of guidance is introduced as follows to assist in the effective application of tcm techniques, e.g. acupuncture and moxibustion in treatment of covid-19. three sections are included in guidance , named the principle of acupuncture-moxibustion interventions, the methods of acupuncture-moxibustion interventions, and the self-interventions of acupuncture and moxibustion at home under the instruction of physician. regarding the principle of acupuncture-moxibustion interventions, guidance emphasizes: the rigorous quarantine and disinfection are required. no matter for the confirmed cases or the convalescent cases, they can be treated in the same room respectively and every suspected one should be isolated in a single room for treatment. during the clinical treatment stage, acupuncture can be combined with western medications and chinese herbal decoction to achieve the collaborative effect. for the cases at the recovery stage, the core role of acupuncture-moxibustion should be played in the rehabilitation. it is recommended to set up acupuncturemoxibustion based covid-19 rehabilitation clinic. in reference to the clinical stage identification of tcm suggested in diagnosis and treatment plan of corona virus disease 2019 (tentative seventh edition) issued by national health commission (nhc) of the prc and state administration of traditional chinese medicine (satcm) of the prc, three stages are included in the treatment with acupuncture and moxibustion, e.g. medical observation stage, medical treatment stage and recovery stage. the therapeutic regimens of each stage are introduced as follows. objective: to motivate the antipathogenic qi of human body and the functions of lung and spleen and scatter epidemic pathogens so as to strengthen the defensive capacity of internal organs. main acupoints: group 1: f ēngmén ( bl12), fèish ū ( bl13), and písh ū ( bl20). group 2: hég ȗ ( li4), q ūchí ( li11), ch ȋzé ( lu5) and yújì ( lu10). group 3: qìh ȃi ( cv6), zús ānl ȋ ( st36) and s āny īnji āo ( sp6). one or two acupoints are selected from each group in one treatment. symptomatic acupoints: for fever, dry throat and dry cough, dàzhu ī ( gv14), ti ānt ū ( cv22) and k ȏngzuì ( lu6) are added. for nausea, vomiting, loose stool, swollen tongue with sticky coating and soggy pulse, zh ōngw ȃn ( cv12), ti ānsh ū ( st25) and f ēnglóng ( st40) are added. for fatigue and anorexia, cv12 and the four points around the umbilicus (1 cun bilateral, directly above and below the center of the umbilicus), bl20 are added. for clear nasal discharge, soreness of the shoulders and the back, pale tongue with white coating and slow pulse, ti ānzhù ( bl10), bl12 and gv14 are added. objective: to propel the antipathogenic qi of lung and spleen, protect internal organs, reduce damage, eliminate the epidemic pathogens, cultivate the earth to generate the metal, block the development of illness, ease the emotions and strengthen the confidence on conquer the pathogens. main for low fever or feverish sensation and discomforts in the body, or fever absence, nausea, vomiting, loose stool, pale or slightly red tongue with white or white sticky coating: bl13, st25, fùjié ( sp14) and pc6 are added. objective: to clear away residual toxins, restore the primary qi , promote the repair of internal organs and recover the functions of lung and spleen. main acupoints: pc6, st36, cv12, st25 and cv6. the main symptoms are shortness of breath, fatigue, anorexia, nausea, vomiting, fullness in the epigastric region, weakness in defecation, loose stool, incomplete bowel movement, pale and swollen tongue with white and sticky coating. for the cases with marked symptoms of lung system, e.g. chest oppression and shortness of breath, cv17, bl13, lu1 are added. for the cases with marked symptoms of spleen and stomach dysfunction, e.g. poor appetite and diarrhea, shàngw ȃn ('¸'š'"'˜cv13) and y īnlíngquán ( sp9) are added. (2) qi and yin deficiency the main symptoms are fatigue, dry mouth, thirst, palpitation, profuse sweating, poor appetite, low fever or fever absence, dry cough with little sputum, dry tongue and lack of moisture, thready or weak pulse of deficiency type. for the cases with marked fatigue and shortness of breath, cv17 and shénquè ( cv8) are added. for the cases with marked dry mouth and thirst, tàix ī ( ki3) and yángchí ( te4) are added. for the cases with marked palpitation, bl15 and juéy īnsh ū ( bl14) are added. for the cases with profuse sweating, li4, fùli ū ( ki7) and st36 are added. for the cases with insomnia, shénmén ( ht7), yìntáng ( ex-hn3), ā nmián ( ex-hn22) and y ȏngquán ( ki1) are added. the main symptoms are chest oppression, shortness of breath, dislike to speak, lassitude, sweating on exertion, cough with sputum, difficulty in expectoration, coarse skin, mental fatigue, loss of appetite, etc. bl13, bl20, bl15, bl17, shènsh ū ( bl23), lu1 and cv17 are added. for difficulty in expectoration, st40 and ex-b1 are added. guidance points out specifically that either acupuncture or moxibustion is optioned corresponding to the individual conditions at each stage of covid-19. additionally, the combination of these two interventions or the combination with acupoint application, auricular therapy, acupoint injection, scraping therapy, infantile tuina or acupoint massage is adopted accordingly. the even needling technique of acupuncture is used and the needle is retained for 20-30 min at each acupoint. moxibustion is exerted for 10-15 min at each acupoint. the treatment is given once daily. the manipulation is implemented in reference to the national standard, gb/t21709 standardized manipulations of acupuncture and moxibustion and clinical experiences. the third section of guidance is the most characteristic: the self-interventions of acupuncture and moxibustion at home under the instruction of physician. moxibustion therapy: moxibustion is applied by the patient him/herself at st36, pc6, li4, cv6, cv4, sp6, etc., about 10 min at each acupoint. acupoint application therapy: the plaster, e.g. moxibustionthermal plaster or moxibustion-like plaster, is used at st36, pc6, cv6, cv4, bl13, bl12, bl20, gv14, etc. tuina therapy at meridian and acupoints: the different tuina methods are exerted at the acupoints on the lung meridian and the heart meridian, the acupoints located below the knee on the spleen meridian and the acupoints on the stomach meridians, such as finger-pressing method, kneading method, palm pressing method, kneading-pressing method, tapping method or knocking method. each manipulation is exerted for 15-20 min till the patient feels soreness and distention in the local area. traditional physical exercise: the traditional physical exercise is optional according to the individual recovery conditions, including yijinjing (exercise for muscle and tendon strengthening), taijiquan ( taiji boxing), baduanjin (eight-section exercise), wuqinxi (five-animal exercise), etc. each physical exercise is applied once daily, 15 to 30 min each time. emotional counseling: the attention is paid to emotional regulation. auricular points, moxibustion, tuina , herbal diet, herbal tea, medicated bath and music are applicable in combination for physical and mental relaxation, anxiety relief and sleep assistance. foot bath and fumigation-washing therapy: the herbs for expelling wind, clearing heat and eliminating pathogen are selected, i.e. j īngjiè ( herba schizonepetae ), àiyè ( folium artemisiae argyi ), bòhe ( herba menthae ), yúx īngc ȃo ( herba houttuyniae ), dàq īngyè ( folium isatidis ), pèilán ( herba eupatorii ), shích āngpú ( rhizoma acori tatarinowii ), làli ǎoc ǎo ( polygonum lapathifolium l .), yùj īn ( radix curcumae ) and d īngxi āng ( flos caryophylli) , 15 g for each, as well as b īngpiàn ( borneolum syntheticum ) 3 g. the decocted chinese herbal liquid is poured into a foot tub and an appropriate amount of warm water is added. when the water is ready at 38-45 °c, foot bath is exerted for around 30 min. all of the interventions above are the dominant techniques of health care in tcm. their utilization fully embodies the idea of "disease prevention" in tcm, meaning, preventing from illness before suffering, preventing from the progress of illness after suffering and preventing from recurrence after cured. they play the crucial role in reducing the incidence of covid-19 and preventing from its recurrence. search and experimental research of acupuncture and moxibustion and in reference to a series of achievements obtained in the effect mechanism research of acupuncture and moxibustion in recent years. firstly, the regimens recommended in guidance are in agreement to the staging of tcm treatment in diagnosis and treatment plan of corona virus disease 2019 (tentative seventh edition) issued by nhc and they focus specially on the characteristics of acupuncture-moxibustion therapies. secondly, the implementation of various therapeutic methods is in compliance with "being convenient, safe and effective". thirdly, guidance determines its efforts for the contribution of acupuncture-moxibustion therapies to each stage of the diseases, points out the combination of acupuncture with western medication and chinese herbal decoction, plays the coordination effect of acupuncture and moxibustion and believes the crucial effect of acupuncture and moxiustion at the recovery stage of covid-19. covid-19 is the seriously epidemic disease. tcm and acupuncture-moxibustion have not been adopted as the first option in treatment. besides the limited understanding in the effectiveness of them, the other key reason is for tcm therapy, especially acupuncture-moxibustion, the physician has to very closely contact with patient during treatment, which highly increases the infectious incidence of medical staffs. therefore, the protection to medical staffs must be in the top priority when exerting acupuncture, moxibustion, seed-pressure of auricular acupuncture, cupping, scraping, etc. the acupuncture physicians who had participated in the treatment of covid-19 responded that it is very inconvenient to operate acupuncture with three-layer protective gloves. in case the gloves are broken, infection may occur. the authors believe that for moxibustion interventions, the mild moxibustion with hand-holding moxa stick is not suggested. the moxibustion device with the function of smoke abatement or smoke discharge should be optioned to avoid the stimulation of moxa smoke to the respiratory tract of patient. but, such mild moxibustion with hand-holding moxa stick can be applicable for the home nursing care. regarding the effectiveness of moxa smoke, the consensus has not been met yet in academic field. but, in reference to the records of ancient medical works and the nowadays popular method of moxibustion in the folk, moxa smoke is applicable for the prevention of infectious diseases. for example, it is recorded in zh ȏuhòu bèijíf āng ( emergency formulas to keep up one's sleeve ), written by hong ge, in the jin dynasty(317 −420ad) that smoking with moxa around the patient's bed, one moxa cone on each side of the bed is optimal to prevent from epidemic infection. the medical masters in the later generations had inherited this idea. the same prevention method is also recorded in tàipíng shènghuìf āng ( formulas from benevolent sages compiled during the taiping era ) and p ȗjìf āng ( formulas for universal relief ). this moxibustion intervention is the earliest-recorded measure of air disinfection in history. the modern research discovers that moxa smoke acts on antibacteria, anti-fungus, anti-virus and anti-pathogen [8] . therefore, on the base of individual tolerance, the appropriate use of moxa smoke in room brings a certain effect of disinfection. in guidance , the duration of moxibustion at each acupoint is 10 to 15 min. but, in clinical practice, the moxibustion is seldom exerted on acupoints one by one. instead, the special device, moxa box or moxa holder is used to cover several acupoints simultaneously in one moxibustion intervention. the duration of treatment is over 30 min generally and it will be even longer if the heat-sensitive moxibustion is exerted. therefore, the authors believe that the duration of moxibustion intervention should be longer to achieve a better effect if the patient is in a comfortable posture and has strong endurance. compared with guidance of the first edition, the content of guidance of the second edition is much richer and more practi-note: picture from cctv cal and instructive. with the development of covid-19, the people are getting deep understanding of the disease and more and more experiences in treatment will be accumulated gradually. it also reflects that the nature of medical development is the process of constant understanding, rectification and conquering disease. at present, covid-19 is spreading in many countries of the world. china's experiences in fight against covid-19 have been recognized and advocated by who. of them, the application of chinese herbal medication, acupuncture and moxibustion have their unique characteristics. undoubtedly, the modern medicine measures give priority to treatment and salvage of covid-19. but, no matter which medical theoretic system is adopted, faced with the epidemic, every measure should aim to treating disease and saving lives. more weapons available in the fight against the disease do bring more benefits to patients. [the english version of the guidance for acupuncture and moxibustion interventions on covid-19 (second edition) can be seen at http://en.wfas.org.cn/news/detail.html?nid=5373&cid=25 ]. the first confirmed patient with covid-19 in japan is discharged is the first case of covid-19 from? who declares global emergency as wuhan coronavirus spreads who-director-general-s-opening-remarks-at-the-media-briefing-on-covid joint mission: "non-pharmaceutic interventions" have played a highly effective role the integrative chinese and western medicine is very effective on the mild case. medication is not encouraged in disease prevention china association of acupuncture and moxibustion. notice on issuing guidance for acupuncture and moxibustion intervention on covid-19 history and current situation of moxibustion in prevention and treatment of epidemic diseases understanding of guidance f or acupunct ure and moxibust ion interv ent ions on cov key: cord-277970-sb1wjd3b authors: kang, qianli; wang, yanyan; cui, qinghua; gong, lili; yang, yong; jiang, haiqiang; rong, lijun; rong, rong; du, ruikun title: screening for anti-influenza actives of prefractionated traditional chinese medicines date: 2020-10-14 journal: evid based complement alternat med doi: 10.1155/2020/4979850 sha: doc_id: 277970 cord_uid: sb1wjd3b traditional chinese medicines (tcms) have proven to possess advantages in counteracting virus infections according to clinical practices. it's therefore of great value to discover novel antivirals from tcms. in this paper, one hundred medicinal plants which have been included in tcm prescriptions for antiviral treatment were selected and prefractionated into 5 fractions each by sequentially using cyclohexane, dichloromethane, ethyl acetate, n-butanol, and water. 500 tcm-simplified extracts were then subjected to a phenotypic screening using a recombinant iav expressing gaussia luciferase. ten tcm fractions were identified to possess antiviral activities against influenza virus. the ic50's of the hit fractions range from 1.08 to 6.45 μg/ml, while the sis, from 7.52 to 98.40. furthermore, all the ten hit fractions inhibited the propagation of progeny influenza virus significantly at 20 μg/ml. the hit tcm fractions deserve further isolation for responsible constituents leading towards anti-influenza drugs. moreover, a library consisting of 500 simplified tcm extracts was established, facilitating antiviral screening in quick response to emerging and re-emerging viruses such as ebola virus and current sars-cov-2 pandemic. influenza a virus (iav) infections usually cause acute respiratory disease with substantial morbidity and mortality [1] . according to the world health organization (who), seasonal influenza causes up to 650,000 deaths annually [2] . vaccines and antivirals are effective countermeasures in combating iav infections. however, current influenza vaccines require reformulation annually and do not always match circulating strains, while resistance to marketed anti-influenza drugs are increasingly emerging [3] [4] [5] . erefore, novel antivirals with different mechanism of action are urgently needed. historically, natural products were the source of virtually all medicinal preparations, such as tcms. more recently, natural products or their derivatives have continued to enter clinical trials, accounting for 32% of new medicines approved by the us food and drug administration (fda) between 1981 and 2014 [6] . however, traditionally naturalproduct research usually subject concentrated extract samples to screening. such extracts are complicated mixtures, and all the components may reach the biological target in the assay, bringing several technical problems, including (i) the concentrations of some components are too low to have measurable effects; (ii) interference or nuisance compounds may confound the signal from the assay; and (iii) the possibility of additive or synergistic effects of several compounds [7] . it is unlikely to isolate each compound from a crude extract in advance, since it is too onerous and uneconomical. alternatively, prefractionation strategies have been reported to solve, at least partially, these problems [8, 9] . for example, in a high-throughput extract prefractionation screening, 80% of the primary-screen hits from prefractionated samples were not observed in assays of the associated crude extract [10] . in the present study, 100 medicinal plants which have been included in tcm prescriptions for antiviral treatment were selected and prefractionated into 5 fractions each. e library consisting of 500 prefractionated tcm extracts was subsequently subjected to a phenotypic screening for antiinfluenza actives [11, 12] . as a result, ten tcm fractions were identified to have antiviral potency against iav, deserving further analysis for novel anti-influenza lead drugs. one hundred medicinal plants that have been previously used for antiviral treatment were purchased from affiliated hospital of shandong university of traditional chinese medicine (jinan, china). e botanical authentication was performed by pro. lingchuan xu (college of pharmacy, shandong university of traditional chinese medicine, jinan, china). voucher specimens of these materials were deposited for references in our lab. e samples were stored at −20°c and pulverized before use. more information of the 100 plants are provided in table s1 2.2. standard extraction preparation. each dry powder (200 g) of tcms was extracted with 1000 ml cyclohexane (cyh) firstly, and then the leftover solution was sequentially extracted using dichloromethane (dcm), ethyl acetate (eac), n-butanol (nba), and distilled water (w), according to the method described by liu et al [13, 14] . e five extracted solutions of 100 tcms were harvested separately by ultrasonic extraction at 40°c for 30 min and repeated twice followed by filtration and evaporation under vacuum. e organic fractions were dried in 45°c vacuum, and the water fractions were freeze-dried. all 500 samples were sealed in vessels and refrigerated separately. a portion of each extracts was removed, dissolved in dimethyl sulfoxide (dmso) at 50 mg/ml, and arrayed in 96well plates as a prefractionated tcms library. to illustrate the stability of extraction method, several active prefractionations were selected for analysis by hplc using a sunfire-c18 tm column (4.6 × 150 mm, 3.5 µm, waters corporation, milford, ma) by a waters 2695 system coupled with a waters 2998 pda detector. e mobile phase consisted of 0.5% formic acid water solution and acetonitrile. e flow rate was maintained at 0.8 ml·min −1 , and the injection volume was 20 µl. supplemented with 10% fetal bovine serum (fbs; gibco, carlsbad, ca, usa), 1,000 units/ml penicillin and 100 μg/ml of streptomycin (invitrogen, carlsbad, ca, usa). e replication-competent reporter influenza a virus carrying the gaussia luciferase gene (pr8-pb2-gluc) and wildtype influenza a/puerto rico/8/34 (h1n1, pr8) were propagated as previously described [11, 12, 15] . infections were performed in opti-mem containing 1.5 µg/ml n-tosyl-l-phenylalanine chloromethyl ketone (tpck)-trypsin (sigma-aldrich, st. louis, mo, usa). a phenotypic screening for antiinfluenza actives were carried out as previously described [11, 16] . in brief, mdck cells growing in white, flat-bottom, 96-well culture plates (perkinelmer, waltham, ma) were infected with pr8-pb2-gluc virus at 0.01 multiplicities of infection (moi) in the presence of test samples of 20 μg/ml. after 36-hr incubation, gluc assay was performed using pierce gaussia luciferase glow assay kit ( ermo scientific, rockford, il, usa) according to the manufacturer's instructions. mock infected cells were used as blank control. dmso and baloxavir acid (bxa) were set as negative and positive control, respectively [17] . for dose-response analysis, pr8-pb2-gluc-infected cells were treated with serially diluted samples, with final concentrations ranging from 40 μg/ml to 0.055 μg/ml. after 36-hrs incubation, the gaussia luciferase activities were determined. e cytotoxicity assay was performed as described previously [18] . mdck cells in 96-well assay plates were treated with serial diluted extracts (twofold diluted from 200 μg/ml to 1.56 μg/ml for 8 dilution series) and incubated at 37°c for 36 hrs. cell viability was assessed by cck-8 (medchemexpress, monmouth junction, nj, usa) according to the manufacturer's instructions. titer reduction assay was performed as previously described [11] . in brief, mdck cells grown in 24-well plates were inoculated with the influenza pr8 virus at an moi of 0.01. after 2-hour incubation at 37°c, inoculations were replaced by fresh opti-mem (1.5 µg/ml of tpck-trypsin) containing test extracts at 20 µg/ml concentration. at 36-hour after infection (p.i.), the supernatants were removed for titration. in order to quantify the robustness of the screen, z′ factor was calculated from the normalized signals from positive and negative control wells on each plate with the following equation: z′ � 1-3 × (sd of positive control + sd of negative control)/(mean of negative controlmean of positive control). sd represents the standard deviation. z′ value between 0.5 and 1.0 is considered robust enough for an hts assay [19] . e percent inhibition of the tested samples was calculated with the following equation: percent inhibition � (signal of negative control-signal of tested compound)/(signal of negative control-signal of positive control) × 100%. tcms have proven to possess valuable advantages in clinical practices, including the treatment of influenza virus which caused respiratory disease [20, 21] . novel anti-influenza actives from tcm samples are therefore anticipated. to this end, 100 medicinal plants which have been recorded as antiviral formula compositions were fractionated with cyclohexane, dichloromethane, ethyl acetate, n-butanol, and water sequentially, generating a library consisting of 500 prefractionated tcm extracts (figure 1, table s1 ). as a quality control, three fractions were randomly chosen for reextraction and hplc analysis. as figure s1 shows, the chromatogram of the tcm fraction replicates displayed identical compositions, suggesting that our library is of high quality and reliable for bioactive screen. previously, we generated a recombinant iav expressing gaussia luciferase, based on which a phenotypic highthroughput screening approach was subsequently established, providing a powerful tool for antiviral discovery [11, 12, 15] . a phenotypic screening was therefore carried out against the prefractionated tcm library for anti-influenza actives. e practical screening procedure is shown in figure 2 . primarily, the inhibitory potency of each tcm fraction at 20 μg/ml against iav was determined. e z′ value of each screening plate (ranges from 0.55 to 0.89) was evaluated as quality control (figure 3(a) ). as a result, 47 samples showing >80% inhibition were cherry-picked as primary hits and subjected to a second round of antiviral determination as well as cytotoxicity assay (figures 2 and 3(a) ). among the 47 primary hits, 13 were excluded due to cytotoxicity, 24 were confirmed as inactives, and the 10 leftover hit fractions were shortlisted for dose-response analysis (figure 3(b) ). since all ten hits showed dose-dependent inhibition to iav replication ( figure s2 ), the ic 50 of each hit fraction was therefore calculated, as well as the cc 50 's and selectivity index (si) ( table 1) . all ic 50 's of the hits ranges from 1.08 to 6.45 μg/ml. moreover, except ethyl acetate fraction of glycyrrhizic, of which the si is lower (7.52), all sis of the other nine hits exceed 10, suggesting high potency as antiviral actives. considering exogenous luciferase expression was used to indicate iav replication when using reporter influenza pr8-pb2-gluc virus, a gluc inhibitor should probably be identified as false positive. to better address the antiviral activities of hit fractions against iav, a conventional titer reduction assay were further performed using influenza a/puerto rico/8/34 (pr8) virus. as shown in figure 4 , all 10 hit fractions suppressed the viral replication significantly at 20 μg/ml, suggesting that all hit fractions comprise anti-influenza components by targeting influenza viral replication. notably, nba fraction of areca catechu l. and eac fraction of magnilia officinalis almost completely inhibited iav yielding. it has been well recognized that, for drug discovery using hts, diversity within biologically relevant 'chemical space' is more important than library size, while natural products provide a different, wider, and more drug-like chemical space than synthetic compounds [22, 23] . moreover, the clinical use of tcms have proven therapeutic efficacy for various diseases [24] [25] [26] , coupling the components and specific targets tightly. in this study, 100 tcm plants were selected as compositions of antiviral prescriptions by literature review [27] , and each plant was prepared into 5 simplified extracts, generating a library consisting of 500 tcm fractions ( figure 1, table s1 ). prefractionation can partially remove compounds that are likely to cause artefacts, greatly reducing the complexity of each extract, and as a consequence, increase the hit rate when subjected to an antiviral screening. in addition, since the fractions were prepared by a chromatographic method, subsequent chromatography on a target fraction can be achieved easily, in contrast to the risk that one may fail to find a responsible constituent in active crude extracts [7] . by using a hts approach based on recombinant reporter influenza pr8-pb2-gluc virus, the antiviral activity of each fraction against iav was evaluated, and 10 simplified extracts were identified as anti-influenza actives ( figure 3 ). all sis of the hits exceed 10, except with ethyl acetate fraction of glycyrrhizic, of which the si is 7.52 (table 1) . it could be proposed that these tcm extracts might contain bioactive components responsible for anti-influenza virus activity at nontoxic concentration, providing a promising source of natural influenza inhibitors. virus titer (tcid 50 /ml) results are the means ± standard deviation. all data have three multiple duplications. * * * , p < 0.0001; ns, no significant difference. e dotted line represents the detection limit. interestingly, it was elucidated previously that the antiviral effect of polygonum cuspidatum is associated with active compounds such as resveratrol and emodin, which inhibit the replication of influenza h1n1 virus directly by inducing ifn-β [28] . however, magnolia officinalis contains polyphenolic compounds that play a protective role in influenza virus-infected mice [29] . in addition, glycyrrhiza, cinnamon, areca catechu l, and spatholobus suberectus have a wide range of pharmacological activities in clinic, including influenza virus infections [30] [31] [32] [33] . ese data on the other hand suggested the accuracy and robustness of our antiviral screening results, and the hit fractions deserve further analysis for antiviral discovery. in summary, we prepared a library containing 500 prefractionated tcm extracts from 100 herbs with potent antiviral activity. as a pilot, a phenotypic screening was carried out against the library using a recombinant influenza a virus expressing gaussia luciferase, and 10 fractions possessing anti-influenza potencies were identified, including fractions of areca catechu l., glycyrrhizin, cinnamon, tripterygium wilfordii, spatholobus suberectus, polygonum cuspidatum, and magnolia officinalis. it is of great interest to investigate the bioactive components of these extracts and the mechanism of action in future. e data used to support the findings of this study are available from the corresponding author upon reasonable request. e authors declare that they have no conflicts of interest. qianli kang and yanyan wang contributed equally to this work. rr and lr conceived and designed the experiments. qk, lg, and hj collected the herbs and prepared the herbal extracts. yw and qc carried out the antiviral screening. rd and yy analyzed the data. qk, yw, and rd wrote the paper. rr and lr edited the paper. all authors contributed to the final version. mortality burden of the 1918-1920 influenza pandemic in hong kong world health organization influenza virus resistance to neuraminidase inhibitors incidence of adamantane resistance among influenza a (h3n2) viruses isolated worldwide from 1994 to 2005: a cause for concern emergence of oseltamivir-resistant pandemic h1n1 virus during prophylaxis natural products as sources of new drugs from 1981 to 2014 e reemergence of natural products for drug discovery in the genomics era pre-fractionated microbial samples-the second generation natural products library at wyeth automated highthroughput system to fractionate plant natural products for drug discovery a simple method for high-throughput extract prefractionation for biological screening a parallel phenotypic versus target-based screening strategy for rna-dependent rna polymerase inhibitors of the influenza a virus a simple and robust approach for evaluation of antivirals using a recombinant influenza virus expressing gaussia luciferase screening of neuraminidase inhibitory activities of some medicinal plants traditionally used in lingnan chinese medicines screening antitumor bioactive fraction from sauromatum giganteum (engl.) cusimano & hett and sensitive cell lines with the serum pharmacology method and identification by uplc-tof-ms a mechanism underlying attenuation of recombinant influenza a viruses carrying reporter genes a cell-based high-throughput approach to identify inhibitors of influenza a virus baloxavir marboxil, a novel cap-dependent endonuclease inhibitor potently suppresses influenza virus replication and represents therapeutic effects in both immunocompetent and immunocompromised mouse models inhibition of endosomal fusion activity of influenza virus by rheum tanguticum (da-huang) a comparative highthroughput screening protocol to identify entry inhibitors of enveloped viruses chinese herbal medicines for the treatment of type a h1n1 influenza: a systematic review of randomized controlled trials houttuynia cordata polysaccharides ameliorate pneumonia severity and intestinal injury in mice with influenza virus infection statistical investigation into the structural complementarity of natural products and synthetic compounds property distributions: differences between drugs, natural products, and molecules from combinatorial chemistry evaluation of the anti-neuraminidase activity of the traditional chinese medicines and determination of the anti-influenza a virus effects of the neuraminidase inhibitory tcms in vitro and in vivo experimental study on antivirus activity of traditional chinese medicine traditional chinese medicine and related active compounds: a review of their role on hepatitis b virus infection research and application of antiviral chinese herbal medicine, shandong science and technology press polygonum cuspidatum and its active components inhibit replication of the influenza virus through toll-like receptor 9-induced interferon beta expression protective effect of a polyphenolic rich extract from magnolia officinalis bark on influenza virus-induced pneumonia in mice uralsaponins antiviral triterpenoid saponins from the roots of glycyrrhiza uralensis in vitro antiviral activity of cinnamomum cassia and its nanoparticles against h7n3 influenza a virus immunomodulatory and antioxidant effects of total flavonoids of spatholobus suberectus dunn on pcv2 infected mice study on herbal textual evolution and flavonoids and their pharmacological of spatholobi caulis table s1 : the information of the selected 100 plants. figure s1 : comparison of hplc chromatogram of two n-butanol fractions extracted by the same method. figure s2 : the dose-response curves of ten active hits. (supplementary materials) key: cord-300452-dqb6em7g authors: wang, wan-ying; zhou, hua; yang, ya-feng; sang, bin-sheng; liu, liang title: current policies and measures on the development of traditional chinese medicine in china date: 2020-09-09 journal: pharmacol res doi: 10.1016/j.phrs.2020.105187 sha: doc_id: 300452 cord_uid: dqb6em7g traditional chinese medicine (tcm) is a medical science and cultural heritage empirically applied and reserved by chinese people for thousands of years. with comprehensive prosperity of china and rapid elaboration of technology, healthcare status of chinese people has become one of the most crucial concerns of the country. nearly 30 policies and measures regarding tcm development have been issued since the 18(th) national congress of the communist party of people’s republic of china in 2012. this review introduced a detailed evolutionary course of tcm in china with an emphasis on understanding the roadmap of tcm related policies and measures in china. traditional chinese medicine (tcm) is one of the most important achievements of chinese civilization which is also a medical science inherited over thousands of years. during the process of fighting against diseases, chinese people formed and developed tcm empirically in their daily life. recently, people in china and around world were infected by sars-cov-2 who might exhibit severe lung injury and lymphopenia [1] . tcm has made great contributions to the treatment of covid-19 [2] with over 90% involvement all over china [3] and showed high effective rate in a multicenter, prospective, randomized controlled clinical trial [4] . these effects are probably through the mechanism of inhibiting the sars-cov-2 replication and reducing pro-inflammatory cytokines [5] [6] [7] . with its long history of absorption and innovation, tcm is not only a method of treatment, it also made great impacts on people's pattern of life. the remedies of tcm against diseases combines a holistic view of harmony, individuality, simplicity and preventive treatment which is on account of assimilation from natural science and humanities [8] . the state council has issued a new guideline to implement the country's healthy china 2030 initiative focusing on disease prevention and health promotion [9] . tcm as a crucial contributor for enhancing chinese people's health status, a large series of laws and policies have been issued for the heritage and innovation of tcm. the awarding of nobel prize in 2015 of tu youyou also highlighted the contributions of tcm to her research and raised artemisinin to a new status worldwide as "a gift from traditional chinese medicine to the world" [10] . since the launching of the 12 th five-year plan, great efforts have been made to improve the development of tcm: sixty-three state science and technology awards were honored to the research in the field of tcm; four tcm drugs have been allowed to conduct phase iii clinical trial in us and a number of chinese patent medicines have been recorded in european and us pharmacopoeia [11] . it is undoubted that the central government and regulatory department are making every effort to promote the development of tcm with the aim of modernization, standardization and informatization so as to provide a precise treatment with a wider coverage. the international recognition of tcm is at the same time growing with the wide access of tcm across 183 countries and regions worldwide. tcm acupuncture and moxibustion have been recognized as important parts of the intangible heritage of mankind by unesco [12] and the chinese medical classics huangdi neijing (inner canon of the yellow emperor) [13] and bencao gangmu (compendium of materia medica) [14] have been included in the unesco memory of the world. according to statistics from the who, 103 member states have authorized the use of acupuncture and moxibustion, of which 29 have established laws and regulations promoting traditional medicines, and 18 states have included acupuncture and moxibustion in their medical insurance systems [15] . the latest 2019 global report on traditional and complementary medicine [16] and who traditional medicine strategy: 2014-2023 [17] have emphasized the contributions of traditional and complementary medicine to the goal of universal health coverage by improving equitable access to safe, quality and effective traditional and complementary medicine services. the global burden of chronic disease also urged the development and enhancement in the collaboration between conventional and traditional medicine [17] . international organization for standardization (iso) created tcm technical committee iso/tc 249 in 2009 focusing on quality and safety of raw materials, manufactured products and medical devices and of informatics [18] . in [19] . sharing one set of standards could help with the development of tcm globally. the developmental status of tcm in china could be introduced in the following five sections including tcm resources, the operation and service of tcm medical establishment, tcm education, tcm research & development (r&d) and financial appropriation income of tcm. (fig.1) for the cultivation of tcm characteristic talents, higher education in tcm subjects serves as a solid support. although the number of tcm institutions of higher education is almost the same (43), more and more western medicine and non-medical institutions are setting up tcm subjects. moreover, the number of current and graduated students is increasing gradually including college students, bachelor students, master students and phd students. the proportion of the education level is almost the same that most tcm-subjected students (nearly 90%) are general undergraduates and continuing education undergraduates, but the percentage of phd students for tcm research is only around 0.7%. tcm r&d is also carried on by ministerial, provincial and local organizations with published scientific articles and academic work, accepted and licensed patents, drug approval certificates, and other achievements at national standards. the number of professionals in tcm scientific research and technical development has increased steadily with more than half from provincial organizations working on scientific and technological activities. the key subjects involving r&d of tcm are evaluated by the number of agencies conducting them, including chinese herbal medicine, j o u r n a l p r e -p r o o f traditional chinese medicine, integrated traditional chinese & western medicine, pharmaceutical chemistry etc. the total income of tcm r&d organizations has increased in the latest years which is comprised of scientific activities, production and operation and other incomes which has nearly reached one billion. funding from the government and domestic and abroad non-government organizations also increased nearly 30% for supporting tcm research and development. detailly, around 7% of national fiscal expenditure has been spent on the section of medical and healthcare, among which, 3% of the money is for health administration and further divided 0.23% goes for tcm agencies. both the amount of appropriation and its proportion increased gradually since 2010. from the aspects of healthcare departments, the appropriation specific for tcm occupies less than 1% of the health administration budget and almost half of them is earmarked from tcm agencies [20] . therefore, tcm has improved gradually in the latest ten years in the above five sections but comparing with its proportion in the whole healthcare system, there still remains large number of challenges to be solved in the future. on the other hand, there still exist obstacles that tcm has to face because of the huge healthcare demand in china [21] . first of all, current tcm medical care system does not have a full coverage across the rural communities because of a limited number of infrastructure and practitioners [22] . according to the statistics in 2017, around 80% of tcm practitioners serve in urban areas while only 20% are in rural areas. secondly, insufficient number of high-level tcm experts leads to a weak point during the operation of tcm inheritance and innovation program. according to a survey of current status of tcm, there are only three tcm practitioners every ten thousand people [23] . the tcm doctors are responsible for more than 7 person-time patients every day, which is slightly higher than the average number of general hospitals but the annual income of tcm doctors are only 80% of the average income of all doctors national wide. the income of tcm hospitals is less than 40% of that of general hospitals which could explain the lower annual income of tcm doctors [20] . thirdly, j o u r n a l p r e -p r o o f the sustained development of tcm is threatened by the destruction of ethnic minority medicine and the declined quality of chinese medical resources which also triggers a relatively low concentrated pharmaceutical industry. chinese crude drugs even have the highest disqualification exposure rate of all the products examined by the regulatory departments in china [24] . there is an urgent request for the completeness of a tcm management system so as to increase its competitiveness under the global environment [22] . fortunately, in order to overcome these difficulties, the government has not stopped guiding the direction in improving the environment for tcm development. the chinese government has set great store by tcm and rendered vigorous support to its development consistently after the founding of people's republic of china in 1949. more importantly, since the 18 th national congress of the communist party of china (cpc) in 2012, the government has issued nearly 30 major policy decisions and plans on tcm so as to improve its normative implementation and development to the rule by law [25] . in president's report to the 19 th cpc national congress, the necessity to pay equal attention to the development of tcm and western medicine and carrying forward the tradition and ensuring the development of tcm was emphasized [26] . tcm is therefore ready for its renaissance with the modernized technologies, normalized system and devoted professionals. the development of tcm is ushering in a fresh age with an integrated scope of treatment, fitness, research, education, industry and culture. people all over the world would benefit enormously from the tcm services in terms of both healthcare and economy. tcm has always been a significant component of traditional chinese culture since it grows with the course of chinese history [8] . dating back to the remote antiquity, chinese ancestors had applied certain creatures, plants and minerals to relieve their symptoms. by assimilating the essence from natural science and humanity, the theories and methods of tcm were gradually formed and recorded in written works. the four diagnostic methods: inspection, auscultation & olfaction, inquiry and j o u r n a l p r e -p r o o f palpation was summarized by bian que in the spring and autumn and warring states period (770-221bc) [27] . the theoretical frame work for tcm came in to place during the qin and han times (221bc-ad220) described in the huang di nei jing (yellow emperor's inner canon) [28] . one of the most important theoretical foundation of tcm was the shang han za bing lun (treatise on febrile diseases and miscellaneous illnesses) created by zhang zhongjing in the eastern han dynasty (25-220), which discoursed how to propose corresponding diagnosis by differentiating the patterns of miscellaneous illnesses [29] . during the same period, the foundation of tcm pharmaceutical theory was advanced by the masterpiece: the shen nong ben cao jing (shennong's classic of masteria medica) which guided the prescription and safety application of tcm so as to enhance their therapeutic effects [30] . later in the ming dynasty (1368-1644), li shizhen complied the ben cao gang mu (compendium of materia medica), the first book in the world that categorized medical herbs scientifically, which enriched the tcm pharmaceutical theory in details [31] . these books transformed the clinical experience into summation of theories of tcm which systematically exposed its principles and methods of treatment, the human physiology, the symptoms of illness, and the preventative treatment. the application of tcm also prospered with the development of the people's republic of china (prc) since 1949. in the early period of prc, one of the three guidelines for health work was uniting chinese and western medicine. the first edition of chinese pharmacopoeia was published in 1953 for guiding the pharmaceutical industry in china while tcm was first recorded in the second edition of pharmacopoeia in 1963 [32, 33] . later in 1978, the cpc central committee transmitted the ministry of health's "report on implementing the party's policies regarding tcm and cultivating tcm practitioners" across the country which forcefully promoted the development of tcm. furthermore, the constitution of the prc stipulates the promotion of modern medicine and tcm to protect the health of chinese people [8] . in 1986, a relatively independent administration of tcm was founded by the state council, following by the establishment of respective tcm administrations in all provinces, autonomous regions and municipalities which functioned as basic organization of [38] . in august 2019, the drug administration law of the people's republic of china was revised in order to ensure the quality of drugs in china with several sections regarding the approval, production, circulation etc. of tcm drugs [39] . these statements revealed the management rules for tcm which adhering to safety first, risk management, whole-process management and control, scientific supervision, and social co-governance. these historical events from ancient china to the latest days provide strong evidence on the importance of tcm which is the backbone of chinese society and chinese culture. the prosperity of tcm would play a critical role in the completeness of a medical and healthcare system providing better healthcare service with chinese characteristics. chapter of this plan emphasized that fully taking the superior advantage of tcm would play a significant role of improving the medical service in china [9] . the aim of these policies and measures on tcm development is to resolve the major obstacles met by tcm so as to improve the health status of chinese people. the holistic characteristic of tcm could explicate its thriving impacts on a number of subsequent fields. construction of a complete scientific framework of tcm has been a long-term goal for a breakinginternationally, tcm has played an important role in the professionals, production and finance supply chain overseas especially along the "one-belt, one-road" countries [65, 66] . the development of tcm has achieved enormous progress after the 18 th cpc national conference. the primary reason is the emphasis and support from the national people's congress and the central the central committee of the party together with the state council and tcm administration departments have made great efforts on the renaissance of tcm. these policies and measures guide the principle of tcm development with detailed tasks in terms of healthcare, economy and culture. the implementation of these policies would contribute to a brighter future for tcm and benefit the well-being of mankind. in conclusion, people should have a strong faith in the reliability of tcm since the government is leading the administrators and experts to make every endeavor to support the development of tcm. j o u r n a l p r e -p r o o f ll and bss supervised all research and revised the manuscript. wyw, hz and yfw collected information. wyw and hz analyzed the data and prepared the manuscript. the authors declare no conflicts of interest. pathological findings of covid-19 associated with acute respiratory distress syndrome contribution of traditional chinese medicine to the treatment of covid-19 all the mobile cabin hospitals in 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standardization of traditional chinese medicine state administration of traditional chinese medicine of the people's republic of china the plan of protecting and developing chinese medicinal plants the plan of developing healthcare service of traditional chinese medicine general office of the state council of the people's republic of china 2015.06.05 the 10 th edition of chinese pharmacopoeia china food and drug administration 2016.02.22 the outline of the strategic plan on the development of plan of developing traditional chinese medicine state administration of traditional chinese medicine and national development and reform commission of the people's republic of china several opinions on further reform and improvement of drug production, circulation and use policies general office of the state council of the people's republic of china 2017.02.14 the 13 th five-year plans for national drug safety state council of the people's republic of china guiding opinions on improving science and technology innovation in medical devices used for traditional chinese medicine state administration of traditional chinese medicine; ministry of science and technology; ministry of industry and information technology key: cord-300469-u6zjdqx6 authors: xu, xiaojie title: new concepts and approaches for drug discovery based on traditional chinese medicine date: 2006-11-09 journal: drug discov today technol doi: 10.1016/j.ddtec.2006.09.008 sha: doc_id: 300469 cord_uid: u6zjdqx6 in this review, we report a new reverse approach (from finding bioactive molecules to separating target compounds in the related plant) by using virtual screening, immobilized enzyme and polyclonal antibody, molecularly imprinted polymers for finding, and separating the active compounds from tcm. this approach is faster and more efficient than the traditional time-consuming approach (from selecting the plant to separating compounds following the bioassay guidance). traditional chinese medicine (tcm) (see glossary) is rich in natural compounds and has been used in china for more than 8000 years [1] . tcm can be considered as a natural combinatorial chemical library, compared with synthetic ones. tcm presents more diversity in structure and bioactivity, and less toxicity [2] . therefore, it represents an attractive source of new active compounds in drug discovery [3, 4] . the conventional approach to find active compounds in tcm involves selecting a potential plant and isolating compounds following bioassay guidance. this approach has been playing an important part in drug development. however, it is often time-consuming and can contain false positives (see outstanding issues). in this review, we report a reverse approach (from finding bioactive molecules to separating target compounds in the related plant) by using virtual screening, immobilized enzymes, polyclonal antibodies and molecularly imprinted polymers (mip) to find and separate the active compounds from tcm quickly and efficiently. computer-aided drug design (cadd) permeates all aspects of modern drug discovery and allows the discovery of new candidates with a desired biological activity more quickly and at a lower cost. the progress and applications of cadd have been presented in references [5] [6] [7] . up till now, there have been very few articles on applications of cadd to tcm owing to the lack of related databases. qiao et al. [8] have developed a tcm information system including tcm formulation database, a tcm plant database and a 3d structure database of tcm components (fig. 1) . the three databases are linked with each other. the 3d structure database contains 15,000 compounds isolated from tcm. it offers not the only basic molecular properties and optimized 3-d structure of compounds but also detailed information on their herb origin, including basic herbal category (e.g. english name, latin name and family), effective parts, clinical effects and related formulations of tcm. jiang et al. [9] in collaboration with neotrident technology ltd. (see table 1 ) developed the chinese natural product database (cnpd), which contains 45,055 nature products, among which 12,521 entries have been checked. cnpd can provide 2d structures and 3d models, related plant information, tcm property and bioactivity. cadd studies derived from tcm typically involve virtual screening, optimization of lead structure, establishment of quantitative structure-activity relationship (qsar), prediction of drug-likeness, prediction of absorption, distribution, metabolism, elimination/toxicity (adme/t) and computer aided molecular structure elucidation. first, information regarding herb mixture related to specific diseases can be retrieved from a tcm formulation database. second, a 3d structure subset of ingredients related to specific diseases can be constructed through searching all original structures of plants consisting of tcm formulations. third, this subset is filtered via virtual screening. there are several screening methods in cadd. for example, molecular docking can be used to study the interaction between bioactive compounds and target enzymes when the target 3d structure is known. pharmacophore searching can be used to search candidate compounds with specific pharmacophoric groups. when candidate compounds are available, they can be subjected to a bioactivity test. but mostly, the bioactivity test must be applied to the fractional extracts of plants containing the candidate compounds. the compounds with higher activity can then be isolated. the hit rates for screening active compounds from tcm database are correspondingly higher than from the chemical database. in very rare cases, a natural product like taxol becomes a drug without any modification. usually, however, the structure of active compounds needs to be modified by cadd (e.g. qsar or docking) before being synthesized. qiao et al. [8] have applied the above method to identify new potential inhibitors of hepatitis c virus (hcv) ns3-ns4a protease. the crystal structure solved by kim et al. [10] was used as a design target. at first they studied the interaction between compound and target protease via a molecular docking module also developed by their group. then several high scoring candidate compounds were selected according to an energy and geometry match. finally, these compounds were extracted from respective plants and subjected to bioactivity test [11] . the structure was modified to improve bioactivity [12] and resulted in nine compounds with ic 50 < 1 mm/ml [13] . the binding energy was calculated by the molecular mechanics/possion-bolzman surface area (mm/pbsa) method, and the results showed that the binding energies were parallel to ic 50 [11] . jiang et al. [9] performed docking screening (see table 1 ) and primary drug-likeness analysis by using cnpd and the 3d model of the eukaryotic k + channels, and got 14 potential potassium ion (k + ) channel blockers. after bioassay tests, four compounds were found that were 20-to 1000-fold more potent that the most extensively used ik blocker-tetraethlammonion (tea). therefore, these compounds might replace tea as the selective i k blockers in neurobiology research. rapid screening of active compounds directly from tcm rapid screening of enzyme inhibitors is a key method for finding drug leads. the most common method used for highthroughput screening (hts) of enzyme inhibitors involves glossary fac-ms: a combination of frontal affinity chromatography with mass spectrometry detection. it is based on the continuous infusion of ligands over a protein target immobilized onto a solid support column, with the eluting ligands detected by ms. when ligands flow through the column, they bind to the target with differing affinities. the breakthrough volume of ligand is dependent on the affinity of the ligand for the target. eq. (1) is the basic equation of frontal affinity chromatography: it also can be shown in other form: where v is the elution volume of the analyte, c is the concentration of the analyte, v 0 is the elution volume of a controlled substance having no affinity, l t is the total amount of immobilized ligand, and k d is the dissociation constant. v approaches its maximum value, v m . if c ( k d , that is, as c is neglibly small compared with k d , the following equation is obtained: mip-spe (mispe): the basic concept for the application of mip in solid phase extraction (mispe) is that the chromatographic parameters are tuned such that the mispe column traps only the analytes, or a group of structurally related compounds, whereas the other interfering components in the sample matrix were washed without retention. tcm: traditional chinese medicine (tcm) is a medical science governing the theory and practice of traditional medicine. it includes chinese medication, pharmacology/herbalogy, acupuncture, massage and qigong. in this article, tcm only is related with traditional chinese medicinal herbs. www.drugdiscoverytoday.com colorimetric or fluorimetric assays. however, there are numerous difficulties associated with hts assay development [14] . enzymes and receptors represent the most common drug targets. target based drug discovery is an important strategy for developing new agents [15] . tcm preparations are a mixture of a large number of compounds, in which the active targets may be unknown and at low concentrations in a background of other active species, so the screening process might lead to false positives resulting from the sum activity of many weakly active compounds in the case of bioactivity guided isolating and screening. biochromatography are widely used for screening the active compounds from tcm [16] . wang et al. [17] used the immobilized human serum albumin (hba) and a 1 -acid glycoprotein (agp) as the stationary phase for screening active compounds from tcm by using high performance liquid chromatography (hplc). he et al. [18] applied biomembrane chromatography with immobilized biological cell membranes on silica supports for the study of tcm. although chromatography is one of the main techniques used in the study of tcm, current chromatography techniques are still unsatisfactory, since it is difficult to distinguish the bioactive component peak from the other peaks [16] and meet the requirements of hts. affinity based screening using frontal affinity chromatography coupled with mass spectrometry (fac-ms) (see glossary) is a more direct and faster method [19, 20] for screening the active compounds from tcm. it is not only quick and efficient for screening active compounds at low concentration, but also can avoid interference from other active compounds. fac-ms was established in 1998 by schreimer [21] . the application of fac-ms to a broad range of biological systems, together with its label-free operation, relatively high throughput, ability to rank ligands and determine dissociation constant k d , makes fac-ms a universal tool enabling convenient and efficient screening for the identification of new potential drug leads [19] . tcm contains many unknown compounds with different unknown concentrations, so the features of a label-free operation, relatively high throughput, ability to rank ligands, and a breakthrough volume that is not related to ligand concentration (when c ( k a ) makes fac-ms a very appealing technique for screening active compounds from tcm (see glossary). zhu et al. developed a very efficient and straightforward procedure for analyzing the binding properties of different inhibitors of the epidermal growth factor receptor (egfr) by combining fac with a mariner electrospray ionization mass spectrometry (see table 1 ) [22] . polyclonal antibodies (pcab) were used in a system, in which the pcab was raised against piceatannol, which was linked with bovine serum albumin (bsa) to be covalently bound to the chromatographic packing for mimicking the egfr. six inhibitors including the half-antigen itself were recognized from the crude extract of caragana jubata. the corresponding dissociation constants (k d ) for these six analytes were estimated and contrasted to the respective bioactivities (ic 50 ). the binding affinity of the pcab for the analyte was stronger as the factor k d was smaller, whereas the bioactivity of the molecule was higher as the ic 50 was smaller. from the results, it could be concluded that the recognition based on the pcab was efficient, and the analyte with higher activity was retained on the affinity column longer. luo et al. [23] reported the application of fac-ms for screening active compounds from an extract of phylantus urinaria l., based on immobilized pcab that are used to mimic hepatitis c virus (hcv) ns3 protease. many articles have been published on the applications of fac-ms to immobilized enzyme for screening the active compounds from a chemical library [24, 25] . the first report using fac-ms for tcm was made by yi et al. they used fac-ms based on immobilized surface spike protein of sar-cov to screen 120 species of tcm and tetra-o-galloy-b-d-glucose (tgg) and luteoline, which bind avidly with the surface spike protein of sars-cov, thus can interfere with the entry of the virus to host cell. using a wild-type sars-cov infect system, it was confirmed that tgg exhibits prominent anti-sars-cov activity with a 50% effective concentration of 4.5 mm/ml and a selective index of 240.0 [26] . the technique of molecular imprinting was introduced in 1972 by wulff. molecularly imprinted polymers are extensively cross-linked polymers containing specific recognition sites with a predetermined selectivity for analytes of interest. the technique involves complexation in a solution of target molecules (template) with functional monomers through either covalent or noncovalent bonds, followed by a polymerization reaction with an excess of cross-linkers. removal of the templates leaves behind specific recognition sites that are complementary to the template in terms of its shape, size and functionality in the polymer network. these recognition sites enable imprinted polymers to be used as the mimics of enzymes, receptors and antibodies for screening various kinds of compounds from a mixture with abundant interferences. up to now, there have been many reviews summarizing the development of mips [27] [28] [29] , which have covered many aspects from the sorbents for sample preconcentration and stationary phase for separation to bioassays, biosensors and mimics for enzymes, receptors and catalysts. theoretically, the more active the inhibitory compound adopted as the template, the more able the resulting imprinted polymer would be for screening other different inhibitors; the microcavities of the corresponding polymer would simulate the binding pocket of the enzyme more successfully owing to the template with higher bioactivity could conjugate to the binding pocket more tightly in terms of its shape, size and functional groups. so mip is an useful technique for screening and separating the active compounds from tcm. steroid receptor mimics, folate receptor mimics and a 2 -adrenoreceptor mimics have been made by mips and used to screen the bioactive compounds from synthetic libraries [29] . dong et al. [30] used mip in solid phase extraction (mispe) (see glossary) of (-)-ephedrine for chromatographic separation of marine and oxymartine from chinese ephedra. li et al. [31] applied fisetin-imprinted polymers for separating the fisetin and analogue quercetin from tcm. all used chromatography to study the behavior of mips. a mip coupled with ms (see table 1 ) was prepared using (e)-piceatannol, a natural potential anti-egfr inhibitor, as the template and 4-vinylpyridine as the functional monomer by zhu et al. [32, 33] . the crude extract of this herb was loaded on the mip column for the binding test, and two different compounds besides the template itself were specifically recognized by the polymer, which were identified as butein and quercetin, possessing potent anti-egfr tyrosine kinase activities with ic 50 values of 10 and 15 mm/ml, respectively. affinity and selectivity for these inhibitors and another three compounds coexisting with the template in this herb were evaluated in the chromatographic mode. for the first time, the affinity of a mip was investigated to be correlative to the bioactivities of the analytes. this work demonstrated that it is feasible to use a mip for screening and separating active compounds, and online identification of inhibitors directly from the crude extract of the herb, which would be very helpful in discovering lead compounds or drug candidates. in the same approach, luo et al. carried out an efficient separation based on a mip applied in phyllanthus urinaria l., from which several novel inhibitors of hepatitis c virus (hcv) ns3 protease were screened out [2] . xie et al. [34] used a coupled liquid-phase chromatography and mass spectrometry (lc-ms) system, consisting of a combination of a column of mips and a ms detector, for affinitive separation and online identification of the antitumor components, harmine and harmaline, from the methanol extract of peganum nigellastrum seeds. the target binding capacities of the mips were evaluated by frontal chromatography. isolation of analytes from urine, plasma, bile and animal tissue is important for pharmacokinetic studies there are only a few studies in which the sample was applied directly to the mip [35] . an anti-quercetin mip with evident hydrophobic matrix was synthesized using acrylamide (aa) as the functional monomer and 2,2-bis(hydroxymethy)butanol trimethacrylate (trim) as the cross linker by xie et al. [36] the affinity and selectivity were evaluated by liquid chromatography, and the binding sites and the dissociation constants were measured by frontal chromatography. the results showed that mip-spe could be used for direct clean up of biological samples for the analysis of functional components in vivo originating from an extract of medicinal herbs. therefore, mip is an important tool in study of the pharmacokinetics of tcm. it is currently estimated that approximately 420,000 plant species exist in nature and over 248,000 species of higher plants have been identified, and from these 12,000 plants are known to have medical properties. however, less than 10% of all plants have been investigated from a phyto-chemical and/ or pharmacological point of view [37] . so far, there have been 11,145 medical plants found in china, of which a very small amount of them have been systematically investigated. [38] . so it is necessary for us to carry out drug discovery research by using available information and knowledge and developing new approaches for screening and separating the active compounds directly from tcm. cadd is a useful approach to utilizing the information and knowledge for finding, optimizing and predicting the properties of active compounds. the main goal for cadd based on tcm is to limit the number of compounds requiring experimental testing while maximizing the hit rate, because it is time-consuming to obtain the pure compounds of tcm. a useful strategy is to use hierarchical multiple filter database screening reported by wang et al. [39] the novel application of immobilized enzymes, pcab and mip in tcm for effective recognition of active compounds immersed in immersed in afforded us a new approach for the discovery of lead compounds or drug candidates, which will be very beneficial in drug development. the immobilized enzyme and pcab methods in combination with fac-ms are only used for screening. although both methods have similarly advanced features in recognizing active compounds, the pcab as a mimic of enzyme has less recognition ability than that of immobilized enzyme. when the immobilized enzyme is not available or not suitable for screening, pcab can be used as an alternative method. mip can be used to mimic the enzyme or receptor for direct screening, separation and online identification of active compounds from tcm, and can speed up drug discovery based on tcm. mip have proven to be feasible mimics in terms of physical robustness, resistance to elevated temperatures and pressures, and inertness towards acids, bases, metal ions and organic solvents, this material can be well employed in various kinds of samples including some biological and cadd, immobilized enzyme, pcab and mip are complementary and should be integrated to the multifaceted platform contributing to the early drug discovery process. at first, virtual screening is used to find potential active compounds. then active fractional parts containing potential compounds are subjected to screening and separation of active compounds by mip in one single step. we can also screen the active compounds firstly by using immobilized enzymes or pcab, then separate active compounds using mip. pcab and mip can be used to find substitutes of patent medicine, which are important yet expensive, from tcm. although tcm has proven useful for many people throughout history, sometimes it has been neglected in western research owing to the constituents and the mechanism for tcm being unclear at present, and the different concepts of illness. tcm is a complex system. it is time consuming and difficult to separate and identify all constituents. the reverse approach may be useful for finding active compounds immersed in interferences. synergy is an important fundamental for the mechanism of tcm and involves multiple targets and pathways. therefore, it is needed to develop approaches for synergy studies. the hit rates for virtual screening based on tcm database are corresponding higher than that from chemical database. the features of label free: operation; ability to rank ligands; break through volume being unrelated to ligand concentration (when c ( k d ); availability for multiple targets, make fac-ms a very efficient approach for screening active compounds in tcm. but sometimes the conformation change should be considered in this process. recent advances in analysis of chinese medical plant and traditional medicines separation and screening of compounds of biological origin using molecularly imprinted polymers drug discovery from medicinal plants from chinese medicine to anticancer drug integrating molecular design resource within modern drug discovery research: the roche experience the many roles of computation in drug discovery ) recent development and application of virtual screening in drug discovery: an overview a 3d structure database of compounds from chinese traditional medicine herbs virtual screening on natural products for discovery active compounds and target information crystal structure of hepatitis c virus ns3 protease domain complexed with a synthetic ns4a cofactor peptide antiviral compounds from traditional chinese medicines galla chinese as inhibitors of hcv ns3 protease search for more effective hcv ns3 protease inhibitors via modification of corilagin in vitro anti hcv activities of saxifraga melanocentra and its polyphenolic compounds hts assay development: is smaller really better? drug discov application of mass spectrometry in early stages of target based drug discovery strategy for analysis and screening of bioactive compounds in traditional chinese medicine fractionation and analysis of artemisia capillaris thumb by affinity chromatography with human serum albumin as stationary phase coating and fusing cell membranes onto a silica surface and their chromatographic characteristics frontal affinity chromatography with ms detection (fac-ms) in drug discovery biosensor alternative: frontal affinity chromatography micro-scale fronted affinity chromatography with mass spectro metric detector: a new method for the screening of compound libraries frontal affinity chromatography combined on-line with mass spectrometry: a tool for the binding study of different epidermal growth factor receptor inhibitor frontal immunoaffinity chromatography with mass spectrometric detection: a method for finding active compounds from traditional chinese herbs frontal affinity chromatography coupled to mass spectrometry for screening mixtures of enzyme inhibitors inhibitor screening using immobilized enzyme reactor chromatography/mass spectrometry small molecules blocking the entry of severe acute respioatory syndrome coronavirus into host cells molecular imprinting: a dynamic technique for diverse applications in analytical chemistry molecularly imprinted polymers as antibody and receptor mimics for assays, sensors and drug discovery molecularly imprinted polymers in the drug discovery process molecularly imprinted solid-phase extraction of (-)-ephedrine from chinese ephedra recent advances in analysis of chinese medical plants and traditional medicines strategy for analysis and screening of bioactive compounds in traditional chinese medicines lessons from natural molecules the many roles of computation in drug discovery biosensor alternative: frontal affinity chromatography solid-phase extraction of active component of chinese traditional medicine fisetin by using molecularly imprinted polymers application of a molecularly imprinted polymer for the effective recognition of different anti-epidernal growth factor receptor inhibitors selective separation of active inhibitors of epidermal growth factor receptor from caragana jubata by molecularly imprinted solid-phase affinitive separation and on-line identification of antitumor compounds from peganum nigellastrum by coupling a chromatographic column of target analogue imprinted polymer with mass spectrometry application of molecularly imprinted polymers to solid-phase extraction of compounds from environmental and biological samples selective extraction of functional compounds derived from herb in plasma by using a molecularly imprinted polymer based of 2,2-bis(hydroxymethyl)butanol trimethacrylate nature products in the process of finding new drug candidates introduction of chinese methods in study of modernization of traditional chinese medicines hierarchical database screening for hiv-1 reverse transcriptase using a pharmacophore model, rigid docking, solvation docking and mm-pb/sa key: cord-336753-4212ftlc authors: luo, lu; jiang, jingwen; wang, cheng; fitzgerald, martin; hu, weifeng; zhou, yumei; zhang, hui; chen, shilin title: analysis on herbal medicines utilized for treatment of covid-19 date: 2020-05-27 journal: acta pharm sin b doi: 10.1016/j.apsb.2020.05.007 sha: doc_id: 336753 cord_uid: 4212ftlc as coronavirus disease 2019 (covid-19) pandemic poses a substantial global public health threat, traditional chinese medicine (tcm) was used in 91.50% of the covid-19 cases in china, showing encouraging results in improving symptom management and reducing the deterioration, mortality, and recurrence rates. a total of 166 modified herbal formulae consisting of 179 single herbal medicines were collected for treating covid-19 in china. glycyrrhizae radix et rhizome, scutellariae radix, and armeniacae semen amarum are the most frequently utilized in clinics, most of which are antipyretic (47, 26.26%), expectorant and cough-suppressing (22, 12.29%), and dampness-resolving (21, 11.73%) from traditional descriptions. a total of 1212 chemical components containing β-sitosterol, stigmasterol, and quercetin were primarily selected. additionally, using complex system entropy and unsupervised hierarchical clustering, 8 core herbal combinations and 10 new formulae emerged as potentially useful candidates for covid-19. finally, following scaffold analysis, self-organizing mapping (som) and cluster analysis, 12 clusters of molecules yielded 8 pharmacophore families of structures that were further screened as pharmacological targets in human metabolic pathways for inhibiting coronavirus. this article aims to make more easily accessible and share historical herbal knowledge used in contemporary treatments in a modern manner to assist researchers contain the global spread of covid-19. while covid-19 is now being effectively controlled within china, it is increasingly affecting other countries worldwide, most notably the u.s., iran, and italy since feb 25, 2020 1 3 with a long history of combating epidemic diseases with relatively low mortality, tcm has accumulated a rich antiviral herb knowledgebase from clinical observation and pharmacological selection. this is historically based on a phenomenological approach and relies on complex mixtures of herbal medicines, as well as nonpharmacological holistic interventions, such as acupuncture and health lifestyle guidance 5 . with pandemic diseases, tcm has shown the agility to be administered more quickly and more efficiently than conventional medicine 4 . it asserts that health is a state of harmony between an individual's internal physiological network of factors and that of an external environmental 6 . diagnosis is through syndrome differentiation called "bian zheng", a holistic analysis of clinically observed information that guides personalized treatment options 4 , which may be adaptably changed dynamically during disease progression 7 . from point of tcm, epidemic disease is considered caused by an external pathogenic attack (traditionally named pestilent qi or evil qi) due to climatic or environmental changes. in the battle between healthy qi (immunity) and pathogenic qi (pathogen), a weakened immune system results in disease, while exhaustion of healthy qi leads to death 7 . consequently, different syndromes can manifest as disease progresses. from tcm perspective, the fundamental pathogenic factor of covid-19 would be termed as "dampness accumulation in the lung", which invades from the exterior to the interior attacking other organs as disease develops from the early stage to mild, moderate, severe, critical, and recovery stages. according to the syndrome differentiations, the pathogenesis in the mild and moderate stages of covid-19 is damp accumulation in the lung. during the severe and critical stages, dampness develops to "damp-heat toxin and congests in the lung". while heat toxin "burns" or rapidly depletes qi and yin, this subsequently would appear as what is termed "dual vacuity of qi and yin of lung and spleen in the recovery stage" 3 . it could be otherwise expressed somewhat as exhaustion of the lung system, its moisture, membranes and resource to recover, along with its fundamental immune supporting system. herbal formulations are then frequently modified as signs and symptoms change along with the diagnosis and corresponding syndrome differentiations. appropriate herbal formulae are administered, containing herbs composed in a hierarchy called "jun chen zuo shi", relating to their primary, secondary, tertiary and quaternary functional class order, respectively 8 . through design, herbal formulae guide a combination of different herbal medicines based on the individual synergistic properties of each herb. the jun 4 (monarch) component is the principal phyto-complex targeting the major symptom of the disease. it synergizes with the chen (minister) herbs to support its therapeutic effects. the zuo (assistant) medicinal reduces or eliminates possible adverse or toxic effects. lastly, the shi (courier) herbs facilitate the delivery of the principal components to desired sites (e.g., target organ), or facilitate the overall action of the other components. the whole formulae thus strive for a synergistic effect that targets active phytochemicals to their designated sites of action 8 . furthermore, herbs can be administered through a diverse number of routes including oral intake, nasal inhalation, moxibustion, and herbal plasters (fig. 1 24, 25 . the rich experience and herbal knowledgebase in fighting pandemics, are now explored here as a foundation 5 to further explore potential effective components and combinations in herbal medicines using more recent advances in data analysis. the components were converted to murcko scaffolds, dissecting molecules into ring systems, linkers, side chain atoms, and frameworks, by scaffold analysis 32 . som arranges the position of these structures in two-dimensional space, after which the dataset contains inherently similar structures and is suitable for inclusion and further cluster analysis 33 . finally, the cluster map of the complete dataset was computer generated followed by visually assessing the largest common groupings of clusters, 6 by reducing the cluster numbers manually until all the disparate clusters without neighbors were included, but the main clusters remained 34 . (2018-007-02, "feather spray"©2018), the r function for statistic computing platform: x86_64-pc-linux-gnu (64-bit)] 35 and pajek visualization 36 . armeniacae semen amarum (ku xing ren) has been used for the treatment of pain and inflammatory diseases such as asthma, bronchitis, emphysema, constipation, nausea, leprosy and leukoderma 77 . the herb has been used to reduce fever, relieve cough and quench thirst. amygdalin is the major compound, which has been reported to have anti-inflammatory and analgesic effects in the inhibition of the cox-2 9 pathway 77 . ephedrae herba (ma huang) has traditionally been used in china for bronchial asthma, coughs, colds, flu, fever, edema, and arthralgias. the aerial parts of different ephedra species contain from 0.02% to 3.4% of six optically active alkaloids. ephedrine is the major isomer comprising 30%-90% of the total alkaloids 78 . it enhances the release of norepinephrine from sympathetic neurons. the vasoconstrictor and bronchodilator effects explain the traditional use of ephedra as a nasal decongestant and anti-asthmatic 78 . it was reported that the growth of h1n1 virus was inhibited when the cells were treated with its extract immediately after infection. its inhibitory effect was completely or partially reversed by fecl 3 , a tannin-reactive agent, suggesting that tannin is one of the active components in the extract 78 . citri reticulatae pericarpium (chen pi) promotes the circulation of qi and is widely taken for coughing by drying dampness and expectorating phlegm 79 we have explored 8 groups of core combinations by hierarchical clustering with 98 individual herbs whose modified mutual information is over 0.03, drawn from the 166 the sixth group focuses on expelling the pathogen and strengthening the spleen. the seventh group aims at tonifying qi and nourishing yin. the last one regulates qi, 11 warms the interior, and relieves pain ( fig. 4a and supporting information table s6 .1). the core combinations found here correspond with the traditional rules of herbal medicine composition and compatibility to reinforce particular functions in the treatment of covid-19. for core combinations of chemical components, only herbs appeared twice or above and with modified mutual information over 0.1 were included, at last 12 core combinations were obtained. some chemical components share the same category of traditional therapeutic effect (fig. 2d) , which may signify potential synergistic effects. there are mutual groupings within these core combinations of herbal pairs and chemical components, thus supporting that the herbs and formulae containing these properties may act as potential candidates for covid-19 treatment ( fig. 4b and table s6 .2). 1164 murcko scaffolds and 40 aliphatic straight chain fragments were removed from the data and not considered further as they produced useless ring structures (fig. 5a ). som resulted in distinctly dispersed map of structural similarly components. therefore, the dataset is diverse yet contains inherently similar structures suitable for inclusion and further cluster analysis. the clusters were self-organized (som) based on the ring system (fig. 5b ). analysis mapping of the nearest neighbours visually exhibited both diverse clusters and clearly associated families of structures (fig. 5c) . finally, 12 significant clusters with distinctly different structures were discovered, from which one representing each family were screened in silico for coronavirus activity, against approximately two million molecules using chembl online database 82 (12%), 229e (16%) and nl63 (72%). herbs containing the same pharmacophore clusters above, due to their chemical scaffold similarity and nearest neighbours, are more likely to behave pharmacologically similar. therapeutically they may possess synergistic properties when used in combinations due to possessing chemical similarities, yet different when act on similar metabolic targets in slightly a different manner. this is the inverse analog of "shotgun chemistry" where similar compounds are applied en masse, often indiscriminately in either chemical, biological, dna analysis or in drug discovery 83 . further pharmacophore synergy investigations are encouraged and could be thought of "selective shotgun" chemistry based on these findings. table s7 ). tcm asserts that pandemic diseases occur naturally and periodically as the climate or geographic situations change. tcm also emphasizes the enhancement of immune function to encourage the body to expel external pathogens. this is also done through the use of herbal formulations derived from careful analysis of syndromes likely to arise in a given year or season. this preventative strategy has also been useful in the treatment of covid-19. in addition to assisting in the relief of symptoms for most patients in all stages, this approach is especially appealing due to the strong emphasis on both prevention and participation in the recovery of various disorders 79 . the prevention strategy appears in three parts: preventing occurrence, deterioration, and reoccurrence. tcm seems to have shown encouraging results in reducing the rate of mild illness, deterioration to severe stage and overall mortality as well as shortening total disease duration. when combined with modern biomedicine, herbal medicines could relieve hypoxemia and chronic obstructive pulmonary disease (copd) 84 this study relies on computational analysis, which has the inherent weakness of not possessing aspects of qualitative judgment and "common sense", that human conducted analysis possesses. to offset this as much as practically possible, this 16 study's scope only focused on herbal medicines which have been developed, selected and proficiently used in practice over thousands of years. additionally, it included herbs only which have been well studied, possessing "drug like" bioavailability, further bringing a "real-world", pharmacological information to the initial dataset. the application of relatively novel computational, pattern recognition and in silico methodologies to a preselected knowledge base of herbal formulae most frequently used, in-part attempts to overcome the shortcomings of the network analysis and computational analysis approach. the 8 resulting pharmacophores and core combinations were based on firstly traditional use, secondly "drug like" characteristics and thirdly reported in silico bioactive pharmacophore structure. therefore, we propose they present the most likely candidates, taking the constraints of this study into account, to be included, in few multiples or in combination to support the composition of completely novel covid-19 herbal formulae. the strengths of computational methods far outweigh their weaknesses. they bestow the ability to recognize and extrapolate useful patterns from herbal datasets which would otherwise take many years, if at all possible for human researchers to explore and uncover. the combination of this blended approach, as presented here, utilizes the combined advantages of both, to enable new useful knowledge obtained from a meaningful practical foundation. the pharmacologically active ingredients of a phyto-complex are not always the original molecules in its natural state, but maybe their host-specific metabolites or molecular complexes formed following co-administration with other herbs. the multicomponent nature of traditional medicines leads to multiple potential molecular interactions, multiple targets, and a myriad of metabolic byproducts, which requires a more network-oriented and holistic approach 94 . the approach could be further refined by the application of omics technologies to optimize the synergistic effect of herbal remedies. with clinicians and basic researchers creating a database of personal therapeutic responses, continual improvements to the evolution and creation of herbal formulations would become possible 5 . integration of western and chinese medical conceptual perspectives has enormous potential for constructing modern technological and social innovations. they are poised to merge within the arena of personalized medicine systems, wherein patients can take a greater role in managing their health and wellness 95 . in a time of increased international awareness of the environment, health and personal responsibility for mankind, an integration of east 17 and west should most likely be mutually beneficial 91 . as the global spread of covid-19 continues to worsen, it is necessary to disseminate the many advantages of traditional medicines for the prevention and treatment of covid-19. bridging the gap between traditional and conventional medicine during this global covid-19 spread is both timely and crucial. we sincerely hope that this study will serve as a reference to the global covid-19 research community. herbal formulae were collected from 26 protocols for treating covid-19. using complex system entropy and unsupervised hierarchical clustering, 8 core combinations and 10 formulae emerged as potential candidates. following scaffold analysis and self organizing mapping, 12 clusters of molecules yielded 8 pharmacophore structures screened as pharmacological targets for inhibiting corona virus. who. coronavirus disease (covid-2019) situation reports who declares coronavirus outbreak a pandemic state administration of traditional chinese medicine information office of the state council anti-influenza virus effect of aqueous extracts from dandelion combining omics and comparative effectiveness 18 research: evidence-based clinical research decision-making for chinese medicine integrated network-based medicine: the role of traditional chinese medicine in developing a new generation of medicine zheng: a systems biology approach to diagnosis and treatments a novel drug discovery strategy inspired by traditional medicine philosophies changes of the temporal-spatial distribution of epidemic disasters 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similarity searching and network analysis for the identification of active compounds r: a language and environment for statistical computing. r foundation for statistical computing programs for analysis and visualization of very large networks national library of medicine, national center for biotechnology information the pharmacological activities of licorice anti-inflammatory and anti-bacterial activities of glycyrrhiza glabra l anti-inflammatory/anti-oxidative stress activities and differential regulation of nrf2-mediated genes by non-polar fractions of tea chrysanthemum zawadskii and licorice glycyrrhiza uralensis clinical features and short-term outcomes of 144 patients with sars in the greater toronto area glycyrrhizic acid as the antiviral component of glycyrrhiza uralensis fisch. against coxsackievirus a16 and enterovirus 71 of hand foot and mouth disease in vitro anti-rotavirus activity of polyphenol compounds isolated from the roots of glycyrrhiza uralensis antiviral activity of liquorice powder extract against varicella zoster virus isolated from egyptian patients glycyrrhizin attenuates kainic acid-induced neuronal cell death in the mouse hippocampus radical scavenging ability of glycyrrhizin glycyrrhizin inhibits the inflammatory response in mouse mammary epithelial cells and a mouse mastitis model glycyrrhizin treatment is associated with attenuation of lipopolysaccharide-induced acute lung injury by inhibiting cycloox-ygenase-2 and inducible nitric oxide synthase expression glycyrrhizic acid and 18β-glycyrrhetinic acidmodulate lipopolysaccharide-induced inflammatory response by suppression of nf-κb through pi3k p110δ and p110γ inhibitions glycyrrhizic acid suppresses cox-2-mediated anti-inflammatory responses during leishmania donovani infection effect of 18β-glycyrrhetinic acid and hydroxypropyl γ-cyclodextrin complex on indomethacin-induced small intestinal injury in mice the beneficial effects of 18betaβ-glycyrrhetinic acid following oxidative and neuronal hmgb1 protein binds to influenza virus nucleoprotein and promotes viral replication effect of glycyrrhizin, an active component of licorice roots, on hiv replication in cultures of peripheral blood mononuclear cells from hiv-seropositive patients glycyrrhizin inhibits highly pathogenic h5n1 influenza a virus-induced pro-inflammatory cytokine and chemokine expression in human macrophages 18β-glycyrrhetinic acid from licorice root impairs dendritic cells maturation and th1 immune responses immunoregulatory effects of glycyrrhizic acid exerts anti-asthmatic effects via modulation of th1/th2 cytokines and enhancement of cd4 + cd25 + foxp3 + regulatory t cells in ovalbumin-sensitized mice immunosuppressive activity on the murine immune responses of glycyrol from glycyrrhiza uralensis via inhibition of calcineurin activity liquiritigenin, a licorice flavonoid, helps mice resist disseminated candidiasis due to candida albicans by th1 immune response, whereas liquiritin 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of anti-inflammatory plant extracts the extract of compound radix scutellariae on mrna replication and ifn expression of influenza virus in mice the flavonoid baicalin exhibits anti-inflammatory activity by binding to chemokines differential inhibitory effects of baicalein and baicalin on lps-induced cyclooxygenase-2 expression through inhibition of c/ebpβ dna-binding activity binding aspects of baicalein to hiv-1 integrase baicalin, an inhibitor of hiv-1 production in vitro human 24 cytomegalovirus-inhibitory flavonoids: studies on antiviral activity and mechanism of action extract from scutellaria baicalensis georgi attenuates oxidant stress in cardiomyocytes effects of armeniacae semen and amygdalin on the lipopolysaccaride-induced prostaglandin e 2 synthesis and nitric oxide production in mouse bv 2 microglial cells ephedra in perspective-a current review citri reticulatae pericarpium (chen pi): botany, ethnopharmacology, phytochemistry, and pharmacology of a frequently used traditional chinese medicine anti-inflammatory property of the urinary metabolites of nobiletin in mouse anti-inflammatory and antioxidant mechanism of tangeretin in activated microglia the chembl database in 2017 meta-sourcetracker: application of bayesian source tracking to shotgun metagenomics exploration of potential clinical application value and mechanism of chinese materia medica for tonifying qi and activating blood in covid-19 with hypoxemia. chin tradit herbal drugs 2020 application of integrative medicine protocols on treatment of coronavirus disease 2019 characteristic analysis on international clinical trial registry of covid-19 analysis report of evidence-based registered clinical trials of tcm treatment for covid-19 clinical study on 34 covid-19 cases treated with integrated medicine covid-19 suspected cases treated with lianhua qingwen decoction: a clinical observation of 63 cases chapter 1: medicine east and west: two ways of seeing, two ways of thinking. chicago: contemporary a global scientific challenge: learning the right lessons from ancient healing practices can chinese medicine be used for prevention of coronavirus disease 2019 (covid-19)? a review of historical classics, research evidence and current prevention programs oseltamivir compared with the chinese traditional therapy maxingshigan-yinqiaosan in the treatment of h1n1 influenza: a randomized trial deciphering ancient combinatorial formulae: the shexiang baoxin pill east is east and west is west and never the twain shall meet: work engagement and workaholism across eastern across eastern and western cultures the authors thank dr. zheng yu all authors declare no conflict of interests. key: cord-289238-f3lv7o4d authors: wu, taixiang; yang, xunzhe; zeng, xiaoxi; poole, phillippa title: traditional chinese medicine in the treatment of acute respiratory tract infections date: 2008-08-31 journal: respiratory medicine doi: 10.1016/j.rmed.2008.03.015 sha: doc_id: 289238 cord_uid: f3lv7o4d summary aims to review the evidence from cochrane systematic reviews for the effectiveness of traditional chinese medicinal (tcm) herbs for treating acute respiratory tract infections (artis) and to discuss the limitations of current clinical trials of tcm. findings evidence from six cochrane systematic reviews was weak owing to the lack of high-quality tcm trials. limitations were usually due to biases that influenced the validity of results. conclusions tcm is widely used for treating artis. however, none of the identified studies has been well designed or conducted. in this overview, we suggest that clinical trials of tcm for artis need to be re-run in accordance with internationally recognized standards. acute respiratory tract infections (artis) range from minor (e.g. common cold) through to very serious conditions (e.g. severe acute respiratory syndrome). artis are caused by over 200 viruses or bacteria. they are transmitted directly through person-to-person contact, either by airborne droplets from a sneeze or cough, or by direct contact with nasal or throat secretions, articles freshly soiled with secretions of the nose and throat, or by transmission via an object indirectly. for example, sore throat can either be a disease in itself, or can result from other diseases, such as influenza and glandular fever. 1e4 uncomplicated artis, such as the common cold and sore throat, recover spontaneously as a result of antibodies produced by the patient's own immune system targeting the virus. in general, no specific antiviral treatment is used. treatment aims to alleviate symptoms and prevent complications. antibiotics are used for bacterial infections. however, antibiotics only have a modest effect over placebo for acute bronchitis 5 and sore throat. 6, 7 for the common cold and influenza, over-the-counter decongestants, antihistamines, cough suppressants, and expectorants may be used for symptomatic relief. traditional chinese medicine (tcm) is a unique system with special aetiology and theories for treatment. tcm drug treatment typically consists of a complex prescription of a combination of components according to tcm signs. these include whether the patients themselves feel cold and chilly; experience nasal obstruction; do not sweat; generally have a high temperature with a thin, white coating on the tongue; have a productive cough; do not feel chilly; have an elevated temperature, with a thin and slightly yellow coating on the tongue; or have a productive cough. colds are categorized as 'chills cold' or 'fever cold'. shigao (gypsum fibrosum) is used to abate fever; caihu (bupleurum chinesenes dc) and jinjie (herba schizonepetae) are used as analgesics; banxia (rhizoma pinelliae) is dispensed to loosen sputum and suppress cough; fangfeng (radix saposhnikiviae) and zhishuye (folium perillae) are used for 'chill cough'; jinyinghua (flos lonicerae) and bohe (herba menthae) for 'fever cough', and so on. elements of a tcm formulation are meant to interact and co-ordinate with each other. these may be combined in a soap-like solution, or 'decoction' of tcm. in this evidence-based review, we aim to summarize the evidence from cochrane systematic reviews for the effectiveness of tcm herbs in treating artis, and to discuss the limitations of tcm clinical trials in the field. we conducted a comprehensive search for cochrane reviews of tcm for artis. we screened the cochrane database of systematic reviews in the cochrane library, issue 3, 2007. the search string contained (traditional and chinese and medicine) or herb*. we found 70 cochrane reviews and protocols. after scrutiny, six reviews were identified that fulfilled the inclusion criteria. the six reviews related to the use of tcm in the treatment of acute bronchitis, influenza, measles, sore throat, common cold and severe acute respiratory syndrome (sars), respectively. the initial version of this review was published in the cochrane database of systematic reviews, issue 3, 2005. 8 fourteen studies were included in the review, involving a total of 2771 participants with acute bronchitis. however, study quality (randomization, blinding and allocation concealment) was poor. because the formulations used were heterogeneous, the outcomes were analyzed separately, and not combined. all the 14 formulations in the studies seemed to show significant benefits compared with conventional medicine. for example, tcm formulation 'xiao'er xiaoji zhike koufuye' oral decoction was more effective than cefotaxime plus fluimucil (n-acetylcysteine) for resolution of cough (wmd à0.62 days, 95% ci à1.12 to à0.12), for clearance of fever (wmd à1.22 days, 95% ci à1.67 to à0.77), for reducing the duration of wheezing (wmd à0.44 days, 95% ci à0.74 to à0.14), and for resolution of rales (wmd à1.00 days, 95% ci à1.47 to à0.53). 'yuxingcao' atomisation aerosol was more effective than gentamicin atomisation aerosol for resolution of cough (wmd à1.37 days, 95% ci à1.67 to à1.07), for clearance of fever (wmd à0.92 days, 95% ci à1.03 to à0.81), and for relief of rales (wmd 0.60 days, 95% ci 0.19e1.01). the tcm patent medicine 'shiwei longdanhua keli' oral decoction plus antibiotics was more effective than antibiotics alone for resolution of cough (wmd à2.40 days, 95% ci à2.84 to à1.96), for clearance of fever (wmd à0.99 days, 95% ci à1.44 to à0.54), and for resolution of rales (wmd à2.76 days, 95% ci à3.26 to à2.26). the tcm formulation 'tanreqing' injection was more effective than levofloxacin for resolution of cough (wmd à3.17 h, 95% ci à5.95 to à0.39), for clearance of fever (wmd à32.13 h, 95% ci à34.81 to à29.45), and for normalization of chest x-ray (rr 1.28, 95% ci 1.01e1.61). the major limitation of this cochrane review was that inclusion of the studies was dependent upon the term 'random' appearing in the text. the original trial authors have now been interviewed by telephone and no trial has been identified as a true randomizedecontrolled trial (rct). this particular cochrane review is in the process of being updated. according to knowledge gained during the summer of 2005, it is estimated that only a small number of claimed rcts published in china are authentic rcts. 9 the initial version of the review on chinese medicinal herbs for influenza was published in the cochrane database of systematic reviews, issue 1, 2005 . 10 eleven studies with the number of participants ranging from 52 to 479, for a total of 2088, were included. one study used a chinese patent medicine, and the other 10 studies used tcm formulations in decoctions prepared in the respective hospitals. two years after publication of the review, the review authors telephoned the 11 trial authors and found that only two studies were authentic rcts. this review is in the process of being updated and will include these new findings. of the two authentic rcts, 61 were children with influenza b infection and 951 were participants with influenza a3/h3n2. for children with influenza b, tcm eshuyou oral decoction (volatile oil extracted from zedoary) had better effects but was not significantly different to ribavirin for recovery within 3 days of treatment (12/32 vs 5/29, rr 2.18, 95% ci 0.87e5.43). for participants with influenza a3/h3n2, ganmao capsule had significantly better effects than amantadine for recovery within 2 days of treatment (168/202 vs 37/230, rr 5.17, 95% ci 3.82e6.99). the review on chinese medicinal herbs for measles was published in the cochrane database of systematic reviews, issue 2, 2006. 11 strict methods for identifying study design were used in this review. twenty-eight studies were retrieved, which claimed to randomly allocate the participants. the authors of the 19 rcts were interviewed by telephone. it was revealed that the allocation methods they had used were not true randomization. three studies were excluded owing to participant complications. the remaining six study authors were unable to be contacted and will be assessed only if they demonstrate random allocation of the participants. thus, there is currently no rct evidence for use of tcm in measles. the review on chinese medicinal herbs for sore throat was published in the cochrane database of systematic reviews, issue 3, 2007. 12 strict methods for identifying rcts were used in this review. the authors of the 54 rcts were interviewed; only seven trials involving 1253 participants were identified as using authentic randomization techniques, but otherwise had poor methodological quality raising the possibility of selection bias or detection bias, or both. conflict of interest may have been another factor in producing a positive result in three studies as the prepared drugs were made in the respective hospitals. three tcm formulations were shown to be superior to the control drug in improving recovery: ertong qingyan jiere koufuye oral decoction was more effective than fufang shuanghua koufuye decoction for acute pharyngitis (or 1.54, 95% ci 1.11e5.74). yanhouling decoction was more effective than the gentamicin atomised inhalation aerosol, a non-standard treatment, for acute pharyngitis (or 5.39, 95% ci 2.69e10.81). qinganlan liyan hanpian tablet was more effective than the fufang caoshanhu hanpian tablet for chronic pharyngitis (or 2.25, 95% ci 1.08e4.67), and four formulations were shown to be equal in efficacy to the control. the review of chinese medicinal herbs for the common cold was published in the cochrane database of systematic reviews, issue 1, 2007. 13 the strict procedure of interviewing the original trial authors of claimed 'rcts', to guarantee the validity of the allocation method used for included studies was also conducted in this review. a total of 348 trials claiming to be randomized were retrieved. the authors of 295 trials were contacted by telephone. of these studies, 234 were excluded either because the trial authors misunderstood the concept of randomization or the trials were multiple printings of same study. one hundred studies were relegated to the 'awaiting assessment' section because the trial authors could not be contacted, or refused to be interviewed. fourteen studies were identified as true rcts and were included for assessment. of the 14 studies, two tested the same preparation against the same tcm formulation control. the other 12 studies tested different preparations for patients with different types of tcm signs (zheng xing). therefore, the data were assessed separately. five studies of herbal preparations reported a statistically significantly shorter duration of symptoms after treatment with the intervention compared with the control. of the five studies, three were for children with 'fever cold' (fengre zheng). qinwen keli oral decoction was more effective than kangbingdu koufuye oral decoction (rr 2.19, 95% ci 1.61e2.96); shuanghua penwuji aerosol was more effective than shuanghuanglian qiwuji aerosol (rr 1.48, 95% ci 1.11e1.79); and tcm cream was more effective than penicillin (rr 2.10, 95% ci 1.20e 3.67). in one trial conducted for adults with 'chills cold' (fenghan zheng), sufeng ganmao koufuye oral decoction was more effective than ganmao qinre koufuye oral decoction (rr 1.43, 95% ci 1.02e1.99); in one trial in 'fever cold' (fengre zheng), qinkailing injection was more effective than lincomycine given in three doses, in the treatment of adults with the common cold (120 ml/day rr 14 an important question arose from the sars outbreak in 2003: ''why was the case-fatality rate lower in mainland china (7%, 349/5327) than in both hong kong (17%, 299/1755) and taiwan (11%, 37/346)?'' the mortality level in mainland china was also lower than that in the rest of the world (9.6%, 774/8096). 15, 16 during the early stage of the sars outbreak, western medicine, specifically corticosteroids, was combined with chinese herbal medicines in an effort to promote non-specific immunity to combat inflammation. the state administration of traditional chinese medicine, the chinese ministry of health general office, issued a rule of combining western and chinese herbal medicine (icwm) for this rapidly spreading disease. sars was classified as a plague that needed to be treated in accordance with the 'wei, qi, ying, xue and sanjiao bianzheng lunzhi' theory. in keeping with this theory, some herbal medicinal extract injections to clear fever (qin re), remove dampness (qu shi), relieve asthma (zhi chuan), promote and regulate immunologic function (fu zheng), resist viruses and remove toxins (jie du), were recommended for clinical use. 17 the cochrane systematic review, conducted by liu et al. 14 included 12 rcts, and one quasi-rct had a total of 654 participants using 12 different tcm formulations. they carried out a combined analysis of two trials using the same tcm formulation plus western medicine, and separately analyzed four studies using different formulations plus western medicine vs western medicine alone to compare mortality between the two therapies. tcm did not show any benefit in reducing mortality compared with western medicine alone (rr 0.31, 95% ci 0.07e1.38, rr 0.27, 95% ci 0.01e6.11; rr 0.41, 95% ci 0.04e4.78; rr 0.30, 95% ci 0.01e7.70; and rr 0.19, 95% ci 0.01e4.06, respectively). whether or not tcms can decrease mortality from sars remains an unanswered question (table 1 ). it is encouraging that clinical trials of tcm in artis have been conducted; however, to date these have in common a weak study design, leading to potential biases in evaluating the effectiveness of the intervention. approaches for minimizing bias such as the use of strict protocols, randomization, concealment of allocation, and double-blinding were underused in these trials. the reporting of tcm trials is usually cursory, with a lack of description surrounding important detailed information, such as how the allocation sequence was generated; recruitment and enrolment of the participants; blinding for assessors and analyzers, statistical methods and number of drop-outs. a large number of the trials claimed to be rcts; however, most of the trial authors misunderstood the concept of randomization allocation. in the reviews in which the reviewers subsequently contacted the authors, the percentage of authentic rcts was 6.7% (23/342). this highlights the need for reviewers, including those doing cochrane reviews, to use a strict method to identify whether the trial authors used the correct method to allocate participants when conducting a systematic review, and not just relying on published reports. it also emphasizes the importance of using a quality scoring system, and planning, a priori, subgroup analysis of trials based on study quality. results from larger, better-quality trials are less likely to be affected by bias and thus more likely to be valid. many trials tested self-prepared formulations of the trial authors or their colleagues, or the decoctions were manufactured by their hospitals or patients themselves. as the trialists were involved in the design of the formulations and conducted the trials, this may have biased investigators in favour of the intervention. few studies used a placebo as a control. instead 'positive effect drugs' were used. most chinese trialists select the control drugs by a rule of 'the effect was commonly acknowledged'. this rule may lead to conflict of interest bias, and subjective over-or under-estimate of the effect of the trial preparation depending on the aim of the study. if a preparation was tested as the intervention, it had a high rate of effectiveness; if used as a control drug by another author, it may have had a much lower rate of one poor-quality trial showed that tcm may decrease influenza symptoms and speed up recovery. overall methodological quality poor. no authentic trial was identified for inclusion. no evidence from rcts yet sore throat seven trials identified and included three formulations were shown to be superior to the control formulation in improving recovery. all trials were of methodologically poor quality. common cold 14 trials identified and included in five studies, treatment with herbal preparations resulted in a statistically significantly shorter duration of symptoms compared with control. sars 13 studies included tcm did not show any benefit in reducing mortality compared with western medicine alone. effectiveness. therefore, it is difficult to determine the efficacy of the intervention drug. where the intervention drug was equal in efficacy to the control drug, no conclusion could be made. sample sizes were not reported in most of the tcm studies, which makes it difficult to assess if observed differences between the two groups were statistically or clinically important, or if trials were underpowered. some studies used unequal arms in their design, with some having a small number of participants in their control group. this would contribute to selection bias. the traditional use of tcm is in contrast to the pharmacological agents used in western medicines, for which the chemical constituents, their quantities, and the percentage of any impurities of contaminants are known precisely. in addition, the variation between different production batches of western medicinal drugs is kept within specified limits. in contrast, variation between formulations and batches of pharmacological agents is inevitable in tcm, although the chinese government specifies the acceptable limits of variation. this variation is a factor that may contribute to any heterogeneity between different study results. the tcm components used in the trials were not adequately described. the variability in individual components of herbal preparations and the variability between different preparations of combination products meant that any meaningful scientific evaluation is difficult to make without precise descriptions of the components of tcm formulations for the decision makers' consideration. because of the variability, use of chinese names alone for herbal preparations is not sufficient. in addition to folk or specific tcm names, each preparation should be described, giving the internationally recognized taxonomic names (genus species) of all plants included, the plant organ, along with proportions. tcm has an overall treatment concept that differs from western medicine. when using a tcm preparation for treating a disease, the type of 'zheng', the tcm signs, of a disease has to be matched. but some studies did not state whether the tcm control drug matched the type of 'zheng' or not. if the control drug does not match the 'zheng', the interpretation of results should refer to a placebo. unmatched formulations may be detrimental to the patient. it was often necessary to include tcm signs as a secondary or an additional outcome in the trials. however, it is difficult to compare or quantify tcm signs as most of them are subjective or non-specific outcomes. for example, 'mai xiang' means pulse presentations. diagnosing 'mai xiang' in tcm is a complex technique, dependent upon the tcm physician's feelings and experience. the descriptors 'marked improvement' and 'improvement' are commonly used to assess the change in tcm signs. these are based on the participants' feelings and assessor's subjective judgment. there seems a need for tcm researchers and physicians to develop an accurate, repeatable, and simple set of tcm measures to use as outcomes in clinical trials. along with the cochrane review on chinese herbs combined with western medicine for sars, 17 there have been two other reviews published addressing the question as to whether tcm lowers case-fatality rates in sars or not. the first of these pooled results for five different tcm formulations in five studies, finding a statistically significant, lower mortality in tcm plus conventional medicine groups than in conventional medicine groups alone (rr 0.32, 95% ci 0.12e0.91). 18 in the other review 19 pooled data from four studies showed a statistically significant lower mortality in tcm plus conventional medicine than in conventional medicine alone (or 0.32, 95% ci 0.14e0.71), but a sensitivity analysis that excluded an unbalanced two-arm study in which the number of severely ill patients was higher in the conventional medicine group than the tcm group (19 vs 13) found that there was no statistical difference between the two groups (or 0.53, 95% ci 0.20e1.41). the difference in mortality between the two therapies may, therefore, have been due to selection bias. the interpretations in these two reviews by liu et al. 18 and wu et al. 19 were similar to that of the cochrane review in that tcm therapy may contribute to a decrease in mortality from sars. however, because of poor methodological quality of the included studies, the evidence was weak an affirmative conclusion cannot be drawn. the tcm effects on secondary outcomes such as symptoms, lung infiltrate absorption, dosage of corticosteroids, quality of life of sars patients, and shortening the length of stay in hospital were similar in the three reviews. 14, 18, 19 this is likely because the data for calculating the results in the three reviews were extracted from different versions of the same studies. however, the number of studies included in the three reviews and the number of participants were different. because of the issues with study quality, and the fact that these are secondary outcomes, it is difficult to draw any conclusions from the results. the limitations of the included studies in the sars reviews were similar to other studies. these included a lack of randomization description; unconcealed allocation sequence, and non-blinding. the shortcomings were obvious in most of the studies, with unbalanced arms suggested by different numbers of male and female participants. it is also reasonable to construe that it was difficult for physicians to mount and conduct rigorous rcts during an outbreak of sars. thus, the methodological issues in these trials may be a more extreme representation of the problems seen in the conduct of tcm trials generally. the sars outbreak was a rare opportunity to demonstrate the value of tcm. unfortunately, as the evidence was derived from poorly designed studies, it remains unanswered whether the use of tcm saved sars patients or not. such studies pose other considerations. as there is such a wide belief in the effectiveness of tcm in the treatment of diseases, particularly those that are not effectively treated by conventional medicine, the possibility of randomization to inactive placebo may not be acceptable to participants. another challenge will be to find acceptable 'gold standard' treatments to compare with tcm formulations. at this stage, as evidence for tcm comes from poorly designed studies, no conclusions can be drawn about the effectiveness of tcm in a range of artis. we would appeal, therefore, for future clinical trials of the effects of tcms to be conducted according to internationally acceptable standards. the consolidated standards for reporting trials of traditional chinese medicine, (consort for tcm) published in 2007, 20 should assist in the design of better-quality trials. cdc. influenza: the disease randomized placebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature antibiotics for sore throat penicillin b for acute throat infections in adults: rapid resolution of symptoms after a 7-day treatment as compared to a 3-day treatment or a placebo; a randomized double-blind study chinese medicinal herbs for acute bronchitis investigation for the quality of claimed chinese medicinal herbs for influenza chinese medicinal herbs for measles chinese medicinal herbs for sore throat chinese medicinal herbs for the common cold chinese herbs combined with western medicine for severe acute respiratory syndrome (sars) world health organization. summary table of sars cases by county world health organization. consensus document on the epidemiology of severe acute respiratory syndrome (sars chinese ministry of health general office. announcement of issue revised diagnostic criteria of infectious atypical pneumonia (draft) and recommend treatment regime and discharge reference criteria systematic review and meta-analysis on the integrative traditional chinese and western medicine in treating sars a systematic review of assessing the effect of integrated traditional chinese medicine with western medicine for severe acute respiratory syndrome consolidated standards for reporting trials of traditional chinese medicine (consort for tcm) (for solicitation of comments) we would like to thank ms liz dooley, co-ordinator of the cochrane acute respiratory infections (ari) group, and the editorial board of the ari group, for their help in writing this article and the reviews included in this article. key: cord-001078-5m29nugu authors: chen, xiaorong; yang, zongguo; lu, yunfei; xu, qingnian; wang, qiang; chen, liang title: clinical features and factors associated with outcomes of patients infected with a novel influenza a (h7n9) virus: a preliminary study date: 2013-09-17 journal: plos one doi: 10.1371/journal.pone.0073362 sha: doc_id: 1078 cord_uid: 5m29nugu objective: the present study aimed to analyze clinical features and factors associated with treatment outcomes of h7n9 influenza a virus infection. methods: the clinical progress in 18 h7n9-infected patients was monitored and recorded. the clinical features of h7n9 infection were noted and factors associated with treatment outcomes were analyzed by univariate analyses. results: the average ages of patients in recovered and critical conditions were 67.0±10.83 years and 72.75±12.0 years, respectively. renal insufficiency developed more frequently in critically ill patients (p = 0.023). the duration of traditional chinese medicine (tcm) therapy was longer in recovered patients than in critically ill patients (p = 0.01). laboratory tests showed that levels of c-reactive protein, serum creatinine, and myoglobin were significantly higher in critically ill patients than in recovered patients (p = 0.011, 0.04, and 0.016, respectively). meanwhile, levels of all t cell subsets examined including total cd3(+), cd4(+), cd8(+), and cd45(+) t cells were lower in critically ill patients than in recovered patients (p = 0.033, 0.059, 0.015, and 0.039, respectively). logistic regression analysis demonstrated that c-reactive protein level, myoglobin level and tcm therapy duration were likely associated with treatment outcomes of h7n9 infection (p = 0.032, 0.041 and 0.017, respectively). conclusion: elderly people may have increased risk for h7n9 virus infection. t cell-mediated responses play an important role in defense against the h7n9 virus. c-reactive protein level, myoglobin level and tcm duration may be associated with treatment outcomes of h7n9 infection. avian influenza caused by influenza a viruses (iav) has become a serious threat to human health in recent years. infections with avian influenza viruses, which usually occur after exposure to poultry and/or wild birds, are commonly characterized by conjunctivitis, upper and/or lower respiratory tract disease, pneumonia, and multiple organ failure [1] [2] [3] . wild birds are believed to constitute the natural reservoir for iavs and play a central role in the spread of the viruses. iavs are classified into subtypes based on different combinations of 16 hemagglutinin (ha: h1 -h16) and 9 neuraminidase (na: n1 -n9) surface antigens, and two pathotypes (low and high pathogenicity) based on lethality for chicken. all highly pathogenic avian iavs known to date belong to the h5 or h7 subtype [4] . the h7n9 viruses, a subgroup of h7 viruses that normally spread among birds have currently been found to cause human infections in china, prompting intensive research to address the challenge of a potential epidemic/pandemic. although h7n9 family clusters have been reported in shanghai and shandong province [5] , no evidence of human-to-human h7n9 virus transmission has been found to date [6] . presently, there is a general lack of information about h7n9 infections, e.g., the transmission mechanism and the number of mild infections in china are unknown. unlike h5n1, which could wipe out a flock of poultry within days, h7n9 infections in poultry are usually asymptomatic or mild. nonetheless, based on what has been learned from the h5n1 avian flu virus which has killed 371 people in 15 countries since 2003 and proved extremely difficult to control, the risk of an h7n9 epidemic/pandemic should not be underestimated, especially in china where poultries are reared with diverse methods without strict biosecurity measures [7] . studies on h7n9 transmission mechanisms and clinical features/outcomes are critical to prevent and control potential h7n9 epidemic/pandemic. overall, few cases of h7 virus transmission to mammals have ever been reported in asia and n9 virus infections in human have never been documented anywhere in the world [8] except h7n9 [7] . the h7n9 variants currently in circulation most likely evolved through a combination of genes from viruses in beijing bramblings, zhejiang ducks, and korean wild birds according to report by chinese scientists. human infections with highly pathogenic h7 viruses generally resulted in conjunctivitis or uncomplicated influenza [3, 8] study protocol for this preliminary investigation and informed consent documents were reviewed and approved by the ethics committee of shanghai public health clinical center affiliated with fudan university. all participants provided written informed consent after receiving information of the aims, methods, anticipated benefits, and potential hazards of the study. all work reported herein was conducted in china. diagnosis of h7n9 infection in patients was made by positive test for h7n9 viral rna. throat-swab specimens were collected from patients and tested for h7n9 viral rna by real-time reverse transcription polymerase chain reaction (rt-pcr), which was carried out using standard rt-pcr protocol at shanghai centers for disease control and prevention. all 18 patients who participated in the study were admitted to shanghai public health clinical center and diagnosed with h7n9 infection from april 6 to april 20, 2013. their medical records were obtained and analyzed. laboratory tests of blood, liver function, renal function, myocardial enzyme, t cells, and immunoglobulins were carried out at medical inspection department of shanghai public health clinical center. other information about patients was either retrieved from patients' medical records or acquired directly from patients via a questionnaire. factors analyzed for possible correlation with clinical features and treatment outcomes in patients included 1) baseline characteristics of patients, such as age, sex, occupation, underlying conditions, exposure to poultry and/or wild birds in the past seven days, date of symptom onset and hospital admission, date of specimen collection, and date of positive diagnosis; 2) results from laboratory tests and imaging examinations; 3) treatment regimen including basic supporting therapy, antibiotic therapy, antiviral therapy, traditional chinese medicine (tcm) therapy, and other therapies if applicable; and 4) current condition of patients including the length of stay in the hospital. following guidelines from the influenza a h7n9 clinic program published by the national health and family planning commission of p. r. china (the 2nd edition, 2013) [9] , we considered patients who met the following criteria recovered: 1) throat-swab specimens tested negative for h7n9 viral rna, and 2) disappearance of fever and other clinical symptoms and signs. following the same set of guidelines, we considered patients who met the following criteria critically ill: 1) pneumonia with two or more complications, such as acute respiratory distress syndrome, heart failure, renal failure, septic shock, encephalopathy, and secondary infections; and 2) no improvement in at least one of the above mentioned complications after 3 d of active treatment. all participating patients were treated by twice daily oral administration of 75 mg oseltamivir. patients were also given antibiotics based on blood and/or throat-swab specimens/sputum tests for bacterial infections. if no specific bacterial pathogens were detected from the specimens, advanced treatment was considered. antibiotics given to h7n9-infected patients if applicable included moxifloxacin, sulbactam and cefoperazone, levofloxacin, meropenem, piperacillin, imipenem, and cilastatin. some patients also received glucocorticoid therapy, intravenous immunoglobulin therapy, and tcm therapy. only chinese herbs prescribed according to specific syndromes were considered tcm in this study. proprietary chinese medicines and injections of chinese medicines were excluded because they could contain certain western drug ingredients. these herbal tcms were prescribed following group discussions of tcm experts from longhua hospital, shanghai university of tcm, department of tcm of zhongshan hospital, fudan university, and xr chen in our hospital. based on syndrome differentiation criteria from wei-qi-ying-xue and clinic programs of influenza a h7n9 implemented by the national health and family planning commission of p. r. china, yinqiao powder and hoisting powder were prescribed for patients with mild syndromes and qingwen-baidu-decoction was prescribed for critically ill patients. tcms were taken orally twice daily at 150 ml decoction per dose. the purchase, decoction, and administration of chinese herbs were supervised by pharmacy department of tcm in shanghai public health clinical center. baseline data were expressed as mean 6 standard deviation (sd) or median values. the kolmogorov smirnov test was used for the test of normality on quantitative data. to analyze differences between baseline data, student's t-test analysis was performed on mean numeric data, mann-whitney u-test analysis was performed on non-numeric data, and fisher's exact test was used for categorical variables. logistic regression models were used to evaluate possible factors contributing to different outcomes in h7n9-infected patients. results were reported as odds ratios (or) with their 95% confidence intervals (ci). all baseline characteristics and laboratory tests were analyzed using univariate analysis. multivariate analysis was not considered suitable for such a small sample study. statistical analyses were performed using pasw statistics software version 18.0 from spss inc. (chicago, il, usa). all p values were two-tailed, and differences with p,0.05 were considered statistically significant. patients were grouped according to their conditions. patients in group a were in recovered condition or had recovered, and patients in group b were in critical condition or had died. there were 14 males and four females in the 18 h7n9-infected patients. as shown in table 1 , 10 patients were in group a and eight were in group b. average ages of patients in group a and group b were 67.0610.83 and 72.75612.0 years, respectively. four patients, including three from group a and one from group b, had a history of smoking. in group a, seven patients had underlying conditions: five had hypertension, one had coronary heart disease, and one average time from onset of symptoms to treatment with antiviral agents was 5 or 6 days in both groups. five patients, including one from group a and four from group b, developed acute respiratory distress syndrome during the course of the disease. seven patients, two from group a and five from group b had heart failure. four patients experienced renal failure and three experienced septic shock, all from group b. three patients in group b were diagnosed with encephalitis based on their clinical symptoms, dysphoria and one in lethargy condition. all three patients developed poor cognitive ability as observed in medical examinations although no csf test was conducted on these patients. two patients died while the third in critical condition with no improvement observed in their neurological condition throughout treatment. moreover, three patients from group b who tested positive in the sputum culture fungal spore test also had secondary infections. renal failure rates were significantly different between the two groups (p = 0.023). as shown in figure 1 , more than half of the 18 h7n9-infected patients suffered from fever (88.9%), cough (77.8%), expectoration (55.6%), fatigue (50.0%), poor appetite (83.3%), dry month (72.2%), thirst (72.2%), dyspnea (66.7%), chest distress (66.7%), and bitter taste in month (61.1%). in addition, five patients suffered from hemoptysis and two suffered from dysphoria. other symptoms such as muscle soreness (3), aversion to cold (2), perspiration (5), pharyngodynia (1), short breath (4), deep yellow urine (3), and cold-limbs (1) also occurred in patients with h7n9 infection. although no statistically significant differences were found in routine blood indices between the two groups, the c-reactive protein level was significantly higher in group b patients than in group a (table 2 ). also, serum creatinine level in group b was higher than that in group a (126.03644.63 mmol/l in group b vs. 76.91610.69 mmol/l in group a, p = 0.04), indicating more severe renal impairment in critically ill patients. while critically ill patients had significantly higher myoglobin levels than recovered patients (p = 0.016), no differences in immunoglobulin concentrations were observed between the two groups. however, all t cell subsets examined including total cd3 + , cd4 + , cd8 + , and cd45 + t cells, were lower in group b patients than in group a. baseline characteristics were included in the univariate analysis to identify possible factors associated with critical outcomes (table 3 ). our univariate analysis indicated that 1 mg/l increase in c-reactive protein (p = 0.032), 1 mmol/l increase in total bilirubin (p = 0.096), 1 mmol/l increase in serum creatinine (p = 0.1), 1 mg/l increase in myoglobin (p = 0.041), and 1 cell/ml increase in cd3 + /cd4 + /cd45 + t cells were likely associated with a critical outcome (p = 0.089, 0.093, and 0.08, respectively). one-day increase in tcm therapy was found to be significantly associated with a critical outcome (p = 0.017). these results might be limited by the small sample size in our study. further studies with larger sample sizes should be conducted to verify our preliminary results. the recent discovery of h7n9 virus infections by a new influenza virus strain in three critically ill patients, as reported by gao et al. [8, 10] , is of major public health significance. laboratory testing conducted in china showed that h7n9 viruses were sensitive to anti-influenza drugs known as neuraminidase inhibitors. these drugs were effective against seasonal influenza and h5n1 virus infections when given early in the course of the illness. however, these drugs had not yet been used to treat h7n9 infections. to date, the national health and family planning commission of p. r. china has released two editions of the influenza a h7n9 clinic programs in which supporting therapies including oxygen therapy, antipyretic therapy, and cough and phlegm relief and medicinal therapy with antiviral drugs such as oseltamivir and zanamivir were recommended. particularly, respiratory support including extracorporeal membrane oxygenation was recommended for critically ill patients. tcm therapy was also recommended as a second-line treatment for h7n9 infection. previous studies have demonstrated that tcms may have beneficial effects on patients with avian influenza [11, 12] . our univariate logistic regression analysis indicated that the duration of tcm therapy could be partially associated with the prognosis in h7n9-infected patients. however, tcm therapy was not considered for four critically ill patients with ards, which might have accounted for the short duration of tcm therapy in the critically ill group. consequently, the therapeutic value of tcm therapy in critically ill patients might have been underestimated. further studies including randomized controlled trials are needed to fully evaluate tcm therapy in this patient population. nine patients were also treated with intravenous immunoglobulins (ivig). six of the nine patients recovered, one was in severe condition, and two died. examination of baseline characteristics of h7n9-infected patients revealed that most patients were elderly males, suggesting that elderly people were at higher risk for h7n9 infection. in contrast, a high proportion of severe cases and deaths in h5n1 infection occurred in children [13] . the high proportion of elderly patients in h7n9 infection might be attributed to higher exposure of the elderly to h7n9 virus or to age-related body functions, such as decreased immune function [14] . although h7n9 infections preferentially occurred in males, our logistic regression analysis did not show any statistically significant differences in clinical outcomes between genders. our results suggested that history of smoking and/or underlying clinical conditions may increase risk for infection, especially for patients with hypertension, diabetes, and heart-pulmonary insufficiency. four patients, including three from group a and one from group b, had a smoking history of 30 to 40 years with 20 to 40 cigarette smoking per day, which could have contributed to their poor respiratory function. nearly half of the patients (8/18) had hypertension, two had diabetes, three had coronary heart diseases, and three had copd, indicating that chronic heart and lung diseases would increase risk for h7n9 infection. poultry and wild birds have been recognized as natural reservoir of iavs [15] . in our study, only three patients had confirmed exposure to poultry or wild birds 7 d before onset of illness. however, according to previous report, 60% of h7n9-infected patients in china had epidemiological links to poultry and/or wild birds [16] . li et al. also reported that 77% of h7n9-infected patients in their study had a history of exposure to live animals, including chicken (76%) [17] . taken together, avoiding contact with poultry and wild birds may effectively reduce the risk of infection. meanwhile, placing infected poultry and wild birds in quarantine is important for the control and prevention of h7n9 infection. our results also suggested that early diagnosis and treatment of h7n9 infection were critical in achieving favorable clinical outcomes. in our study, nearly all h7n9-infected patients were treated as common pneumonia in the early stage of the illness. the average time from onset of symptoms to h7n9 virus confirmation was 7.162.03 days in group a and 6.3862.07 days in group b. antiviral treatment was not initiated until 5-6 days after the onset of illness. the delayed diagnosis and treatment for this highly pathogenic avian influenza virus infection might have partially contributed to the poor prognosis in h7n9-infected patients. we believe that early surveillance and early diagnosis are of great importance for favorable clinical outcome. full characterization of clinical features of h7n9 infection should speed up diagnosis and treatment. most h7n9-infected patients in our study had developed severe conditions with one or more complications, such as acute respiratory distress syndrome, heart failure, renal failure, septic shock, encephalopathy, and secondary infections. our results suggested that such complications significantly worsened the clinical outcomes of h7n9-infected patients. effective management of complications in the course of the disease would be critical to achieve favorable clinical outcomes and prevention of death. our results showed that h7n9-infected patients in critical conditions had higher c-reactive protein level and more severe renal insufficiency and myocardium injury. c-reactive protein level might be used as an early marker for clinical prognosis in h7n9 patients based on results from our logistic regression analyses, which was in agreement with previous studies showing that c-reactive protein level might serve as a marker for severity of illness in influenza infections [18, 19] . since multivariate analysis was not performed in our small sample study, further research is needed to verify this. interestingly, levels of t cell subsets including total cd3 + , cd4 + , cd8 + , and cd45 + t cells, were all lower in patients in critical conditions than those in recovered conditions. the protective role of cd8 + t cells in aiv infections has been discussed in previous studies [20, 21] . it has been shown that cd8 + t cell-mediated responses in patients were mainly directed against conserved viral proteins, enabling cd8 + t cells to provide protection against heterologous influenza strains [22] . cd4 + t cells have also been reported to contribute to immunity against influenza. previous studies showed that cd4 + t cells were induced after influenza virus infection and played a central role in acquired immunity through induction and maintenance of cd8 + memory t cells and assisting b cells in antibody production [23, 24] . cd45 + t cells were found to be not only essential for efficient t-and bcell antigen receptor signal transduction but also involved in cytokine signaling [25, 26] . cd45ko mice and humans who lacked cd45 expression were severely immunodeficient and had very few peripheral t lymphocytes with impaired t and b cell responses [27] [28] [29] . results of our analysis suggested that t cellmediated responses might play an important role in immune defense against h7n9 virus infection. further studies on t cellmediated responses during h7n9 infection might provide useful information to help develop effective therapies such as h7n9 vaccines. we used glucocorticoid therapy for most h7n9-infected patients in our observational study. some controversies exist in the use of glucocorticoid therapy for iav infection. han et al. reported that early use of parenteral glucocorticoid therapy for fever reduction and pneumonia prevention in patients with pandemic influenza a (h1n1) infection increased the risk of critical disease and death [30] . likewise, he et al. advised that glucocorticoids should not be used in critically ill patients with h1n1 influenza infection [31] . however, carter argued that while steroids should not be used as monotherapy in the treatment of avian influenza, they might provide therapeutic benefits as an adjunct therapy to antiviral agents if prescribed at appropriate dosages [32] . we found no clear association between glucocorticoid therapy and clinical outcomes in h7n9-infected patients in our study. future studies with larger patient populations are required to evaluate the benefits and risks asscocaited with glucocorticoid therapy in treatment of h7n9 infections. in conclusion, successful treatment of h7n9 influenza depends on early diagnosis of h7n9 infection at the onset of clinical symptoms even if they are mild. knowledge of risk factors, clinical features, and potential complications discussed in our paper would help clinicians who triage patients with suspected or confirmed h7n9 infection determine appropriate treatment strategies and fight potential epidemic/pandemic. increased research and surveillance are required to further understand the pathogenesis of h7n9 infection and epidemiological factors that contribute to severe conditions. further studies are also needed to identify h7n9 natural reservoirs and delineate mechanisms of transmission. 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patients with h1n1 influenza a rationale for using steroids in the treatment of severe cases of h5n1 avian influenza key: cord-330674-enq6kgab authors: yu, jung-sheng; ho, chung-han; hsu, yao-chin; wang, jhi-joung; hsieh, ching-liang title: traditional chinese medicine treatments for upper respiratory tract infections/common colds in taiwan date: 2014-06-12 journal: eur j integr med doi: 10.1016/j.eujim.2014.06.003 sha: doc_id: 330674 cord_uid: enq6kgab introduction: traditional chinese medicine (tcm) has been used to treat upper respiratory tract infections/common colds (urtis) in asian countries for over 2000 years. however, chinese medicine doctors (cmds) follow the traditional treatment rules to select or administer these diverse chinese medicine formulae. the main purpose of our study was to explore data on the frequency of medication and medication habits by cmds for the treatment of urtis with chinese herbs and chinese medicine formulae. methods: the tcm treatments for patients consulting with an urtis were analyzed from the national health insurance research database using the appropriate codes from the international classification of diseases, ninth revision, clinical modification diagnoses for taiwan in 2009. a data mining and association rules, were used to analyze co-prescriptions of tcm for patients with urtis. results: for 472,005 patients who sought the treatment of urtis, a total of 46,805 patients with urtis received tcm treatments, of these 29,052 patients sought both tcm and western medication treatments. of the urtis patients who had received a tcm treatment, 79% presented with an acute common cold, 9% had influenza, and 9% had acute upper respiratory infections. furthermore, 53.89% of the sample were aged between 20 and 49 years, and 62.84% were women, 3.56% of the patients used yin-qiao-san and 2.76% used jie-geng. yin-qiao-san and ma-xing-gan-shi-tang were the most commonly combinations of prescriptions for patients with urtis. conclusions: the patients experiencing urtis were more likely to request tcm treatment if their symptoms were mild and they were women. the chinese medicine doctors treating urtis generally followed tcm theory. a coding system for tcm diagnostic classifications could improve evaluations of tcm treatments. traditional chinese medicine (tcm) has been used to treat upper respiratory tract infections/common colds (urtis) in asian countries for over 2000 years. urtis-related symptoms, complications, treatment methods, and principles were thoroughly recorded in shanghanzabinglun, which was written by zhang zhongjing during the han dynasty in china (150-219 a.d.) [1] . as part of the long-term development of urtis treatment theories, wen bing theory advocated by wu jutong was published during the qing dynasty http://dx.doi.org/10.1016/j.eujim.2014.06.003 1876-3820/© 2014 elsevier gmbh. all rights reserved. (1758-1836 a.d.) because febrile diseases, including infectious diseases such as encephalitis, were added to the texts [2] . to the best of our knowledge, the current principles of the tcm treatments used for diseases, such as urtis remain diverse. therefore, this study employed a database analysis to investigate the basis of chinese medicine doctors' (cmd) treatments. several reports have described how tcm treatments for urtis and related diseases, including influenza, can alleviate symptoms with fewer side effects [3, 4] . the efficacy of tcm possibly results from the antibacterial and antiviral effects of the chinese herbs and formulae [5] . many articles mention chinese herbal medicines may shorten the symptomatic phase in patients with the common cold and treat or prevent seasonal influenza. however, these articles are weak owing to the lack of high quality tcm trials. well-designed clinical trials are required [6] [7] [8] . in spite of this, many extracts of medical herbs have been found to have the potential to treat urtis and prevent colds [9, 10] . some chinese herbs have even been recommended as a treatment to prevent severe acute respiratory syndrome (sars) [11] . the same chinese herbs or formulae may be used to treat many diseases, and cmds may use a single chinese herb or a mixture of herbs, depending on their experience. nevertheless, how cmds follow the treatment rules to select or administer these drugs or chinese medicine formulae remains diverse [12] . this required further investigation. to the best of our knowledge, there are no population based pharmacoepidemiologic studies of tcm for the treatment of urtis. the main purpose of our study was to explore the data on the frequency of medication and medication habits by cmds for the treatment of urtis with chinese herbs and chinese medicine formulae. taiwan's national health insurance system was established in 1995 and covers 99% of inpatient and outpatient medical benefit claims for taiwan's 23 million residents. the detailed clinical information for each patients for each visit includes the date of diagnosis, diagnostic codes, payments for consultations and prescriptions, and is contained in this claims data [13, 14] . traditional chinese medicine is also covered in taiwan's national health insurance program. the prescriptions are written by cmds for treating various disorders that are recorded by the international classification of diseases, ninth revision, clinical modification (icd-9-cm) codes [15] . we used a cohort database from the nhird that comprises of a million randomly sampled individuals who were alive in 2000. the tcm claims database for 2009 was analyzed in this study. the 2009 ambulatory file (cd2009) and corresponding prescription file (oo2009) were included in the tcm claims data. encrypted personal identifications were used to protect patient privacy for avoiding the possibility of the ethical violation. ethical approval and exemption was obtained from the institutional review board of chi mei medical center (irb no. 10202-e09). urtis patients were identified from the 2009 ambulatory file (cd2009) and corresponding prescription file (oo2009) based on the icd-9cm codes 460 (acute nasopharyngitis [common cold]), 462 (acute pharyngitis), 463 (acute tonsillitis), 465 (acute upper respiratory infections of multiple or unspecified sites), and 487 (influenza). patients received either both western and tcm medication, or only tcm treatment or western medication in this study. the mean (standard deviation) and frequency (percentage) were presented as continuous variables and discrete variables, respectively. the frequency of each variable category according to age group and tcm prescription patterns of a single herb or herbal formulae were shown as distributions among the urtis patients. for exploring the prescription patterns of the single tcm herbal drugs or formulae among the urtis patients, a data mining method, association rule, was used to analyze individual patterns and combinations to determine the most common prescription patterns [16] . the method of association rule was often used in large databases for finding frequent item sets which are the lists of commonly displayed together or finding the strong relationships between two items [17, 18] . this method has been used extensively in various published studies using the taiwan nhird [19] [20] [21] [22] . each single herb or chinese medicine formula was set as an independent fixed prescription to estimate the support probability of all of the prescriptions in the data set containing the fixed prescription in order to measure how frequently the association rule occurred in the data set. the minimum level of support was 0.4%. statistical software r (version 2.13.2) and its package a rules were employed to perform all the statistical analyses. in our study, 472,005 patients sought the treatment of urtis, including; 425,200 for the western medication only, 29,052 for western medication and tcm, and 17,753 for the tcm only. a total of 46,805 (9.92%) urtis patients sought the tcm treatment, which accounted for 17.04% of the 274,662 patients underwent tcm treatment. those 46,805 urtis patients receiving tcm treatment as an outpatient, included; the common cold (79%), influenza (9%), acute upper respiratory infections of multiple or unspecified sites (9%), acute pharyngitis (2%), and acute tonsillitis (1%) (fig. 1) . the results showed that the most patients who suffered from urtis mainly sought western medicine treatment. the common cold was a most common condition for patients who sought treatment of tcm treatment. the age distribution of the 46,805 patients with urtis showed that most of all (19.07%) were aged between 40 and 49 years, and 18.78% were between 30 and 39. the use of tcm to treat urtis among women (62.84%) exceeded that for men (37.16%); the usage ratio for women to men was approximately 1.69:1 ( table 1 ). the main seasons of morbidity from urtis were december and january (fig. 2) . the results indicated that the distribution was between 30 and 49, with females more likely than males consulting for tcm if they had a urti. there were 6075 (12.98%) patients who also presented with comorbidity of gastroenteritis, 4054 (8.66%) with hypertension, 3097 (6.62%) with allergic rhinitis, 1586 (3.39%) with diabetes mellitus, and 1108 (2.37%) with urinary tract infections. other comorbid conditions such as: mental disorders, cancer, chronic kidney disease, and cerebrovascular accidents for each accounted for less than 2% ( table 2 ). the results showed that the most common comorbidity was gastroenteritis in these urtis patients. a total of 596,801 tcm prescriptions to treat urtis were issued in taiwan in 2009. there were 21,260 (3.56%) prescriptions for yin-qiao-san, the most popular tcm prescription, followed by 16,087 (2.70%) for xin-yi-qing-fei-tang, 14,566 (2.44%) for ma-xing-gan-shi-tang and 13,909 (2.33%) for chuan-xiong-cha-tiao-san (table 3) . jie-geng (radix platycodi) was the most popular chinese herb and was included in 16,465 (2.76%) prescriptions of the total 596,801. this was followed by yu-xing-cao (herbahouttuyniae) with 11,852 (1.99%), and bei-mu (bulbus fritillaria) with 10,659 (1.79%) ( table 3) . overall, 3224 (0.54%) prescriptions contained combinations of yin-qiao-san and ma-xing-gan-shi-tang, followed by 3191 (0.53%) with yin-qiao-san and ban-lan-gen (radix isatidis) and 3085 (0.52%) with yin-qiao-san and xin-yi-qing-fei-tang (table 4 ). in summary, according to the tcm principle of clearing heat for the common cold, the tcm pattern of wind-heat was a common trend for urtis in taiwan during 2009 the yin-qiao-san, xin-yi-qing-fei-tang and ma-xing-gan-shi-tang formula, and ban-lan-gen belong to cold characteristics. this study was a database analysis of the taiwanese population who used tcm to treat urtis. a total of 46,805 patients with urtis received tcm treatment in 2009. the primary reason for using tcm among people in taiwan was the belief that chinese herbs are natural products and, consequently, their associated side effects are less than those of western drugs [23] . of the urtis patients, 79% presented with a common cold. the majority reported mild cold symptoms including nasopharyngeal inflammation [24] , running and/or stuffy nose, oropharyngeal irritation or discomfort, cough, and fever [25] . tcm treatment of patients with influenza, acute pharyngitis, acute tonsillitis, or acute upper respiratory infections was relatively rare. symptoms and signs of these diseases included a severe sore throat, tonsillar exudate, fever, and cervical lymphadenopathy [25, 26] . our results indicated that most patients with urtis treated with tcm ranged between 30 and 49 years of age. people in this age group are generally healthy; thus, their urtis symptoms were milder compared to those in older or younger age groups. our results also indicated that the percentage of clinical visit for urtis female patients receiving tcm treatment was higher than for males (1.69:1). this result was very similar to the reports of chen et al., who found the tcm utilization ratio was higher for females than males in taiwan between 1996 and 2001 [15] , but the real reasons still remain unclear and need further study. in 2009, the period with the highest frequency of tcm treatment of urtis was from october to april, and the main month of morbidity from urtis was january. during the winter and spring, the weather is colder and the incidence of urtis corresponds to the weather [27] . although lowen et al. concluded that both cold and dry weather favor transmission of the influenza virus [28] , and the annual influenza epidemic season is the winter [20] , the results of this study did not provide sufficient evidence to support their conclusion because the 9% influenza rate in 2009 was low. the most likely connection between gastroenteritis and urtis is the common mucosal immune system for the respiratory and gastrointestinal tracts. in this immune system, secretory iga plays a critical role because it originates from the lymphoid tissue of the gastrointestinal and respiratory tracts, forming the first line of defense in these tracts [29] . numerous patients had comorbid of hypertension. one study has reported that the coxsackie virus is related to hypertension because it can cause cardiovascular disease and myocarditis [30] . we contend that this is unlikely because urtis development resulting from coxsackie viral infections is uncommon. a more probable suggestion is that hypertension is the underlying disease and a urtis may cause rhinitis and sinusitis, resulting in obstructive sleep apnea and a lack of oxygen, which then leads to increased blood pressure [31] . allergic rhinitis is another type of urtis. one study reported that 42.55% of pre-school children had a history of allergic rhinitis and often experienced urtis; they assumed that this association was because of an immunity deficiency [32] . a large environmental study suggested that a humid climate and airborne mold could easily induce multiple respiratory tract diseases including asthma, bronchitis, respiratory infections, common colds, and allergic rhinitis [33] . in other words, allergic rhinitis and urtis can occur concurrently because of environmental factors. in addition, these two diseases may produce several similar symptoms, such as allergic rhinitis, a sore throat, coughing for longer durations, and a runny nose because of external environmental factors [34] . a number of chinese herbs have been used to treat urtis. tcm treatment of disease in taiwan is generally in accordance with tcm theories and the personal experience of the cmds. our results showed that yin-qiao-san was the most popular tcm formula that was used to treat urtis. yin-qiao-san first appeared in the record of wenbingtiaobian (1798-1836 a.d.) and remains a common tcm prescription for treating seasonal influenza [35] , as well as the common cold, fever, cough, and other respiratory tract diseases [36] . yin-qiao-san is comprised of the following 9 herbs: jin-yin-hua (flos lonicerae), lianqiao (fructus forsythiae), niu-bang-zi (fructus arctii), jing-jie (herba schizonepetae), bo-he (herba menthae), dan-do-chi (semen sojae praeparatum), zhu-ye (herba lophatheri), lugen (rhizoma phragmitis), and gan-cao (radix glycyrrhizae). based on the theory of tcm, yin-qiao-san can be used to treat a cough or sore throat resulting from warm-heat diseases (febrile disease). one study reported that lian-qiao (fructus forsythiae) had antiviral, antibacterial, anti-inflammatory, and antioxidant effects, and that jin-yin-hua (flos lonicerae) had anti-inflammatory, anticancer, and immune-boosting effects [37] . the second most popular chinese medicine formula for treating urtis was xin-yi-qing-fei-tang. xin-yi-qing-fei-tang is comprised of the following 10 chinese herbs: xin-yi (flos magnoliae), bai-he (bulbus lilii), zhi-mu (rhizoma anemarrhenae), shi-gao (gypsum fibrosum), pi-pa-ye (folium eriobotryae), sheng-ma (cimicifuga foetid), mai-dong (radix ophiopogonis), zhi-zi (fructus gardeniae), huang-qin (radix scutellariae), and gan-cao. one study reported that xin-yi-qing-fei-tang was the most commonly prescribed formula for treating allergic rhinitis [38] . xin-yi is primarily used to treat allergic rhinitis, sinusitis, and headaches in tcm. another study found that xin-yi had anti-allergic and anti-inflammatory effects, and that these effects resulted from the inhibition of histamine, prostaglandin e2 (pge2), platelet active factor (paf), nitric oxide (no), pro-inflammatory cytokine interleukin-1␣ (il-1␣), and tumor necrosis factor-␣ (tnf-␣) [39] . in tcm, ma-xing-gan-shi-tang is used mainly for the treatment of urtis with a fever, cough, and yellow phlegm. the primary ingredients are the following 4 herbs: ma-huang (herba ephedrae), xing-ren (semen armeniacae amarum), gan-cao, and shi-gao (gypsum fibrosum). an animal study found that ma-xing-gan-shi-tang was an excellent antipyretic agent because of its antiviral and t-cell regulation effects. therefore, ma-xing-gan-shi-tang can inhibit the proliferation of influenza a [35] . jie-geng has long been employed in asian countries for the treatment of urtis, including the common cold, coughs, sputum, tonsillitis, and even asthma [40] . furthermore, a number of studies have found that jie-geng has an immune regulatory effect and can inhibit the production of inflammatory substances, such as il-6, pgd2, ltc4, and cox-2 protein, by mast cells; thus, it may reduce allergic reactions [40] . jie-geng is also an expectorant that can prevent secondary respiratory tract infections [41] . in tcm, yu-xing-cao is considered to have heat-clearing and detoxifying actions, although this has seldom been investigated [42] . yu-xing-cao (herbahouttuyniae) has also been suggested to have weak antibacterial efficacy [43] ; however, it has been employed to treat severe acute respiratory syndrome (sars) [44] . bei-mu (bulbus fritillaria) is commonly used to treat urtis because it is an expectorant. in actuality, bei-mu is divided into zhe-beimu (bulbus fritillariae thunbergii) and chuan-beimu (bulbus fritillariae cirrhosae), and chuan-beimu is further divided into fritillaria unibracteato, fritillaria przewalskii, and fritillariadelavay [45] . chuan-beimu is considered the best antitussive and expectorant in tcm. zhe-beimu contains a cholic acid-verticinoneester that may regulate central opioid receptors; thus, its excellent antitussive and expectorant effects are believed to be superior to those of codeine phosphate [46] . extant studies had shown that ban-lan-gen (radix isatidis) possesses anti-helicobacter [47] , anti-e. coli [48] , and anti-endotoxic effects [49] . thus, we can conclude that the common chinese herbs used to treat urtis have antitussive and/or expectorant properties. the cmd treating disease is accordance with the principles of tcm, treating cold with heat and treating heat with cold. the yin-qiao-san, xin-yi-qing-fei-tang and ma-xing-gan-shi-tang formula, and ban-lan-gen are belong to cold in character. therefore, we suggested the most common type of urtis in taiwan belonged to the tcm wind-heat pattern. although the results of this research investigated the prescription patterns of tcm for patients with urtis, there are several limitations to this study: (1) some patients with urtis may buy chinese herbs from pharmacies by themselves, so the frequency of tcm treatment may be underestimated. however, the nhi program has the encyclopedic coverage of all population, so this selection biases may have been minimized by the large sample size; (2) the cmd prescribes a treatment according to the patient's clinical manifestations, which is, symptoms, the color and quality of the tongue, and the various pulse formations that comprise the so-called 4 examinations of tcm. these methods differ from the etiological diagnoses of western medicine. therefore, when selecting herbs for the treatment of disease, patient symptoms, such as appetite, thirst, and mood, play a crucial role [1] ; (3) the study did not use condition probability to explore the relationship between herbs and diseases and further analysis the different patterns of herb or herb combination; (4) the study did not record the usage of western medication, so therefore, information for common polypharmacy was unavailable; (5) the study is limited to the use tcm theory to explain the simple descriptive statistics. but the logistical regression analysis could not be carried out or that there was no statistical relationship. in the future research, developing a suitable coding system for tcm diagnostic classifications could improve evaluations of tcm and link the western medicine for increasing the efficacy of tcm. the results suggested that patients experiencing urtis 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extract platycodin d and d3 increase airway mucin release in vivo and in vitro in rats and hamsters antimicrobial and antioxidant activities of cortex magnoliae officinalis and some other medicinal plants commonly used in south-east asia susceptibilities of mycoplasma hominis to herbs symptom combinations associated with outcome and therapeutic effects in a cohort of cases with sars herbological study for the beimu categorical chinese medicine on the original plants addictive evaluation of cholic acid-verticinone ester, a potential cough therapeutic agent with agonist action of opioid receptor screening test for anti-helicobacter pylori activity of traditional chinese herbal medicines thermochemical studies on the quantity -antibacterial effect relationship of four organic acids from radix isatidis on escherichia coli growth the anti-endotoxic effect of o-aminobenzoic acid from radix isatidis this study is based in part on data from the national health insurance research database provided by the bureau of national health insurance, department of health and managed by national health research institutes. the interpretation and conclusions contained here in do not represent those of bureau of national health insurance, department of health or national health research institutes. all authors were involved in the design and writing of the study, and chh conducted the statistical analysis. all authors approved the submitted version of the manuscript. no current external funding sources for this study. the authors declare that they have no conflict of interest. key: cord-290412-m6fesoyb authors: zhao, chang-qing; zhou, yang; ping, jian; xu, lie-ming title: traditional chinese medicine for treatment of liver diseases: progress, challenges and opportunities date: 2014-09-30 journal: journal of integrative medicine doi: 10.1016/s2095-4964(14)60039-x sha: doc_id: 290412 cord_uid: m6fesoyb abstract traditional chinese medicine (tcm) is commonly used in treating liver diseases worldwide, especially in china. the advantages of using tcm for treatment of liver diseases include: protecting hepatocytes, inhibiting hepatic inflammation and antifibrosis in the liver. in this article, we introduce tcm herbal preparations from the chinese materia medica (such as fuzheng huayu) that are typically used for the treatment of liver diseases. literature surrounding the mechanisms of tcm therapy for treatment of liver diseases is presented and discussed. we propose that side effects of herbal compounds are often under-appreciated, and that more care should be taken in the prescription of potentially hepatotoxic medicines. further, to deepen the understanding of tcm mechanisms, new techniques and methodologies must be developed. future studies will lead to the enhancement of clinical outcomes of tcm. as complementary and alternative therapies, tcms will play an expanding role in the future of liver disease treatment. in china, traditional chinese medicine (tcm), especially traditional chinese patent medicine, has been, and continues to be widely used to treat various diseases. even during the severe acute respiratory syndrome (sars) outbreak in 2003, tcm, combined with western medicines were used to control and eventually halt the spread of the disease. compared with western medicine alone, patients receiving treatment with western medicine and tcm had reduced hospital stays, pneumonia duration and mortality. early tcm treatment can also decrease glucocorticoid dosage needed in the treatment of sars [1] . before western medicine was introduced into china, the chinese health care system mainly depended on tcm. although tcm does not treat specific conditions, it treats patterns of illness such as those associated with infectious diseases [2] [3] [4] , cardiovascular and cerebrovascular diseases [5] [6] [7] [8] [9] [10] [11] , respiratory diseases [12] [13] [14] , digestive diseases [14] [15] [16] , urinary diseases [17] [18] [19] , reproductive diseases [20] and blood system diseases [21] , as well as fractures [22] , trauma [23] , ear, nose and throat diseases [24, 25] , skin diseases [26] and mental disorders [27] . tcm can improve the clinical symptoms, reverse some pathological changes and restore traditional chinese medicine for treatment of liver diseases: progress, challenges and opportunities the body's normal physiological function. since western medicine was introduced into china in the 16th century ce, most diseases listed above are treated mainly with western medicinal interventions. gradually, tcm has become an alternative medicine rather than mainstream medicine. even so, tcm therapy still has its advantages in some medical fields where western medicine has not been as effective, such as in liver diseases. this review will introduce tcm in the treatment of liver diseases. liver diseases are mainly classified into viral hepatitis, nonalcoholic fatty liver, alcoholic liver disease, autoimmune liver disease, schistosomiasis liver disease, drug-induced liver injury, hereditary liver disease, liver cirrhosis due to various causes and diverse liver tumors. tcm is widely applied in the treatment of liver diseases in china by both chinese medicine doctors and western medicine doctors because its ability to protect hepatocytes, inhibit hepatic inflammation and reduce fibrosis in the liver. in recent years, the application of tcm in liver cancer treatment has been increasingly widespread [28, 29] . it has been confirmed that tcm can not only reduce the toxic side effects of chemotherapy or radiotherapy, but also inhibit tumor growth and increase survival of patients with tumors [30] . although tcm has many uses in treating liver diseases, it cannot replace other treatment methods such as antiviral drugs, hormones, schistosomicide, surgical operation and transplantation. tcm can be applied to treat diseases in one of the two ways: treatment based on disease differentiation or syndrome differentiation [31] . for the disease differentiation approach, western medicine methods are typically employed to diagnose specific liver diseases. subsequently the appropriate tcm formula or patent drug is selected to treat the disease according to tcm's characteristics and advantages. the evaluation of the curative effect is based on the recovery of liver function or improvement in pathological changes. in the syndrome differentiation approach, tcm diagnosis of a patient's symptoms and signs is used to determine to which syndromes the patient belongs. the appropriate tcm formula or patent drug is then chosen to treat that tcm syndrome. the evaluation of the curative effect depends on the relief or elimination of the symptoms and signs. it is believed that the combination of two kinds of therapies can obtain greater curative effects for liver diseases [32] . 3 chinese materia medica is frequently used to treat liver diseases in acute stage of liver diseases, liver inflammation is prominent. materials listed in the chinese materia medica, especially those for heat-clearing and detoxifying, are often applied to protect the liver, inhibit inflammation, decrease activity of serum transaminase and reduce serum bilirubin [32] . meanwhile according to the symptoms and signs of each patient, a matching therapy, such as adjusting yin and yang, invigorating qi and blood, soothing the liver, regulating qi, clearing heat and removing dampness, is also applied. in the chronic stage of liver diseases, the symptoms of the disease are more complicated. treating the source of the disease (i.e., the virus) is one important and necessary approach. western medicine does well in inhibiting the viruses that cause hepatitis b (hbv) and hepatitis c (hcv). tcm has little effect in inhibiting the virus, but works well to protect liver function, inhibit inflammation, decrease activity of serum transaminase, reduce serum bilirubin, lower lipid levels [33] , promote diuresis [34] and relax the bowels [35] . depending on the stage of liver disease progression, or different syndrome classifications, tcm can be used to adjust yin and yang, invigorate qi and blood, sooth liver, regulate qi, clear heat and remove dampness [36] [37] [38] . zhang et al [39] summarized and provided a critical meta-analysis of randomized controlled trials (rcts) of tcm formulations for the treatment of chronic hepatitis b (chb) that were reported in china from 1998 to 2008. the results showed that (i) tcms (tcm formulations alone or in combination with interferon (ifn) or lamivudine (lam)) had a greater beneficial effect than ifn (p=0.000 3) and slightly better effect than lam (p=0.01) on normalization of serum alanine aminotransferase; (ii) tcms had a similar beneficial effect on antiviral activity when used in conjunction with inf or lam for chb, which was evidenced by the reduction of serum hbeag and hbv dna; (iii) treatment with tcms in conjunction with inf or lam resulted in improved liver function. when the liver tissue is damaged, its repair is accompanied by the formation of an extracellular matrix, also known as fibrosis. fibrosis is the common pathological process of many liver diseases, and is also reversible. antifibrotic effects are an important component in the treatment of various chronic liver diseases [40] . one famous hepatologist, professor hans popper, once said, "anyone who can stop or delay liver fibrosis would be able to cure most chronic liver diseases" [41] . the focus of western medicine scientific and medical research has been on discovering targets for antifibrotic therapy, and developing customized multi-drug regimens [42] . according to the tcm theory, diseases of liver zang will transmit to the spleen zang, thus in the course of treatment, the spleen zang should be strengthened before it is impaired. if the liver disease has been long-standing, kidney yin should be evaluated during the treatment because the liver zang and kidney zang are derived from the same source. in clinical practice, symptoms and signs of spleen-qi deficiency journal of integrative medicine www.jcimjournal.com/jim are frequently seen in patients with liver diseases. they always complain of fatigue, pain or weakness in the legs, abdominal fullness, right upper quadrant discomfort or pain, loose stool, pale tongue or swollen tongue (teeth-marked tongue) with whitish fur and weak pulse. patients with chronic liver disease additionally present symptoms and signs of kidney-yin deficiency, such as dry mouth, internal-heat, red (or red and dry) and uncoated tongue, and weak pulse. according to the theory of syndrome differentiation therapy, methods of invigorating spleen-qi and nourishing kidney-yin should be used to treat liver diseases. in tcm, the pathogenesis of liver diseases does not necessarily relate to the liver zang, it can also be related to the spleen and kidney. table 1 shows tcm functions matched with herbs and dosages commonly used in the treatment of liver diseases. herbs with different functions are selected according to syndrome differentiation. dosages within the recommended range are determined by the severity of the symptoms and signs. several patent drugs (chinese herbal formulas) for treatment clinical observations showed that fzhyc can effectively improve liver function and decrease the expression of fibrosis biomarkers such as serum hyaluronic acid, collagen type iv, procollagen type iii and laminin, in chronic liver disease patients with fibrosis or cirrhosis [43, 44] . fzhyc can also regulate immune function [45] , balance amino acid [46] and endocrine [47] metabolism and reduce portal hypertension [48] . the results of several multicenter rcts have confirmed that tcm can reverse liver fibrosis [49] [50] [51] . fzhyc was used to treat liver fibrosis in patients with chb for six months. fifty patients in the trial group were treated with fzhyc. a control group of 43 patients was treated with heluo shugan capsule, another chinese patent medicine. all patients received liver biopsies pre-and post-treatment. pathology results showed that in the treatment group, the stage of fibrosis was decreased by one or more in 52% of the patients; the remaining 48% of the patients in the trial group had no changes. however, in the control group only 23.3% patients had a decrease in fibrosis stage, 55.8% patients had no change and 20.9% of the patients had an increase in fibrosis stage [49] . in another study, fzhyc reversed the fibrosis at a rate of 57.9% early cirrhotic patients with chb [52] . to prevent esophageal variceal bleeding in cirrhotic patients, a multicenter randomized and placebo-controlled trial was carried out. the probability of survival in the fzhyc group was higher than that in the propranolol group (90.22% vs 70.92%, p=0.044 9). compared to the propranolol group the probability of esophageal variceal bleeding in the fzhyc group was significantly reduced (43.0% vs 23.9%, p=0.013 1). when the two treatments were taken together there was an even lower probability of bleeding which was also significantly lower than the propranolol alone (12.4% vs 43.0% p=0.008 6). in patients with small esophageal varices, treatment with fzhyc reduced the size of the varices. its effects may be related to the prevention of hepatic fibrosis, amelioration of liver function, and the decrease of et-1 concentration in the blood plasma [53] . a meta-analysis was conducted to evaluate the efficacy and safety of fzhyc combined with nucleoside antiviral drugs in treating fibrotic patients with chb. the analysis included seventeen rcts, with a total of 1 320 patients with chb, of which 636 were in control groups and 684 in trial groups. the meta-analysis showed that there was no significant improvement in serum hbeag level and hbv-dna copies. however, there was a statistically significant improvement in liver fibrosis and liver function after treatment for 24 or 48 weeks [54] . for the past six decades, many researchers have carried out extensive research to explore the mechanism of tcm in the treatment of liver diseases. it was found that tcm can improve hepatic microcirculation, scavenge oxygen free radicals, resist lipid peroxidation, promote bilirubin metabolism, accelerate synthesis of liver glycogen and protein, and increase the content of liver microsomal cytochrome p-450 [55] . these effects lead to a decrease in hepatocyte necrosis, inhibition of apoptosis and promotion of the hepatocyte regeneration [56] . we searched the literature for studies exploring the mechanism of fzhyc's antifibrotic activity. it has been shown that fzhyc can protect hepatocytes, resist lipid peroxidation and inhibit some cytokines [57, 58] . fzhyc can also inhibit the activation and proliferation of hepatic stellate cells (hscs), which play an important role in hepatic fibrogenesis and fibrosis [58] . fzhyc can also promote apoptosis of activated hscs, inhibit synthesis and secretion of collagen, inhibit angiogenesis and promote degradation of collagen [59] . studies showed that fzhyc achieved its antifibrotic activity through multiple signal pathways and targets [57, 58, [60] [61] [62] [63] , such as transforming growth factor β-1 (tgf-β1), smads, insulin-like growth factors-1 (igf-1), phosphatidylinositol 3-kinase (pi3k), extracellular signal-regulated kinase (erk), p38 mitogen-activated protein kinase (p38 mapk), rhoa/rho-associated coiled-coil forming protein kinase (rock) and renin-angiotensin system (ras) signaling pathways [64, 65] . the elevation of portal vein pressure is a common symptom of liver cirrhosis. the portal vein pressure is positively correlated with endothelin-1 (et-1) concentration in the liver tissue during the process of liver cirrhosis [66] . fzhyc can dramatically decrease cirrhosis-induced elevation of portal vein pressure by reducing et-1 levels in the liver tissue [67] . due to multiple ingredients in the chinese formula, the compound could not be used to incubate cells directly in vitro. only individual components or ingredients of herbal medicine are suitable for in-vitro research. to explore the underlying mechanisms of fzhyc's antifibrosis activity, we looked in the literature for research on salvianolic-acid b (sa-journal of integrative medicine www.jcimjournal.com/jim b), a component of danshen that is the main constituent herb of fzhyc. studies show that the effects of sa-b are just like fzhyc in the treatment of hepatic fibrosis and cirrhosis [64, 65, 68] . sa-b dramatically decreased the fibrosis level of rats with fibrotic liver, and also markedly decrease cirrhosis-induced elevated portal vein pressure and liver et-1 levels [16] . sa-b achieves its antihepatic fibrosis effect by inhibiting the erk and the p38 mapk pathways of tgf-b1 in hscs. it inhibits the erk pathway by inhibiting phosphorylation of mek. sa-b inhibits the p38 mapk pathway by blocking phosphorylation of mkk3/6 and inhibiting expression of myocyte enhancer factor 2 (mef2, a transcription factor), in hscs with or without tgf-b1 stimulation [69] . further, sa-b inhibits the crosstalk of the samd signaling pathway to the erk signaling pathway [63] . sa-b also significantly reduces et-1-activated hsc contractility by inhibiting rhoa/rock ii activation and the downstream mypt1 phosphorylation at thr696 [64] . although some positive effects of tcm in liver diseases are reported, we should also note the possibility of liver damage induced by some herbs during treatment. the perspective that herbs, as natural medicine, have no side effects is outdated and wrong. some chinese herbal medicines, which were used to treat liver diseases, have been reported to have hepatotoxicity in high doses or even in standard doses, such as heshouwu (polygonum multiflorum [70] . this potential toxicity should serve as a reminder that clinical practitioners should administer chinese medicine with as much caution as western pharmaceutical drugs. it is very important to take precautions against drug-induced liver injury when selecting herbs and their doses. generally speaking, applying herbs in accordance with the pharmacopeia is quite safe. for example, an aqueous solution of zhizi (gardenia jasminoides) extract, which has been reported to have hepatotoxicity, has no significant side effects on mice liver at medium dose (equivalent to 18 g dose for adults) and low dose (equivalent to 9 g dose for adults). the medium and low doses of zhizi extract did not obviously affect structure of the liver tissue or damage hepatocytes. we suggest that zhizi is not suitable for chronic use at a high dose, but short-term use at a modest dose (9 g per day) is still safe [71] . further, by appropriate preparation of herbal products, such as heshouwu, the hepatotoxicity can be reduced [72] . it is also important to note that in chinese medicine, herbs with similar names cannot be used interchangeably. for instance, using tusanqi (gynura segetum), which has severe hepatotoxicity, as a substitute for shensanqi (panax notoginseng) is dangerous, and they come from very different plants. 6 new techniques and methodologies are needed for studying tcm although tcm therapy is effective in the treatment of liver diseases, more research is required to understand the underlying mechanisms of action. at present, the pharmacological studies of chinese medicinal formulae are carried out extensively in vivo, however, the induced animal models cannot be relied on to fully mimic clinical pathogenesis of human patients. studies that examine the mechanisms behind tcm can only be conducted in vitro, are ill suited to the complex formulations of herbs used in chinese medicinal remedies and are restricted by existing research techniques and methodology [73] . current research technology is not designed to evaluate responses from multi-dimensional variables, like the herbal formulations used in tcm. this may be one of the reasons that the curative effects of tcm have been slow to receive approval among western medicinal practitioners. new research techniques and methodologies should be developed to evaluate the curative effects of tcm and to elucidate its mechanisms [74, 75] . we believe that as techniques and methodologies evolve to address the complex nature of tcm herbal formulations, a more mechanistic understanding of the use of tcm in treating liver diseases will emerge. these studies will thus lead to the improvement of clinical results and refinement of the contemporary practice of tcm. as a complementary and alternative therapy for the treatment of liver diseases, tcm is a powerful but underused tool in the present, and has great potential for future use. the authors have no conflicts of interest to declare. journal of integrative medicine (jim) is an international, peer-reviewed, pubmed-indexed journal, publishing papers on all aspects of integrative medicine, such as acupuncture and traditional chinese medicine, ayurvedic medicine, herbal medicine, homeopathy, nutrition, chiropractic, mind-body medicine, taichi, qigong, meditation, and any other modalities of complementary and alternative medicine (cam). article types include reviews, systematic reviews and meta-analyses, randomized controlled and pragmatic trials, translational and patient-centered effectiveness outcome studies, case series and reports, clinical trial protocols, preclinical and basic science studies, papers on methodology and cam history or education, editorials, global views, commentaries, short communications, book reviews, conference proceedings, and letters to the editor. • no submission and page charges • quick decision and online first publication for information on manuscript preparation and submission, please visit jim website. send your postal address by e-mail to jcim@163.com, we will send you a complimentary print issue upon receipt. effect of glucocorticoid with traditional chinese medicine in severe acute aespiratory syndrome (sars) interaction of a traditional chinese medicine (phy906) and cpt-11 on the inflammatory process in the tumor microenvironment artemisinin: discovery from the chinese herbal garden anti-infective and cytotoxic properties of bupleurum marginatum a review of the pharmacological mechanism of traditional chinese medicine in the intervention of coronary heart disease and stroke puerarin: a review of pharmacological effects potential benefits of chinese herbal medicine for elderly patients with cardiovascular diseases danqi pill protects against heart failure through the arachidonic acid metabolism pathway by attenuating different cyclooxygenases and leukotrienes b4 chinese medicine shensongyangxin is effective for patients with bradycardia: results of a randomized, double-blind, placebo-controlled multicenter trial effects of chinese herbal medicine yiqi huaju formula on hypertensive patients with metabolic syndrome: a randomized, placebo-controlled trial favorable circulatory system outcomes as adjuvant traditional chinese medicine (tcm) treatment for cerebrovascular diseases in taiwan randomized controlled multicenter clinical trial for integrated treatment of community-acquired pneumonia based on traditional chinese medicine syndrome differentiation prevention of allergic airway hyperresponsiveness and remodeling in mice by astragaliradix antiasthmatic decoction the anti-asthma herbal medicine ashmi acutely inhibits airway smooth muscle contraction via prostaglandin e2 activation of ep2/ep4 receptors clinical effects of the method for warming the middle-jiao and strengthening the spleen on gastric mucosa repair in chronic gastritis patients modified da-cheng-qi decoction reduces intra-abdominal hypertension in severe acute pancreatitis: a pilot study optimized project of traditional chinese medicine in treating chronic kidney disease stage 3: a multicenter double-blinded randomized controlled trial efficacy and safety of traditional chinese medicine (shenqi particle) for patients with idiopathic membranous nephropathy: a multicenter randomized controlled clinical trial tripterygium wilfordii hook f (a traditional chinese medicine) for primary nephrotic syndrome clinical effect of jiutengzhuyu tablets on promoting blood circulation in women with oviducal obstruction study on the efficacy and safety of xueyou mixture in treating hemophilia beneficial effects of traditional chinese medicine on the treatment of osteoporosis on ovariectomised rat models a traditional chinese medicine therapy warming meridians to nourish blood in treating chronic pain due to soft tissue injury of the neck and shoulder: a randomized controlled trial trial of chinese medicine wu-ling-san for acute low-tone hearing loss mechanism of traditional chinese medicine in the treatment of allergic rhinitis identifying core herbal treatments for urticaria using taiwan's nationwide prescription database effect of yi-gan san on psychiatric symptoms and sleep structure at patients with behavioral and psychological symptoms of dementia traditional herbal medicine in preventing recurrence after resection of small hepatocellular carcinoma: a multicenter randomized controlled trial treatment of middle/late stage primary hepatic carcinoma by chinese medicine comprehensive therapy: a prospective randomized controlled study clinical observation on the treatment of middle-late stage liver carcinoma by combined therapy of hepato-arterial chemo-embolising and chinese drugs for strengthening pi and regulating qi studies on treatment of fatty liver with traditional chinese medicine experience of treatment for posthepatitic cirrhosis based on tcm syndrome differentiation clinical study on effect of jiangan jiangzhi pill in treating nonalcoholic fatty liver diseases effects of baogan lishui decoction on patients with ascites due to cirrhosis: a report of 84 cases. guang ming zhong yi protective effect of compound tongfu granule on intestinal barrier in patients with cirrhosis of decompensation stage effects of method of regulating qi to dissipate blood stasis and phlegm with chinese herbs on expression of srebp-1c/fas in rats liver tissue with non-alcoholic steatohepatitis a prospective cohort study on the influence of high doses of herbs for clearing heat and resolving stasis on survival rates in patients with hepatitis b-related acute-on-chronic liver failure clinical observation of clearing heat and removing dampness, cooling blood and detoxicating therapy for acute on chronic liver failure in hepatitis b. beijing zhong yi yao contemporary clinical research of traditional chinese medicines for chronic hepatitis b in china: an analytical review liver cirrhosis procollagen iii levels in serum: do they provide additional information in liver disease? reversal of hepatic fibrosis -fact or fantasy? effect of fuzheng huayu 319 recipe on serological parameters of fibrosis in treating chronic hepatitis b. zhongguo zhong xi yi jie he za zhi multicenter clinical study about the action of fuzheng huayu capsule against liver fibrosis with chronic hepatitis b effect of ganping capsule on posthepatitic cirrhosis in adjusting abnormal immune function influence of fuzheng huayu capsules on abnormal amino acids spectrum in chronic liver diseases effect of fuzhenhuayu recipe in adjusting endocrine disorders in cirrhotic patient clinical research of ganping capsule against liver fibrosis in patients with chronic hepatitis b multicenter clinical study on fuzhenghuayu capsule against liver fibrosis due to chronic hepatitis b capsule oxymatrine in the treatment of liver fibrosis in patients with chronic virus hepatitis: a randomized, double blind clinical study on treatment of alcoholic liver disease by qinggan huoxue recipe results set of traditional chinese medicine basic theory research in 973 program a randomized controlled study of fuzheng huayu capsule for prevention of esophageal variceal bleeding in patients with liver cirrhosis meta-analysis on fuzhenghuayu capsule combined with nucleoside antiviral drug for chronic hepatitis b clinical frequently used chinese crude drugs with hepatoprotective effect research progress on mechanism of clinical hepatoprotective drugs effect of fuzheng huayu formula and its actions against liver fibrosis role of the igf-1/pi3k pathway and the molecular mechanism of fuzhenghuayu therapy in a spontaneous recovery rat model of liver fibrosis effects of fuzhenghuayu decoction on collagen synthesis of cultured hepatic stellate cells, hepatocytes and fibroblasts in rats therapeutic efficacy of traditional chinese medicine 319 recipe on hepatic fibrosis induced by carbon tetrachloride in rats curative effects of fuzheng huayu capsules on hepatic fibrosis and the functional mechanisms: a review role of jak/stat pathway in ccl 4 -induced rat liver fibrosis model and molecular action mechanism of fuzheng huayu recipe in treatment of liver fibrosis salvianolic acid b inhibits erk and p38 mapk signaling in tgf-β1-stimulated human hepatic stellate cell line (lx-2) via distinct pathways. evid based complement alternat med salvianolic acid b lowers portal pressure in cirrhotic rats and attenuates contraction of rat hepatic stellate cells by inhibiting rhoa signaling pathway salvianolic acid b attenuates rat hepatic fibrosis via downregulating angiotensin ii signaling therapeutic potential of targeting the renin angiotensin system in portal hypertension traditional chinese medicine can improve liver microcirculation and reduce portal hypertension in liver cirrhosis salvianolic acid b inhibits hepatic stellate cell activation through transforming growth factor β-1 signal transduction pathway in vivo and in vitro effect of salvianolic-acid b on inhibiting mapk signaling induced by transforming growth factor-β1 in activated rat hepatic stellate cells facing the hepatotoxicity of chinese herbal medicine observation of treatment effect and hepatic toxicity of gardenia in mouse with acute liver injury effective components, toxic effects and research advances of present situation of modernization on compound prescriptions. zhongguo shi yan fang ji xue za zhi research status, problems and thinking of multi-component of chinese medicine. zhong yi xue bao discussion on research and development models in innovative chinese material medica key: cord-253286-ieyqoxe6 authors: xu, judy; yang, yue title: traditional chinese medicine in the chinese health care system date: 2008-10-22 journal: health policy doi: 10.1016/j.healthpol.2008.09.003 sha: doc_id: 253286 cord_uid: ieyqoxe6 objectives: this study examines the role and value of traditional chinese medicine (tcm) in the current health care system in china. methods: based on literature review and publicly available data in china. results: the study shows that tcm is well integrated in the chinese health care system as one of the two mainstream medical practices. also, the chinese government is supportive of tcm development by increasing investment in tcm research and administration. however, there is downsizing of tcm utilization, a lack of tcm professionals with genuine tcm knowledge and skills, and limitations of and increasing public opinions on modernization and westernization. conclusions: tcm is still facing many challenges in playing critical roles in improving public health in china. these challenges can be explained from different perspectives. in addition to the unique characteristics of tcm, economic, cultural, and historical evolution in china may also be major determinants. tcm is based on the chinese philosophy of yin-yang and five elements. the oldest classic of tcm is huangdi neijing (inner canon of huangdi or the yellow emperor's medicine classic), which was written 2000-3000 years ago [1] . the basic theory of tcm includes five-zang organs and six-fu organs, qi (vital energy), blood, and meridians. tcm is based on the holistic principles and emphasizes harmony with the universe. it categorizes the causes of diseases into two groups: external causes and internal causes. it differentiates syndromes according to the eight principles (yin, yang, exterior, interior, cold, heat, deficiency (xu) and excess (shi)). although acupuncture and chinese massage have been well known and practiced in the west, clinical diagnosis and chinese herbology are very important components of tcm. the typical tcm diagnostic methods are inspection, auscultation/olfaction, inquiring and palpation. chinese herbal medicine not only includes plants, but also includes medicinal uses of animals and minerals. the herbal medicine preparation (pao zhi) and formulas (fang ji) are also very critical and unique. tcm has been carried over for thousands of years for a variety of clinical treatments of different kinds of diseases and symptoms in china. it also has experienced further development and modernization over time [2, 3] . in the 1950s, chairman mao zedong authorized an attempt to create an academic/formal/systematized medicine. one of the major changes in the medicine is it eliminated everything considered to be superstitious. one example of such a concept is "hun-po" 1 of which there was no mention in the texts of the 1960s and 1970s. in terms of acupuncture practice a certain standardization of the acupoints and needling techniques took place which was exported with the early teachers who came to the west and founded acupuncture schools on the tcm academic model. herbal medicine and zang fu syndrome differentiation were also standardized. thus, strictly speaking, the term tcm in the west should be referred as chinese medicine rather than tcm. during the qing dynasty, especially in the nineteenth century, western missionaries entered china and western medicine 2 started to dominate the market. currently, western medicine and tcm are the two mainstream medical practices in china. tcm/western integrated medicine, which attempts to combine the best practices of tcm and western medicine, and chinese medicine of minorities, such as mongolian medicine and tibetan medicine, are also formally practiced in the chinese health care system. 3 the chinese health prevention and delivery system is based on the three-tier system developed in the 1950s, which includes hospitals, health centers, and clinics. table 1 shows the number of health institutions in 2006. in general, hospitals have the best facilities and resources while health clinics/health service centers provide most of the health services, especially for treating patients with common illnesses and non-severe health conditions. currently, 99% of the health centers are in the rural areas and they are also very important for rural health delivery. before the economic reform in 1978, the central government was responsible for both health care financing and delivery. since 1978, a series of health care reforms were conducted to decentralize and privatize health care organizations. although most of the hospitals are still state-owned, many private clinics have opened in both urban and rural china. the government also dramatically reduced their financial investment in health care services, but still has tight price-control in the health sector [4] . the current chinese health care system is undergoing major reforms in order to increase health insurance coverage, improve quality of care, reduce health care costs, and minimize inequality of health care access between rural and urban areas. in the following, the paper describes the situation and changes of tcm in the health care system in the past decade. it also discusses the challenges and opportunities facing tcm in china. chinese herbal medicine is currently categorized into three groups in china: raw herbal medicine (zhong yao cai), sliced herbal medicine (zhong yao yin pian), 4 and patent medicine (zhong cheng yao). 5 in addition to 561 herbal resource centers in china that produce raw herbal medicine, there are over 1500 manufacturers producing sliced herbal medicine and 684 manufacturers producing patent medicine [5] . although herbal extracts are regarded as herbal medicine, strictly speaking, they are not chinese herbal medicine since they are not based on chinese herbology, but active ingredients or compounds extracted from herbs. they are listed as biomedicine in china. in addition to the drug administration law of the people's republic of china, chinese herbal medicine production, distribution, pricing, and utilization are under the regulations of different government agencies, such as the chinese state food and drug administration and the national development and reform commission. although the chinese government has implemented quality control systems on medical production, such as implementations of the good agricultural practice (gap), the good laboratory practice (glp), and the good manufacturing practice (gmp) for many years, there is still need to improve the quality control in the production of herbal medicine. due to the complexity of chinese herbal medicine, the critical component combinations and the appropriate standard component combinations are not quite clear. for example, since there is neither strict standards for controlling critical components in the patent medicine nor regulations on the process for sliced herbal medicine, some manufacturers are either using less effective components or cheap substitutes [6] . 4 sliced herbal medicine is the herbal medicine that has been processed. in addition to basic processes such as slicing, steaming, and drying, some raw herbal medicine is processed with ginger, honey, licorice, and sulfur. the major purpose of these processes is to reduce toxicity as well as to sanitize. 5 patent medicine is the herbal medicine formula that has been standardized rather than been "patented". tcm products have been exported to about 163 countries in the world. based on the report from the china chamber of commerce for import & export of medicines & health products (cccmhpie), the tcm herbal medicine export is almost us$ 1.2 billion in 2007, which increased 8% from 2006. depending on different definitions and calculation, chinese herbal medicine represents 20-50% of the herbal medicine market share worldwide. historically, tcm knowledge and skills were passed on only to family members or a couple of students through apprentice-master relationships. since the 1950s, tcm education has been formalized into an academic training. typically, tcm medical professionals are educated at medical schools or pharmacy schools with the same standards, admissions, and years of training as western medical professionals. students usually take 3-8 years' of training to get associates, bachelors, masters, or doctoral degrees from either tcm or other universities ( table 2) . among the 400,000 enrolled students, there are almost 4000 foreign students enrolled. 90% of them are from asia, followed by 4% from north america and 4% from europe. in addition to tcm theories and methodology, the fundamental tcm curriculum includes western medical science such as physiology and molecular biology. in 1959, tcm curriculum requires the course time ratio to be no less than 7:3 between tcm and western medicine. the current tcm training is much more westernized with the ratio of 6:4 or even 5:5, which causes concerns from tcm experts about the quality and time limitations in providing sufficient tcm knowledge and training [7] . tcm is also under the same registration and licensing procedures as is western medicine. in 1999, the chinese government implemented medical professional licensing requirements. after receiving regular degree training, both doctors and pharmacists 6 are required to do 1 to 3 years of residency in a medical institution before taking a national license examination to get their licenses [8] . since tcm is a practical study, which emphasizes the clinical experience as well as family lineage, those tcm practitioners who have studied traditional medicine under 6 in china, herbalists are called chinese medicine pharmacists (zhong yao shi). a teacher for at least three years or have really acquired specialized knowledge of medicine through many years' experience are also allowed to participate in the examination for the qualifications of medical practitioners. however, the complex process and certain requirements of the exam (e.g. some specific western medical science knowledge) prevent some tcm practitioners from getting their licenses. tcm professionals dramatically decreased from 800 thousand in 1911 to 500 thousand in 1949 due to the growing popularity of western medicine [9] . the number of tcm professionals also dropped further after the chinese government implemented medical professional licensing requirements in 1999. fig. 1 in health clinics, doctors who practice western medicine comprise 50.3% of the total doctors, followed by 32.3% of doctors who practice tcm/western integrated medicine, and 17.4% who only practice tcm [10] . currently, about 12% of the licensed doctors are tcm doctors and only 6% of pharmacists are licensed tcm herbalists. very few licensed tcm doctors or pharmacists work in township health centers or village clinics. tcm has been used for thousands of years in treating different types of diseases and symptoms, such as pulmonary, cardiovascular, gynecological, and pediatric, as well as mental illness [11] [12] [13] [14] [15] [16] [17] [18] . during the epidemic of severe acute respiratory syndrome (sars) in 2003, the sars death rate in china (6.5%) is less than the average international death rate (9.5%) [19] . among the 5326 sars patients treated, 3104 cases involved tcm treatment. this represents 58.3% of the total. specifically, in guangzhou, where the integration of tcm started the earliest, the death rate was only 4%. in beijing, the death rate decreased 80% after integrating tcm treatments. recently, the state administration of traditional chinese medicine of the people's republic of china, the chinese ministry of health, and the treasury department are collaborating on a program to provide free tcm however, along with other countries worldwide, the safety and efficacy issues of tcm are still major challenges in china. for example, tcm is more often used for chronic conditions than acute conditions. it is more complicated to evaluate its clinical effects. for example, some chinese herbal medicine is prescribed to treat diseases from the root cause rather than to decrease the symptoms immediately. so, it might take months or years for patients to recover, which is problematic for most of the clinical designs in order to evaluate long-term outcomes. currently, there are about 800,000 references and abstracts to literature on tcm in the traditional chinese medical literature analysis and retrieval system (tcmlars). however, very few of them are regarded as "rigorous" scientific evidence of efficacy and safety of tcm treatment based on western medical methodology, such as randomized clinical trials (rct). although both chinese and western experts realize that rct may not be appropriate to evaluate tcm since it requires individualized treatment based on the diagnosis of each patient, there is not any innovative evaluation design available [20] . to fill the gap between tcm and evidence based medicine (ebm), efforts have been put on conducting systematic reviews and clinical studies in china [21] . for example, as part of the international cochrane collaboration, the chinese ebm/cochrane center was established in china in 1999. it provides both clinical control trial studies and metaanalysis reviews on the available studies of tcm. many government agencies are also involved and increasing their investment on tcm research. in addition to tcm diagnosis, such as pulse diagnosis and tongue diagnosis, the common tcm treatments include herbal medicine, acupuncture/moxibustion, cupping, gua sha, 7 and chinese massage (tuina, an muo and qian yin). the total number of tcm out-patient visits is almost 1.3 billion per year, which is about one third of the total outpatient visits in china [10] . almost 40% of these tcm visits are delivered in village clinics/community health service centers, followed by 28% in tcm hospitals, 16% from health centers, 10% in other hospitals, and 7% from private clinics and others. table 1 shows that tcm hospitals represent 13.8% of all hospitals in china and tcm/western medicine integrated hospitals only represent 1.1%. in addition to the small proportion, the relative growth rate of tcm hospitals is much slower than general hospitals (fig. 2) . tcm hospital outpatient visits are only about 18% of the general hospital visits. the ratio of tcm hospitals to other hospitals and their visits does not provide us the whole picture of tcm practices in hospitals since tcm and western medical practices are mixed in both types of hospitals. first, about 90% of the general hospitals have tcm departments although the tcm department outpatient visits only represent 8% of the total outpatient visits in general hospitals [10] . second, in tcm/western integrated hospitals, tcm related treatment is about 40-45% of the total treatments given. third, almost all of the tcm hospitals are practicing western medicine as well as tcm [19] . in addition to using stethoscope and biomedical diagnostic tests, western surgeries for different kinds of diseases (e.g. liver, stomach, kidney, and breast cancer) are also common practice in tcm hospitals. as discussed earlier, the challenges of tcm clinical effectiveness may explain in some part the use of western medicine in the tcm hospitals. furthermore, due to the health reforms in the 1990s, most of the hospitals in china have to take care of themselves financially with less and less government investment [4] . in general, tcm practice is much cheaper and has a lower profit margin than western medicine. many tcm hospitals depend on government subsidies for survival [23] . it was reported that almost three quarters of the tcm prices are lower than their actual costs [24] . thus, most of the tcm hospitals implement western technology in diagnosis and treatment. since the government regulates and controls most of the utilization prices in hospitals, most of the hospital profits are from prescription drugs. this causes further overuse of western medication in many tcm hospitals as well as general hospitals. it was reported that 37% of outpatient medication revenue in tcm hospitals were from western medicine, followed by 35% from patent medicine and 28% from raw/sliced herbal medicine [25] . western medication utilization is even higher among in-patients in tcm hospitals. western medication revenue comprises almost 78% of the total medication revenue and 37.4% of the total revenue in tcm hospitals. chinese herbal medicine only represents 22% of the medication revenue and 8.1% of the total revenue in tcm hospitals. similar to hospitals, both tcm and western medicine are practiced alongside each other in health centers and health clinics. about 75% of health centers have a tcm department. including tcm/western integrated medicine treatment, the total tcm out-patient visits were 330 million, which was much higher than those visits in all tcm hospitals in 2001 [10] . in health centers, chinese herbal medicine revenue represented less than 15% of the total medication revenue. however, about one third of the total medical utilization in health clinics was from tcm, which was more than the tcm utilizations in tcm hospitals and health centers. although a majority of chinese believe in tcm, only a small portion of them prefer tcm treatment to western medical treatment when they are sick. in a survey conducted among 1161 out-patients, 19% of the respondents said they have never had any tcm treatment. 25% of the respondents said they have tcm treatment because they have chronic conditions while another 17% said they have tcm treatment because western medicine failed to cure them [26] . another larger household survey of 42,819 people in both urban and rural china also showed that 54% of the population prefers western medical treatment, 25% prefers tcm/western integrated treatment, 12% prefers tcm treatment only, 5% western medicine for acute conditions while tcm for chronic conditions, and 1% prefers western medicine for diagnosis while tcm for treatment [10] . for those people who prefer tcm treatment, the main reason to choose tcm is their belief in tcm (50.7%), followed by its good clinical outcome (21.5%), its treatment of the cause (11.2%), frequent adverse-reaction of western medicine (8.7%), and inexpensive price (6.8%). in general, age is positively related to people's choice of tcm treatment although after 65 the trend reverses. people with less than a grade school level of education and those with higher than college are more likely to use tcm. females, people who live in urban areas, and people with professional occupations are also more likely to use tcm. tcm is well integrated in the chinese health care system. however, tcm is still facing many challenges in playing critical roles in improving public health in china. these challenges can be explained from different perspectives. in addition to the unique characteristics of tcm, economic, cultural, and historical evolution in china may also be the major determinants. first, although the tcm philosophy is an important part of the chinese culture, tcm theories and methodologies are still not confirmed or measurable by modern science. for example, the mechanism of the different functions of the five-zang and six-fu organs is not clear. it is still hard to measure different kinds of qi, such as vital qi and wei qi. tcm diagnosis tools are less tangible and its clinical outcomes are less documented than western medicine. in addition, chinese herbal medicines are neither as easy to take nor as fast to reduce symptoms as western medications. these factors are important in explaining why western medicine is used more than tcm in china. second, due to the success of economic reform in the past 30 years, the concept of westernization and modernization are popular among the chinese people. some medical professionals and consumers regard tcm as far behind or less developed than western medicine [27] . although some chinese, especially those with a high level of education understand the side-effects and medical error problems of western medical treatment, very few studies or statistics are available on the issues in china. so, the knowledge and concerns about the adverse-effects of western medicine are much less than those in the us or in europe. currently, there are many highly regarded tcm programs and practitioners in china, such as beijing tcm university and shanghai tcm university. however, due to the difficulty in evaluation and regulation of tcm throughout history and adulterants of chinese herbal medicine and quack tcm doctors some negative opinions of herbal medicine and tcm professionals still exist. in rural china, the situation is worse since there is lack of health facilities and professionals. specifically, very few licensed tcm professionals are available there. these may not only explain why western medical treatment is more used than tcm in rural china, but also indicate the complex environment for public health services. third, due to the historical evolution and cultural changes, some of the traditional knowledge is lost in both the formal tcm practice and the education system. as discussed earlier, the lack of the genuine knowledge also causes problems in chinese herbal medicine production and regulation, which results in a negative impact on tcm clinical outcomes. experts argue that if chinese herbal medicine is prepared, prescribed, and used properly based on the tcm principles and chinese herbology (e.g. the principle of jun, chen, zuo, shi), they are very safe. most of the severe adverse-effects and toxicity occurred not due to high risks of chinese herbal medicine, but due to misuse or lack of genuine tcm knowledge [28] [29] [30] . similar to herbal extracts and intravenous (iv) formulae of herbal products, some of the new chinese patent medicines are not fully developed based on the tcm principles and chinese herbology [3] . although they are approved by the chinese state food and drug administration, the clinical outcomes of these products are not as remarkable as these traditional formulae. fourth, the limitations of hospital finance may also push the movement of western medicine in china. as discussed earlier, since chinese hospitals are expected to generate revenue to cover the majority of their expenses, they have incentives to use western medical devices and treatment due to the lower profit margin of tcm. the low profitability of tcm makes the tcm labor market less attractive. students also have less incentive to carry on the genuine tcm practice and tcm professionals have more incentive to practice western medicine. finally, there are also concerns on the integrated practice of tcm and western medicine since they are based on different philosophies and theories. as previously discussed, the integrated practices are found not only in those tcm/western medicine hospitals, but in all other type of medical institutions and with different forms. in addition to integrated treatment, some patients use western medicine for diagnosis and use tcm for treatment. some others use tcm for chronic conditions and use western medicine for acute conditions. although some studies have shown that integrated practice has the potential to improve clinical results [31] , there are also concerns that the traditional tcm characteristics are more likely to be ignored in the integrated practice. a study showed that only 30,000 tcm doctors in china are still prescribing raw/sliced herbal medicine based on tcm theory and chinese herbology [9] . the majority of tcm doctors only prescribe western medications. in response to these challenges, the chinese government is putting a lot of effort in protecting and expanding the roles of tcm in the health care system in the past decade. in addition to increasing investment in clinical research and regulation as discussed earlier, different government agencies are collaborating to develop a series of initiatives to promote tcm, such as studying the basic theory of tcm, identifying and supporting senior tcm experts to pass along the ancient knowledge, and training a group of tcm elites to inherit the experience [32] . the chinese government is also looking for ways to fit the traditional tcm care framework into the current health care system. for example, a trial study on permitting tcm doctors to treat and prescribe herbal medicine to patients in herbal medicine shops will be conducted in nine cities/counties in china from july 2007 to march 2008 [33] . since the chinese health care system is very centralized, the government's role is very critical for the future of tcm. with the on-going major health care system reforms to provide accessible, affordable, and equal health care, the chinese government should consider how to provide sufficient investment on tcm and allocate the limited resources rationally. specifically, government needs to build up its own infrastructure and provide regulations and public polices on tcm to facilitate consumers and health services providers. after developing a reasonable, simple, transparent and consistent tcm regulation system, more focus should be on how to effectively implement and enforce those regulations and initiatives. complete investigations should be conducted to evaluate whether these regulations and initiatives are cost effective from society's perspective. in addition to educating the public on tcm, the government should also educate the public on the risks of western medicine. in addition to investigating and releasing information on adverse-reaction and medical errors, the government can also provide knowledge and studies on the current development of traditional medicine and alternative and complementary medicine in western health systems. this knowledge will encourage the chinese people to open their minds and reconsider the value of tcm in the chinese health care system. under the current economic situation in china, further studies should also investigate the competitiveness of the tcm market and the behavior of consumers and health providers. it is critical to develop well-designed survey studies in order to further investigate the determinants of the tcm utilizations. for example, what is the impact of health insurance and other socio-economic factors? do historical factors, such as the adverse campaign on tcm during the cultural revolution result in some cohort differences in the tcm utilization? for example, what is the funding impact from pharmaceutical companies and medical device companies on western medicine usage and tcm medicine? do the pharmaceutical companies and herbal medicine manufacturers have different profitability, marketing strategies, social and political impact on health care policies and regulations, which directly or indirectly influence western medicine and tcm practices? better understanding of the pattern of tcm utilization can help government reform the health delivery and financing infrastructure. it can also guide government to provide specific policies, such as promoting tcm in specific geographic locations, for subgroups who may receive more benefit from tcm treatment, and to efficiently allocate tcm resources. knowledge, imagery in an ancient chinese medical text traditional chinese medicine could make 'health for one' true. world health organization the greatest benefit to mankind: a medical history of humanity privatization and its discontents-the evolving chinese health care system the problems and suggestions on traditional chinese patent medicine processing a couple of thoughts on how to train students with tcm thinking skills comparative analysis of jinxian dai licensing procedure and rules for tcm doctors the curative effect and prospect of tcm against aids demand and utilization of tcm services in china. hei long jiang scientific and technology publisher current situations of tcm treatment on coronary heart disease and angina review of tcm research on epilepsy effect of chinese herbs in treating hepatic fibrosis induced by chronic hepatitis b tcm treatment on refractory nephrotic syndrome (rns) the study about diagnosis and treatment of child attention deficit-hyperactivity disorder in chinese traditional medicine research progress on anti-diabetic chinese medicines current tcm development and administration reform committee on the use of complementary and alternative medicine by the american public. complementary and alternative medicine in the united states. institute of medicine. the national academies press study on application of evidence based medicine in internationalization of traditional chinese medicine. world science and technology/modernization of progress and prospects of research on information processing techniques for intelligent diagnosis of traditional chinese medicine health in china: traditional chinese medicine: one country, two systems major roles of western medicine in tcm hospitals. finance and economics daily decreasing tcm clinical utilization. health newspaper a study of tcm treatment choices among outpatients traditional medicine in china today: implications for indigenous health systems in a modern world tcm herbal drug toxicity analysis and prevention methods analysis of 169 cases of adverse reactions induced by puerarin injection causes for adverse reactions of traditional chinese medicine injections: a case study of the "houttuynia cordata injection event effect of integrated traditional chinese medicine and western medicine on the treatment of severe acute respiratory syndrome: a meta-analysis outlines on tcm innovation and development temporary regulation on tcm doctors' practice in herbal medicine shops we would like to give our thanks to mr. brian mckenna for his comments. key: cord-300517-41pr3dwa authors: zhang, dan; zhang, bing; lv, jin-tao; sa, ri-na; zhang, xiao-meng; lin, zhi-jian title: the clinical benefits of chinese patent medicines against covid-19 based on current evidence date: 2020-05-05 journal: pharmacol res doi: 10.1016/j.phrs.2020.104882 sha: doc_id: 300517 cord_uid: 41pr3dwa the outbreak of emerging infectious pneumonia caused by 2019 novel coronavirus (2019-ncov) has posed an enormous threat to public health, and traditional chinese medicine (tcm) have made vast contribution to the prevention, treatment and rehabilitation of coronavirus disease 19 (covid-19) among chinese population. as an indispensable part of tcm, chinese patent medicines (cpms) are highly valued and critically acclaimed in their campaign to contain and tackle the epidemic, they can achieve considerable effects for both suspected cases under medical observation period, and confirmed individuals with serious underlying diseases or critical conditions. given this, based on the guideline on diagnosis and treatment of coronavirus disease 2019 in china, the present review summarized the basic information, clinical evidence and published literatures of recommended cpms against covid-19. the details were thoroughly introduced involving compositions, therapeutic effects, clinical indications, medication history of cpms and the profiles of corresponding research. with regard to infected patients with different stages and syndrome, the preferable potentials and therapeutic mechanism of cpms were addressed through the comprehensive collection of relevant literatures and on-going clinical trials. this study could provide an insight into clinical application and underlying mechanism of recommended cpms against covid-19, with the aim to share the chinese experience in clinical practice and facilitate scientific development of tcm, especially cpms in the fierce battle of covid-19. in the theory of traditional chinese medicine (tcm), 2019-ncov infected pneumonia was deemed to the category of "pestilence", and the characteristics of its pathogenesis was "dampness, toxin, stasis and closure" [19] [20] . over the past few months, tcm exhibited remarkable benefits against covid-19 in china, and it was convinced that tcm achieved satisfactory therapeutic superiority for patients infected by 2019-ncov with regard to preventive treatment of diseases, comprehensive therapies and rehabilitation by the accumulation of clinical experience and scientific evidence [21] [22] . as recommended in the guideline on diagnosis and treatment of coronavirus disease 2019 (revised 7th version) which was officially released by national health commission of the people's republic of china, tcm could exert favorable effects for patients with different syndromes and distinct stages of covid-19, contributing to infections in the periods of both medical observation and clinical treatment [23] . recently, the latest official data showed that 91.5% of confirmed subjects with covid-19 (74,187 cases) received tcm in china, and increasing results of clinical observation indicated that the total effective rate of tcm reached more than 90% [24] . these promising advantages were associated with its unique therapeutic principles including syndrome differentiation and treatment, boosting the individual's endogenous healing ability, balancing yin and yang, various therapies and personalized treatment in first-line clinic [25] [26] . with the development of technology in tcm domain, chinese herbal products were transformed into varied dosage forms, chinese patent medicines (cpms) were consumer-near and popular "folk medicine" that contributed to widely application in clinical practice among chinese citizens [27] [28] . compared to herbal decoction, cpms had the advantages of stable quality, curative efficacy, considerable safety, rapid absorption, high bioavailability, convenience of taking, carrying and storing [29] [30] . similarly, as an indispensable part of tcm, cpms were substantial utilized in combination with western medicine for the management of covid-19, and proposed as adjunctive and therapeutic options to fight the public health emergency of 2019-ncov by national and provincial guidelines in china [31] [32] [33] . given the paucity of published english research concerning cpms against covid-19 currently, the present review performed a descriptive analysis of recommended cpms from both clinical trials and published literatures, based on the following aspects: information retrieved from their instructions (compositions, therapeutic effects, and clinical indications), medical evidence, pharmacodynamic mechanism, dominant components, applicable patients, clinical cautions and so on. as regarding to some types of cpms without accessible published evidence for treating 2019-ncov, we introduced the relevant results of infectious or health-threatening diseases. the aim of present review was to provide the scientific basis and share clinical experiences for promising choices of cpms against covid-19. j o u r n a l p r e -p r o o f first, the comprehensive retrieval of electronic databases in both chinese and english (the china national knowledge infrastructure database, wangfang database, sinomed database, pubmed and embase) was performed for collecting the published research from inception to apr 10, 2020. on the one hand, the following terms of covid-19 were adopted: "covid-19 [supplementary concept]," "2019 novel coronavirus", "covid19", "sars-cov-2", "2019-ncov", "coronavirus disease 2019", "coronavirus disease-19". on the other hand, the searching terms of cpms mainly included their mandarin chinese and trade name. the results of literature search were displayed in figure 1a , a total of 28 citations were yielded initially for eight cpms. only one eligible study was in english, focused on the anti-viral and anti-inflammatory activities of lianhuaqingwen capsule for treating covid-19, which published by the team of distinguished academician nanshan zhong. in addition, the on-going clinical trials concerning on cpms anagist covid-19 were supplemented to identify the potential evidence by utilizing the platform of chinese clinical trial figure 1b ). according to aforementioned guidelines of covid-2019 in china, totally 14 types of cpms were officially issued to prevent and treatment covid-19, 57.14% (8 types) of them were chinese herbal injection, and others were oral dosage forms of tcm. as illustrated in figure 2 figure 3 . further, the details involving compositions, therapeutic effects, clinical indications for recommended cpms were summarized in table 1 , to provide the relative references for clinician j o u r n a l p r e -p r o o f and specialists to control the spread of this fatal disease. based on the findings of related review, the cpms including huoxiang zhengqi capsule, jinhua qinggan granules, lianhua qingwen capsule, shufeng jiedu capsule could be presumably as preventive measure for the patients in the medical observation period [34] . it was noteworthy that early treatment was essential for suspected or mild cases, accumulated evidence of bioinformatics, pharmacodynamics and clinical findings suggested that these multiple component chinese herbal products also exerted effects on immune regulation, symptom improvement, anti-inflammation and so on during the treatment of covid-19. the results of previously pharmacological research indicated that huoxiang zhengqi capsule or other dosage forms could improve gastrointestinal dysfunction, modulate immune responses, and anti-inflammation [35] . with regard to the national and provincial guidelines against covid-19 in china, huoxiang zhengqi capsule was recommended for patients with fatigue and gastrointestinal discomfort [36] . through the techniques of network pharmacology and molecular docking, huoxiang zhengqi oral liquid could regulate multiple signaling pathways involving hepatitis b, small cell lung cancer, non-small cell lung cancer and inhibit the replication of 2019-ncov to exhibit the preventive or therapeutic effects on covid-19, and its active compounds had definite affinity with angiotensin converting enzyme ii (ace2) and 3-chymotrypsin-like protease (3clpro) [37] [38] . compared with other recommended cpms, jinhua qinggan granules posed the shorter period of medication history, nevertheless, it was proved that the application of jinhua qinggan granules could significantly alleviate clinical symptoms such as fever, cough, fatigue, expectoration, and relieve psychological anxiety of mild cases suffered from covid-19 [39] . the results of systems biology and bioinformatics revealed that the mechanism of jinhua qinggan granules in the treatment of covid-19 involving multiple targets, namely mapk1, casp3, tp53, alb, tnf, il6, and multiple pathways, which might be related to antiviral, immune regulation, inflammation inhibition and apoptosis regulation via pi3k-akt, hif-1, tnf, mapk, nf-κb pathways, and dominant principles including kaempferol, baicalein and oroxylin a could take participate in multiple signal pathways (such as ptgs2, hsp90ab1, ptgs2, bcl2 and casp3) by binding with ace2 [40] [41] [42] . relieving typical symptoms and representative complications, diminishing inflammation and infection, the chinese herbal products of lianhua qingwen capsule was recognized as an excellent antidote in this anti-epidemic by adequate clinical and fundamental research [34, 43] . according to preliminary clinical evidence of retrospective, multicenter study and cases reports, for general type patients and suspected cases with covid-19, the scheme of lianhua qingwen capsule combined among them, only xiyanping injection was applied for treating severe patients, whereas others were also recognized as the complementary choices for critical cases with covid-19. compared with oral administration of tcm, the chinese herbal injections possessed the benefits of rapid onset, high bioavailability, and content accuracy [57], therefore, they were more suitable for the severe or critical patients with covid-19. some scholars concluded that xiyanping injection was reputed as effective alternative to antibiotics in clinical practice [58] . modern pharmacological studies showed that its active ingredient, sulfonated andrographolide had notable effects of antipyretic, anti-inflammation to treat various infectious diseases [59] . in addition, prevenient chinese research pointed out its clinical j o u r n a l p r e -p r o o f advantages that were related to improve respiratory symptoms, inhibit concurrent bacterial infection, and regulate immune function, superior clinical safety, especially certain hepatoprotective effects, suggesting it might have potentials to relieve some drug-induced liver injury during the treatment of covid-19 for serious cases [60] . remarkably, it was reported that andrographolide sulfonate could ameliorate sepsis in mice through suppressing mapk, stat3 and nf-κb pathways, these pathways also played the important role in pulmonary diseases [61] [62] [63] . the prescription of xuebijing injection originated from therapeutic principles of tcm, that was proposed by famous integrative medicine emergency experts, professor jin-da wang, it was approved as second grade national new medicine for treating sepsis in china over 15 years [64] [65] . in this clinical fight against covid-19, considerable effects of xuebijing injection had been displayed by retrospective study and relevant review, the results revealed that xuebijing injection could promote the absorption of lung infection, and improve clinical efficacy and negative rate of nucleic acid [66] [67] . besides, some research demonstrated its characteristics of multi-target and multi-pathway in treating covid-19 based on the approaches of network pharmacology and molecular docking. among a series of involved signaling pathways, such as hif-1 and pi3k-akt were represented pathways against covid-19 in terms of lung inflammation, virus infection and lung injury. besides, core targets including tnf, mapk1, jun, il6, stat3, egfr, etc. were closely correlation with the inhibition of cytokine storm in severe cases, and fatal risk of cytokine storms in the immune system of serious patients might result in organ failure and even death [68] [69] [70] . reduning injection was widely utilized to treat upper respiratory tract infection with multiple functions such as clearing heat, dispelling wind, and detoxification, and previous pharmacological research proposed that it could ameliorate paraquat-induced acute lung injury involved in regulating ampk/mapk/nf-κb signaling pathways [71] . in this regard to treating covid-19, reduning injection might be related to anti-inflammatory, immunoregulation of active compounds through multi-target and multi-pathway. on the one hand, the critical targets were namely ptgs2, ptsg1, ccl2, rela, nos2, hmox1, casp3, il6 and mapk1, some of them belonged to chemokines, which posed the immune activation profiles of 2019-ncov. on the other hand, kegg pathway enrichment analysis revealed 45 related pathways, mainly il-17, c-type lectin receptor, hif-1 and nf-κb signaling pathways [72] [73] . a large number of clinical data had accumulated to confirm superior efficacy of tanreqing injection in the treatment of acute bronchitis disease, tuberculosis and so on [74] [75] . in particular, the severe patients with covid-19 suffered similar clinical manifestations of its dominant diseases. meanwhile, the underlying mechanism and binding activity of tanreqing injection were elucidated, the results in molecular level showed that it might be potential as antiviral agent due to critical interesting, the core targets involved il6, il1b, mapk1, il10, il4, cxcl8, ip10, etc. [76] . this finding was consistent with former clinical report regarding severe patients with higher level of il2, il7, il10, gscf, ip10 in the plasma [77] . the commercialized injectable product of xingnaojing injection was extracted and refined scientifically from classic chinese emergency prescription "angong niuhuang pill", it had the functions of clearing heat and detoxication, cooling blood and activating blood circulation, inducing resuscitation and widely used in the treatment of intracerebral haemorrhage, cerebral ischemia, and nervous system disorders in china [78] [79] [80] . in view of critical cases with covid-19 might suffer from consciousness disturbance, xingnaojing injection had major biological effects to relax the cerebral vascular and protect the mature neuron, in vivo and in vitro research, it was confirmed that the mechanism of cerebrovascular protection might be relevant to the activation of pi3k/akt/enos signaling pathways and the suppression of nlrp3 inflammasomes [81] [82] . in aforementioned guidelines, five cpms were recommended as adjuvant rescue just for critical infections with covid-19, namely suhexiang pill, angong niuhuang pill, shenfu injection, shengmai injection, shenmai injection. currently, there were paucity of accessibly published evidence concerning on these cpms and 2019-ncov simultaneously, it was urgent and essential that subsequently clinical trials or pharmacological research to provide sufficient references for clinical recommendation. herein, we brief summarized the findings in the field of infectious or health-threatening diseases to supplement the correlative knowledge. although both of them were famous chinese emergency prescription and contained same resuscitation-inducing aromatic herbs as bingpian (borneolum syntheticum), suhexiang pill and angong niuhuang pill were used for patients with opposite syndromes. the former was adopted to seizures, infantile convulsions and stroke with cold syndromes [83] , therefore, suhexiang pill might achieve therapeutic effectiveness for covid-19 cases with critical conditions such as delirium, phlegm syncope, central nervous depression, and coma or worsen. its neuroprotective, anticonvulsant and antioxidative effects had been proven by fundamental research both in vitro and in vivo, suggesting its pharmacological mechanism involved the suppression of jnk hyperactivation and apoptosis, inhibition of egfr/erk pathways and glial cell proliferation, decreasing ros formation and restoring mitochondrial function [84] [85] [86] [87] . as a recipe of "liangkai sanbao" in tcm theory, the latter was recognized to treat heat diseases only, including acute ischemic stroke, viral encephalitis, acute hemorrhagic stroke, and trauma brain injury, angong j o u r n a l p r e -p r o o f niuhuang pill could play desirable role for treating critical infections with 2019-ncov in attenuating the negative symptoms including hyperthermia, stupor, coma, etc. [88] . meanwhile, based on the research was conducted on a high-fat and vitamin d3-induced rodent model of atherosclerosis, the results presented that angong niuhuang pill had antiplatelet aggregation, lipid regulatory, antioxidant, anti-inflammatory and anti-apoptotic properties contributing to robust antatherosclerosis and cardio-protective effects [89] , which might be beneficial for critical cases with cardiovascular and cerebrovascular diseases. the mechanisms of angong niuhuang pill exhibited the neuroprotection was related to depressed bax/bcl-2 ratio and caspase-3 level, resulting the inhibition of apoptotic cell [90] . injection had similar therapeutic effects of tonifying qi and preventing exhaustion, they could be adjuvant rescue and alternative treatment of covid-19 patients with septic shock, viral myocarditis, and cardiogenic shock in clinical practice [91] [92] [93] . for example, in rabbits with lps-induced septic shock, shenfu injection could increase mean arterial pressure, decrease the serum lactate dehydrogenase (ldh), aspartate aminotransferase (ast), and glutamate transaminase (alt) levels, improve the tissue morphology of heart, liver and kidney, and increase the contents of atp and taurine in the heart tissue during septic shock [94] . besides, previous studies demonstrated that shenfu injection, shengmai injection and shenmai injection were associated with protective effects on lung ischemia-reperfusion injury, reducing chemotherapy-induced adverse effects, and promoting cellular immunity and cognitive dysfunction and so on, presumably, these clinical functions might improve symptoms of critical patients with covid-19 in terms of lung inflammation, virus infection, drug-induced disease lung injury [95] [96] [97] [98] . since the globally health-care-associated outbreaks of 2019-ncov, in china, the implementing "attach equal importance to tcm and western medicine" policy in clinical practice exerted essential effects for treating covid-19 [99] [100] . based on unique guiding principles of syndrome differentiation and treatment in tcm, its clinical superiority had considerable recognition and public acclaim in the furious battle for 2019-ncov, the cumulative number of research revealed that its curative advantages involved in whole treatment process, namely prevent disease progression, alleviate clinical symptoms, improve the hospital stay and negative results of nucleic acid detection, and promote the physical recovery [21] [22] 101] . [104] [105] . moreover, our study highlighted that its clinical beneficial effects in severe cases was closely associated with the inhibition of cytokine storm, improve virus infection and lung injury, superior binding activities with 3clpro and ace2. in addition, three types of recommended herbal injectable dosage forms contained hongshen (ginseng radix et rhizoma rubra), ginseng was generally known for its tonic properties, and previous findings also suggested it might be a promising supplemental remedy against infectious diseases, this administration of ginseng could fast and accurate adjust excess or deficiency between yin or yang and restore their balance among critical patients [106] [107] [108] . when great attention was paid to the application of tcm in real-world, there were growing concerns related to the potential toxicity or inevitable adrs of herbal medicines. the results of pharmacovigilance pointed out the risk factors of adrs triggered by tcm including responsible chinese materia medica, susceptible patients and clinical administration [109] . in this regard, our research should emphasize the following aspects, including poisonous composition, the safety status of chinese herbal injection, special population, and irrational drug use. first, angong niuhuang pill contained cinnabar (hgs) and realgar (as 2 s 2 ) which were correlated to hepatorenal toxicity [110] . fuzi (aconiti lateralis radix praeparaia) in shenfu injection was associated with narrow therapeutic window, its cardiac adrs has been frequently observed that mainly manifested as palpitations, hypotension, arrhythmia, ventricular fibrillation, and even shock [111] [112] . second, compared with other dosage forms of tcm medications, chinese herbal injections were associated j o u r n a l p r e -p r o o f with the higher risk of adrs, especially serious side effects [113] [114] . therefore, during the treatment of covid-19, corresponding measures including drug safety monitoring and risk management for cpms should be strengthened to achieve optimal benefits and minimal hazards. third, the available evidence highlighted that special population including children, gravida and elderly people were particularly vulnerable to unfavorable drug responses, because their pharmacokinetic and pharmacodynamic profiles differed from the general population [115] . indeed, clinical medication was complicated, the irrational uses reflected in misuse or abuse application of in the treatment of covid-19 was more effective than patients receiving western medicine alone, which can significantly shorten the hospitalization, improve clinical symptom and imaging results [117] . in conclusion, the present study was devoted to summarize the comprehensive information and the authors of the manuscript that titled "the clinical benefits of chinese patent medicines against covid-19 based on current evidence" declared that there are no conflicts of no financial/personal interest. emerging 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comparative replication and immune activation profiles of sars-cov-2 and sars-cov in human lungs: an ex vivo study with implications for the pathogenesis of covid-19 tanreqing injection for acute bronchitis disease: a systematic review and meta-analysis of randomized controlled trials clinical efficacy and safety of tanreqing injection for pulmonary infection in patients with tuberculosis: a meta-qnalysis mechanism of tanreqing injection on treatment of coronavirus disease 2019 based on network pharmacology and molecular docking clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet role of xingnaojing combined with naloxone in treating intracerebral haemorrhage: a systematic review and meta-analysis of randomized controlled trials meta-analysis of the effects of xingnaojing injection on consciousness disturbance meta-analysis for clinical evaluation of xingnaojing injection for the treatment of cerebral infarction xingnaojing injection protects against cerebral ischemia reperfusion injury via pi3k/akt-mediated enos phosphorylation xingnaojing injections protect against cerebral ischemia/reperfusion injury and alleviate blood-brain barrier disruption in rats, through an underlying mechanism of nlrp3 inflammasomes suppression suhexiang wan essential oil alleviates amyloid beta induced memory impairment through inhibition of tau protein phosphorylation in mice neuroprotective effect of suhexiang wan in drosophila models of alzheimer's disease neuroprotective effects of suhexiang wan on the in vitro and in vivo models of parkinson's disease suppressive effects of suhexiang wan on amyloid-β42-induced extracellular signal-regulated kinase hyperactivation and glial cell proliferation in a transgenic drosophila model of alzheimer's disease inhibitory effects of the essential oil from suhexiang wan on the central nervous system after inhalation use of angong niuhuang in treating central nervous system diseases and related research. evid based complement alternat med anti-atherosclerosis and cardio-protective effects of the angong niuhuang pill on a high fat and vitamin d3 induced rodent model of atherosclerosis an-gong-niu-huang wan protects against cerebral ischemia induced apoptosis in rats: up-regulation of bcl-2 and down-regulation of bax and caspase-3 shenfu injection attenuates rat myocardial hypertrophy by up-regulating mir-19a-3p expression an overview of systematic reviews of shenmai injection for healthcare. evid based complement alternat med herbal medicines for viral myocarditis effect of shenfu injection on lipopolysaccharide (lps)-induced septic shock in rabbits protective effect of shenfu injection preconditioning on lung ischemia-reperfusion injury effects of shenfu injection on chemotherapy-induced adverse effects and quality of life in patients with advanced nonsmall cell lung cancer: a systematic review and meta-analysis comments on shenfu injection for improving cellular immunity and clinical outcome in patients with sepsis or septic shock shenmai injection enhances the cytotoxicity of chemotherapeutic drugs against colorectal cancers via improving their subcellular distribution administrations of preoperative shenmai injection and postoperative shenfu injection, two ginseng containing tcm formulas, improve cognitive dysfunction in aged rats effects of shengmai injection add-on therapy to chemotherapy in patients with non-small cell lung cancer: a meta-analysis interpretation of the expert guidance on a comprehensive intervention program of traditional chinese medicine for the recovery of novel coronavirus pneumonia(draft) in silico screening of chinese herbal medicines with the potential to directly inhibit 2019 novel coronavirus clinical features and treatment of covid-19 patients in northeast chongqing protective effect of phillyrin on lethal lps-induced neutrophil inflammation in zebrafish phillyrin is an effective inhibitor of quorum sensing with potential as an anti-pseudomonas aeruginosa infection therapy protective effects of phillyrin against influenza a virus in vivo efficacy of xuebijing injection for sepsis (exit-sep): protocol for a randomised controlled trial microcirculatory disorders and protective role of xuebijing in severe heat stroke effects of radix ginseng on microbial infections: a narrative review protective roles of ginseng against bacterial infection the characteristics and regularities of cardiac adverse drug reactions induced by chinese materia medica: a bibliometric research and association rules analysis a review of cinnabar (hgs) and/or realgar (as4s4)-containing traditional medicines study on cardiotoxicity and mechanism of "fuzi" extracts based on metabonomics a review of traditional and current methods used to potentially reduce toxicity of aconitum roots in traditional chinese medicine safety profile of traditional chinese herbal injection: an analysis of a spontaneous reporting system in china safety concerns of traditional chinese medicine injections used in chinese children respiratory syncytial virus prophylaxis and the "special population do ethanol and metronidazole interact to produce a disulfiram-like reaction? observation on clinical effect of modified qingfeipaidu decoction in treatment of covid-19 this work is supported by the programs foundation for leading talents in state administration of traditional chinese medicine of china-"qihuang scholars" project (10400633210004), the national natural science foundation of china (grant no. 81874349), and national special support plan for high-level talents (plan of ten thousand people)-famous teacher program to professor bing zhang. heat diseases including invasion of pericardium by evil, febrile convulsion, coma and delirium. apoplectic coma, encephalitis, cephalomeningitis, toxic encephalopathy, hematencephalon, septicemia belongs to the above syndromes. key: cord-340119-af8i359n authors: wang, shi-xin; wang, yan; lu, yu-bao; li, jie-yun; song, yu-jun; nyamgerelt, munkhtuya; wang, xue-xi title: diagnosis and treatment of novel coronavirus pneumonia based on the theory of traditional chinese medicine date: 2020-04-15 journal: j integr med doi: 10.1016/j.joim.2020.04.001 sha: doc_id: 340119 cord_uid: af8i359n since the outbreak of novel coronavirus pneumonia (coronavirus disease 2019, covid-19) in december 2019, it has rapidly spread to 187 countries, causing serious harm to the health of people and a huge social burden. however, currently, drugs specifically approved for clinical use are not available, except for vaccines against covid-19 that are being evaluated. traditional chinese medicine (tcm) is capable of performing syndrome differentiation and treatment according to the clinical manifestations of patients, and has a better ability of epidemic prevention and control. the authors comprehensively analyzed the etiology and pathogenesis of covid-19 based on the theory of tcm, and discussed its syndrome differentiation, treatment and prevention measures so as to provide strategies and reference for the prevention and treatment with tcm. since december 2019, the novel coronavirus pneumonia (coronavirus disease 2019, outbreak in wuhan, hubei province, china has rapidly spread across the world and has now infected a total of 348678 people in 187 countries (march 21, 2020) [1] . china has listed covid-19 as a class b infectious disease and has undertaken preventive and control measures according to class a infectious diseases [2] . with the spread of the epidemic, presently, patients infected with the novel coronavirus, as well as those with asymptomatic infection, are the main sources of infection; thus, covid-19 is an infectious disease with a medium to slightly high contagious capacity [3] . the incubation period of the disease is generally 7 days, and the longest is 14 days; however, some cases have reported an incubation period of 24 days as well [4] . common clinical manifestations include fever, dry cough and fatigue. computerized tomography of the chest can show multiple ground glass shadows of the pulmonary lobes, indicative of conditions such as respiratory distress syndrome, shock and sepsis, which can even lead to death [5] . thus far, although china has announced six trials and strategies for the diagnosis and treatment of the disease, the focus remains mainly on symptomatic treatment, new drugs specifically approved for the infection are not available. clinical trials for new drugs such as remdesivir and coolidge are underway; however, the clinical promotion and short-term use of these drugs is unlikely. therefore, given the particularities of this disease, it is of critical clinical value to formulate a set of treatment plans using integrated traditional chinese medicine (tcm) and western medicine, based on the concept of prevention and treatment. to utilize the advantages of integrated traditional chinese and western medicine in the prevention and treatment of covid-19, this paper discussed the etiology and pathogenesis of covid-19 from the viewpoint of integrated tcm and western medicine, the treatment measures for different susceptible groups, and the effect along with matters needing attention, so as to provide a reference for the prevention and treatment of covid-19. coronavirus is a type of a ribonucleic acid virus with an envelope structure, characterized by rod-like protuberances on the surface and can infect multiple host species, causing a variety of diseases [6] . the covid-19 pathogen is a novel coronavirus (2019-ncov), which can infect humans and is significantly clustered with the bat-like severe acute respiratory syndrome coronavirus (sars-cov) sequence isolated in 2015, with a nucleotide similarity of 88%. based on these results, it can be concluded that 2019-ncov is similar to sars-cov and middle east respiratory syndrome coronavirus (mers-cov) [7] . it is a zoonotic pathogen that can cause severe respiratory diseases in humans and can be transmitted from person to person [8] . therefore, the international committee on taxonomy of viruses announced that the official classification of the novel coronavirus is sars-cov-2. there is no virus theory in tcm, and according to the clinical characteristics of covid-19, the disease belongs to the category of "plague" [9] . as the general treatise on the etiology and symptomology says [10] , "if a person feels grumpy and gets sick, he will be easily infected by evil qi, which may even exterminate the family, and extend to outsiders." the common symptoms in the early stage of covid-19 in mildly infected patients include fever, fatigue and dry cough, which could be easily confused with other common exogenous diseases. however, according to wu you-ke's the treatise on epidemic febrile diseases [11] , which mentions "the febrile disease is non-wind, non-cold, non-heat and non-damp; it is a different feeling between heaven and earth," the cause of this disease is very clear, differing from the other six exotic evils, and presenting characteristics of a strong and contagious epidemic virus. wuhan, the center of the outbreak pathogen, is located in the east of jianghan plain of china. the vertical and horizontal water areas of the city's rivers account for one-fourth of the total city area, demonstrating the natural environmental basis of "damp evil" [12] . at the initial stage of this epidemic, most patients presented symptoms of fever; however, there were also patients with no fever or low fever, and some patients presented gastrointestinal symptoms, such as indigestion and loose stool, as well as chest tightness and fatigue, coinciding with the characteristics of "damp evil" in tcm. hence, this disease is an epidemic, with the primary nature of "damp" and "toxic," and thus can be termed "damp toxin disease." furthermore, in 2019, wuhan experienced a warm winter climate, with incoming heat instead of cold. from the perspective of tcm, this kind of climate change is prone to generate damp-heat in the human body, which persists and is difficult to eliminate from sanjiao (one of the six fu-organs in tcm theory). some patients have a recurrent fever, bitter mouth, insomnia, upset, chest tightness and shortness of breath, fatigue, yellow or greasy tongue coating, and slippery pulse, which are manifestations of the evil underlying shaoyang meridian according to the six-meridian syndrome differentiation theory [13] . notably, the most severe cases developed dyspnea one week later, which even progressed to acute respiratory distress syndrome, septic shock, intractable metabolic acidosis, and coagulation dysfunction, leading to death [14] . according to tcm, the toxins from these patients not only hurt the qi but also injure the nutrient blood and result in blood stasis; the pericardium transmission channel is also reversed, resulting in mental changes. dampness stagnates for a prolonged period and turns into heat; heat toxin accumulates for a long time, resulting in stasis; stasis and heat combine mutually and then generate syncope, which consumes qi and yin and leads to a deficiency. according to the principle of "three factors and measures," there exist various etiological characteristics in different regions, as well as climatic factors. fan et al. [15] observed and analyzed the tcm pathological characteristics of "dryness" in hunan cases, and concluded that dryness and dampness are mainly due to "child disease to mother" in the course of the disease. in the theory of tcm, dryness evil can easily injure the lung. lung and spleen belong to "gold" and "soil" in the five-element theory of tcm. dryness turns into dampness. dampness easily traps spleen. wet soil is the mother of dryness "gold." furthermore, excessive lung dryness injures the spleen "soil"; hence, both lung dryness and spleen dampness are significant. in contrast, yu et al. [16] summed up the data and concluded that the diseases in guangdong province and gansu province were caused by warm-heat toxin or epidemic toxin, which was closely related to their regional environment. guangdong province is hot and humid all year round, and the epidemic qi can easily mix with evils of damp and heat to attack the lung; however, the overall 2019 winter temperature in gansu province was higher than that experienced in previous years. additionally, gansu is located in the northwest region of china, which is mostly dry and warm, and susceptible to the evil of dryness that can cause lung disease. tcm runs through the whole idea of disease differentiation all the time, and the unified relationship between man and nature has been called "correspondence between man and nature" in ancient books, which presents considerable advantage in the treatment of covid-19 in different populations and regions. compared with other diseases, the evil qi of the "damp toxin epidemic" is relatively fixed, and hence, the etiology and pathogenesis are relatively fixed, with obvious stages of disease progression in clinical settings. understanding the consistency of the stages also allows for clinical diagnosis and evidence-based treatment. after careful assessment of the four pieces of diagnostic evidence available regarding the confirmed cases, it was observed that this epidemic is mainly caused by a dampness pathogen, with the disease location of mainly sangjiao, and the core pathogenesis is "dampness, heat, poison, blood stasis and deficiency," which runs through the whole process of dampness and intoxication and closure of the lung. the treatise on epidemic febrile diseases [11] ascertains that typhoid fever does not infect people, but epidemic diseases can infect people. the evil of typhoid fever enters from the orifices, while the evil of epidemic disease enters only from the mouth and nose; it has been observed that during an epidemic, the evil comes from the mouth and nose, remains in the membrane, and unconsciously lurks in the human body [17] . covid-19 is located in the lung, where evil qi first invades the body from the mouth and nose, repressing the lung qi. in turn, the lung fails to disperse and descend, with symptoms of dry cough. the "damp evil" is heavy and viscous, blocking the qi mechanism and causing chest tightness, body heat, and muscle soreness. "damp evil" traps the spleen, easily injuring yang qi. the spleen dominates and transports water and food through the body. when the qi fails to rise, the spleen cannot be nourished, and symptoms begin to appear, including fatigue, gastric congestion and loose stool. the spleen and stomach act as the exterior and interior of each other; hence, the spleen's dysfunction affects the stomach's absorption. the dampness accompanying the epidemic toxin into heat is manifested as high fever, occasional yellow phlegm, obvious asthma due to the dampness toxin, and sticky stool due to the stagnation of dampness. wang qingren stated in correcting mistakes in medicine that "the plague toxin burns its blood inside, and if the blood is burned and refined, the blood will coagulate [18] ." during this period, the heat toxin burns the body fluid, and dampness suppresses the qi mechanism, resulting in the stasis of blood, manifested in the form of increased dyspnea and additional mental problems occurring during the reverse transmission of the pericardium. in the later stage, the body is damaged by fluid consumption, and is deficient in both qi and yin. during this period of treatment, attention should be paid to whether there is any residual evil in the body. given the differences in etiology and pathogenesis attributed to climatic factors in different regions, fan et al. [19] observed and stated that owing to climatic factors, dryness has been present in the lung for a prolonged period. on encountering the epidemic toxin, dampness and cold will collide with each other, and obstruct the lung and chest, injuring vital qi, leading to the stagnation of the qi mechanism and abnormal rise and fall of evil qi, finally leading to a deficiency of vital energy. although there exist differing opinions, combined with the clinical manifestations of the published and confirmed cases, the main etiology and pathogenesis can be attributed to "dampness, heat, toxin, blood stasis and deficiency." furthermore, the pathogenesis may differ among individuals. in the case of adults without underlying diseases, because of being in the prime of life, the presence of vital qi, as well as the balance and coordination of movement and transformation of qi, blood, yin and yang, is sufficient to resist external evil, demonstrating no susceptibility or mild susceptibility, with a short disease course and a good prognosis. in children, for the viscera are not well developed, presenting delicate viscera, unfilled shape and qi, and immature yin and yang, they fall sick easily and quickly [20] . however, in the overall growing phase, they are made up of "pure yang", are robust, and will recover easily. patients with underlying diseases, such as diabetes, hypertension, heart disease, chronic tracheitis, tumors, or other diseases, usually suffer from a deficiency of vital qi; if they experience the external evil, the disease is often characterized by severe illness, rapid progression, and rapid transmission, resulting in critical illness and even death. pregnant women have a special physiological state, with a relative deficiency of yin-blood and relative hyperactivity of yang qi. the growth of the fetus blocks the rise and fall mechanism of the qi in pregnant women, which may lead to poor operation of qi and blood. therefore, the elderly, the infirm, children and pregnant women require close monitoring. currently, there are no drugs specifically approved for covid-19. in the treatment plan announced by the national health commission of the people's republic of china [21] , western medicine offers mainly symptomatic treatment support, including early oxygen therapy and the use of corticosteroids. the treatment plan comprises antiviral therapies, including interferon-α, lopinavir, ritonavir and ribavirin; however, the curative effect remains unsatisfactory. chinese medicine is now fully involved in the treatment of covid-19 patients [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] , utilizing the advantages of tcm syndrome differentiation and treatment, improving the cure rate, and reducing mortality (table 1) . fever is the main symptom of the disease, with most hiding fever not accompanied by a cold. other symptoms include sleepiness and discomfort, dry cough and less phlegm, thirst without the desire to drink, chest tightness and palpitation, occasional muscle aches, nasal congestion and runny nose, and loose stools. no sweat, no sthenic heat or irritable heat sensation, and no sore throat. the tongue is dark red, or its edge is red, the moss is thin and white, and the pulse has no fixed point. currently, according to published data, covid-19 clinically manifests as different stages of disease progression. tcm treatment requires syndrome differentiation and treatment based on the stages, which are defined as initial stage (mild), progressive stage (severe), extreme stage (extremely severe) and recovery stage (convalescent stage). the medicines' sources, medicines' names in latin and english are presented in table 2 . the damp toxin in the shangjiao membrane should be treated for "damp-heat clearance to cure the lung," including separating and dissipating the damp-heat, paying critical attention to the smooth release of lung qi. furthermore, it is crucial to closely monitor the potential of the toxin to enter the blood in order to resolve the dampness, eliminate the filth, promote the qi mechanism, resolve blood stasis, and relieve the blood vessel networks, thereby following the principles of the huopu xialing decoction and sanren decoction [14] . the combination prescription includes guanghuoxiang, peilan, banxia and doukou for aromatizing, drying and regulating qi; xingren for promoting lung qi; fuling, zexie, huashi, tongcao, danzhuye and yiyiren for relieving and removing dampness or allowing the removal of dampness; and mudanpi and chishao for resolving blood stasis. the combination of these herbs can smoothen the sanjiao qi mechanism, dissipate and dissolve the dampness, resolve blood stasis, and dredge collaterals. toxins causing dampness can increase the heat in the body; this dampness and heat can lead to infection of the lung and negatively affect the functioning of the lung. during the progressive stage, if the disease is not properly treated, the heat and dampness cause the lung to close, with the possibility of internal closure and external prolapse appearing. it is necessary to discuss treatment from the point of qi this period is dominated by asthenia, with many changes necessitating individual syndrome differentiation and treatment. some studies have emphasized that xue's wuye lugen decoction can be used as reference to clear the residual evil and promote lung circulation, activate the spleen, and strengthen healthy qi [14] . the five leaves in the formula float and bring the evil to the surface. among them, huoxiang leaf, bohe, fresh lotus leaf and peilan leaf are all fragrant and good at invigorating the spleen. lugen and dongguazi can be used for infiltration. the formula is light and nimble and can be used for dispersing, purging, and infiltration. additionally, it is necessary to pay attention to the following points. (1) focus on removing dampness. the process of dampness removal is considered during diagnosis and treatment of the disease. although the epidemic toxin is mainly characterized by toxic heat, dampness and turbidity, it is difficult to separate the heat and dampness characteristics from the initial stages of the infection to the end. it is also difficult to only get rid of heat without removal of dampness as well. dampness is yin evil, and it is unsuitable to use cold and cool drugs during the early stage; warm and tonic herbs in the later stage should also be used cautiously. furthermore, it is permissible to use a combination of drugs to resolve dampness, dry dampness, and drain dampness during different stages. (2) promoting blood circulation and resolving blood stasis. the patients should be treated with drugs for promoting blood circulation and resolving blood stasis immediately after the appearance of lung shadow. during covid-19, the patients present high fever, sputum mixed with blood, dark purple-colored tongue, and consolidation or ground glass shadows in early lung images. pathological reports indicated diffuse alveolar damage, hyperemia, hemorrhage, edema, and pulmonary interstitial inflammation, which are all manifestations of blood stasis. therefore, during the different stages of treatment, it is necessary to combine products promoting blood circulation and eliminating blood stasis, dredging blood vessels, removing blood stasis, reducing alveolar damage, preventing pulmonary interstitial fibrosis, and reducing sequelae, which is conducive to the comprehensive rehabilitation of patients. additionally, there are no specific chinese medicine prescriptions for the elderly, pregnant women, children, and patients with underlying diseases. hence, it is essential to study the signs and symptoms of covid-19 cases to provide effective treatment. tcm focuses on the idea of "prevention of disease," advocating prevention before the disease occurs and prevention of change after disease. therefore, those who have a history of exposure or have been in close contact with epidemic areas should be prioritized with the treatment principles, including stabilizing qi and strengthening the exterior, removing heat, and detoxifying the body according to the composition of the prescription and climatic factors in different regions, to practice prevention before disease occurrence. in the cases of patients with chronic illness or those susceptible to infection, emphasis should be given to strengthening the vital energy, improving immunity, and using yupingfeng powder to invigorate qi and solidify the exterior [26] . individuals with underlying diseases can be treated regionally according to their diseases. according to tcm, after conception, the whole body's yin-blood is gathered in chong meridian, ren meridian, and the uterus, placing the pregnant women in a special physiological state of a relative deficiency of yin-blood and relative hyperactivity of yang qi. the growing fetus will block the rise and fall of qi and blood, resulting in poor operation of qi and blood. "it should be cool before pregnancy and warm after birth" is the general principle of regulation and stabilization in tcm before and after pregnancy. this can be adjusted and treated in advance to prevent the occurrence of disease, and the method of nourishing yin and clearing heat, regulating the qi mechanism, and calming the fetus is adopted. young children are not full of qi; their yin and yang are immature, and their viscera are delicate, especially, the lung, spleen and kidney [26] . hence, it is recommended to protect the qi of the spleen and stomach in advance to nourish other organs, strengthen their physique, and resist the evil of epidemic disease, utilizing sijunzi decoction or yupingfeng powder to invigorate the qi for consolidating superficies [26] . according to tcm, different people have different physical characteristics, and hence, different treatment principles and medication plans should be generated based on their physical characteristics (table 3) . based on the existing treatment schemes, the prescription composition and dosage recommended for prevention and treatment of covid-19 during different stages are introduced in table 4 . renshen 9 g, baizhu 9 g, fuling 9 g, gancao 6 g shengmai drink renshen 9 g, maidong 9 g, wuweizi 6 g, danshen 6 g guizhi decoction guizhi 9 g, shengjiang 9 g, dazao 9 g, honey-fried gancao 6 g shenzhu powder cangzhu 1000 g, chenpi 1000 g, houpo 1000 g, honey-fried gancao 360 g, guanghuoxiang 250 g, sharen 120 g huangqi guizhi wuwu decoction huangqi 15 g, guizhi 12 g, baishao 12 g, shengjiang 25 g, dazao 4 g huopu xialing decoction and sanren decoction guanghuoxiang 6 g, peilan 6 g, banxia 9 g, doukou 6g, xingren 9g, fuling 9 g, zexie 6 g, huashi 18 g, tongcao 6 g, danzhuye 6 g, yiyiren 12 g, mudanpi 6 g, chishao 6 g progressive stage lei's aromatic turbid-resolving method guanghuoxiang 3 g, peilan 3 g, chenpi 6 g, banxia 6 g, dafupi 3 g, houpo 3 g, heye 9 g jiedu huoxue decoction combined with shengjiang powder lianqiao 6 g, gegen 6 g, chaihu 9g, danggui 6g, shengdihuang 15g, chishao 9g, taoren 24g, honghua 15 g, zhiqiao 3 g, gancao 6 g, jiangcan (wine fried) 6 g, chantui 3 g, jianghuang 9 g, dahuang (raw) 12 g extreme stage shenfu sini decoction honey-fried gancao 12 g, fuzi 10 g, ganjiang 6 g, renshen shigao 1500 g, hanshuishi 1500 g, huashi 1500g, shuiniujiao 500 g, lingyangjiao crumbs 500 g, muxiang 500 g, chenxiang 500 g, xuanshen 500 g, shengma 500 g, gancao 240 g, mangxiao 5000 g, xiaoshi 930 g, shexiang 38 g, zhusha 90 g, jinbo 3000 g, dingxiang 30 g suhe xiang pill suhexiang 60 g, baizhu 60 g, muxiang 60 g, shuiniujiao 60 g, xiangfu 60 g, zhusha 60 g, hezi 60 g, tanxiang 60 g, anxixiang 60 g, chenxiang 60 g, shexiang 60 g, dingxiang 60 g, bibo 60 g, longnao 60 g, ruxiang 60 g recovery stage xue's wuye lugen decoction huoxiang leaf 6 g, bohe leaf 1.8 g, fresh lotus leaf 3 g, pipaye 15 g, peilan leaf 4.5 g, lugen 30 g, dongguazi 15 g according to the description of discharge criteria in the diagnosis and treatment protocol for covid-19 (trial version 7) [40] , the evaluation of covid-19 should be based on body temperature (more than 3 days after returning to normal), obvious improvement of respiratory symptoms, and pulmonary imaging (obvious alleviation of inflammation). if the above symptoms and signs are relieved and the respiratory pathogen nucleic acid test is negative for two consecutive times (the sampling interval is at least 24 hours), patient can be considered to be cured. however, we believe that the quantification of lung imaging related to the above efficacy evaluation index is insufficient. hence, we suggest that the lung imaging of patients with covid-19 should be comprehensively evaluated, based on the definition of the lung segment and the density criteria of high, medium and low grades, to better evaluate the treatment efficacy. the use of tcm adopts the holistic concept, combined with symptoms, signs and other corresponding manifestations, to examine the syndromes and seek the causes, to support the selection of drugs based on syndrome differentiation. syndrome differentiation and treatment, as one of the characteristics and advantages of tcm, is very important in diagnosis and treatment. for example, in the treatment of covid-19, the syndrome types differ among individuals in different regions, under different climatic conditions, and for relatively different physiques. syndrome differentiation should be clearly defined in combination with different factors and clinical syndrome characteristics. prescriptions are mainly used to improve immunity, balance human qi, blood, yin and yang, and recover organ function. according to the study of covid-19 treatment herbs [41, 42] , chinese herbal medicines with a higher probability to directly inhibit sars-cov-2 have been selected, including lianqiao, gancao, sangbaipi, jinyinhua, sangye, pipaye, and other herbs, commonly used to treat viral pneumonia. drugs should be selected and utilized according to the corresponding syndrome types. furthermore, with disease development, the drugs should be given the flexibility to deal with different syndrome types, and the whole process should be adjusted according to the principle of "three factors and measures," undertaking multi-target treatment. tcm also plays a leading role during the recovery period and post-discharge convalescence. currently, although some patients present a negative nucleic acid test accompanied by alleviated pneumonia and recovered body temperature, they may still demonstrate symptoms, including fatigue, shortness of breath, loss of appetite, and anxiety. some patients may present pulmonary fibrosis due to poor absorption of pulmonary inflammation, which may affect the quality of life; additionally, some patients may suffer adverse reactions during drug therapy. it is crucial to resolve such related issues when tcm is involved. however, we do not advocate taking medicine without incident, and the preventive prescription is only a corresponding choice for people with an imbalance of qi, blood, and yin and yang. when selecting the prescription, attention should be paid to the syndrome and symptoms, especially in special groups, such as children, pregnant women, and the elderly. moreover, any special physique should be closely monitored when using medicine of china on screening effective prescriptions for the prevention and treatment of the novel coronavirus pneumonia [43] . as of february 5, four pilot provinces have used the qingfei paidu decoction to treat 214 confirmed cases, with a treatment course of 3 days, demonstrating a total efficacy rate exceeding 90%, among which over 60% of the patients showed significant improvement in symptoms and imaging manifestations, and 30% patients demonstrated stabilized symptoms without aggravation. concurrently, lianhua qingwen granule [44] is used in clinical treatment based on the principle of clearing away epidemic toxin, dispersing the lung, and expelling heat. reportedly, it has been confirmed to significantly improve fever, cough, expectoration, and shortness of breath in confirmed cases of covid-19. according to the feedback of clinical data, the efficacy of tcm in the clinical treatment of covid-19 is great, and it still needs to be adjusted and improved with the clinical accumulation. in brief, the combination of chinese and western medicine can complement each other's advantages, which can improve the comprehension of the core of the disease, and cooperate actively and effectively in clinical settings to enhance overall efficacy. the study was not supported by any funding. wsx and lyb wrote the article; wy revised part of the article and made grammatical corrections; wxx provided research ideas; ljy reviewed the article and provided guidance; nm and syj collated the data. the authors declare that they have no conflict of interest. tracking coronavirus: map, data and timeline pharmaceutical work guidance and 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of china. notice on issuing the diagnosis and treatment plan for pneumonia infected by novel coronavirus (trial fourth edition) beijing municipal administration of traditional chinese medicine. notice of beijing administration of traditional chinese medicine on issuing the prevention and treatment plan for pneumonia infected by novel coronavirus in beijing (trial second edition) shandong provincial health commission. prevention program of winter and spring influenza and novel coronavirus infection in shandong province notice of municipal health commission on issuing traditional chinese medicine prevention and treatment plan for pneumonia infected by novel coronavirus in tianjin (for trial implementation) notice on issuing the traditional chinese medicine treatment plan for pneumonia infected by novel coronavirus in guangdong province gansu provincial health commission. notice on issuing the prevention and treatment plan of traditional chinese medicine for pneumonia infected by novel 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traditional chinese medicine treatment plan for pneumonia infected by novel coronavirus (for trial implementation) guizhou announced the ethnic medicine and traditional chinese medicine prescriptions for prevention of yunnan provincial health commission. prevention and treatment program of traditional chinese medicine for novel coronavirus pneumonia jiangxi provincial health commission. notice on issuing the prevention and treatment program of traditional chinese medicine for pneumonia infected by novel coronavirus in jiangxi province (for trial implementation) china news network. tcm diagnosis and treatment of pneumonia caused by novel coronavirus in shanghai (trial) traditional chinese medicine in jilin province actively participated in the treatment of novel coronavirus pneumonia tibetan medicine administration of tibet autonomous region. the tibetan medicine administration of tibet autonomous region announced the tibetan medicine prevention and treatment plan for pneumonia infected by novel coronavirus comprehensive analysis of the diagnosis and treatment plan of traditional chinese medicine for the prevention and treatment of pneumonia infected by novel coronavirus general office of the national health commission of the people's republic of china. diagnosis and treatment protocol for covid-19 (trial version 7) in silico screening of chinese herbal medicines with the potential to directly inhibit 2019 novel coronavirus traditional chinese medicine is a resource for drug discovery against 2019 novel coronavirus (sars-cov-2) clinical observation of qingfeipaidu decoction in the treatment of novel coronavirus pneumonia retrospective clinical analysis on treatment of coronavirus disease 2019 with traditional chinese medicine lianhua qingwen. zhongguo shi yan fang ji xue za zhi 2020; epub ahead of print key: cord-284833-g914vww5 authors: qiu, tingting; liang, shuyao; dabbous, monique; wang, yitong; han, ru; toumi, mondher title: chinese guidelines related to novel coronavirus pneumonia date: 2020-10-08 journal: journal of market access & health policy doi: 10.1080/20016689.2020.1818446 sha: doc_id: 284833 cord_uid: g914vww5 background and objective: china has managed to control the coronavirus disease (covid-19) with confinement measurements and treatment strategies, while other countries are struggling to contain the spread. this study discusses the guidelines related to covid-19 in china in order to provide important references for other countries in the fight against covid-19. methods: chinese guidelines relevant to covid-19 were systematically searched via the china national knowledge infrastructure database, yimaitong database, and world health organization (who) covid-19 database on march 20(th), 2020. guideline information was extracted, including date of publication, source, objectives and the target population. guidelines specific to the pharmacological treatment of covid-19 were further investigated to identify the types of antivirus drugs recommended and to report on how treatment recommendations for covid-19 have evolved overtime. results: a total of 100 guidelines were identified, of which 74 were national guidelines and 26 were regional guidelines. the scope of included guidelines consisted of: the diagnosis and treatment of covid-19, the management of hospital departments and specific diseases during the outbreak of covid-19. fifty-one of the included guidelines targeted overall covid-19 patients, while the remaining guidelines concentrated on special patient populations (i.e. geriatric population, pediatric population, and pregnant population) or patients with coexisting diseases. fifteen guidelines focused on the pharmacological treatments for all covid-19 patients. interferon, lopinavir/ritonavir, ribavirin, chloroquine, and umifenovir represented the most recommended antivirus drugs. among them, 7 chinese guidelines have recommended chloroquine phosphate or hydroxychloroquine for the treatment of covid-19. conclusions: china has generated a plethora of guidelines covering almost all aspects of covid-19. chloroquine, as one widely affordable treatment, was recommended by chinese national guidelines and provincial guidelines. considering the continuous debates around chloroquine, confirmatory studies with robust methodology are awaited to address the unanswered questions on its potential benefits and risks on covid-19. in late december of 2019, the first pneumonia case with unknown microbial origin was reported in wuhan, china. a novel coronavirus was subsequently identified as the causative pathogen, provisionally named as the 2019 novel coronavirus (2019-ncov), and finally named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), now commonly referred to as covid-19 [1] . although the number of newly infected cases per day appeared to decline within china, including the hubei province [2] , the number of covid-19 cases outside china increased drastically. concerned by its alarming levels of global spread and severity, covid-19 was declared a pandemic by the world health organization (who) on march 11 th , 2020 [3] . covid-19 initially spread quickly to neighboring asian countries, with south korea being the most affected [4] . following this, a sharp growth in confirmed cases was witnessed in europe, with many european countries reporting nation-wide community transmission; thus, rendering europe the most affected world region of the pandemic. however, the usa (us) began to report tens of thousands of new cases beginning on march 24 th , 2020, eventually exceeding the 123,776 confirmed cases in china recorded on march 29 th , 2020, therefore, rendering the us the new center of the pandemic [5] . as of march 28 th , 2020, 82,230 patients have been identified as infected by sars-cov-2 in china, with a total of 3,301 deaths [2] . based on the data available, as of the 17 th of march 2020, the overall fatality rate was 7.2% for confirmed covid-19 cases in italy [6] , which was much higher than the observed fatality rate of 2.7% in mainland china [7] . this could be due to factors, such as italy's high proportion of older patients confirmed with covid-19 and patients with mild symptoms no longer being tested beginning on the 25 th of february 2020 and no longer being accounted for. although the accurate estimation of mortality rate is unavailable as the denominator is impossible to assess, the absolute number of deaths is relatively high. however, comparisons in mortality rates between countries also depend on how cases are counted, which varies by country. according to the largest retrospective study consisting of 44, 672 confirmed cases published by the chinese center for disease control and prevention, older patients and patients with comorbidities, including cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer, were all associated with an increased risk of death [8] . a high sequential organ failure assessment (sofa) score and d-dimer >1 μg/ml could be important indicators for poor prognosis at an early stage [9] . the outbreak seems to be under control in china as several provinces have declared no infected cases remain. however, the rapid expansion of covid-19 is still ongoing in europe. the number of covid-19 infections and deaths in europe has not yet peaked, despite approximately 16,000 deaths already across italy, germany, and france as of the 29 th of march 2020 [2] . therefore, it may be insightful to understand the chinese experience and what guidelines have been established to control the spread of covid-19. guidelines related to patient channeling, the organization of the health care system, patient triage, and patient investigations may not be transferable due to inherently different healthcare systems in different countries. the authors have focused on the specific pharmacological guidelines for the treatment of covid-19. the objective of this manuscript is to identify and describe the pharmaceutical guidelines developed in china and to analyze adjustments in the treatment of covid-19 over time based on the increasing experience in treating covid-19 patients. the china national knowledge infrastructure (cnki) database was searched on the 20 th of march 2020 to identify guidelines relevant to covid-19. the following keywords were used: novel coronavirus pneumonia, covid-19, sars-cov-2, expert consensus, guideline, guidance, recommendation, advice, standard pathway, and clinical pathway. additionally, yimaitong database, as one of the most prestigious databases for collecting healthcare information in china, was also complementarily searched in order to identify guidelines potentially published in grey literature. the who database of publications on covid-19 was also searched to ensure all important guidelines were identified, collected, and analyzed. for guidelines with updated versions with the generation of new evidence, all guideline versions were included. the following characteristics of included guidelines were extracted: 1) date of publication, 2) source of the guidelines, 3) objectives of the guidelines, and 4) target population of the guidelines. guidelines were classified according to the objectives of the guidelines, which were the main aspects relating to covid-19. these included: 1) prevention, 2) diagnosis, 3) pharmacology treatment, 4) nonpharmacology treatment, 5) management of patients with specific diseases (e.g. myocardial infarction) under the outbreak of covid-19, 6) management of specific hospital departments (e.g. cardiology department) under the outbreak of covid-19, and 7) pharmacy service. the target populations of the covid-19 guidelines were further categorized: 1) overall patients with covid-19, 2) patients with a certain degree of severity of covid-19, including suspected cases and confirmed cases (mild cases, severe cases, and critical cases), 3) special patients, including the geriatric population, pediatric population, and pregnant population, 4) patients with other comorbidities, such as oncology and cerebrovascular disease. moreover, pharmacological treatments including traditional chinese medicine (tcm) and western medicine (wm), were extracted to investigate what medicines were most recommended in the treatment of covid-19 patients. considering the diversity in the names of tcms, only the tcms with brand names were investigated in this study. diagnosis and treatment protocol for novel coronavirus pneumonia (referred to as the diagnosis and treatment protocol), as the most important chinese national guideline, its different versions the were further analyzed. the publishing date of each protocol and the evolving history in the recommendations on the pharmacology treatments in protocols were extracted and discussed. chloroquine and hydroxychloroquine for the treatment of covid-19, guidelines recommending or mentioning chloroquine and hydroxychloroquine were additionally extracted and evaluated, including the publishing date, guideline name, publishing organization and the key information related to chloroquine and hydroxychloroquine. among the total of 100 published guidelines identified, 15 of them were published in january of 2020, 58 of them were published in february of 2020, and 27 of them were published in march of 2020. considering the national and regional source of the included guidelines, 74 of them were national guidelines, which were mainly published by the national medical association of china (figure 1 ), including the national health commission and national associations for varying medical subjects, such as the respiratory branch of chinese medical association. twenty-six of the included guidelines were regional guidelines, which were released by 8 provinces and 2 municipalities. scope of included guidelines the diagnosis and treatment of covid-19 was the most-discussed subject in all of the published guidelines ( figure 2 ). management of special hospital departments during hospital outbreaks was paramount, among which, the management of the emergency department, surgery department (e.g, cerebrovascular surgery, colorectal surgery, and articulation surgery), and intensive care units were most targeted. management of patients with specific diseases was also covered extensively, including the cardiovascular diseases, oncological diseases, parkinson's disease, secondary fungal infection, and malaria. guidelines on providing recommendations for key pharmacy service, such as handling the abundant supply of covid-19 medicine, the control of donated medicine, the report of adverse effects, and the process for therapeutic drug monitoring, were also available. non-pharmacology treatment covered nutrition guidelines and guidelines on rehabilitation with tcm. nutrition guidelines, especially for severe and critical cases, provided important instructions related to energy intake, nutrition regimes, and nutrition evaluation in order to prevent the occurrence of malnutrition in covid-19 patients. guidelines on rehabilitation with tcm were developed to standardize its appropriate application and to alleviate the patients' symptoms, such as tai chi, acupuncture, massage, and cupping therapy. more than half of the guidelines applied to overall patients affected by covid-19 ( figure 3 ). nine guidelines targeted patients with certain degree of disease severity, 5 applied to severe and critical cases, 2 guidelines applied to suspected cases, and 2 guidelines applied to convalescent cases. thirteen guidelines focused on special patients: 6 guidelines discussed the prevention and control of covid-19 in children, from wearing pediatric medical masks, observations of changes in daily activity, to the education on appropriate use of medicines; six guidelines concentrated on the management of covid-19 in pregnant women, including psychological counseling, the selection of drugs with lower pregnancy risks, and the assessment of patients' conditions to terminate the pregnancy. only one guideline specifically targeted elderly patients. twenty-seven guidelines focused on covid-19 patients with coexisting diseases, where patients with cardiovascular diseases and cancer fostered the largest part of discussions. a total of 15 guidelines focusing on pharmacological treatments for all covid-19 cases were further investigated (table 1) , including 3 national guidelines: the 'diagnosis and treatment protocol for novel coronavirus pneumonia' released by the national health commission, the 'guideline for the appropriate use of traditional chinese medicine (tcm)' released by china association of chinese medicine, and 'notifications on the dosage adjustment of chloroquine phosphate' released by national health commission. twelve were provincial guidelines, including 4 focused on the diagnosis and treatment released in beijing, shanghai, hubei province, shandong province, and guangdong province, 6 guidelines for the appropriate use of tcm in the treatment of covid-19, and 2 guidelines provided recommendations specific to the optimal use of chloroquine phosphate. in guidelines discussing wm treatments for covid-19 (n = 7, excluding guidelines specific for tcm and for chloroquine phosphate), antivirus therapies were regarded as the general pharmacological treatment for all covid-19 patients. however, all 7 guidelines outlined that there were no 'specific antivirus medicines' to eradicate the sars-cov-2 infection and to show 100% effectiveness in all patients across different disease stages. interferon (ifn) was recommended in 6 guidelines, with the exception of one beijing guideline. ifn-α was the only ifn-type medicine recommended in 6 guidelines, except for the shanghai guideline, which recommended ifn-k as first choice and ifn-α as second choice. lopinavir/ritonavir was recommended in 6 guidelines, with the exception of the shanghai guideline. ribavirin was recommended in 4 guidelines published after february 1 st of 2020, with the exception of the shanghai guideline. chloroquine phosphate was recommended in 3 guidelines published after 19 th of february 2020 . the shanghai guideline recommended both hydroxychloroquine (first choice) and chloroquine phosphate (second choice), the shandong guideline recommended hydroxychloroquine only, and 2 guidelines recommended chloroquine phosphate only. umifenovir was recommended in the national guideline and 4 provincial guidelines. other antivirus medicines, oseltamivir and remdesivir, were recommended in the rapid advice guidelines published by the tongji hospital on the 22 nd of january 2020 and by the zhongnan hospital on the 1 st of february 2020, respectively. with regards to tcm therapy for covid-19 treatment, the diagnosis and treatment protocol for novel coronavirus pneumonia recommended 5 tcm oral preparations during a medical observation period, 5 tcm injections for severe cases, and 7 tcm injections for critical cases. all other included provincial guidelines specific to tcm treatments added several tcm treatments to those recommended by the national protocol, with the number of additional tcm treatments ranging from 1 (the shangxi guideline) to 13 (the beijing guideline). for mild cases, reyanning injection, shuanghuanglian oral liquid, and siji kangbingdu injection were recommended in more than 2 tcm guidelines. for severe cases, angong niuhuang capsules and suhexiangwan were recommended in more than 2 tcm guidelines. other pharmacological treatments were recommended for use depending on the severity of covid-19 and other coexisting disorders secondary to covid-19. these treatments included: 1) shortterm corticosteroid therapy recommended for patients who demonstrated progressively deteriorating oxygenation index, rapid imaging progression, and overactive inflammatory responses, 2) antibiotic therapy, with inappropriate use of antibiotic therapy being avoided, and caution taken in combinations with broad-spectrum antibiotics, and 3) tocilizumab, as an immunosuppressive agent, which was first recommended in the diagnosis and treatment protocol for novel coronavirus pneumonia on the 4 th of march 2020, and then included in the guangdong guideline on the 10 th of march 2020. the diagnosis and treatment protocol issued by the national health commission of the people's republic of china has been updated as additional research evidence and knowledge on covid-19 have become available. since the release of the first version of the protocol on january 15 th , 2020, 7 versions in total have been produced with 8 updates over a 50-day period. the first and second versions of the diagnosis and treatment protocol are currently not published on the official website, 6 updates are recorded as the fifth version of the protocol underwent 2 updates ( table 2 ). beginning with version 3 of the diagnosis and treatment protocol for novel coronavirus pneumonia, the inclusion and elaboration on the use of tcms in the diagnosis and treatment protocol have been gradually improved. the diagnosis and treatment protocol determined that covid-19 met the definition of plague caused by the epidemic pathogenic factors from the perspective of tcm. it was stressed in the protocol that tcm treatment regimens for covid-19 should be adjusted according to the varying local climate characteristics, individual state of illness, and physical conditions. the 3 rd version of the protocol states that the choice of tcms should be made based on patient symptoms, such as dampness, heat, poison, and stasis of the lung, yet no recommendations were given on the specific tcms to be used. the 4 th protocol version introduced a selection of recommended tcms to be used either in a medical observation period where patients were only suspected cases of covid-19 or in a clinical treatment period where patients were confirmed cases of covid-19. four kinds of tcm oral preparations were recommended in the medical observation period, including huoxiangzhengqi (pills, liquid, or oral solution), jinhuaqinggan (granules), lianhuaqingwen (granules), and shufengjiedu (granules). for patients in the clinical treatment period the recommendations for use of tcm were further divided based on clinical manifestations during 4 subperiods. these subperiods included the mild subperiod characterized by cold and damp stagnation lung syndrome, the moderate subperiod presenting plague poison and lung-closing syndrome, the severe subperiod identified by syndrome of inner blocking causing collapse, and the convalescent subperiod showing lung and spleen qi deficiency syndrome. no tcm injection was recommended for the mild subperiod. two kinds of tcm injections, xiyanping injection and xuebijing injection, were recommended for treatment during the moderate subperiod, and three kinds of tcm injections, xuebijing injection, shenfu injection, and shengmai injection, were recommended for treatment during the severe subperiod. no changes in the recommendations of use and types of tcms for the treatment of covid-19 were made in either of the 2 updates of the 5 th version of the protocol. the diagnosis and treatment protocol for novel coronavirus pneumonia's 6 th protocol version added lung cleansing and detoxifying decoction as a general prescription for the clinical treatment period. the 6 th protocol version redefined the subperiods characterizing the clinical treatment period and further divided it into 5 subperiods. the five subperiods of the clinical treatment period were based on disease severity and included mild subperiod (cold dampness and stagnation lung syndrome or dampness and heataccumulation lung syndrome), moderate subperiod (cold dampness lung syndrome or dampness and stagnation lung syndrome), severe subperiod (plague poison and lung-closing syndrome or syndrome of flaring heat in qifen and yingfen), critical subperiod (syndrome of inner blocking causing collapse), and convalescent subperiod (lung and spleen qi deficiency syndrome or qi and yin deficiency syndrome). there were several tcm injections newly included for the treatment of covid-19 patients, which improved the selectivity and precision of medication use. three more tcm injections, reduning injection, tanreqing injection, and xingnaojing injection, were recommended in the severe subperiod and four more tcm injections, reduning injection, tanreqing injection, xingnaojing injection, and shenmai injection, were recommended in the critical subperiod. no changes in the recommendations of use and types of tcms for the treatment of covid-19 were made in the 7 th version protocol. at the beginning of the covid-19 outbreak, no specific wm with robust evidence was available. drug repurposing and the combined use of existing broad-spectrum antiviral drugs have constituted the most effective and efficient methods to combat covid-19. inf-α inhalation and oral lopinavir/ritonavir were the only 2 antiviral therapies recommended in the 3 rd version the diagnosis and treatment protocol for covid-19. ribavirin was then recommended in the 5 th version of of all the antivirus targeted drugs recommended in the protocol, chloroquine appears to have the potential to emerge as the standard choice due to promising preclinical evidence, preliminary clinical results and clinical experience unpublished [10, 11] . thus far, results from more than 100 patients have demonstrated that chloroquine phosphate is superior to the control treatment in inhibiting the exacerbation of pneumonia, improving lung imaging findings, promoting a virus negative conversion, and shortening the disease course. for example, covid-19 patients treated with antiviral drugs, lopinavir/ritonavir and umifenovir, showed negative nucleic acid detection on an average of 6 to 7 days of treatment, while the average time for chloroquine phosphate treatment to show negative nucleic acid detection was 4.2 days. however, another well conducted study has shown no benefit of lopinavir/ritonavir [12] . despite the limited clinical evidence, experts from health regulation authorities and clinical trial organizers generally supported chloroquine phosphate as having a potent impact against sars-cov -2. this contributed to the inclusion of chloroquine phosphate in the 6 th protocol version. as chloroquine emerged as the preferred treatment option, the recommendations related to the dosage regimen of chloroquine for treatment of covid-19 were updated and improved along with the accumulation of research evidence and knowledge on disease progression for covid-19. seven guidelines (table 3 ) published in china supported the used of chloroquine phosphate for the treatment of covid-19. the dosage of 500 mg chloroquine phosphate, twice per day, and for a duration no longer than 10 days was first proposed for the treatment of covid-19 in the 6 th protocol version. the health commission of guangdong province supported this recommendation, but outlined the importance of monitoring adverse events associated with the chloroquine phosphate, such as the risk of prolongation of q-t interval when combined with macrolide antibiotics (e.g. azithromycin). afterwards, the health commission of hubei province warned that chloroquine phosphate could cause the occurrence of sudden death at a dosage of 2 ~ 4 g. with the emergence of the safety issues mentioned above, the national health commission adjusted the dosage of chloroquine phosphate for adults by taking into consideration a patient's age and body weight. additionally, the contraindications for the use of chloroquine phosphate were also specified, such as in patients with underlying cardiovascular diseases. the new dosage adjustment of the chloroquine phosphate was included in the 7 th version of the diagnosis and treatment protocol for novel coronavirus pneumonia and the guangdong expert consensus. hydroxychloroquine shares similar chemical structures and mechanisms of action with chloroquine phosphate, thus it is less surprising that hydroxychloroquine may also be a candidate to combat the sars-cov-2 infection. encouraging results proved that hydroxychloroquine also had an in-vitro impact against sars-cov-2. on february 15 th , 2020, the website of people's hospital of wuhan university released a report titled 'hydroxychloroquine showed short-term efficacy in the treatment of novel coronavirus pneumonia'. in this report, researchers found that none of the 80 patients with systemic lupus erythematosus treated in the hospital's dermatology department were infected by covid-19 during the period of sars-cov-2 transmission in wuhan. the researchers suspected that hydroxychloroquine might hold promises to protect the patients from covid-19. therefore, hydroxychloroquine was recommended for the first time in the shanghai expert consensus for covid-19. the shandong expert consensus specified the dosage of hydroxychloroquine as 200 mg, three times per day. it is evident that china has taken the development of guidelines for the treatment of covid-19 very seriously with the available guidelines targeting multiple topics and aspects relating to sars-cov-2. interestingly, these guidelines have provided support for most of the issues healthcare professionals and hospital managers may face. most of the guidelines were developed at the national level, with most of the regional guidelines in line with national guidelines, yet also customized to regions and providing more detailed instructionswith the exception of shanghai, where guidelines tend to deviate from national guidelines and where, ultimately, the guidelines focused on hydroxychloroquine. all of these provinces, except for shanxi province and liaoning province, were severely afflicted areas and were among the top 15 regions with the largest number of infected cases in china. the provinces of hubei and guangdong were the regions reporting the largest and second-largest number of confirmed cases and published the greatest number of regional guidelines. beijing and shanghai both released their clinical pathways for the diagnosis and treatment of covid-19 due to their powerful roles in research and academia in china. china is traditionally highly centralized and, at the same time, its decentralized model has proven to be effective in such an outbreak. the development of guidelines has been a very dynamic process with very fast and continuous updating of existing guidelines. although the guidelines provide limited information on the rational for their updates, it is considered that they were updated based on the development of clinical experience in treating patients and the evidence emerging from the large range of ongoing open studies. fifteen guidelines have been targeting the pharmacological management of covid-19 patients. initially, interferon-α and interferon-k (in shanghai guideline only), were recommended. lopinavir/ritonavir combination was recommended in all guidelines, except in shanghai. a randomized, controlled, open-label trial involving 199 hospitalized adult patients with severe covid-19 could provide an answer for the exclusion of lopinavir/ritonavir combination in the shanghai expert consensus, as no benefit was observed with lopinavirritonavir treatment beyond the standard of care [13] . umifenovir was approved in russia and china, but not approved in europe and the us. oseltamivir and remdesivir, have been initially widely recommended for influenza and other viral diseases, but were recommended to a lesser extent as an antiviral therapy for covid-19. it does not seem that these products have gained significant interest since. tocilizumab was just recommended for severe cases in the latest 7 th version of the diagnosis and treatment protocol. tcms were widely used, alone or in combination with other antivirus drugs, in several going clinical trials in china. however, the potential for use of tcms outside of china remains very limited in the current crisis. in virology, it is well established that in-vitro results are poorly predictive of clinical outcome even in the case of chloroquine phosphate and hydroxychloroquine for treating a variety of viruses [14] . researchers in shanghai showed confidence that hydroxychloroquine could be a potential choice to reverse this pandemic. this was due to the fact that the number of new severe and critical covid-19 cases in shanghai have decreased significantly since hydroxychloroquine was used for the treatment of covid-19 since the 5 th of february 2020 [15] . the effectiveness of hydroxychloroquine (combined with basic treatment) was studied in 20 patients with covid-19 beginning on the 17 th of february 2020. after treatment with hydroxychloroquine, the clinical symptoms of these 20 patients were significantly improved in 1 ~ 2 days. chen et al. conducted a randomized study including 62 patients to investigate the efficacy of hydroxychloroquine, which suggested a significant shorter time to clinical recovery, temperature recovery, and cough remission in patients receiving hydroxychloroquine compared with those in control group [12] . gautret et al. also reported that hydroxychloroquine alone or in combination with azithromycin reduced the detection of sars-cov-2 rna in upper respiratory tract specimens compared with the control group in an open label, nonrandomized clinical trial [16] and showed a rapid decline in the detection of sars-cov-2 rna in upper respiratory tract specimens and length of stay in highly contagious wards in his later observational study including 80 patients [11] . however, one small pilot study including 30 patients investigating the standard dose of hydroxychloroquine (400 mg, once per day) in the treatment of patients with covid-19 did not show significant clinical benefits compared with the standard of care (other antiviral therapies) in the negative conversion rate of covid-19 nucleic acid [17] . several factors may explain these differences in the clinical results between the two studies. when patients are treated at an early stage of disease with a relatively lower risk of further progression, they will likely resolve the disease spontaneously, thus bringing the response rate very high and being unable to detect the differences between study groups. however, when patients are treated too late, the acute inflammation related to cytokines blast [18] will prevent treatments to reach their target and make the patients unresponsive to potentially effective drugs. the effectiveness of chloroquine phosphate and hydroxychloroquine still remains to be examined in rigorous, comparative studies before any firm conclusions may be drawn. furthermore, the adverse effects of chloroquine must be closely monitored to minimize its potential harms in already vulnerable covid-19 patients. it remains unfortunate that more knowledge has not yet been shared at this point at the time of publication when the pandemic may severely target africa. in africa, the healthcare infrastructure will be unable to absorb the consequences of a pandemic that may affect up to onethird or more of the population. physical distancing is unlikely feasible due to the extreme poverty and cultural standards and habits. people are living together in large numbers, with as many as 20 persons in a single large room. houses in large cities and suburbs with different families are all built one next to the other, with no clear dividers distinguishing properties and where who lives exactly. it is also common, cultural practice that when someone gets sick, all their relatives and close friends visit to check on the ill person and to spend time with them, thus increasing contact with ill people. most people live off of informal, noncontractual work. they are, therefore, paid every day and with these low wages they must manage to feed their family. a pandemic, such as covid-19, may force people in such situations to choose between either respecting confinement and losing their jobs and daily wages, therefore being unable to feed their families, or they will leave home in order to work and disseminate the virus, overwhelming their ill-prepared healthcare system. in africa, they are recommended to wash their hands frequently, yet a vast majority do not have access to water and even when they do, they must carry it by hand over long distances. moreover, they have little access to soap and cleansing products. they are recommended to blow their nose in disposable handkerchiefs, which they cannot afford, and are recommended to sneeze in their elbows, while in this season will find many dressed in short sleeves. it is apparent that without an effective, affordable pharmaceutical, such as hydroxychloroquine or chloroquine phosphate, or any other potentially effective product, a pandemic disaster is bound to impact africa. many of the obstacles faced by africa are currently being seen in india as well. the 21-day nationwide lockdown plan implemented by prime minister narendra modi's, might only work for india's middle and upper classes, who have less difficulties to meet their basic life needs and who may even work from home, using modern technology. however, social distancing is impractical for the approximate 74 million people living in the country's slums, which are known for their extreme poverty, unsanitary conditions, and inaccessibility to bathrooms and clean water [19] . as of the 1 st of april 2020, india has recorded 1466 covid-19 cases and 38 deaths [20] . the actual number of patients affected by covid-19 in india could be underestimated due to their limited detection capacity. it is concerning that a catastrophe will occur in this country, home to the world's second largest population. other developing countries generally share the common features and face the same threats as those in india. the lack of clear who recommendations for using this ammunition considered by the chinese as one of the ultimate options to control the pandemic may have long-term consequences on the who's credibility in developing countries. china has generated and continues to generate a massive source of information with several guidelines addressing almost all aspects of covid-19 management. guidelines were mainly from the central government and national associations, however, customization of guidelines was also allowed at the regional level. only the shanghai province deviated from central government guidelines, with hydroxychloroquine and chloroquine phosphate being the most preferred treatments. these guidelines were likely based on evidence that is critical for defeating the covid-19 pandemic. it would be of significant importance that chinese scientists could share their valuable knowledge and insights on covid-19 timely with global scientific communities. as the pandemic continues to unfold, additional clinical evidence for the treatment of covid-19 will continue to emerge from china as well as other countries. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding world health organization. coronavirus disease (covid-2019) situation reports world health organization. who director-general's opening remarks at the media briefing on covid-19-11 transmission potential and severity of covid-19 in south korea number of covid-19 cases in usa critical care utilization for the covid-19 outbreak in lombardy, italy: early experience and forecast during an emergency response wuhan and hubei covid-19 mortality analysis reveals the critical role of timely supply of medical resources clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study covid-19: risk factors for severe disease and death hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial a trial of lopinavirritonavir in adults hospitalized with severe covid-19 of chloroquine and covid-19 diagnosis and treatment protocol for novel coronavirus pneumonia (5th trial version) hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial a pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (covid-19) induction of pro-inflammatory cytokines (il-1 and il-6) and lung inflammation by coronavirus-19 (covi-19 or sars-cov-2): anti-inflammatory strategies social distancing is a privilege of the middle class. for india's slum dwellers, it will be impossible ministry of health and family welfare-government of india notifications on the adjustment of dosage of chloroquine phosphate for the treatment of novel coronavirus pneumonia branch of hospital medicine in china association of chinese medicine. expert consensus for appropriate application of tcm for covid-19 diagnosis and treatment protocol for novel coronavirus pneumonia (7th trial version) a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia peking union medical college hospital. peking union medical college hospital's proposal for diagnosis and treatment of "novel coronavirus-infected pneumonia" (v2.0) a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (full version) shandong medical aid expert group for novel coronavirus pneumonia. shandong expert consensus on the diagnosis and treatment for novel coronavirus pneumonia shanghai expert consensus on the integrated treatment for novel coronavirus pneumonia shanghai: protocal for the use of traditional chinese medicine for the diagnosis and treatment of covid-19 2020 hospital pharmacy professional committee of chinese pharmaceutical association hubei provence: protocal on the use of traditional chinese medicine for epidemic prevention and control of covid-19 shanxi province: protocal for the use of traditional chinese medicine of covid-19 shanxi chinese medicine guangdong expert consensus on the chinese integrative medicines for the prevention and treatment of novel coronavirus pneumonia hubei health commission. close monitoring the adverse effects of chloroquine phosphate for the treatment of novel coronavirus pneumonia expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia diagnosis and treatment protocol for novel coronavirus pneumonia (3rd trial version) diagnosis and treatment protocol for novel coronavirus pneumonia (4th trial version) diagnosis and treatment protocol for novel coronavirus pneumonia (5th trial revised version) diagnosis and treatment protocol for novel coronavirus pneumonia (6th trial version) the authors declare that they have no conflicts of interest. the authors received no financial support for the research, authorship and/or publication of this article. key: cord-304021-e0zj7apb authors: tang, haitao; huang, wenlong; ma, jimei; liu, li title: swot analysis and revelation in traditional chinese medicine internationalization date: 2018-01-25 journal: chin med doi: 10.1186/s13020-018-0165-1 sha: doc_id: 304021 cord_uid: e0zj7apb traditional chinese medicine (tcm) is currently the best-preserved and most influential traditional medical system with the largest number of users worldwide. in recent years, the trend of tcm adoption has increased greatly, but the process of tcm internationalization has suffered from a series of setbacks for both internal and external reasons. thus, the process of tcm internationalization faces formidable challenges, although it also has favourable opportunities. using swot analysis, this paper investigates the strengths, weaknesses, opportunities and threats for tcm. these findings can serve as references for tcm enterprises with global ambitions. at present, the pace of the expansion of traditional chinese medicine (tcm) into the overseas market continues to accelerate. both the chinese government and chinese medicine enterprises are making efforts to promote tcm as it moves into the overseas market. however, particular issues associated with tcm, such as its complex composition, various effects of its actions, insufficient systematic studies during its internationalization, etc., hinder the adoption of specific tcm drugs in the internationally recognised pharmaceutical market. in this study, we use the swot method to analyse the current situation of tcm internationalization, and the analysis is divided into four aspects. there are many strengths of tcm in the treatment of diseases which are not found in western medicine (table 1) . first, tcm and western medicine are two different medical theoretical systems with different modes and substantial differences in such aspects as theoretical foundations, methods of thinking, as well as diagnostic and treatment approaches. in the latter, the treatments are partial; in the former, symptoms and root causes are treated simultaneously. tcm has a unique theory as well as diagnostic and treatment techniques and methods. compared with modern western medicine, which focuses on detailed molecular targets, tcm thought takes an overall approach and pays attention to syndrome differentiation based on an overall analysis of the illness and the patient's condition. tcm adopts multiple levels (dimensions) and a multi-targeted method to make overall adjustments and restore the human body to achieve the goal of treating both the manifestation of the disease and its cause. second, tcm can be used to treat various diseases and especially has advantages for treating incurable diseases and chronic diseases [1, 2] . berberine exhibits beneficial anti-inflammation effects for the inflammatory bowel diseases, it also differentially modulates the activities of erk, p38 mark, and jnk to suppress th17 and th1 t cell differentiation indicating that it could be a potential therapeutic drug to treat type 1 diabetes mellitus (dm) [3] . even for a disease without an obvious clinical manifestation according to western medicine principle, tcm treatment can use its theoretical advantages of syndrome differentiation and effective timing to relieve the disease and make up for the deficiencies of modern western medicine [4, 5] . for example, in management of metabolic syndrome, tcm is an excellent representative in alternative and complementary medicines with a complete theory system and substantial herb remedies. ginseng, rhizoma coptidis (berberine, the major active compound) and bitter melon were discussed for their potential activities in the treatment of metabolic syndrome [6] [7] [8] [9] [10] [11] . recently, a search of active ingredient(s) from some commonly used tcm has revealed a wide variety of compounds that are biologically active with therapeutic potentials. about 62% of the 240 species were found to contain chemical compounds with pharmacological procies were found for the treatment of at least one disease and 53% of them for two or more diseases [12] . virtual mapping between databases of chinese herbal ingredients and molecular targets of diseases is likely to offer a new avenue for drug discovery [13] . third, some new tcm drugs are being successfully developed based on many years of clinical practice; these drugs can generally have precise effects and have only less adverse side effects [14] . only minimal adverse effects were reported for chinese medicines used in treating type 2 dm indicating certain advantages in the prevention of diabetes and delay of its complications [15] . at the same time, combined traditional chinese and western medicine has good effect in the treatment for patients which is beneficial to improve patients' quality of life [16] . for example, tcm in combination with insulin exhibited better clinical effect in the treatment of gestational diabetes [17] . in present-day society, the concept of healthy living has undergone tremendous changes, and people are increasingly pursuing improved health and quality of life. the unique effects of tcm are not only valued by domestic intellectuals but have also attracted the attention of the international community. correspondingly, the demand for natural botanical medicine is also increasing. compared with the research and development (r&d) of tcm, there are some problems in r&d of chemical medicine. first, the process of chemical drug discovery is long and arduous that it begins from the search of a potential candidate to the development of a marketable drug. the course could be as long as more than a decade [18] . second, the r&d cost for a new drug can be, in average, more than 800 million usd in the united states (us) [19] . third, the development of new chemical drugs remains very a low rate of success. among thousands chemical compounds only a few candidates could reach their first markets as new drugs in recent years. finally, synthetic chemical drugs are often associated with undesirable side effects in patients. it is now clear that the need of therapeutic intervention in many clinical conditions cannot be satisfactorily met by synthetic chemical drugs. since the research and development of new chemical drugs remain time-consuming, capital-intensive, safety issues, and undesired side effects, much effort has been put in the search for alternative routes for drug discovery in china [20] . tcm has a long history of use, with extensive literature and clinical applications covering thousands of years. such as berberine, an active ingredient from coptis chinensis franch, is widely used for the treatment of infectious diseases in china [21] . as tcm has the advantages of treatment of special diseases safety, and so on, there are many countries and regions begin to study it. at present, more than 150 countries and regions [22] have established natural botanical institutions, and pharmaceutical companies are increasingly focusing on research and development of botanicals, paying attention to the construction of traditional botanical studies and development teams, and focusing on the search for effective natural medicines to replace chemical treatments. furthermore, there are over 1300 medicinal plants used in europe [23] . as safe and healthy treatments are associated with a return to nature, tcm can make up for the shortcomings of western medicine in many areas. we can find the solutions to different kinds of diseases that are hard to cure by using the innovations and developments of tcm. tcm displays a distinctive curative effect for different diseases that are hard to cure and for technological difficulties that are recognized worldwide, such as tumours [24] , chronic liver disease [25] and chronic kidney disease [26] . china has rich natural medicine resources, with the world's largest treasure of chinese herbal medicine, and [27] . at present, domestic cultivation is a widely used and generally accepted practice in china. cultivation provides the opportunity to use new techniques to solve problems encountered in the production of medicinal plants, such as toxic components, pesticide contamination, low contents of active ingredients, and the misidentification of botanical origin. cultivation under controlled growth conditions can improve the yields of bioactive components and obtain improved yields of target products [28] . china has a number of large-scale tcm enterprises with strong scientific research abilities. chinese tcm enterprises are strengthening their research and development abilities while continuing to conduct studies of listed products and move forward with adaptions for the international market. at the same time, drug regulatory authorities continue to promote chinese production and quality management systems in connection with international standards and to improve the good manufacturing practice (gmp) management level. chinese tcm enterprises should achieve the gmp requirements and make efforts to connect to the international production management system. they have increased their investment in technological transformation so that the tcm production quality management level has reached a historical new height through the improvement of the production environment and conditions as well as the promotion of staff quality and production quality management. in addition, in recent years, upstream and downstream enterprises and industries related to tcm, such as chinese herbal planting, research and development; the manufacture and marketing of pharmaceutical equipment; tcm transportation; and many other supporting industries, have continued to grow and develop through the promotion and rapidly expanding development of the tcm industry. thus, the development of the tcm industry can also advance the development of supporting industrial chains, forming a favourable interaction. we have analyzed the strengths of the internationalization of tcm, but we should also realize that many unfavourable factors are also related to the internationalization of tcm. chinese medicine theory has many ancient chinesebased terms that cannot be expressed in objective and modern scientific language and evidence, so that many chinese medicine terms, such as yin-yang and the five elements, assistant and guide and other traditional theories and terms, are not understood and accepted by the international community [29] . tcm is a medical system developed on the basis of taoist philosophy. the theory of tcm was first documented in an ancient chinese book, huangdi neijing (yellow emperor's inner classic). the book proposes that the human body contains yin and yang. a disease is a consequence of disbalance of yin and yang. qi (air) and blood serve as mediators in communication between yin and yang. the primary aim in the treatment of illness is to restore the balance, and replenish qi or blood. herbal medicines, acupuncture, and massage are often used to restore the balance in the clinical practice in tcm [2, 30] . eastern and western cultures are different not only in language systems but also in values, ways of thinking, etc. chinese medicine and pharmacy are a huge, complex system of long-term experience based practice, emphasizing an overall view that is totally different from the perspective of western medicine and pharmacy. in the tcm theory, diabetes is considered a result of yin deficiency with dryness-heat. the treatment of diabetes should be focused on replenishing yin (fluid) and evacuating fire (heat) from the body [31] . however, for western medicine, such as metformin is commonly used in the treatment of diabetes. it acts primarily by decreasing hepatic glucose output, largely by inhibiting gluconeogenesis [32] . chinese medicine is based on a holistic approach, while western medicine is based on a reductionistic approach. for example, in the treatment of cancer, western medicine often take the tumor mass reduction as the ultimate goal, regardless of normal cells; while the tcm in addition to tumor inhibition, but also intend to alleviate the symptoms, strengthen the body resistance, improve the quality of life, prolong the survival time of cancer patients for the therapeutic purpose [32, 33] . in the cultivation of herbs, the quality of chinese medicinal herbal products directly affects the quality of tcm. however, most of the cultivation, harvesting and processing management procedures of chinese herbal medicinal materials are extensive. there is a lack of relevant technological innovations, the production process is not well scientifically based, the yield per unit area is low, the quality of the herbs is uneven, and the classification of species is not strictly enforced. there are no effective means to manage and resolve the problems of pesticide residues during pest control, and heavy metal residues occur through the process of planting, leading to the existence of unwanted chemicals in the herbs [34] . there are only a few quality control indicators for most of chinese medicinal materials, and some of them have no quantitative indicators and even no qualitative indicators. currently, the majority of the existing chinese medicinal materials quality control specifications are not effectively to ensure the stable quality of chinese medicinal materials, and the medicinal ingredients in these materials, which are the most direct causes for the unstable quality of tcm and the unevenness of its clinical efficacy [34] . tcm is more complex and comprehensive than western medicine in terms of finished product quality, whether for a single drug prescription (prescriptions consisting of a single medicinal material) or a compounded chinese medicine (prescriptions consisting of two or more medicinal materials). there is a lack of studies on material basis, active ingredients, and mechanism of action and no scientific and reasonable quality control indicators and methods [35] . therefore, the uniformity, safety and effectiveness of inter-assay stability for tcm products cannot be guaranteed. the implementation periods required by chinese good clinical practice (gcp), good laboratory practice (glp), gmp and other specifications are shorter than the international standards for pharmacology, toxicology, standardization, gmp construction, etc. the foundation is weak, various research data have not yet gained acceptance in international communities, and there is still a long way to go before tcm can harmonize with international standards [36] . most tcm enterprises commonly experience the following problems: there is not enough application of advanced technology, and there is a large gap between tcm practices and international advanced technologies [37] . although the implementation of a new version of the gmp forced out some non-standard enterprises, some chinese medicine enterprises still use outdated hardware and facilities, including outdated technologies for extraction, concentration and purification of chinese herbal medicines; therefore, some key parameters are unclear and cannot be effectively controlled. there is a large gap between china and developed countries in terms of the extraction process and production technology of natural medicine. regardless of specific national drug regulations there is an international consensus that all tcm drugs must meet stipulated high quality standards focusing on authentication, identification and chemical composition [38] . chinese herbal medicine and tcm itself have complicated components that change constantly during the production of tcm, especially in the extraction process. some components are not originally from chinese herbal medicine itself but are transformed during the process of extraction and concentration, leading to difficulty in the identification of tcm components. in addition, tcm emphasizes mutual synergy, so it cannot simply use one or several indicators to fully represent the effect of tcm products. tcm consists of many chemical ingredients, and these ingredients play synergistic roles in human body [39] , thus, the active medical ingredients are not clear. tcm adopts multi-target, multi-functional method to make overall adjustments and restore the human body to achieve the goal of treating both the manifestation of the disease and its cause. tcm is difficult to be clearly expressed by the chemical compositions in accordance with the requirements of chemical drugs, where the compositions are clearly expressed in chemical formulas. at present, many enterprises and research institutions are committed to the pharmacology and composition of traditional chinese medicine research. advances in phytochemistry, high throughput screening, dna sequencing, systems biology, and bioinformatics can reveal the chemical composition and molecular mechanisms of tcm [39] [40] [41] . in the tcm hospital bad kã¶tzting, 171 tcm drugs underwent an analytical quality proof including thin layer as well as high performance liquid chromatography [38] . as from now mass spectroscopy will also be available as analytical tool. the findings are compiled and will be published one after another. the main issues of the analytical procedure in tcm drugs like authenticity, botanical nomenclature, variability of plant species, as well as medicinal parts processing are pointed out and possible ways to overcome them are sketched [38] . at present, the construction of chromatographic fingerprints plays an important role in the quality control of complex herbal medicines [42] . many companies utilize advanced technologies to develop multi-component determination technics and chromatographic fingerprint analysis for qualitative and quantitative assessments. these assays will create a complete monitoring and evaluation system to ensure the efficacy, consistency, and inter-batch stability of the product. it is possible to clarify the role of the composition of tcm in the future. in recent years, europe, the us, japan, south korea and many other developed countries and regions have adopted modern research methods and techniques to increase the development of traditional botanical drugs, the screening and confirmation of active ingredients, the establishment of international advanced quality standards and the development of new formulations [43] . most domestic chinese enterprises and research institutes make relatively less investment in the r&d of tcm. insufficient r&d investment leads to a lack of competitiveness of the enterprise products. chemical drugs and biological products enjoy obvious competitive advantages, seriously affecting the growth rate of the market share of tcm. tcm products feature more impurity or low purity and a lack of innovation in dosage forms; traditional dosage forms still hold a dominant position. the development and application of quick-acting, long-term, efficient and convenient emergency dosage forms and other new dosage forms are still in the beginning stage. the production and application of new pharmaceutical excipients are insufficient and have a large gap with the mainstream trend of international drugs, directly affecting the competitiveness of tcm in the international market [43] . with the progress of society and changes in the human disease spectrum, the medical model has undergone tremendous changes; people are not simply seeking disease treatment but are focusing on the comprehensive management of disease prevention, treatment and health protection [44] . people are inclined to treat disease with natural medicine due to the obvious toxic and side effects of chemical drugs, and chinese medicine is aligned with this development tendency [45] . in addition, many national governments have gradually accepted and attached importance to tcm and natural herbal medicine because of the high bio-pharmaceutical r&d costs, medical costs, long-term costs and other issues. the international community continues to accept natural medicine, and market demand will continue to grow. more than 90 countries and regions are introducing laws and regulations for the registration of chinese herbal medicine [46] . tcm herbal drugs are increasingly used in many countries of the eu [47] . in europe, it is very good to know that european pharmacopeia (ph eur) is working on tcm herbal drug quality monographs. the european directorate for the quality of medicines (edqm) has established two groups of experts in pharmacognosy, who elaborate monographs on herbal drugs and herbal drug preparations. since 2007 a special working group has been established with the elaboration of monographs on traditional chinese medicinal plants and preparations [48] . till now, a working program, existing of 75 monographs was established by the commission of ph eur, out of which almost 50 new tcm herbal drug monographs have been implemented for the ph eur so far [49] . the standards put forward in these monographs not only define the quality of these products, but also eliminate dangerous counterfeit, substandard, adulterated and contaminated (traditional) herbal medicinal products [48] . with many tcm herbal drug monographs are implemented in the ph eur, this will be a significantly contribution to the acceptance of tcm worldwide [50] . all aspects relevant to the quality parameters have to be achieved in an adequate manner, requiring a broad range of analytical methods to be applied for new herbal drug monographs in the ph eur [47] . first, due to the equivalent access for world trade organization (wto) members, china's admission to the wto gave it more opportunities to participate in international exchanges and cooperation, to promote the wider spread of chinese medicinal culture, and to recommend tcm products with minimal side effects and high efficiency in treating both symptoms and causes of disease, which will establish a good foundation for popularizing tcm in the international community [25] . second, chinese medicine is becoming more popular for treating and preventing many diseases, especially incurable diseases and chronic diseases, in many countries due to the poor efficacy and obvious side effects of western medicine. third, due to a decline in tariffs [51] , many enterprises are more able and more willing to introduce foreign advanced technologies and equipment into china, which will speed up the production technology and accelerate the internationalization of traditional chinese medicine. in recent years, china has introduced a series of new policies and regulations to support the development of chinese medicine, while increasing the support for international cooperation in chinese medicine, indicating that the development of chinese medicine has risen to a strategic governmental level. china attaches great importance to the inheritance and innovation of chinese medicine, which will greatly promote the entry of chinese medicine into the international market. in addition, the implementation of the national strategy "one belt and one road" will create a new historical opportunity for chinese medicine to move into the international community [52] . the development strategy of "one belt and one road", utilizes the ancient "silk road" historical symbols, actively develops economic cooperation partnerships along with the countries with geographical proximity and cultural similarities to create great opportunities for the development of chinese medicine industry [52] . with the "one belt and one road" strategy, we can promote the communication of tcm cultures. through constantly tcm cultural exchange, we can bridge the gap between eastern and western medical systems to enhance the tcm internationalization. at the same time, the advantages of tcm and the international market demand provide great possibilities for tcm under the "one belt and one road" strategy. tcm has the feature of both humanity and medical sciences, therefore, its great resource in the economy, cultural and health care, should be regarded as one of the best mediums of cultural exchanges and international cooperations between china and the countries along the "one belt and one road". moreover, "one belt and one road" strategy also provides the platform for inheritance and innovation of tcm, which will promote the further development of chinese traditional medicine [53] . during this period, we can make full use of related resources and strengthen the international exchange and cooperation related to tcm. cooperation and exchange include enhancing the policies and regulations for traditional medicine, improving herbal medicine quality standards and control indicators, and establishing administration regulations. there will be more exchanges between the chinese government and international organizations, and the cooperation with foreign universities, research institutions, and hospitals as well, to co-establish academic and clinical research centres or groups to let more academic authority institutions accept and recognize tcm. the unique role of tcm has been widely recognized by the international community in the process of severe acute respiratory syndrome (sars) prevention and control and has been highly praised by the world health organization. chinese medicine can effectively reduce the mortality rate of sars patients and the sequelae in the process of treating the sars virus, and the treatment costs are significantly reduced. the specific function and significance of chinese herbal medicine in treating sars have been recognized by who experts and have also helped reduce prejudice against the supposed inaccurate efficacy of tcm in the international community [54, 55] . a researcher at the china academy of chinese medical science, tu youyou, was awarded the 2015 nobel prize in physiology or medicine for the development of artemisinin. tu youyou made an exploratory investigation of tcm and found that the components extracted from the plant artemisia annua are effective in the treatment of malaria. by referring to ancient books and many studies, tu youyou found the best extraction method for artemisinin. artemisinin is the invention not only of tu youyou but also of china and is an achievement of tcm heritage and innovation, which deserve popularization. this important invention created a sensation in the world [14] . due to differences between chinese and western cultures, china's tcm theory cannot be accepted by the international community [56] . tcm theories advocate "discontinuing medication when the patient is cured", oppose the long-term medication. long-term medication or even increase of dose to several times of standard dose may inevitably lead to side effect [57] . this also exposes the differences between chinese and western cultures. chinese medicine emphasizes the principle of syndrome differentiation. however, from western medicine perspective the concept of tcm is hardly understood and accepted, therefore tcm is not well positioned and accepted [5] . the officially entering of tcm to europe union (eu) market is at a slow rate, and there are only four products produced by chinese enterprises registered in the eu; no real tcm is sold in the us; and the tcm industry is facing enormous challenges. china's botanical drugs have only a small share, less than 5%, of the international botanical market, 2% in the united kingdom and the us, and 0.2% in germany [58] . as natural medicine has been recognized by the international community, tcm and natural medicine have become the target of many large multinational companies. the international herbal medicine market is highly competitive. at present, japan, south korea and other countries are competitive with china in the international herbal medicine market and pose a great threat to china's exports. in addition, a large number of foreign tcm companies based in japan, south korea and india have impacted the tcm market in china. china is the world's largest tcm market, and its demand for natural medicine is also very large. in recent years, due to the continuous opening of china's pharmaceutical market, many large-scale foreign pharmaceutical enterprises have entered the chinese market, and approximately 40 types of natural medicine manufactured in more than 10 countries and regions are successfully registered and listed in china [59] . the practice standards of china's tcm industry remain in the progress of standardization. after entering the wto, china had to align its standards with international standards. however, many countries and regions in the world, especially the western developed countries, restrict foreign products entering their territory through various administrative measures and requirements, high-tech trade barriers and the "green trade barriers" threshold, including measures for medication safety and protection to strengthen the supervision of imported drugs; develop or improve relevant technical requirements, such as quality standards for heavy metal residues, pesticide residues, aflatoxin and others; standardize the technology of plant extracts and environmental standards; and so on [42] . chinese medicine has a 5000-year history in china, and in a traditional comprehensive theoretical system, the related intellectual property should belong to china. however, the implementation of patent protection and technical protection of the novel tcm drugs in china began late, and there is a lack of study of protection of tcm intellectual property rights; therefore, most chinese medicine enterprises lack experience in patent applications in foreign countries and are not ready to protect their intellectual property. most tcm can easily be imitated or limited by patents in foreign countries; thus, many valuable chinese medicine product technologies and knowledge are under threat of advanced applications for patents by foreign enterprises. the developed countries, which have rich experience in drug patents, can not only obtain for tcm intellectual property rights but also compete for other resources related to chinese medicine by using intellectual property advantages. with the swot analysis of the internal and external environments, we can observe the advantages, disadvantages, opportunities and threats of tcm during the internationalization process (table 2) . overall, the advantages outweigh the disadvantages, and the opportunities outweigh the threats. to deal with these disadvantages and threats, we can provide some recommendations. first, we can strengthen the international communication on chinese culture. we should make full use of related resources at home and strengthen the international exchange and cooperation related to tcm, thereby promoting the development of tcm culture. we should strengthen the exchange between the chinese government and the leadership of international organizations; strengthen the cooperation with foreign institutions of higher educations and hospitals and co-establish clinical research centers or groups to make more academic authority institutions accept and recognize tcm. second, we can increase the input into tcm research. to align the foreign regulations concerning natural medicines, tcm can start with each individual medicinal materials. enterprises can take some multi-herbal formula of tcm with specific curative effects, and take the effective part as an "effective body", then control the composition and contents of the "effective body", and gradually reach the purposes of "safe, effective, controllable, and stable". the "effective body" in individual medicinal material can also be analyzed and summarized with the "assistant and guide" theory of tcm. we should explore and investigate the traditional formulas and carry out secondary development with modern innovative technologies to develop and produce new products. third, we can enhance the standardization and modernization of tcm quality. we should issue tcm product quality standards that are applicable to both china and the world as soon as possible and establish strict management of planting and production, to ensure that the consistency of tcm quality can be controlled. we should regulate each step of the tcm industrial process, apply high and new technologies, use advanced equipment and adopt strict standards to transform the tcm production and reach the goals of modernizing the technologies for the extraction, formulation, and quality control of tcm based on related conventional theories. finally, we must carry out intellectual property protection training among the practitioners of the tcm industry and 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herbal medicine in european member states opportunities, challenges and countermeasures of china's pharmaceutical industry after china's accession to wto study on transcultural communication of culture of traditional chinese medicine in countries along one belt one road inheritance and innovation of chinese traditional medicine in the background of "one belt and one road statistical evidence for the usefulness of chinese medicine in the treatment of sars the efficacy of chinese medicine for sars: a review of chinese publications after the crisis traditional chinese medicine in views of system science and system complexity study on the influencing factors and preventive methods of toxic and side effects of chinese herbal medicine the challenge to china's pharmaceutical enterprises after wto entry export of chinese medicine: difficult to develop not applicable. ht, wh, jm and ll conceived and designed the review. ht, jm and ll wrote the manuscript. all authors read and approved the final manuscript. the authors declare that they have no competing interests. not applicable. all of authors consent to publication of this work in chinese medicine. not applicable. not applicable. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. submit your next manuscript to biomed central and we will help you at every step: key: cord-297599-y4lu8m4k authors: luo, hua; zhao, mingming; tan, dechao; liu, chang; yang, lin; qiu, ling; gao, yan; yu, hua title: anti-covid-19 drug screening: frontier concepts and core technologies date: 2020-10-28 journal: chin med doi: 10.1186/s13020-020-00393-z sha: doc_id: 297599 cord_uid: y4lu8m4k the outbreak of covid-19 has recently evolved into a global pandemic. up to july 2020, almost every country has confirmed covid-19 cases reported worldwide. many leading experts have predicted that the epidemic will persist for relatively a long period of time. thus far, there have been no remedies proven effective against the disease. as the nation where covid-19 broke out first, china has adopted a combination of traditional chinese medicine and western medicine to fight against the disease, and has achieved significant clinical result. up to now, the covid-19 pandemic has been effectively controlled in china. however, the rest of the world (except for a limited number of countries and regions) is still in deep water. this paper thoroughly summarizes interdisciplinary notions and techniques, including disease model, biochip, network pharmacology, and molecular docking technology, etc., providing a reference for researchers in the screening of drugs for covid-19 prevention and treatment. these methodologies may facilitate researchers to screen out more potential drugs for treating covid-19 pneumonia and to tackle this global crisis. covid-19 is an acute respiratory infection caused by a novel coronavirus (sars-cov-2). the main symptoms of this disease include fever, dry cough, and fatigue, often accompanied by diarrhea, sore throat, runny nose, muscle pain, and so on. severe cases can rapidly develop into respiratory distress syndrome, septic shock, metabolic acidosis and coagulopathy, and multiple organ failure [1] . sars-cov-2 is a coronavirus with a membranous envelope, in a spherical or oval shape, often polymorphic, with a diameter of 60-140 nm [1] . the viral infection involves entry of sars-cov-2 virus into host cells [2] [3] [4] [5] mainly via a cell receptor angiotensin-converting enzyme ii (ace2). covid-19 can be transmitted through human saliva and physical contact, with an incubation period of 1-14 days. it is also highly contagious during the asymptomatic period, with 44 percent of transmission occurring before the onset of symptoms. the viral load in the patient's saliva peaked during the first week of the onset of new covid-19 symptoms such as fever and cough [3, [6] [7] [8] [9] . no precise vaccine or drug has been approved to prevent covid-19 effectively, leading to the rapid global spike of confirmed cases. until 3rd august in 2020, more than 17 million cases of covid-19 infections and with more than 680,000 deaths have been confirmed in 209 countries and regions worldwide. in china, anti-viral drugs such as interferon-α, ribavirin, lopinavir/ritonavir, chloroquine phosphate and arbidol, as well as a combination with traditional chinese medicine (tcm) are recommended to treat covid-19 [1] . however, lopinavir or ritonavir did not outperform the benefits to those of the standard treatment in hospitalized adults with severe covid-19 [10] . on the other hand, tcm has been observed to play an important role in preventing and controlling the epidemic. according luo et al. chin med (2020) 15:115 to data released by chinese center for disease control and prevention on 23rd march 2020, 74,187 of the newly diagnosed patients of covid-19 in china were treated with chinese medicine, accounting for 91.5 percent of total patient population at that time. in hubei province, 61,449 patients were treated with tcm, accounting for 90.6 percent [11] . clinical observation showed that the total effective rate of chinese medicine reached more than 90% [11] . tcm efficiently relieved the symptoms of the patients and promoted a fast recovery of their bodies, thus effectively reducing the number of patients whom changed from mild to severe conditions, as well as the overall mortality rate of the patients [11] . at present, a large amount of research work has been invested in searching for the treatments of coivd-19 worldwide. in china, promising therapies for coivd19 have been recommended according to the accumulated experiences of tcm in fighting with various epidemics during the long history. in this paper, we mainly focus on summarizing the advantages of tcm in treating covid-19 and several advanced techniques and concepts for drug screening of anti-covid-19 drug candidates. varieties of in vitro and in vivo models for drug screening are also introduced. we expect that this review to provide researchers valuable ideas and approaches in fast finding out the precise therapies and/or effective drugs against covid-19. as a single-stranded rna virus belonging to the c family of coronavirus, sars-cov-2 features four structural proteins, s protein, n protein, m protein, and e protein [12] . the current results suggest that the virus enters cells by binding to the host surface receptor, ace2, via the s protein, and then fuse with the host cell [13] . compared with sars-cov and mers-cov, the pathogenicity of sars-cov-2 is lower but is easier to spread [14] . whether fecaloral route transmission of sars-cov-2 plays an important role in spreading the virus, reminiscent of sars-cov, needs to be further studied for confirmation. of particular concern is whether sars-cov-2 will become as seasonal as community-acquired hcov. the heredity, pathogenicity, and continuous transmission of sars-cov-2 in the human body will influence the developing trend of covid-19 which is currently outbreaking globally [14] . to the origin of sars-cov-2 virus, researchers have thus far put forward two hypotheses: (1) it is a natural selection in animal hosts before zoonosis transfer; (2) it is natural selection after the zoonosis shift [15] . both hypotheses are helpful for further investigate and elucidate how the virus initially transmitted from animals to humans. at this stage, some researchers believed that the virus was originally from a natural host of bat, a report show that the 2019-ncov is 96% identical at the whole-genome level to a bat coronavirus [3] . the rtg13 sequence helped reveal key rbd (receptor-binding domain) mutations and multiple base-cutting sites. the virus may recombine to evolve in wild animals such as pangolins, and then cross the species barrier to humans through other intermediate hosts [16] . as of april 5, sars-cov-2 has been observed and reported to be effectively replicated in ferrets and cats, and transmitted through respiratory droplets in cats [17] . at present, there are two main detection methods for sars-cov-2 virus: nucleic acid detection and immunological detection. nucleic acid detection methods include gene sequencing, fluorescent quantitative pcr, digital micro-drop pcr, gene chip, and loop-mediated isothermal amplification. immunoassays include immunochromatographic strips, elisa, and chemiluminescence immunoassay [12] . since the outbreak of covid-19 pneumonia, there has been no precise drugs for treatment of this disease with regulatory approval. next, we will review and make a comprehensive analysis of drug targets, as well as possible therapeutic paradigms such as vaccine and therapeutic antibody, general antiviral drugs, protease inhibitor, and convalescent plasma therapy. the s protein is the receptor via which the virus binds to the host cell, and participates in cell fusion. it is a key target for the development of antibodies, vaccines (especially polypeptide and mrna vaccines), small molecular compounds against this virus. the receptor for sars-cov-2 infected cells is ace2, which is similar to sars-cov and also relies on transmembrane serine protease, is also a target for drug development [18] . according to the previous research of sars-cov, a rbd region on the correct conformation of s protein may be an ideal immunogen for vaccine design and development [16] . besides, an inhibitor of lipoprotein nucleotide fusion based on hr2 sequence was designed, called ipb02, which is highly active in sars-cov-2 s protein-mediated cell-to-cell fusion and pseudovirus infection [19] . sars-cov-2 major protease (mpro) is a key cov enzyme, which plays a pivotal role in mediating viral replication and transcription, making it an attractive drug target. shanghai institute of materia medica, in collaboration with several institutions, has designed and synthesized two lead compounds against sars-cov-2 mpro, both of which have shown effective anti-infectious activity [19] . besides, activation of nlrp3 (nucleotide-binding domain, leucine-rich-containing family, pyrin domaincontaining-3) inflammatory bodies is lacking in bats, so the use of nlrp3 inhibitor mcc950 may be helpful in the treatment of covid-19 [14] . viral 3-chymotrypsinlike cysteine protease (3clpro), which controls the replication of coronavirus, is a drug target of sars-cov and mers-cov. nine potential anti-sars-cov-2 active compounds have been identified via this molecular pathway [20] . as the most effective medical means of epidemic prevention and control, vaccine can effectively block the spread of the virus [21] . at present, china is focusing on the simultaneous implementation of three technical routes: influenza vector vaccine, recombinant protein vaccine, and nucleic acid vaccine. led by academician wei chen from the medical research institute of the academy of military medical sciences, the team has successfully developed a recombinant new crown vaccine, which is now in phase i clinical trial (registration number of recombinant sars-cov-2 vaccine (adenovirus vector) registration no. chictr200030906). at the same time, some international pharmaceutical companies include gene one life science inc. and inovio pharmaceuticals inc. have conducted relevant animal experiments to develop the covid-19 vaccine. moderna and the vaccine research center of the national institute of allergy and infectious diseases conducted the first phase i clinical trial of a novel lipid nanoparticle (lnp)encapsulated mrna-based vaccine, mrna-1273, which encodes the spike protein (s protein) of sars-cov-2, began in the united states [22, 23] . scholars proposed two very far-sighted global solutions in the event of a new virus that triggers a pandemic in the future. one solution is to establish a global distribution of production capacity, where surveillance in animal reservoirs combined with characterization of the virus can identify members of the virus family that are likely to cause a pandemic, candidate vaccines using these isolates can then be produced, and this capability can be activated if new viruses emerge. this strategy is currently applied to h5 and h7 avian influenza vaccines. another solution is the development of a broad-based protective vaccine covering the entire family or genus of the virus, which is currently underway for influenza viruses and may be applied to coronaviruses in the future [24] . therapeutic antibodies are also specific therapeutic drugs. sars-cov-2 and rbd of sars-cov have high homology. the strong neutralizing antibody cr3022, which targets sars-cov rbd, can be effectively combined with sars-cov-2 rbd. thus it is a potential anti-sars-cov-2 antibody [18] . mode rna therapeutics, wuxi biologics and vir biotechnology are developing monoclonal antibody for sars-cov-2 and several pre-clinical studies have been completed and clinical trials have also begun. vaccines, in the form of monoclonal antibody, oligopeptides, and peptide molecules, take months to years to develop. considering approved antiviral drugs against a variety of viruses such as hiv, hbv, hcv, sars, and mers, guangdi li et al. recommended some of these current antiviral drugs for treating covid-19, such as nucleoside inhibitors favipiravir, ribavirin or ridgisivir [25] ; common antiviral drugs chloroquine phosphate, favipiravir, and arbidol; protease inhibitors disulfiram or lopinavir/ritonavir and immunosuppressants may also work against covid-19 [25] . in the absence of specific therapeutic drugs, convalescent plasma therapy (cpt), a passive immunotherapy, has been one of the potential treatment options for covid-19 [26] . the strategy has been used to treat flu, viral infections, sars, and other infectious diseases. since the plasma who meets the medical requirement is rather limited, and the quality of blood products is demanding, the use of cpt has failed to popularize, in spite of demonstrated efficacy [26] . therefore, researches on exploring and developing effective drugs for preventing and treating covid-19 are necessary and urgent. as very limited modern medicine has shown clinically approven efficacy for covid-19, lessons can be drawn from the effective treatment experience from the use of the combination of tcm and western medicines. during the screening of effective drugs and potential formulations or medicinal combinations, a variety of in vitro and in vivo screening models has been employed. therefore, disease models and some core technologies would be introduced in the following paragraphs for facilitating researchers to screen drugs for treating covid-19. using in vitro models (e.g. certain cell lines), the antiviral effect of a drug candidate could be quickly predicted preliminarily. at present, the most commonly used cell line in antiviral test of chinese medicine is mdck (madin-darby canine kidney) cells. in addition, hep-2, a549, mbck, and mouse macrophage raw264.7 are also frequently applied for screening of antiviral drugs. mdck cells are susceptible to multiple influenza virus strains, supporting numerous passages of virus replication (capable of 35 consecutive rounds), and are widely used in antiviral activity assessment, mechanism research, and influenza vaccine development. mdck cells are the most widely used cell lines for antiviral research in tcm [27] [28] [29] . single herb such as scutellariae radix (黄芩) [30] , isatidis radix (板蓝根) [31] , lonicerae japonicae flos (金银花) [32] , houttuyniae herba (鱼腥草) [32] , etc. and tcm formulations such as fufangyizhihao granule (复方一枝蒿颗粒) [33] and lianhua qingwen capsule (连花清瘟胶囊) [33] have shown potentials on attenuating the proliferation of a/ pr/8/34(h1n1), a/aichi/2/1968(h3n2) and other influenza viruses in mdck cells. a549 human lung adenocarcinoma epithelial cell line is a commonly used tool to investigate the interactions between virus and host, the biochemistry of viral proteins, and to analysis genes that are overexpressed to suppress viral infections, to perform large-scale drug screening, for example, screening for crispr activation, [34] . it was previously demonstrated that tcm reseda odorata (木犀草) decreased the caspase-9, caspase-8 and caspase-3 expression in a549 cells infected with h1n1 virus [35] and chuanxiong rhizoma (川芎) [36] . in addition, the inhibitory effects of scutellariae radix on a 1/fm/166/85(h1n1) virus and influenza a and b viruses have been demonstrated in a549 cell line [37, 38] . researchers have used vero e6 cells to understand covid-19. for instance, vero e6 cells were used to test the antiviral activity of lianhua qingwen capsule against sars-cov-2 [39] . more interestingly, recent studies on vero e6 cells demonstrated that tmprss2 could enhance sars-cov-2 infection, which was in common with middle east respiratory syndrome and sars-cov. given the various variants containing point mutations or 15-30-bp deletions (del-mut) found accordingly at the s1/s2 junction via plaque purification of vero-e6 cells cultured with sars-cov-2 and the fact that adaptive function could disappear due to replication of permissive vero-e6 cells, it was suggested that strong selective pressure might be responsible for sars-cov-2 infection in humans promoted by the unique cleavage motif [40] . additionally, a tmprss2-expressing veroe6 cell line was considered helpful for propagating and isolating sars-cov-2, because it was easily accessible to infection of sars-cov-2 [41] . yi zhi hao granule has been reported to present obvious anti-h1n1 activity on human laryngeal carcinoma epithelial cell hep-2, and can alleviate lung injury and reduce the mortality of infected mice [42] . xiaoqinglong decoction (小青龙汤) can effectively inhibit the infection of hep-2 cells by the human respiratory syncytial virus [43] . in addition, mouse macrophages, raw264.7 are increasingly favored for screening antiviral drugs. for instance, yinhua ping gan granule (银花平感颗粒) was observed to efficiently inhibit the proliferation of a/pr/8/34(h1n1) virus in raw264.7 cells, which might be related to the following elements: regulates type i interferon and pattern recognition receptor signaling pathway; up-regulates the expression of ifn-γ and anti-myxvirus protein 1; downregulates the expression of il-6, tnf-α and phosphorylated tank binding kinase 1, and signal transduction and transcription activator 1 [33] . as in vitro screening can only offer potential drugs against covid-19, proper animal models have to be established to further understand covid-19 disease evolvement and to screen drugs for effective treatment, before possible clinical trials. researchers are testing mice, rats, ferrets, and even monkeys to answer key questions about the diseases and to fast-track potential drugs and vaccines for clinical trials. after outbreak of covid-19, china institute of laboratory animal sciences (cnilas) has taken the lead in establishing the disease models in transgenic mice and rhesus monkeys with covid-19, enriching the understanding of the etiology and pathology of covid-19. with the model, 5 patent medicines have been thoroughly evaluated in vivo for potential treatment of covid-19, and 6 vaccines and 4 more patent medicines are currently evaluated [44] . it was reported that academician dr. zhong nanshan's team has created the world's first non-genetically modified mouse model infected with sars-cov-2. compared with the traditional receptor transgenic mouse model, this model has a shorter construction time and does not need to reproduce; therefore, it is suitable for large-scale popularization in a short time. this model is useful for in vivo validation of antiviral drug and protective neutralizing antibodies, and vaccines. besides, the model can be used to study the immune response and pathogenesis of sars-cov-2 in vivo. in addition to mice and rhesus monkeys, other animals similar to human viral infections have been used in previous studies to screen for an antiviral drug. mouse plays an important role in researches on the pathogenesis of respiratory diseases associated with human virus infection [45] [46] [47] [48] [49] . some researchers are currently using mice as an animal model to test drugs and vaccines and to investigate the nature of the infection of sars-cov-2 [49] [50] [51] . however, mice often shrug off infection with sars-cov-2 and only exhibited a relatively mild clinical disease [24, 52] , because mouse ace2 receptor features several differences from that of humans [53] . for instance, out of 29 key amino acids in this important domain,11 in mouse were different from that in human [54] . luckily, engineering mice that could express both the human and mouse version of the receptor's gene, ace2, has been suggested as an effective way to remove the roadblock. in fact, in a study led by qin chuan on sars, engineered mice that could express human ace2 protein was successfully established, leading this chinese team pioneered the establishment of a sars-cov-2 infected hace2 transgenic mouse model [54] . during investigation of the pathogenicity of the virus in this mouse model, weight loss and virus replication in the lung was observed. therefore, this model still needs to be optimized since the weight loss and signs of pneumonia were mild and very different from that of humans [54] . currently, researchers are accelerating animal model research for sars-cov-2, and the transgenic mice developed for sars-cov are in short supply. for example, an effective and convenient novel mouse model in evaluating in vivo protective capacity of the sars-cov-2 vaccines was developed through stitching the human gene for ace2 into an adenovirus by perlman et al. in his unpublished work, in which mice was infected with it then receptor was created by some of their lung cells [55] . surprisingly, 20% of weight loss, which was greater than twice in qin's study, ruffled fur, other illness sign with no death were occurred in those mice infected with sars-cov-2. in addition, pacific inflammatory responses and pneumonia were found in the most recent study, in which both young and aged wild-type balb/c mice were effectively infected with mouse-adapted sars-cov-2 at passage 6 (macsp6) [55] . furtherly, a receptor-binding domain (rbd)-based sars-cov-2 subunit vaccine was found to conferred full protection against sars-cov-2 macsp6 challenge and elicited highly potent neutralizing antibodies, and the protective activity of it was determined in vivo. of the 29 amino acids in the key region of the human ace2 receptor that binds to the virus, 13 amino acids differ from that of the rat [54] . therefore, rats might not be a suitable model for studying sars-cov-2 infection. in terms of susceptibility to sars-cov-2, rats also had no advantage. however, the large size of rats has some advantages in many experiments that require repeated blood collection. syrian hamsters are gaining increasing attention in the fight against covid-19. in hamster, only 4 of 29 amino acids of ace2 receptor are different from those of human [56] . despite of the subtle symptoms, coronavirus was found to easily infect hamsters and cause serious acute respiratory syndrome (sars) as early as fifteen years ago, nevertheless, hamster did not catch much attention as an effective animal model for the disease at that time [57] . now, however, the tables have turned in the case of covid-19 since this model comes under spotlight again caused by a related virus, sars-cov-2. the first new hamster model was published in january by a physicianscientist of the university of hong kong (hku) jasper fuk-woo chan, whose work become one of the earliest studies in which asymptomatic infection and humanto-human transmission of sars-cov-2 were reported. eight hamsters were infected with sars-cov-2 by chan and his co-workers in their study, afterwards, a body weight loss, ruffled fur, lethargy, a hunched posture and rapid breath occurred with high levels of sars-cov-2 found in the lungs and intestines, tissues studded with the virus' target, ace2 of the animals [58] . interestingly, another team also at hku. led by hui-ling yen suggested comparable results closely behind of this study [58] . what's more inspiring, those hamster studies may contribute to understand the spreading way of the virus. in both above studies, transmission of sars-cov-2 happened whenever an uninfected hamster was put together with an infected one in a cage, apart from the possible transmission through respiratory droplets, chan and his colleagues also noticed the fact that hamsters ate feces, and therefore, a fecal-oral spread way could not be ruled out [58] . ferret shares remarkably similar lung physiology with humans, unsurprisingly, it is widely used in researches of respiratory viruses that infected humans and as one of the best animal models for another respiratory disease and influenza [59] . they are susceptible to human influenza viruses and various of the clinical symptoms of influenza infection in humans can be found on them [59] . a team of researchers in china recently found that sars-cov-2 could replicate in the upper respiratory tract of ferrets for up to eight days, without causing severe disease or death. the authors believed that the ferret could be a potential candidate animal model for assessing vaccine candidates and antiviral drugs against covid-19 [60] . by contrast, in the same study, livestock including chickens, pigs and ducks were demonstrated to not susceptible to sars-cov-2, while dogs had low susceptibility and cats were highly susceptible to the virus. besides, kim et al. [61] reported similar results. they found that ferrets were highly susceptible to sars-cov-2 infection, and exhibited the elevated body temperature and virus replication. although fatalities were not observed, ferrets effectively transmitted the virus by direct or indirect contact, recapitulating human infection and transmission. more importantly, kim also suggested that older ferrets might serve as a better animal model than younger ones. regardless of the unclear reasons, it is widely accepted that sars-cov-2 strikes the elderly much harder than the younger in humans, and similar phenomenon happened in the ferrets. kim had observed more severe symptoms causing loss of white blood cells and platelets in older ferrets infected with the virus, besides, 93% of older ferrets died of viral infection while no symptoms showed in younger ones infected with the same virus [62] , which indicated again that ferrets might be an ideal animal model for understanding and defeating against covid-19 since it presents similar features. non-human primates, especially rhesus monkeys, have similar immune responses to human viral infections due to their genetic and physiological similarities [63] . nonhuman primates are the closest species to human being who is subject to the infection of viruses [64] . different species of monkey have been infected with sars-cov-2 by intense efforts that closely followed by the isolation of the virus from human. a team from wuhan institute of virology, chinese academy of sciences, published the first study of sars-cov-2 infected rhesus monkey model [65] . they found that sars-cov-2 caused acute localized-to-wide to spread pneumonia as proved by pathological studies in rhesus macaques, although without obvious clinical symptoms of respiratory disease. another research team observed more serious interstitial pneumonia in old monkeys infected by sars-cov-2 than that in young monkeys, which provided insights into the pathogenic mechanism and may facilitate the development of vaccines and therapeutics against sars-cov-2 infection. in their study, two 15 years old and three 3-5 years old rhesus macaques were infected with sars-cov-2, then viral replication of anal swabs, nasopharyngeal swabs and the lung in old monkeys was found to be more active than that in young monkeys 14 days after the virus infection [44] . typical interstitial pneumonia characterized by thickened alveolar septum along with edema and inflammation was developed in monkeys, and diffuse severe interstitial pneumonia was observed in old monkeys. the research team led by qin chuan has obtained similar conclusions. they further found that sars-cov-2 had a conjunctival infection transmission route in the rhesus monkey model, which suggested conjunctival infection could cause mild covid-19 symptoms [66] . another critical finding was that the reinfection by sars-cov-2 of rhesus macaques might be decreased by a remarkably enhanced neutralizing antibody response, suggesting that primary sars-cov-2 infection might contribute to protection of monkeys from subsequent reinfection [67] . besides, some scientists inoculated cynomolgus macaques with sars-cov-2 or mers-cov and compared with historical sars-cov infections and found that the severity of sars-cov-2 infection was intermediate between that of sars-cov and mers-cov [68] . lu et.al recommended that macaca mulatta could be used to investigate viral pathogenesis and evaluate vaccines and drugs of covid-19. two different families of non-human primates, including new world monkeys (6 callithrix jacchus) and old world monkeys (6 macaca fascicularis, 12 macaca mulatta) were involved in their study, and they reported that macaca mulatta was most susceptible to sars-cov2 infection, followed by macaca fascicularis and callithrix jacchus [69] . a mers-cov primate model was successfully established in a latest study, which firstly reported the dosedependent effects of highly pathogenic coronavirus infection of primates and used a route of infection (small particle aerosol) with potential relevance to mers-cov transmission in humans with twelve african green monkeys [70] . african green monkeys may serve as primate model for covid-19, with considerably potential value in viral pathogenesis and therapeutic development researches [70] . taken together, monkeys might be used as suitable animal models to evaluate vaccines and drugs for covid-19. through data mining to screen the clinical use of the tcm formula for covid-19, high frequency/core drugs in tcm formula could be selected. also, the induction and analysis of four properties and five tastes (四气五 味) and meridian tropism (归经) of many chinese medicines from tcm formula could be made. effective guidance for the prevention as well as clinical treatment of covid-19 could be provided through investigations of the characteristics of commonly used medicine. through data mining, the key chinese medicine to prevent new coronary pneumonia is saposhnikoviae radix [72] . from the meridian tropism point of view, the lung meridian, stomach meridian are dominant. according to the classification of efficacy, the top four herbs used most frequently were heat-clearing herbs, antipyretic herbs, qi-invigorating herbs, and yin-tonifying herbs. it was found that in the prescriptions of tcm for the prevention and treatment of covid-19 in various regions, the main methods were to clear away heat and reinforce deficiency, and to strengthen the spleen and stomach. in the later period, most of tcm used were tonifying qi and yin. molecular docking is a model based on applied mathematics, biology, and computers to predict the binding affinity of small molecules to specific receptors, which can be used to predict drug affinity at target binding sites and drug-specific metabolic enzyme interactions to better understand the complexity of living systems. studies have shown that sars-cov virus infections are through the expression of s-protein and human ace-2 binding, which leads the virus to enter the cells [65, 73] . through molecular docking technology, 46 active components from tcm formula with high binding capacity could act on the binding region of sars-cov-2 s-protein of human ace2 protein. the screened components mainly belong to lonicerae japonicae flos, mori folium and other seven herbs [74] . papain-like protease (plp) plays an important role in the replication of coronavirus. in the process of virus replication, the small rna virus first encodes a large polymer precursor protein, and then the polymer protein is hydrolyzed to produce a functional protein, the hydrolysis process is mainly completed by 3clpro. therefore, it is important to search for inhibitors of 3cl hydrolase of sars-cov-2 coronavirus for the prevention and treatment of covid-19. through molecular docking technology, trichosanthis fructus (瓜蒌) and fritillariae cirrhosae bulbus (川 贝母), obtained by plp inhibitors screening and ace2 inhibitors screening respectively, were parts of the sangbei zhisou powder (桑贝止嗽散) and xiaoxianxiong decoction (小陷胸汤), which had the effect of clearing away heat and phlegm [75] . they can be applied to the syndrome of cough with slight dyspnea caused by external pathogenic factors in the early stage of viral action. radix et rhizoma rhei (大黄) and trichosanthis fructus, screened by mpro and plp respectively, are in maxing shigan decoction (麻杏石甘汤) and xuanbai chengqi decoction (宣白承气汤). they can be applied to syndrome types of the lung obstructed by pathogenic heat or blocked by toxin, and viscera-solid knot in the severe stage of the disease. mori folium, lonicerae japonicae flos and forsythiae fructus obtained by ace2 inhibitors screening have been included in the sangju beverage (桑 菊饮) and yinqiao powder (银翘散), which can be used in the early stage of the disease, such as the syndromes of warming evil invading the lung and slight cough and asthma. network pharmacology, which constructs network models centering on medicinal materials and disease targets, can provide a reasonable experimental basis and a brandnew research idea for discovery of new drugs and excavation of potential drugs. combining the study of the entire network with the holistic characteristics of tcm, network pharmacology can be used to study the basic theory of tcm from the perspectives of multi-approach, multi-component, and multi-target. screening the active substances, predicting the target protein, finding the signal pathway, constructing the network and analyzing it by network pharmacology, so the potential mechanism between the active components, target proteins and the network of pathways related to the occurrence and development of diseases may get understood, consistent with the overall concept of tcm. subsequently, the function of the key active components and covid-19 related proteins can be studied by molecular docking technique, and the potential material basis of treating covid-19 with prescription can be therefore explored, which could provide theoretical reference for preventing and treating covid-19 with prescriptions. using jean-baptiste de lamarck genetic algorithm and virtual docking technology, small molecular components of chinese herbal medicine were screened from the component library of chinese herbal medicine based on s-protein and ace2. using s-protein as the target, 12 [76] . through the analysis of weixuening mixture by network pharmacology, 326 components and 555 related targets were obtained, of which 35 targets corresponding to 101 components were closely related to covid-19. more specifically, herbs-active compounds-targets network and gene ontology function enrichment analysis as well as kyoto encyclopedia of genes and genomes pathway enrichment analysis were performed by cytoscape software and database for annotation, visualization and integrated discovery. the enrichment analysis of the target pathway showed that weixuening mixture mainly acted on infectious disease, inflammatory reaction, and immune regulation. it is suggested that weixuening mixture may play a potential role in the prevention and treatment of covid-19 by regulating the immune and inflammatory responses [77] . besides, with network pharmacology, it was found that the core active compounds in yupingfeng powder (玉屏风散) regulates multiple signal pathways by binding with ace2 to esr1, ar, ptgs2, and other targets to prevent and treat covid-19 [78] . jinhua qing gan granule (金花 清感颗粒) can regulate the signal pathway of ptgs2, hsp90ab1, hsp90aa1, ptgs1, and ncoa2 by combining 2019-ncov3cl hydrolase and ace2 to prevent and treat covid-19 [79] . taking advantage of the nascent computer technology and professional software, researchers could quickly screen out the regular pattern of anti-covid-19 drugs according to the existing pharmacological knowledge. in combination with clinical experience, it can further provide effective suggestions to clinical medication. this method can also screen out the active substances, target proteins, and possible signal pathways of related drugs. the application of computer virtual screening technology can greatly reduce the blindness in the screening of prescriptions and medicines, and save manpower, material, and financial resources. however, this method is limited by the information of drug structures and targets. biochip technology can detect numerous information simultaneously, which is helpful to explore the molecular mechanism of compounds from chinese medicine, optimize the dosage and prescription. gene chip can connect the characteristics of multicomponent, multi-target, multi-pathway action, and gene expression together; compare their difference in expression profiles; and determine the corresponding gene expression targets. according to the expression of organ specificity and the level of expression and the compound theory of monarch, minister, assistant and guide, and correlates with medication dose. at the same time, according to the interaction of the corresponding gene targets of different compatibility, the close relationship between each compound medicine can be analyzed, and the material basis of drug action and internal compatibility law would be elucidated. through gene chip technology observing the changes of gene transcription in an apoptotic signal pathway, a study found that luteolin could down-regulate the differentially expressed genes of casp3, casp8, and myd88, and interfere with cell apoptosis in a549 cell infected by h1n1 [80] . therefore, biochip technology presents great potential being used for screening tcm formulas in treating covid-19. the response of clinical studies of tcm in the prevention and treatment of covid-19 have been very rapid, and the current registration scheme covers the whole process of disease prevention, treatment, and rehabilitation. tcm formula has the characteristics of multi-component, multitarget, and multi-way synergy, which are the advantages of clinical treatment of tcm. however, perspective from the modern medicine, clarification of the relationship between chemical basis and biological mechanisms for tcm is still a challenge to be concerned. the substance basis, curative effect, and mechanism of tcm formula need to be further investigated and demonstrated. besides, many means of tcm diagnosis and treatment rely on personal experience. to guide the clinical medication, it is important to establish an objective and standardized diagnosis and treatment standards. traditional methods for screening antiviral chinese medicines are limited by the experimental cycle; since the high infectivity of sars-cov-2, the high requirements of laboratory conditions greatly lag the progress of drug screening. the common techniques of computer-aided drug design (cadd) include molecular docking, reverse docking, qsar, pharmacophore, and prediction of drug absorption, distribution, and metabolic transport. discovery and optimization of drug targets and the application of lead compound in the absorption, distribution, metabolism, excretion, and toxicity prediction of compounds have greatly accelerated the process of drug screening. cadd is also a tool for studying tcm, expounding the mechanism of action of tcm, and optimizing the development of new tcm prescriptions. among them, the technologies of molecular docking (dock), inverse molecular docking (invdock), similarity search, substructure search, pharmacophore search, pharmacophore screening, and chemical component toxicity prediction are of great significance to the study of tcm and its prescription. it is an important tool to explain the mechanism of tcm scientifically and reasonably [80] . in order to find out the potential chinese medicines or active ingredients against covid-19, scholars used data mining and network to mine the highfrequency chinese medicines and formulas from ancient prescriptions, then explored binding rates between the main ingredients in high frequency chinese medicines and the key targets of sars-cov-2 via using molecular docking approach. finally, a network pharmacology was used to uncover the potential molecular mechanism [81] . researchers can quickly screen out potential medicines by cadd, but further animal experiments and clinical studies should be performed to confirm the safety and effectiveness of these medicines. the tcm prescription is composed of different compounds, and its function is to target multiple target genes. it can directly inhibit viruses by target protein, and indirectly inhibit virus by human target protein. therefore, predicting the gene-target interactions of active components could help to decipher the mechanism of multitarget action for tcm. in the search for new antiviral drugs, studies have been conducted on molecular docking and molecular dynamics simulations to identify components or derivatives of chinese medicines or tcm formulations that can block channel activity or drugs at sialic acid binding sites. a study examined six viral proteins that could be targeted by antiviral drugs, including neuraminidase, hemagglutinin, matrix protein 1, m2 proton channel, nucleoprotein, and nonstructural protein 1 [82] . molecular docking techniques were used to identify potential inhibitors of 13,144 tcm compounds. the results showed that 56 compounds could inhibit more than two drug targets simultaneously. the interactions of these compounds with host targets were studied by molecular reverse docking. finally, it was found that 22 compounds inhibitors could stably bind to host targets with high binding free energy [82] . significant research works have provided indispensable insights into the technology and methodologies in screening drugs treated coivd-19 that likely contribute to the development and progression of interdisciplinary strategies in the understanding to prevent and treat coivd-19. as stated prior, in vivo and in vitro models have been developed to verify the effectiveness of anti-covid-19 drugs. but there is still wanting in the most commonly used model that provides an inexpensive, simple and reproducible model to study coivd-19. it is our hope that our further understanding of the role of frontier concepts and core technologies in screening anti-covid-19 drugs that may lead to new therapeutic targets for preventing and treating covid-19. national administration of traditional chinese medicine. diagnosis and treatment protocol for novel coronavirus pneumonia structure, function, and evolution of coronavirus spike proteins a pneumonia outbreak associated with a new coronavirus of probable bat origin the digestive system is a potential route of 2019-ncov infection: a bioinformatics analysis based on single-cell transcriptomes evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission temporal dynamics in viral shedding and transmissibility of covid-19 temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov-2: an observational cohort study a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster clinical features of patients infected with 2019 novel coronavirus in wuhan a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 three chinese patent medicines and three tcm prescriptions" have obvious curative effect, and traditional chinese medicine played an important role in fighting against novel coronavirus disease research progress on detection methods of sars-cov-2 genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding zoonotic origins of human coronaviruses the proximal origin of sars-cov-2 research progress in covid-19 susceptibility of ferrets, cats, dogs, and different domestic animals to 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medicines sheng jiang san, a traditional multi-herb formulation, exerts anti-influenza effects in vitro and in vivo via neuraminidase inhibition and immune regulation anti-influenza virus effect of radix scutellariae-rhizoma zingiberis in vitro research progress on anti-influenza effective components of isatidis radix the research on inhibitory effect of honeysuckle and houttuynia on influenza a virus replication in vitro new progress on anti-influenza activity and mechanism of chinese materia medica alternative experimental models for studying influenza proteins, host-virus interactions and anti-influenza drugs luteolin's intervention effect and its mechanism of apoptosis induced by h1n1 in vitro effects and mechanism of ligustrazine on apoptosis of a549 cells induced by h1n1 virus in vitro wogonin, a flavonoid isolated from scutellaria baicalensis, has anti-viral activities against influenza infection via modulation of ampk pathways inhibitory effect of baicalin on influenza virus a h1n1 in vitro lianhuaqingwen exerts anti-viral and antiinflammatory activity against novel coronavirus (sars-cov-2) attenuated sars-cov-2 variants with deletions at the s1/s2 junction enhanced isolation of sars-cov-2 by tmprss2-expressing cells antivirus effect of compound yizhihao pellets on influenza virus h1n1 infection in mice xiao-qing-long-tang (sho-seiryu-to) inhibited cytopathic effect of human respiratory syncytial virus in cell lines of human respiratory tract age-related rhesus macaque models of covid-19 evaluation of the potential effects of as03-adjuvanted a(h1n1)pdm09 vaccine administration on the central nervous system of non-primed and a(h1n1)pdm09-primed cotton rats genetic contributions to influenza virus attenuation in the rat brain viromimetic sting agonist-loaded hollow polymeric nanoparticles for safe and effective vaccination against middle east respiratory syndrome coronavirus single-dose, intranasal immunization with recombinant parainfluenza virus 5 expressing 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potential treatments of covid-19 from traditional chinese medicine (tcm) by using a data-driven approach study on the mechanisms of active compounds in traditional chinese medicine for the treatment of influenza virus by virtual screening publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to acknowledge and thank prof. yitao wang for his wonderful help with organizing and designing this study; we would like to thank prof. xiuping chen for participating in the revision. authors' contributions hy organized, conceived, and supervised the study. hl, mz, dt, cl, ly, and ql drafted the manuscript. yg and hl revised the manuscript. all authors read and approved the final manuscript. the authors declare that they have no competing interests.received: 25 may 2020 accepted: 15 october 2020 key: cord-282298-8tcw3cll authors: wang, jie; xiong, xingjiang title: current situation and perspectives of clinical study in integrative medicine in china date: 2012-02-21 journal: evid based complement alternat med doi: 10.1155/2012/268542 sha: doc_id: 282298 cord_uid: 8tcw3cll integrative medicine is not only an innovative china model in clinical practice, but also the bridge for tcm toward the world. in the past thirty years, great achievements have been made in integrative medicine researches, especially in clinical practice. the clinical achievements mainly include the following three: innovating methodology of disease-syndrome combination, excavating the classical theory in traditional chinese medicine (tcm), preventing and curing refractory diseases. the development ideas and strategies of integrative medicine for future mainly include (a) standing on frontier field of international medicine and improving the capability of preventing and curing refractory diseases; (b) moving prevention and control strategy forward and improving the curative effect of common and frequent disease; (c) excavating the classical theory of tcm and broadening the treatment system of modern medicine; (d) improving the innovation level of new high effective drugs on the basis of classical prescriptions and herbs in tcm; (e) rerecognizing the theory of formula corresponding to syndrome in tcm and enhancing the level of clinical research evidence based on evidence-based medicine. integrative medicine will do obtain greater achievements in creating new medicine and pharmacology and make more tremendous contributions for the great rejuvenation of the chinese nation and human health care. the coexistence of western medicine (wm) and traditional chinese medicine (tcm) began to appear when wm was introduced to china from the middle of 16th century. the tendency of "confluence of chinese and western medicine" appeared as the two medical systems contacting and influencing with each other since then. with the development of modern medical technology, intercourse, and cooperation between tcm and wm, integrative medicine was established in the 1980s. under the guidance of "system learning, comprehensively mastering, sorting, and improving," predecessors of integrative medicine have been exploiting the complementary advantages of macro and micro, global and local, structure and function, traditional and modern, disease differentiation, and syndrome differentiation in wm and tcm, in order to create new medicine and pharmacology theory. through unremitting efforts of integrative medicine staffs at home and abroad, remarkable achievements have been made in health care, teaching, researching, academic development, discipline construction, talent training, and so forth. so we can say that integrative medicine is not only an innovative china model in clinical practice, but also the bridge for tcm toward the world [1] [2] [3] . now the clinical achievements of the past 30 years and developing strategies of integrative medicine are described as follows. research. the relationship between disease and syndrome is thought to be one of the most significant problems in tcm clinical and basic practice. as a new mode for syndrome research, disease-syndrome combination mainly refers to absorbing the idea and theory of disease differentiation in western medicine (wm) as 2 evidence-based complementary and alternative medicine well as syndrome differentiation in tcm. the mode, which originates from the medical practice since more than half a century ago, has realized mutual compensation of advantages of tcm and wm [1, 2] . combining whole thinking, imagery thinking, and dialectical thinking in tcm with materialism of modern medical sciences, the mode can be regarded as a good cut-in point and successful control pattern for integrative medicine [3] . it has complementary advantages of wm and tcm and marks a new era created by integrative medicine in clinical researches. seminar on the academician chen keji's academic thinking about "the new mode of disease-syndrome combination and its application in clinical practice" was held in beijing on may 23, 2011. professor chen and his students discussed the scientific connotation of this new mode and its application in diagnosis, treatment, and scientific research together. china news of traditional chinese medicine, a famous domestic media, made followup report on the symposium, which had evoked large repercussions. academician chen keji pointed out that modern view of disease-syndrome combination includes six aspects: (a) mode of disease differentiation by wm combined with syndrome differentiation by tcm; (b) mode of syndrome differentiation and treatment combined with specific prescription for certain illness; (c) mode of treating according to disease staging; (d) mode of differentiation of the basic pathogenesis combined with syndrome differentiation and treatment in tcm; (e) mode of treating according to syndrome differentiation rather than disease differentiation when there's no disease can be diagnosed in wm; (f) mode of treating according to disease differentiation rather than syndrome differentiation when there's no syndrome can be diagnosed in tcm [4] . the emphasis of the mode could be played on either syndrome or disease. as the connotation of syndrome in tcm is significantly different from disease in wm, laying special emphasis on syndrome means that syndrome is just the basis of therapeutic scheme. on the contrary, effective therapeutic plans should be formulated according to disease differentiation when special emphasis is laid on disease. this new mode is beneficial to the original innovation in diagnosis and treatment. the advantages of the mode include four aspects as follows. (a) definitely diagnosing. as the disease diagnosis in tcm is vague and extensive, it is entirely necessary and possible to absorb some relevant achievements of disease diagnosis in wm for definitely diagnosing. (b) targeted treating. as the new mode pays more attention to the therapeutic evaluation of disease, it could achieve more definite therapeutic targets and stable curative effect compared with syndrome differentiation mode alone. (c) accurately prognosing. summarization of clinical phenomena is the principal judgment basis for prognosis in tcm, therefore, the prognosis judgment is always not very accurate. however, the new mode has vital guidance value for treatment and prognosis judgment. (d) deepening classics. due to the succinctness and conciseness of tcm classics, the essential features of the disease and syndrome could be rerecognized and deepened through combining with the modern cognition of pathology, diagnostics and pharmacology study in wm. syndrome is not only the core of tcm basic theory and syndrome differentiation, but also the bridge to associate disease and formula. different from diagnosis based on pathological mechanism, syndrome is a classification according to subjective symptom and objective sign collected by physical examination [5] [6] [7] . premise studies on diseasesyndrome combination lies in syndrome diagnostic criteria and therapeutic evaluation system. researches on syndrome diagnostic criteria aim at establishing the scientific and normative diagnosis system, while researches on therapeutic evaluation aim at constructing an objective evaluation system. under the leadership of academician chen keji, we are the first to study and report on blood stasis syndrome in coronary heart disease based on the new mode. contributed to the diagnosis of blood stasis syndrome in coronary heart disease, 19 items such as precordial pain, dark purple tongue color, and erythrocyte deformability were selected based on the calculation analysis of 48 kinds of examination items in 92 cases patients with coronary heart disease. and the clinical diagnosis accordance rate was 89%. 6 items giving the greatest contribution to diagnosis such as blood viscosity and total cholesterol (tc) were confirmed by a stepwise regression analysis for 21 items such as hemorheology and blood lipid [8] . correlation analysis of blood stasis syndrome and pathological changes shown in coronary angiography with coronary heart disease showed that the blood stasis syndrome score was significantly correlated to the maximal stenosis degree and coronary lesion score demonstrated by coronary angiography before percutaneous coronary intervention (pci), and the correlation was increased along with the increasing of the patients' age and the course of the disease. conclusions were also verified in our related researches [9] [10] [11] . through mathematical statistics method and computational intelligence approach, it was found out that the major syndrome factors of coronary heart disease are blood stasis, qi deficiency, turbid phlegm, qi stagnation, heat deposition, yang deficiency, yin deficiency, and cold coagulation based on calculation analysis of 5099 cases patients reported on literatures and 1069 cases patients with coronary heart disease validated by coronary angiographic. we also constructed the diagnosis scales of blood stasis syndrome and its accompanied syndromes in coronary heart disease, such as qi deficiency and blood stasis syndrome and qi stagnation and blood stasis syndrome [12] [13] [14] . in the study of therapeutic evaluation system, taking coronary heart disease as example, important indexes such as syndrome evaluation scale, clinical critical events, and quality of life were selected on the basis of completely evaluating the present indexes through application of clinical epidemiology-/evidencebased medicine method. meanwhile, high validity and reliability of therapeutic evaluation system of coronary heart disease was constructed through comprehensive analysis of various index by the hall for workshop of metasynthetic engineering. clinical efficacy scale of tcm syndrome and the primitive entry pool of scale for patient-reported outcomes of coronary heart disease were established by our team [15] . evidence-based complementary and alternative medicine 3 it is meaningful to promote the original innovation in integrative medicine researches through further understanding the connotation of syndrome diagnosis, therapeutic principle, and classical prescription by modern science and technology. among these studies, three researches below are honored. the first one is blood stasis syndrome theory and the clinical application of the method of promoting blood circulation and removing blood stasis. blood stasis syndrome theory is first recorded in the songs of chu, a classical literature written in ancient china. shuo wen jie zi (text notes and word explanations) written by xu shen in the eastern han dynasty explained that blood stasis is hematocele. and it was frequently mentioned in tcm classics such as the canon of internal medicine, treatise on febrile diseases, and synopsis of golden chamber. inspired by the prominent tcm doctor guo shikui's experience in treating angina pectoris by decoction for removing blood stasis, a classic formula developed by wang qingren in qing dynasty, academician chen keji advocated treating coronary heart disease by activating blood circulation to dissipate blood stasis principally. his team was the first to study the diagnostic criteria of blood stasis syndrome and report the quantitative scoring method, which had been extensively used in domestic and was the first study in using objective quantitative method in tcm syndrome study. objectified study of abdomen diagnosis on blood stasis syndrome was also superior to the research methods of japan in the same period. standards of syndrome differentiation and therapeutic evaluation of coronary heart disease were formulated according to above-mentioned researches, which had already become national standards. the essence of blood stasis syndrome and mechanism of treating coronary heart disease by activating blood circulation to dissipate blood stasis had been elucidated at various levels of intact animal, tissue, cell, molecule, and gene protein expression. as coronary restenosis after coronary artery balloon injury and stent placement have been considered an international difficult problem, academician chen firstly treated it by decoction for removing blood stasis and optimized the prescription to a more simplified and effective recipe, xiong shao capsule (xsc). a randomized controlled trial (rct) about xsc showed that the restenosis rate in xsc group treated by xsc on the basis of routine western therapy was decreased by 45% compared with routine western therapy group, and the experimental studies showed that xsc could suppress the gene expression of proliferation of vascular smooth muscle cells [16] [17] [18] [19] . with important academic value and clinical significance, the study has promoted the academic development of tcm greatly, which had been awarded the first award of national science and technology progress in 2003. the second study is the theory of dispelling interior pathogenic factors and purgation and its application in the treatment of acute abdomen. according to the theoretical basis of "the six fu-viscera function well when unobstructed," academician wu xianzhong began to explore integrative medicine therapy on acute abdomen in early years. through unifying standard for syndrome differentiation and defining operative indication, his team accumulated a large number of valid acute abdomen cases with the therapeutic method of expelling pathogens by purgation. under the leadership of professor wu, the multidisciplinary and prospective researches included the effects of dispelling interior pathogenic factors and purgation on the splanchnic blood flow and caecal single smooth muscle cell, the clinical characteristics of multiple organ dysfunction syndrome (mods) caused by several different kinds of elements, the changes of nerve-endocrine-immunological network in mods and the effects of purgative herbs on information transmission mechanism of immune cells through four times of different scale joint research in the seventh to tenth five-year plan period. after years of efforts, significant progress had been made and the operation rate had been reduced in the treatment of acute abdomen, such as severe acute cholangitis, acute severe pancreatitis, and complicated biliary stones, which was awarded the second award of national science and technology progress in 2003 [20] [21] [22] . the third one is the theory of "treating the toxifying disease with poisonous agents" and researches for arsenic trioxide (as 2 o 3 ) treating acute promyelocytic leukemia (apl). the theory is a traditional simple understanding of hypertoxic drug treating difficult and complicated diseases. it was recorded in compendium of materia medica that the herbal nature of arsenolite is very hot and poisonous, while white arsenic sublimed from arsenolite is more poisonous. white arsenic is a traditional external drug for removing the necrotic tissue and promoting granulation plaster, the effective component of which is as 2 o 3 . the research was enlightened by the prominent tcm doctor's experienced external prescription for treating skin cancer. on the basis of verification of curative effects and optimizing prescription, researchers developed the arsenous acid injection from the experienced external prescription, which had definitive curative effect for the patients with apl and reached the top level in the world [23] [24] [25] [26] . the mechanism of arsenous acid treating apl was illustrated from the perspective of molecular oncology, including degradation of pml/rara fusion proteins, downregulating gene expression of bcl2 and inducing apoptosis in leukemia cells. arsenous acid became the first antileukemia drug of inducing apoptosis in the world arousing the medical research fever of arsenic trioxide [27] [28] [29] . it was honored as "ancient remedy performs new tricks" in 1996 by science [30] . sloan-kettering and his coworkers reported that 12 patients with recurrence of apl after conventional chemotherapies were treated with as 2 o 3 , and 11 cases of them relieved completely in 1996. this paper, published in new england journal of medicine, directly led to the widely acceptance of as 2 o 3 in the treatment of apl in the international medical field [31] . as the frontier field and hot issue of cardiovascular diseases, restenosis after percutaneous coronary intervention and myocardial ischemia reperfusion injury (miri) during open heart surgery of cardiopulmonary bypass has become the best innovative points of clinical studies in integrative medicine. researches showed that restenosis after percutaneous coronary intervention was closely related to blood stasis syndrome. predominantly evaluated by restenosis (rs) rate estimated by coronary angiography (cag), a prospective randomized controlled study was carried out on rs after pci to observe the intervention effect of xiong shao capsule (xsc). compared with the control group, the incidence of rs rate in the xsc group was significantly lower (24.1% versus 48.5%, p < 0.05) and the extent of angiostenosis and diameter of the culprit arteries, determined by cag, also significantly reduced after patients had been treated for 6 months with [(2.21 â± 0.85) mm versus (1.72 â± 0.99) mm, p < 0.05], and [(26.58 â± 20.72) % versus (41.19 â± 30.92) %, p < 0.05], respectively. the incidence of clinical end-point event was significantly lower in the xsc group than that in the control group (11.7% versus 27.6%) and the p value was close to statistical significance (p = 0.051). comparing with the control group, the blood-stasis syndrome score in the xsc group was also significantly lower (p < 0.01). the results showed that xsc had a wide range of therapeutic effects including effectively preventing rs after pci in combination with conventional western medical treatment, decreasing the attack of angina pectoris and improving the blood stasis syndrome. experimental researches on blood activating herbs showed that it can significantly inhibit pathological vascular remodeling after balloon injury, thus reduce late lumen loss and prevent restenosis [32] [33] [34] [35] [36] . as the establishing the cardiopulmonary bypass of open heart surgery is key point of successful operation, myocardial ischemia reperfusion injury (miri), which is very obvious during the recovery of circulation, has become the hot issue needed to be resolved. some scholars found that the pathogenesis of miri during open heart surgery of cardiopulmonary bypass is deficiency of heart qi in the origin and excess of heart blood stasis and internal turbid toxin in the superficiality and the therapeutic principles are boosting qi and nourishing heart, activating blood circulation and resolving toxin simultaneously. it was proposed that of astragalus injection and tetramethylpyrazine injection for boosting qi and activating blood circulation should be given by vein injection during operation and hu xin bao (compatibility of extracts of ginseng and panax notoginseng with taurine) for boosting qi, activating blood circulation, and resolving toxin should be given by oral administration before operation. the research showed that astragalus injection combined with tetramethylpyrazine injection could reduce the content of mda and myocardial enzymes' release and improve the activity of sod, no, and nos. serial studies demonstrated that boosting qi combined with activating blood circulation have significantly synergetic effects, and boosting qi, activating blood circulation, combined with resolving toxin were superior to those simple boosting qi, activating blood circulation, resolving toxin, and boosting qi combined with activating blood circulation [37, 38] . multiple organ dysfunction syndrome (mods) is one of the difficult problems in the field of the critical care medicine, which is characterized by acute onset, rapid progress, and extremely high mortality. since the 1970s of 20th century, some scholars began to take vigorous action to explore a new way of preventing and treating mods by integrative medicine and a new theory of "bacteria and bacterial toxin treated simultaneously" was presented ultimately. they also perfected schemes for the diagnosis procedure and treatment standard of mods by both tcm and integrative medicine. and four therapeutic principles for the main types of syndromes were put forward, such as activating blood circulation to dissipate blood stasis therapy on blood stasis syndrome, clearing heat and toxin therapy on heat toxin syndrome, reinforcing the vital energy and consolidating the constitution therapy on acute deficient syndrome, and dispelling interior pathogenic factors and purgation therapy on yangming fu-organ syndrome. integrative medicine therapy can effectively improve the clinical efficacy and shorten the course of the disease thus reducing mortality. a famous injection of chinese medicine, "shen nong 33," with the effect of activating blood circulation to dissipate blood stasis and antiendotoxin, was developed, which has reduced the mortality of international recognized infectious four or more organs failure from 100% to 50% and reached the international advanced level. furthermore, a new strategy of "bacteria, bacterial toxin, and inflammatory mediator treated simultaneously" was put forward on the basis of the theory of "bacteria and bacterial toxin treated simultaneously." xue bi jing injection, the first chinese medicine preparation in emergency medicine, was developed, which have made great contributions to the advancement of critical care medicine [39] [40] [41] [42] [43] . chronic hepatitis b is the common disease in china, as well as in the world, causing great affliction to patients. it has become the major issue in the treatment of chronic liver disease. the progression of chronic hepatitis b may lead to liver cirrhosis and hepatocellular carcinoma. hepatic fibrosis is the common pathological end stage of various chronic liver diseases regardless of the etiology, and blocking the occurrence and development of fibrosis of liver is very important in chronic hepatic diseases' treatment and prognosis. tcm has become the important therapy in treating chronic hepatitis, liver fibrosis, and liver cirrhosis. some scholars put forward the hypothesis that liver fibrosis and early liver cirrhosis can be reversed. they found out that the basic pathogenesis of liver fibrosis is weakened body resistance and blood stasis, so therapeutic method of strengthening body resistance and dispelling stasis was established, and "fu zheng hua yu capsules," a new drug for treating liver fibrosis, was developed. predominantly evaluated by liver tissue fibrosis, clinical researches were carried out to observe the curative effect of the therapeutic method of strengthening body resistance and dispelling stasis. the total inversion rate of liver tissue fibrosis was 52% to 58.3% compared before and after treatment, which also confirmed that liver fibrosis can be reversed and treated. the mechanism includes significantly inhibiting lipid peroxidation, the proliferation of hepatic stellate cell and activation of collagen expression, reducing inflammation of hepatocytic injury model, increasing the activity of matrix metalloproteinases, promoting the degradation of pathological liver collagen, and so on [44] [45] [46] . combining the macroscopic view with microscopic view, syndrome differentiation with disease differentiation, regional with global, taking stopgap measures with taking radical measures, supporting healthy aspects with eliminating pathogens, tumor treatment model by integrative medicine emphasizes contriving individual treatment plan and evaluation standard on the basis of biological characteristics and the course of disease. malignant tumors could be treated by tcm therapies such as reinforcing the vital energy and consolidating the constitution, supplementing qi and nourishing yin, and clearing away heat and toxic materials, combined with conventional therapies such as radiotherapy, chemotherapy, and surgery. tcm treatment has significances in decreasing toxicity and increasing efficacy on radiotherapy and chemotherapy. integrative medicine theory has a remarkable effect in alleviating symptoms such as dry mouth in hyperpyrexic consumption of yin syndrome and deficiency of both qi and yin syndrome caused by head and neck cancer after radiotherapy, relieving symptoms such as cough caused by acute radiation pneumonitis, improving immune function, and survival quality of postoperative patients, preventing the tumor from recurrence or metastasis and prolonging survival time. the new model of combining tcm and modern cancer treatment has attracted widespread attention in the world, which is known as "china model for cancer treatment" [47] . in addition, screening of tumor inhibition from more than 3,000 species of chinese herbs and nearly 300 chinese herbal compound, effective components having directly killing effect on cancer cell such as indirubin, camptothecin, vinblastine, matrine, and aclitaxel were extracted. some chinese herbs, having the effect of immunological enhancement and biological response modifier-like action such as polyporus, poria cocos, and mushroom, were also found out. apl is a special type of acute leukemic (al). tcm suggests that the pathogenesis of apl is weakened body resistance and excessiveness of pathogen, so therapeutic method of eliminating pathogenic factors and strengthening body resistance was established. some scholars developed the compound realgar natural indigo tablets (realgar, indigo naturals, salvia and radix pseudostell) on the basis of clearing away heat and toxic materials and supplementing qi with activating blood circulation and promoting hemogenesis method. 155 cases of apl patients were treated by the compound realgar natural indigo tablets and the remission rate was 97.42% after treating for 6 months. no side effect, serious infection, bleeding, and dic were found during the treatment course. it was also characterized by higher negative conversion rate of pml-rarî± fusion gene and simple application. the results demonstrated that the complete remission rate of treatment of the compound realgar natural indigo tablets were 10-15% higher than that of all-trans retinoic acid (atra). on this basis, the effect of post-remission therapy mainly with compound realgar natural indigo tablets on long-term survival of 74 cases patients with apl showed that the median remission time was 48 months with recurrence rate only 14.86% and 10-year survival probability was 75.38% [48] [49] [50] . since the 1970s of 20th century, the basic syndrome of type 2 diabetes included yin deficiency with internal excessive heat, deficiency of both qi and yin, and deficiency of both yin and yang, therefore, iii-type differentiation of type 2 diabetes was established and developed. it had already been adopted by national guidelines for new drug in the late 1980s. as deficiency of both qi and yin was the important basic syndrome of the disease, "jiang tang jia tablets," a new chinese herb of supplementing qi and nourishing yin, could improve insulin resistance, islet î²cell function, and the level of glucose and lipid metabolism, the total effective rate of which was 76.54%. in addition, researches of tang wei kang capsule treating early diabetic nephropathy and tang xin ping treating diabetic cardiopathy have gotten progress [51, 52] . some scholars also found out that blood stasis was another significant pathogenesis of type 2 diabetes due to the changes of hemorheology with different degree were found. so they advocated treating the disease by promoting blood circulation and removing blood stasis principally. based on this idea, promoting blood circulation by removing blood stasis recipes, such as nourishing yin and activating blood recipes and xian zhen tablet of reinforcing kidney and activating blood, were developed. those recipes have multilevel and multitarget effects, including improving symptoms, reducing blood glucose, improving blood rheology and blood flow, lowering triglycerides (tgs), and malondialdehyde (mda), enhancing activity of erythrocyte sod, na + -k + -atp enzyme and ca 2+ -mg 2+ -atp enzyme, and so forth. the experimental studies showed that the effect of xian zhen tablet includes lowering blood glucose and glycosylated hemoglobin, decreasing urine protein excretion, improving renal function, reducing the pathological changes of glomerular mesangial expansion and basement membrane thickening, decreasing ages amounts of renal cortex, and downregulating rage-mrna expression in renal cortex and endothelia of heart vessel. it provided a new idea for preventing and treating diabetic and chronic vascular complications [53, 54] . severe pancreatitis, namely, acute hemorrhagic necrotizing pancreatitis, is characterized by acute onset, rapid progress, high mortality, and poor prognosis. 65% of the death cases are due to complicating with acute respiratory distress syndrome (ards). according to the theoretical basis that "the six fu-viscera function well when unobstructed" and "the lung and the large intestine are interior-exteriorly related," acute pancreatitis is treated by expelling pathogens by purgation, and the average cure rate reached to 97%, while the average cure rate of severe pancreatitis was 80%. compared with our country and abroad, the mortality has reached the lowest level. qing yi decoction, a famous antipyretic and purgative prescription, protected the lung from injury in many aspects, by preserving the damage of gut barrier function, reducing or eliminating endotoxemia derived from the gut, inhibiting the production, and release of tnf, il-6, and the translocation of bacteria. the results may fully show the superiority of integrative medicine in treating serious diseases [55, 56] . a certain progress was also made on dermatosis and burn medicine by integrative medicine therapy. vitiligo was effectly treated by taking modified tao hong si wu decoction, external application of compound tar traditional chinese rubbing-drugs and melagenine extracted from placenta. evidence-based complementary and alternative medicine 243 patients with vitiligo were treated by modified tao hong si wu decoction and the total effective rate was 68.2%, the mechanism of which was related to upregulation of tyrosinase activity, increasing the melagenine content, and promoting melanocyte proliferation [57] . moist exposed burn therapy (mebt), a new therapeutic system of burn medicine in integrative medicine, has become the leading enabler throughout the world. it is found out that the burn wound should be kept in a moist but not macerated environment in order to promote in nature recovery and generation of the skin rather than in traditional dry environment. and the exact curative effect was obtained by mebt and moist exposed burn ointment (mebo) [58] . severe acute respiratory syndrome (sars) has aroused international attention for strong infectiousness, rapid progression, poor prognosis, and high mortality, which has no special effective therapy yet. 524 patients of sars in china were divided into integrative medicine treatment group (n = 318) and western medicine treatment group (n = 206). the existence rates for the symptoms of weakness, short breath, dyspnea in the first group were significantly lower than that in the second group after treatment. the duration of weakness was averagely shortened by 1.5 days in the first group. and short breath, dyspnea, and muscle aching pain were averagely shortened by 2 days, 1 day, and 2 days, respectively. researches showed that the effect of integrated therapy of tcm and wm for treating sars was superior to wm treatment alone, and the integrative medicine could improve clinical symptoms such as weakness, short breath, and dyspnea [59] [60] [61] . the exact clinical curative effect was also recognized by world health organization (who). diseases. previous achievements in clinical researches of integrative medicine showed that it is absolutely necessary to keep a foothold at frontier field of international medicine and life science and derive the wisdom and new theories from these subjects in order to find the innovation and breakthrough from subject cross and osmosis. aiming at the hot issues and knotty problems confronted in clinical medicine, we could put forward scientific hypotheses in exploring the etiology and pathogenesis of the disease and seek for the effective therapeutic principles and classical prescriptions. basing on the research mentioned above, the clinical efficacy should be objectively evaluated by randomized controlled trials (rct), and the potential mechanism should be illustrated ultimately. by summarizing the clinical regularity in time, it will contribute to the innovation of the medical theory and guide clinical practice. taking coronary heart disease as example, despite great advancements in the fields of basic and clinical researches made by modern medicine, there are still some issues to be resolved, such as acute coronary syndrome complicated by microvascular thrombosis, myocardial ischemia-reperfusion injury, no-reflow phenomenon, stent thrombosis, obvious subjective symptoms such as hypodynamia and shortness of breath remained after percutaneous coronary intervention (pci), and ventricular remodeling following myocardial infarction [62] [63] [64] . previous study showed that the prospects of integrative medicine is brightening in treatment for coronary stent thrombosis and protecting the myocardial ischemia-reperfusion injury. in addition, as viral infectious disease belonged to the category of epidemic febrile disease in tcm thousands years ago, chinese ancients had accumulated rich experience and formed a systematic and complete theory in treatment. currently, better therapeutic efficacy of viral infectious diseases could be achieved by combining two medical systems, especially in sars, n1h1, and bird flu. also, more similar breakthrough points of integrative medicine can be found, for instance, improving the low success rate of assisted reproductive technology (art) by combining art with tcm therapeutic method of reinforcing kidney and activating blood, and so forth. disease. "moving prevention and control strategy forward" is a national macrohealth policy, which well adapted to the new medical model, "physiological-psychological-socialenvironmental" model. it means that the focal point of medicine will be transferred from treating disease to health care, and disease prevention will be paid more attention to. therefore, the policy of "prevention first" will be carried out instead of traditional ideological concept "treatment is more major than prevention." it is similar to the tcm theory of "preventive treatment of disease," including principles of "preventing measure taken before the occurrence of disease" and "preventing measure taken after the occurrence of disease" in canon of internal medicine. concrete measures of "moving prevention and control strategy forward" include concept forward, funding forward, emphasis of the researches forward, and measures to be carried out forward. it could reduce the incidence of the major diseases from the origin and effectively control the medical expense and save resources in medicine and health. integrative medicine researches should also observe the principles above and pay more and more attention to improve the curative effect of common and frequent diseases. taking cardiovascular disease, for example, there are about 30% of the population in the world died from cardiovascular and cerebrovascular events, among which 62% of stroke and 49% of cardiovascular events were directly caused by hypertension [65] . according to the china cardiovascular reports (2008-2009), the occurrence and mortality of cardiovascular disease is still increasing in our country, and it is estimated that the number of patients with cardiovascular disease is at least 230 million. it also demonstrated that there were about 200 million hypertensive patients in china with more than 10 million patients increased annually. as the primary cardiovascular risk factor, the risk level of hypertension is equivalent to three other cardiovascular risk factors together. that is why more evidence-based complementary and alternative medicine 7 emphasis should be taken on prevention and intervention of earlier-stage hypertension in clinical researches of integrative medicine. additionally, hyperlipidemia, hyperglycemia, obesity, and other risk factors also should be paid more attention to. it is reported by world health organization (who) that if risk factors were controlled as early as possible, 80% of the disease can be prevented effectively, such as coronary heart disease, stroke, and diabetes. furthermore, paying 1 yuan in prevention will save 7-8 yuan in treatment. broadening the treatment system of modern medicine. jama, an international authoritative journal, have commented that traditional medicine should joint tracks with modern medicine. it suggested that not only should we inherit traditional academic thoughts but also keep an eye on modernization of tcm and study it in a scientific and systematic way [66] . the target is to fully digest the traditional chinese medicine, and apply it to modern medical system. how to do it? the first is further understanding of the essence in tcm, while giving up the dross. the second is illustrating the mechanism of the traditional therapy by using advanced scientific technology in order to improve the safety of the treatment and alleviate the toxicity adverse effect. viscera, meridians, prescriptions, and syndromes, the precious wealth in tcm left by our ancients, are worth deeply researching into. however, as the theory is profound, classical, and concise, combining with clinical practice is the unique way to understand the connotation. for example, the lung and the large intestine are interior-exteriorly related, that is to say, the lung was associated with the large intestine by meridians. in the clinical practice, dysfunction of the large intestine conduction could cause no descending of the lung qi, conversely, no descending of the lung qi also can result in obstruction of fu-qi. it is reported that introducing fuunblocking and purgation therapy into adults' acute pneumonia is a rapid and effective treatment. in the 70th of the last century, professor wang had applied liang ge san (cool diaphragm powder) to treat sirs and mods, which mainly manifested as yangming visceral substantive syndrome. the result demonstrated that the respiratory function of 80% patients with respiratory failure was rapidly improved, and the recovery was greatly promoted. among the patients with acute pancreatitis accompanied with mods, the therapy also received superior efficacy. all of these theories mentioned above, including blood stasis syndrome theory, theory of dispelling interior pathogenic factors and purgation, and theory of "treating the toxifying disease with poisonous agents," were all worth deeply excavated, which have being greatly broadened the treatment system of modern medicine. compared with tcm theory, chinese herbs are much easier to be modernized and recognized. therefore, it is of great significance in promoting modernization, industrialization, and industrialization of the chinese herbs, by ways of combining modern technology with fully understanding of classical prescriptions and herbs. china is a great power with rich herb resources. according to the records in formula dictionary of traditional chinese medicine, there are approximately 100 thousand prescriptions, including special prescriptions and herbs for certain diseases. the classical prescriptions and herbs provided with definite clinical indications are of more meaning to be developed. that will provide an effective shortcut to improve the capability of developing new drugs, which is characterized by definite chemical structure, explicit action mechanism, obviously curative effect, advanced formulations, convenience for taking, and low price. at present, the effective fractions and monomers extracted from chinese herbs had obtained reliable clinical benefits. for instance, artemisinin extracted from sweet wormwood (artemisia annua l.) have a definite effect in the treatment of falciparum malaria, which had been confirmed by multinational joint researches. the new therapy developed by professor tu youyou has saved millions of lives across the globe, especially in the developing world, which had also been listed in the catalog of "essential medicines" by the world health organization (who) [67] [68] [69] [70] [71] . therefore, professor tu was awarded the 2011 laskerâ�¼debakey clinical medical research award for the discovering artemisinin and its utility for treating malaria. the research will raise a new global round of climaxes of modernization and internationalization of tcm. in addition, indirubin extracted from indigo naturals in danggui long hui wan (pill of angelica sinensis, gentian and aloe) could treat leukemia. diterpenonid versicolaction extracted from tripterygium wilfordii hook can be used as immunosuppressive agents for treating rheumatoid arthritis (ra). biphenyl dimethyl dicarboxylate (ddb) extracted from schisandra chinensis could decrease the alt and ast activity. tetramethylpyrazine extracted from ligusticum chuanxiong hort has showed a good effect for ischemic cerebrovascular disease. cantharidin extracted from mylabris could treat liver cancer. moreover, other active components such as ginsenoside, total puerarin flavonoids, polyporus umbellate polysaccharides, ganoderma lucidum polysaccharide, anisodamine, tanshinone, trichosanthin, tetrahydropalmatine, tetrandrine, rubidate, ilexonin a, and ferulic acid sodium. evidence-based medicine (ebm) is a new subject quickly developed in the clinical medicine field in the 1990s. the core thinking is to combine evidence, personal experiences, and patients' actual situation to formulate scientific measures for preventing diseases, promoting the recovery and improving life quality. among them, clinical evidence originates mainly from randomized controlled trial (rct), systematic review, and meta-analysis. with medical science transforming from traditional experience medicine into evidence-based medicine, fundamental changes have taken place in clinical medicine. therefore, following the principle of respecting science and evidence, it is of the utmost importance to enhance the level of clinical research evidence in tcm and integrative medicine [72] [73] [74] . it is noteworthy that the treatment concept, formula corresponding to syndrome, lied in classical works of tcm, is similar to the ideas of ebm. however, it had been ignored for a long time. the theory of syndrome differentiation and formula corresponding to syndrome are two characteristic inheritance veins in tcm. generally speaking, the former is always the mainstream ideology in tcm, while the latter has been paid little attention. clinical medication based on pathogenesis is the core idea of syndrome differentiation, while clinical medication based on formula syndrome is not exactly the same as it. the most significant difference between them is whether giving attention to the objective evidences of formula utilization. the theory of formula corresponding to syndrome attaches great importance to the objective indications of herbs, which mainly comes from long-term, large-scale and repeated clinical trials by chinese ancients. as the indications of herbs are objective and concrete, clinical effect could be repeated at anytime, anywhere, and for anybody. so it is suggested that, facing with one patient, 10 tcm physicians may prescribe the identical prescription and get rapid treatment effect simultaneously according to the indications of formulae and herbs. this is just the reason why the significant curative effect can be by classical prescriptions get in treating severe and lingering illness. the extractive process of indications is similar to the evidencebased research, and indications of herbs have probably exceeded the category of expert experience in ebm. therefore, carrying out clinical studies under guidance of ebm and formula corresponding to syndrome is helpful to summarize the indications of formulae and herbs, and enhance the level of clinical research evidence in tcm [75] [76] [77] [78] [79] . the history of man's science development showed that the crossing and blending of two kinds of knowledge systems will be able to set up a new knowledge system. integrative medicine, an unprecedented task in present world, is a new pattern of medicine, which is formed by the integration of tcm and wm. the current situation of integrative medicine career was highly evaluated by academician han qide. he pointed out that integrative medicine is an inevitable choice for the development of chinese medicine and the breakthrough point of development for modern medicine, which have unique advantages and will play an important role in china. with changing of the disease chart, increasing of metabolic disease, malignant tumor, iatrogenic disease and drug-induced disease, and the coming of senile society as well as the change of people's views on health and medical mode, both opportunities and challenges have been brought to the development of integrative medicine. thus we believed that under the guidance of "pay equal attention to both wm and tcm" and "implementing the integrative medicine and developing tcm," integrative medicine will obtain great achievements in creating new medicine and pharmacology, which builds on the combination of both wm and tcm, and make tremendous contributions for the great rejuvenation of the chinese nation and human health care [80] . mao zd and integrative medicine chinese medicine pattern diagnosis could lead to innovation in medical sciences integrative medicine: the experience from china past and present of combination of disease differentiation and syndrome differentiation a systematic analysis of the theory and practice of syndrome differentiation pondering on syndrome 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screening of primitive entry pool of rating scale for patient-reported outcomes of coronary heart disease angina xs0601 reduces the incidence of restenosis: a prospective study of 335 patients undergoing percutaneous coronary intervention in china inhibition of vascular remodelling in a porcine coronary injury model by herbal extract xs0601 a multi-center randomized double-blind placebocontrolled trial of xiongshao capsule in preventing restenosis after percutaneous coronary intervention: a subgroup analysis of senile patients analysis on outcome of 5284 patients with coronary artery disease: the role of integrative medicine modern research on purgation method of traditional chinese medicine-application of the method in acute abdominal diseases and experimental studies clinical and experimental study of effect on acute phase protein of multiple organ dysfunction syndrome treated with dachengqi decoction effect of dachengqi granules on level of endotoxin in ente rogenous endotoxemia in rats clinical observations on 6 cases of leukemia treated by ailing injection study on chinese herbs containing arsenic treating leukemia studies on treatment of leukemia with traditional chinese drugs containing arsenic arsenic trioxide, a therapeutic agent for apl use of arsenic trioxide (as 2 o 3 ) in the treatment of acute promyelocytic leukemia (apl): i. as 2 o 3 exerts dose-dependent dual effects on apl cells use of arsenic trioxide (as 2 o 3 ) in the treatment of acute promyelocytic leukemia (afl): ii. clinical efficacy and pharmacokinetics in relapsed patients in vitro studies on cellular and molecular mechanisms of arsenic trioxide (as 2 o 3 ) in the treatment of acute promyelocytic leukemia: as 2 o 3 induces nb4 cell apoptosis with downregulation of bcl-2 expression and modulation of pml-rarî±/pml proteins ancient remedy performs new tricks complete remission after treatment of acute promyelocytic leukemia with arsenic trioxide clinical study on effect of xiongshao capsule on restenosis after percutaneous coronary intervention clinical effect of xiongshao capsule on preventing restenosis post-ptca or/and stenting effect of xiongshao capsule on vascular remodeling in rabbit with experimental atherosclerosis prevention and treatment of restenosis after pta in rabbit with xuefu zhuyu concentrated pills effect of xiongshao capsule on vascular remodeling in porcine coronary balloon injury model clinical study on myocardium protection of huxinbao during open heart surgery of cardiopulmonary bypass clinical study on effection of replenishing qi, activating blood circulation and the compatibility of replenishing qi and activating blood circulation in myocardial ischemia reperfusion injury during open heart surgery of cardiopulmonary bypass bacteria and bacterial toxin treated simultaneously' in 50 patients with infections multiple system organ failure (msof): a new theory and verification of its clinical value bacteria, bacterial toxin and inflammatory mediator 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qingyitang on acute lung injury induced by severe acute pancreatitis in rats curative efficacy and mechanisms of modified tao-hong-si-wu-tang, a traditional chinese medicine, in the treatment of vitiligo chinese medical concept of moist exposed burn therapy effect of integrated therapy of tcm and wm on clinical symptoms in 318 cases of sars preliminary study on clinical efficacy of integrative chinese and western medicine in treating severe acute respiratory syndrome (sars) efficacy evaluation of tcm in treatment of patients with severe acute respiratory syndrome (sars) in recovery stage coronary microembolization: from bedside to bench and back to bedside reperfusion injury, microvascular dysfunction, and cardioprotection: the "dark side" of reperfusion prevention of no-reflow phenomenon in acute coronary syndrome hypertension, society, and public policy promoting the integration of tcm and wm by fully utilizing modern science and technology a new sesquiterpene lactone-qinghaosu 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traditional medicine with biomedicine towards a patient-centered healthcare system the current work was partially supported by the national basic research program of china (973 program no. 2003cb517103) and the national natural science foundation project of china (no. 90209011). the first author and the corresponding author contributed equally in this paper. all authors manifest that there is no conflict of interests. key: cord-031315-p7jb4gf2 authors: kong, qing; mo, shuming; wang, wenqian; tang, zihui; wei, ying; du, yijie; liu, baojun; kong, lingwen; lv, yubao; dong, jingcheng title: efficacy and safety of jia wei bushen yiqi formulas as an adjunct therapy to systemic glucocorticoids on acute exacerbation of copd: study protocol for a randomized, double-blinded, multi-center, placebo-controlled clinical trial date: 2020-09-03 journal: trials doi: 10.1186/s13063-020-04669-5 sha: doc_id: 31315 cord_uid: p7jb4gf2 background: systemic glucocorticoids are effective for the management of chronic obstructive pulmonary disease (copd) exacerbation but have serious adverse effects. traditional chinese medicine (tcm) can bring additional benefits to these patients but has few adverse effects. the present study aims to evaluate the efficacy and safety of jia wei bushen yiqi (jwby) formulas in patients who suffer from copd exacerbations and to investigate whether the short-term (5-days) systemic glucocorticoid therapy is non-inferior to the long-term (9-day) regime. methods: in this multi-center, randomized, double-blinded trial, eligible inpatients with copd exacerbation are randomly assigned to four groups (a, b, c, and d). group a will receive placebo plus 5-day prednisone, group b will receive placebo plus 9-day prednisone, group c will receive jwby formulas plus 5-day prednisone, and group d will receive jwby formulas plus 9-day prednisone. the primary outcomes are the time interval to the patient’s next exacerbation during a 180-day following up and the copd assessment test (cat) during treatment. secondary outcomes include lung function, tcm syndrome assessment, laboratory tests, and safety. the changes of the hypothalamic pituitary adrenaline axis (hpa axis) and inflammatory cytokine will be measured as well. discussion: by demonstrating the advantages of utilizing tcm and an appropriate duration of systemic glucocorticoids, this effectiveness comparison trial will provide new references to physicians on how to improve the management of copd exacerbation. the results of hpa axis and inflammation cytokine measurements will shed light on the molecular mechanisms and entail further mechanism studies. trial registration: www.chictr.org.cn chictr1900023364. registered on 24 may 2019. chronic obstructive pulmonary disease (copd) will become the third leading cause of death worldwide in 2030 [1] . 13 .7% of the population over 40 years old suffer from copd in china [2] , creating a large socioeconomic burden [3] [4] [5] . copd exacerbation is defined as the acute worsening of respiratory symptoms that require additional therapy [6] [7] [8] . acute exacerbations of copd impair pulmonary function and exponentially increase the risk of death [9] . therefore, effective management of copd is critical to human health. according to international guidelines and evidencebased reviews, systemic glucocorticoids are recommended to treat copd exacerbation [10] [11] [12] [13] [14] [15] . the advantages include shortened recovery time and hospitalization duration, improved lung function and oxygenation, and reduced relapse risk and treatment failure, which have been demonstrated by numerous randomized clinical trials (rct) [16] [17] [18] [19] [20] [21] [22] . however, the side effects like hypertension, hyperglycemia, gastrointestinal bleeding, psychiatric disease, and hypothalamic pituitary adrenal axis (hpa axis) suppression increase with the extension of treatment duration and the escalation of dose [23] . controversy over the optional duration continues. on one hand, a dose of 40 mg prednisone (a common oral systemic glucocorticoid) daily for 5 days has been recommended by the global initiative for chronic obstructive lung disease (gold) science committee report based on the reduce randomized clinical trial since 2015 [24] . the trial indicated the efficacy of 5-day systemic glucocorticoids is noninferior to 14-day systemic glucocorticoids regarding relapse within a 6-month follow-up, but significantly reduced glucocorticoid exposure. on the other hand, a dose of 30-40 mg prednisone daily for 9-14 days [10, 12, 13] was suggested by another academy of china, korea, and europe in 2017. yet, no clinical trials have determined the difference between the 5-day and 9-day regimes. in addition, treatment individualization brings benefits. for instance, an inhaled corticosteroid (ics) is more efficacious in patients with high blood eosinophils [25] [26] [27] . however, present pharmacotherapy has failed to reverse the downtrend in pulmonary function completely [28] . hopefully, traditional chinese medicines (tcm) can expand copd treatment in terms of syndromic difference, also called zheng [29] . not only has tcm alleviated symptoms such as coughing, shortness of breath, and sputum for thousands of years, but also has demonstrated its efficacy and safety [30] [31] [32] [33] [34] . however, there are rarely studies focused on copd patients during the acute exacerbation period, most of them focused on the relatively stable period. we conducted a randomized and placebo-controlled trial enrolling stable copd patients in 2014, which illustrated that tcm formulas called bushen yiqi (by) formulas can improve the lung function, reduce the frequency of acute exacerbation of copd, and modulate the hpa axis [35] . dr. shen replaced glucocorticoid therapy with tcm formula (by) totally in chronic inflammatory disease [36] . moreover, several ingredients in by can decrease the inflammatory reactions in copd animal models [37] . recently, we have observed that by formulae combined with another two chinese herbs-huang qin (scutellaria) and chi shao (paeoniae rubra radix)-demonstrate more effectiveness on the management of acute exacerbation of copd in clinical practice, such as relieving the symptoms including the cough, sputum, as well as shortness of breath. interestingly, the laboratory experiments showed that the main compound of these two chinese herbs benefits the animal of copd model. for instance, scutellaria baicalensis in huang qin significantly improved lung function, ameliorated the pathological damage, and attenuated inflammatory cytokines infiltration into the lungs [38] . similarly, paeonol in chi shao showed antiinflammatory and antioxidant effects against cs-induced lung inflammation in both in vivo and in vitro experiments [39] . therefore, we propose that jia wei bushen yiqi formulae (jwby)-bushen yiqi formulae combined with huang qin and chi shao-will benefit patients with acute exacerbation of copd. this study aims to demonstrate non-inferiority of a 5-day therapy compared with a 9-day regimen of systemic glucocorticoids based on the copd outcome during the 180-day follow-up period. it also seeks to determine the relative inferiority of jwby formula as an adjunct treatment to systemic glucocorticoids compared with systemic glucocorticoids alone for copd exacerbation. this is a multi-center, double-blinded, placebocontrolled, randomized clinical trial. this trial will be conducted in two stages: a 9-day treatment and then a 180-day follow-up. qualified patients will be randomized to 4 groups: group a will receive placebo plus 5-day prednisone, group b will receive placebo plus 9-day prednisone, group c will receive jwby formulas plus 5day prednisone, and group d will receive jwby formulas plus 9-day prednisone. assessments will be performed on day 6 and on day 10 during treatment and telephone calls will be conducted on day 90 and on day 180 when patients are discharged (fig. 1) . the 9 day-treatment is chosen for two reasons. first, it is because of the two aims that were mentioned above. second, the 9-day treatment period is based on our investigation result that most copd exacerbation symptoms can be alleviated within 10 days. in other words, 9 days are the common hospitalization time in ten subcenters. therefore, the 9 day-treatment is a good time for patients to complete the study during hospitalization, which will promote the compliance of patients and collect as much data as possible. the 180-day follow-up time is based on the results from the reduce randomized clinical trial research published on jama in 2014. it is reported in this trial that the median number of days of follow-up was 180 in both the conventional group (10th percentile, 179; 90th percentile, 181 days) and in the short-term treatment group (10th percentile, 178; 90th percentile, 181 days). this trial will be conducted at ten hospitals located in shanghai, yunnan, xinjiang, and jiangsu province in china. five hospitals are selected because they are attached to universities and another five hospitals are selected because they are experienced in rct. also, these hospitals are spread out throughout china ( table 1 ). the principal investigator (pi) work at huashan hospital and is responsible for the steering committee meeting, which includes protocol training, supervision of safety, quality control, feedback of progress, and study reports. pis of other hospitals will organize their clinical physicians and nurses to carry out recruitment and follow-up. patients that are hospitalized with copd acute exacerbation and meet the inclusion and exclusion criteria ( table 2) will be eligible to be study participants. acute exacerbation of copd with clinical grade 2 is defined as follows: respiratory rate > 30 times/min, application of assisted respiratory muscles, no mental state change, hypoxemia can be improved by the 25%-30% oxygen concentration in the inner cover of the venturi, and hypercapnia or partial pressure of carbon dioxide (paco 2 ) increases to 50-60 mmhg from the baseline value. patients who are diagnosed as having respiratory failure but without the risk of death are appropriate for ordinary hospitalization, as recommended by the chinese expert consensus on the diagnosis and treatment of acute exacerbation of chronic obstructive pulmonary disease (aecopd) (2017 update) [10] . in other words, a moderate degree of copd exacerbation does not indicate the need for intensive care unit (icu) admission according to 2019 gold guideline [24] . tcm syndrome differentiation-fei_shen_qi_xu_yu_ re zheng in chinese-specifies people who have lung and kidney qi deficiency mixed with blood stasis and (table 3) . study centers are selected from level a hospital in china. the investigators will be selected from attending physician who majors in respiratory disease. prior to the trial, all sub-center physicians, nurses, and other staff will be trained to understand the protocol. attending physician who will take charge of the patients obtains consent from potential participants or authorized surrogates. firstly, attending physician will introduce the trial including the origin of tcm formula, the prednisone effect, what they should do, and what will benefit them if they volunteer to participate in this trial. then, physician will reply to the questions that confuse patients. finally, both the physician and patient will sign the informed consent form to indicate the patient's full understanding of the protocol. in the consent form, participants will be asked if they agree to use of their data should they choose to withdraw from the trial, and if they are volunteer to provide another 25 ml blood for storage, which are used to explore their inflammation level, hpa axis function, and the relationship between effectiveness and gene type. participants will also be asked for permission for the research team to share relevant data with people from the hospitals who take part in the research. as we mentioned in background, prednisone of 30-40 mg once daily is recommend for copd exacerbation management since 2014 by golg guideline. the evidence is from a clinical trial that compare the efficacy of 14 days of prednisone treatment with 5 days. the participants come from sweden. as in other countries like china, the duration of prednisone treatment is recommended as 9-14 days. the differences of the outcomes between 5 days of treatment and 9 days are unknown in the chinese patients. since we choose the relatively mild patients with copd exacerbation, the minimum dose of prednisone 30 mg once daily is decided in this trial. in addition, tcm formula has been used for copd therapy for thousands of years. we have observed the superiority of tcm as an adjunct therapy in copd administration. but there is no evidence to show the exact outcomes. the doses of five tcm herbs are decided by a group of experienced tcm physician who used the principle of tcm in treating copd for many years. the control group is placebo that contains 10% true herbs with the same appearance and smelling as the drugs. severe impairment of heart, liver and kidney function (heart function 3-4 degree, aspartate aminotransferase (alt) and/or alanine aminotransferase (ast) exceeds 1.5 times of the upper limit of normal, creatinine (cr) exceeds the upper limit of normal) 6 . received systemic glucocorticoids within 2 weeks or participation in other drug clinical trials within 3 months prior to the trial 7. other conditions that the investigators consider to be improper all the participants will be provided with standard of care (soc) according to the 2019 gold guideline for copd exacerbation during hospitalization and after discharge (table 4) . a 9-day adjunct medication includes systemic glucocorticoids and tcm herbs or their placebo. a basic dose of 30 mg prednisone daily for 5 days will be provided for all participants. the prednisone will be continued in the long-term glucocorticoids arm of the trial in the following 4 days and replaced with the placebo in short-term glucocorticoids arm of the trial. the 9-day treatment period is based on the fact that most copd exacerbation can be relieved within 10 days. meanwhile, participants will be treated with tcm herbs or placebo. participants will be randomized to four groups with different adjunct medication ( fig. 1) . because of the complex and variety in copd exacerbation, variation among patients will be allowed. any variation like another antibiotic used for the indication will be recorded in the case report form (crf). tcm treatment is in accordance with the most common tcm syndromes of copd in a real-world study [40] . the dosage of jwby formula is selected according to the pharmacopeia of chinese medicine, and the effective ingredient of its granules is determined according to the pharmacopeia of pharmacopeia. jwby formulas contain 5 kinds of herbs: huang qi (astragalus) 30 g, yin yang huo (epimedy) 20 g, sheng di huang (radix rehmaniae) 15 g, chi shao (red peony) 30 g, and huang qin (scutellaria) 30 g, concentrated as 20.48 g granules. to use, patients can infuse 10.24 g granules into 125 ml of boiling water and ingest orally after breakfast and supper, twice daily. its placebo is identical in appearance, shape, size, and package with jwby formulas, but only contains 10% real herbs. the granules will be produced and packed by huarui sanjiu pharmaceutical industry in shenzhen, china. granule production will be certified to get the standard certification of the tcm national drug regulatory authority. modification or discontinuation of the intervention will be decided by the pis in each center, according to the requests from participants, or when a participant's disease is worsened to grade 3 which indicates the need for icu admission, or when unexpected adverse effects happen. prednisone and jwby granules are free as study drugs. five-day drugs will be provided to participants at baseline by a sub-center investigator and another 4-day drug at day 6. participants will use patient diaries for recording medication and changes in symptoms. all unused packs of drugs and empty bags will be returned to investigational site on day 6 and on day 10. compliance will be calculated by counting drugs or empty bags for a 9day course. compliance % of medication = [actual dose/ (specified daily dose × days)] × 100%. total medication consistency ranging from 80 to 120% will be eligible for the protocol analysis set. patients enrolled in the trial will be all hospitalized and all the laboratory tests will be performed on standard schedule, which aids in the monitoring of adherence. once the patient is randomized, the investigators will take every reasonable effort to follow the patient for the entire course of the study. all examination and transportation costs in the 30-day will be covered and the results of symptoms and physical exams will be explained at every visit. messages will be sent through wechat or by phone prior to every visit to remind the patients of the follow-up visits. extra copd-related drugs, such as leukotriene receptor antagonists, antihistamines, immunosuppressants, and antioxidants, will be forbidden during the trial. tcm herbs that are tonifying kidney, benefiting qi, clearing away heat, and promoting blood circulation, whose tcm characteristics are like those within jwby formulas, will be avoided. drug combinations will be recorded in the case report form at each follow-up visit. "tonifying kidney" ("bushen" in chinese) is a tcm term of treatment, which aims at the tcm syndrome "deficiency of kidney" ("shen_xu" zheng in chinese). the chinese herbs used in "tonifying kidney" treatment can relieve "deficiency of kidney" syndrome including shortness of breath, deterioration with movement, fatigue, waist and knee area sore, and their weakness, tinnitus, dizziness, incontinence, or heavy urine volume. patients that are enrolled into the study will be covered by indemnity through the standard national health service indemnity arrangements. the pi will provide the compensation to those who suffer due to trial participation. primary outcomes measurements 1) the time to the next exacerbation of copd during the 180-day follow-up is defined as one primary outcome. the definition of exacerbation is deterioration of the cardinal symptom of dyspnea, increased sputum purulence and volume, and purulent sputum. this may be combined with one of the other symptoms: increased cough and wheeze, sore throat, nasal congestion due to cold, fever (oral temperature > 37.5°c), increased cough, and increased wheezing. the above changes should last for ≥ 2 days at least. a minimum of 1 week between two exacerbations is needed in order for them to be considered as separate events. the duration of exacerbation is measured from the onset of acute exacerbation to a significant reduction which is defined as the symptoms return to the level before the exacerbation per the records in patients' dairies. the diaries are distributed to participants during the treatment and after the treatment. participants record changes of their symptoms and their health status by choosing the right description in terms of feeling. the primary symptom is measured with modified british medical research council (mmrc) and copd assessment test (cat) scores. the days of exacerbation are calculated from the onset date of the primary symptom to the date when all symptoms disappear. the degree is classified as mild (treated with short acting bronchodilators only, sabds), moderate (treated with sabds plus antibiotics and/or oral corticosteroids), or severe (patient requires hospitalization or visits to the emergency room). severe exacerbations may be associated with acute respiratory failure. 2) the mean difference of cat scores between day 6 or day 10 and baseline is another primary outcome. the cat involves an 8-dimension measurement of health-status impairment in copd. cat is universally acknowledged as a reliable and valid measurement in evaluating the changes of copd. 1) tcm syndrome assessment will be evaluated from baseline to day 6 and day 10. according to the guiding principles for clinical research of new drugs in traditional chinese medicine, the syndrome score is calculated as efficacy index n = (pre-treatment score − post-treatment score)/ pre-treatment score × 100%. in terms of mild, moderate, and severe symptoms, the primary symptoms are given 2, 4, and 6 points while the secondary symptoms are given 1, 2, and 3 points respectively. total score = scores of the primary symptoms + scores of the secondary symptoms. 2) lung ventilation function will be assessed by forced expiratory volume in 1 s (fev1), forced vital capacity (fvc), and peak expiratory flow (pef) from baseline to day 6 and day 10 with standardized equipment (erich jaeger uk ltd., market harborough, uk jaeger master-screen, germany) and per the standard procedure recommended by american thoracic society (ats) [39] . 3) blood gas analyses including partial pressure of oxygen (pao 2 ), partial pressure of carbon dioxide (paco 2 ), infectious indexes including blood eosinophil count in cells per micrometer (eos), creactive protein (crp), and proclamation will be tested by clinical laboratories in the sub-center from baseline to day 6 and day 10. side effects will be collected at day 30, day 60, and day 180 during follow-up. this specifically refers to (1) the changes in hyperglycemia: fasting plasma glucose ≥ 5.6 mmol/l or random plasma glucose ≥ 7.8 mmol/l or rise ≥ 20% in daily doses of insulin or any increase in oral anti-diabetic drugs or initiation of one or more antidiabetic therapeutics, (2) changes in hypertension: systolic blood pressure ≥ 140 mmhg and/or diastolic blood pressure ≥ 90 mmhg or the addition of one or more anti-hypertensive drugs to previous treatment regimens, and (3) the number of psychiatric symptoms, asphalt, vomiting coffee samples, and new infection. laboratory tests which include routine blood test, routine urine test, electrocardiogram (ecg), kidney and liver function, and x-ray computed tomography (ct scan/x-ray) of the chest will be conducted at baseline, day 10, and day 30 during the follow-up. if the results of ct scan/x-ray and ecg are normal at baseline, it will be skipped in the follow-up. the pathology of copd is relevant to the inflammation and the suppression of the hpa axis that follows the treatment with glucocorticoids. therefore, changes in the hpa axis including corticotropin-releasing hormone (crh), adrenocorticotropic hormone (acth), and cortisol and the inflammation cytokines including interleukin-6, interleukin-8, and interleukin-10 at baseline and on day 6 and day 10 will be measured. there are four groups with two variables in this trial-tcm treatment and systemic glucocorticoid treatment. therefore, according to primary endpoints collected from previous trial [34, 41] , we choose the maximum sample size needed, as calculated by two way on http:// www.powerandsamplesize.com (table 2 ). at the 5% significance level, a total of 67 patients per group will be required for a 2-group, 1-sided calculation to achieve 80% power and the differences of 10.30 ± 6.31 and 12.95 ± 5.99 in cat mean score between the tcm treatment group and placebo group (table 5) . meanwhile, a total of 88 participants will be required for a 2group non-inferiority calculation to achieve the mean difference of the time to next exacerbation (43.5, 29) and a non-inferiority margin of 10, under the condition that the standard deviation of the groups is equal to 12 (table 5) . a loss of 15-20% to follow-up is predicted based on experience-this increases the sample size to 200 participants per group, resulting in 400 in total. all investigators in the sub-center will advertise and distribute posters in their emergency department and nearby communities. in addition, we will set up a hierarchical medical system in shanghai-communities refer the potential patients to huashan hospital directly where the clinical trial is undertaken. participants will be randomized with equal probability (1:1:1:1) to receive one of the four treatments that were mentioned above. as the size of each group is predicted to be 100, the allocation sequence is generated with sample randomization and stratification by trial center. the sequences will be generated by software and in excel format. before the study begins, a series of random numbers will be generated by the computer, and the pharmacists involved in the study place the random numbers in plain, closed envelopes marked with patient numbers. envelopes will be made and stored at the pharmacy and opened by the pharmacist only when the subjects are randomized. the envelopes will be not accessible to individuals directly involved in the study. allocation sequence will be generated by a statistician who will not participate in enrolling participants. participants will be blindly randomized and allocated with an identified number. principal investigators including attending physician and nurses will involve in enrolling participants. pharmacist will distribute an independent emergency envelope for each participant, which contains the treatment assignment. the participants in the placebo group will be given the same number of pills and followed the same medication schedule as the treatment group. to ensure the implementation of the blinding method, the pill and herbs in both the treatment group and the placebo group will be made in the same shapes, smells and tastes. trial participants, care providers including attending physician and nurse, outcome assessors including pi and sub-pi, and data analysts will be blinded after the assignment of interventions. double-grade unblinding will be adopted. first grade unblinding: it will be conducted before the data analysis. after the double input of all the crf data into the computer and blinded review, the data will be locked. afterwards, the personnel who keep the blinded materials will unblind them for the first time, which is to divide the groups corresponding to the case numbers into blinded codes of two groups and to tell the statisticians so as to statistically analyze all the data. second grade unblinding is after the statistical analysis and the completion of clinical trial report. it will be conducted at the wrap up meeting for the clinical trial. the treatment group and control group will be unblinded. place of unblinding will be the unit where the clinical trial is in charged. executive personnel will be the chief researcher and statisticians of the unit that are in charge of the trial. if there is severe adverse event, which impedes the progress of the trial and the selection of the treatment measures, urgent unblinding can be carried out. during the process, all the researcher, sub-pi, and clinical supervisors should take part. the local administrative unit should be informed within 24 h. the reason, time, and place of unblinding should be recorded in detail and all the records should be signed off. afterwards, the clinical supervisors should be informed timely. the case data should be kept intact. prior to the start of the trial, sub-center physicians will be trained. the results of laboratory tests from different hospitals are adjusted per the huashan hospital standards during analysis. demographic information (date of birth, gender, etc.) and medical condition (medical history, concomitant medication, etc.) will be recorded at baseline. all the questionnaires will be answered by patients without inducement. when adverse events that are related to study drugs happen, emergency envelope can be considered as needed to be opened by pis and physician. the investigators will report the reasons and outcome to the pi within 24 h. prior investigation shows that the mean hospitalization duration time is about 8-9 days in these 10 hospitals, which matches the trial requirement of 9 days of treatment. after screening and completing baseline evaluations, participants will visit the physician at day 6 and day 10 during adjunctive treatments and day 30 when patients are discharged (fig. 2) . we will provide free tcm granules and partial examination reimbursement to participants. the participants and their family member will be informed that standardized treatment is beneficial to reduce copd exacerbation, which will reduce medical expenses the benefits. two telephone calls will be conducted on day 90 and day 180. the writing and transfer of case report the case report will be written by the doctor who has participated in the trial. every case should have a complete case report. the case report, once completed, should be checked by the supervisor. afterwards, it will be transferred to the data administrator for data entry and management. all the information in crf table will be recorded in a specialized clinical experimental database that is designed by chinese academy of traditional chinese medicine. the format of the database should be close to that of the crf table so as to facilitate the data entry. the variables in the crf table will be encoded and the codes will be kept unchanged during the whole process of clinical research. the crf data will be entered by highly trained specialists from the research centers. the audit of data can be divided into two forms: manual audit and system audit. the former refers that the administrator checks the consistency and logic of the data so as to find the mistakes and to generate the question list. sas software sets the limit of all variables and rules out automatically the unqualified data by running the system program. the question list is sent to the clinical supervisor who transfers it to the researcher for reconfirmation. the related revision should be signed and dated by the researcher. the researcher will correct the data for the last time after the return of all question lists. all the corrections and updates should be recorded and filed. after the data is verified, the data administration meeting will be held so that the corrections and updates can be summarized. at last, the data administrator will announce the locking of database and keep the cipher code. the statistical analysis prospectus will not be changed after the database lock. the data will be transferred to the statistical department for analysis. all the data should be kept according to the requirements of gcp. after the experiment, all the original copy of case reports and records for the administrations of clinical drugs should be checked, signed, and stamped by the supervisors, head researchers, and representatives from gcp office of each clinical center, and finally, these records will be sent to the leading site where the database will be established and the data will processed. statisticians will analyze the data and materials from the participating centers, and the summary of the clinical trial will be completed in the leading site. case report form (crf) collects all the information throughout the trial for every participant. as soon as verification is completed, data will be securely stored and sent to huashan hospital from the sub-centers. a data management group will be established, and the information will be entered into the database provided by http://www.rilintech.comt through independent doubledata entry. the errors and inconsistencies of data will be checked during the entry process. the user identification code and password will be protected by the data management group. the pis will be given access to the cleaned data sets. sub-investigators will only have access to the data sets in their own hospital. original paper forms will be kept in huashan hospital for 5 years. plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} the process and collection of blood samples separation of 1-2 ml of plasma from 4 ml of whole blood the anticoagulant and aprotinin (for concentration and amount, please refer to the note) will be added to the blood-collection tube, which is placed at 4°c for precooling, and then1.5 ml of whole blood will be collected. the samples will be mixed in the tube slowly, and afterwards, the mixture will be centrifuged at a low temperature (4°c, 4000 r/min, 15-20 min). 0.5 ml of plasma will be collected and kept at a low temperature (− 80°c). if the collected blood cannot be centrifuged immediately, it can only be stored in 4°c freezer for up to 1 h. note: the concentration and amount of anticoagulant and aprotinin. anticoagulant: 0.3medta.2na concentration (20ul/ ml) or 1% heparin (10ul/ml); aprotinin (500 iu/ml). there are two kinds of aprotinin: liquid (the concentration will be noted on the label) and solid (10,800 iu/mg). the solid form of aprotinin can be dissolved in normal saline, so its concentration can be adjusted to 500 iu/20 μl. requirements for sample storage the samples should be kept immediately in − 80°freezer. throughout the transportation, the samples cannot be taken out. in huashan hospital, all of the samples are checked. the samples should be labeled with case codes and collection date. blood serum should be kept in dry ice for transportation. primary and secondary outcomes the tcm intervention arm-jwby (jia wei bushen yiqi formulas)-will be compared against the placebo. the short-term systemic glucocorticoid (ssg) arm will be compared against the long-term systemic glucocorticoid (lsg) arm. four groups will be compared with each other independently. statistical package for social sciences for windows, version 24.0 (spss, chicago, il, usa) will be used for analysis. the tests will be 2-sided, and a p value with alpha ≤ 0.05 level is considered significant. p values will be reported to four decimal places with p values less than 0.001 reported as p < 0.001. the bonferroni method will be used to appropriately adjust the overall level of significance for multiple comparisons, assuming an exchangeable correlation structure. categorical variables will be summarized by absolute numbers and percentages of total. the difference of categorical variables will be assessed with the generalized estimating equations (gee). gee will also be used to assess the impact of potential clustering of participants in the same hospital. safety outcomes will be analyzed with summary statistics (frequency, count, percentage). the method of analysis of each variable are summarized in table 6 . the score of copd assessment test (cat) will be collected at baseline, day 6, day 10, and in the 30 days, 90 days, 180 days after discharge. the mixed effect normal model (menm) will be used to compare each outcome against the tcm intervention group and placebo. the estimate of treatment effect will be presented as unadjusted rate ratio followed by an adjusted ratio with adjustment for a set of pre-specified baseline variables. the list of pre-specified variables is as follows: centers (as a random effect), age (in years), gender (male or female), weight (in kilogram), smoking (pack per year), fev1% predicted, the number of copd exacerbation in the previous 1 year, and home-oxygen therapy. fixed effects will include the visit number, treatment, and all the prespecified variables. participant and visit interaction will be fitted as random effects. an autoregressive correction structure will be used throughout. the difference of interval time to next exacerbation during follow-up in the 30 days, 90 days, and 180 days will be compared between ssg and lsg groups using the generalized linear model (glm) with a log-link function, a propriety over dispersion parameter, and length of time as an offset. the numbers will be described respectively in three gradesoutpatient, inpatient, and icu. durations of copd exacerbation will be compared between each two of the four groups with glm in the similar manner as before. specially, the shortness of breath measured by mmrc dyspnea scale (1-5 degree) in the diary will be undertaken in the logit link function independently. the changes in tcm syndrome score, infectious index, lung function, blood gas analysis, inflammatory cytokine levels, and hpa axis will be collected in baseline, at day 6, and at day 10. glm will be used to analyze the change between each two of the four groups as well. none. in this trial, interventions for participants include 9 days of tcm granules and 5 or 9 days of prednisone. these two interventions will be carried out during hospitalization and they are routine treatments in china, so there are no anticipated problems that will be detrimental to the participant. therefore, there will be no interim analyses and there are not anticipated formal stopping rules for the trial. methods for additional analyses (e.g., subgroup analyses) {20b} subgroup analysis the potential subgroups have been listed in table 3 . the analysis of primary outcomes will be repeated in the subgroups. methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} analysis will be in accordance with the intent-to-treat principles. the safety set (ss) includes participants that are randomized and have received adjunct treatments and one post-treatment safety assessment at least. the full analysis set (fas) includes participants that are randomized and have received adjunct treatment, and their primary outcomes are available at least in one visit. the per protocol set (pps) includes participants in accordance with all the following conditions: valid baseline values, compliance with the program, no violation of the inclusion and exclusion criteria specified in the program, completion of all assessments, and good compliance (defined as participants taking at least 80% of expected doses of study drugs as determined by counting). missing data is predicted to appear on day 30 and during the two telephone calls after discharge. the imputation of all the outcomes will be replaced by the mean of the group. plans to give access to the full protocol, participant level data, and statistical code {31c} full protocol participant level dataset in chinese will be accessible in the register site. and statistical code will be provided by trial statistician. for sharing purpose, data will be available to outside investigators at the end of the trial. the finding of this trial will be published in peerreviewed journals and presented at conferences. the results of the study will be released to the participating physician and patients. composition of the coordinating center and trial steering committee {5d} multi-center trial coordination committee will be established. the huashan hospital affiliated to fudan university will take charge of the committee, and the main researchers of the participating units will serve as the members. the committee will be responsible for the implementation of the whole experiment and resolve problems during the trial process. the head researcher should strengthen quality surveillance of the clinical trial in his own center. composition of the data monitoring committee, its roles and reporting structure {21a} the data monitoring committee is unnecessary in this trial, because the drug duration in this trial is short-9 days. tcm granules and prednisone are routine treatment in china and will be carried out during hospitalization; only minimal risks are anticipated. adverse event report regardless of whether it is related to the study drug or not, any clinically significant abnormalities of medical events or laboratory tests will be defined as an adverse event (ae). for all adverse events, the time, duration, treatment measures and outcomes, the severity of the disease, and the association with the study drug will be evaluated and recorded. it is divided into mild, moderate, and severe according to the following list: conscious symptoms, ability to tolerate, impact on daily activities, duration, whether it is relieved during continued medication, and whether treatment is required. serious adverse events (sae) will be defined as death or life-threatening events. if a sae occurs, the doctor will immediately take emergency measures and report it to the pi and the ethics committee within 24 h. according to the occurrence of adverse events and a reasonable time interval, and alleviation after withdrawal of the study drugs, the correlation between adverse events and study drugs will be evaluated as affirmative (sure), probably related (very likely), may be relevant (possible), may be unrelated (suspicious), and irrelevant (impossible). due to the unsatisfactory treatment effect, the patient will withdraw from the trial. the emergency letter of the case will be opened, and the patient's family will coordinate with the follow-up and report the result to the lead center. the relevant information will be recorded in the case report form. although the formula is optimized to instant granule instead of tcm herbs decoration in our study, some participants who never accepted tcm herbal previously may have gastrointestinal reactions such as nausea and vomiting. they will be suspended for 3 days and evaluated on their abilities to continue to participate in. because the participants are in the acute exacerbation period, their disease may deteriorate to grade 3 at any time with the worsening of clinical symptoms including increase of dyspnea, mental consciousness changes, blood gas analysis of acidosis, and hypoxemia that cannot be improved by oxygen absorption or other treatments. participants will be admitted to the intensive care unit (icu) if it happens. due to the worsening of the disease or the unsatisfactory effect, the emergency letter of the case will be opened. the physician-incharge will communicate with the patient's family if participant needs to withdraw from the study. the relevant information is reported to pi and recorded in the case report form. as for any deterioration syndromes that arise after discharged, participants will be advised to come to the hospital. the investigator will provide free medical services appropriately. the recommend dose of prednisone by 2017 chinese consensus is 30-40 mg daily for 9-14 days. the low dose of 30 mg is chosen. extra management measures were suggested during the initial meeting. first, the participants will be informed that the withdrawal symptoms include fatigue, joint muscle soreness, low mood, poor appetite, and even nausea and vomiting. second, participants discharged from the hospital with adrenal insufficiency will receive instructions on how to take less than 30 mg daily if they cannot tolerate the treatment. finally, participants will be advised to take the following preventive measures against possible adverse events. closely and modulate the number of hypoglycemic agents or insulin. 2) investigators will pay attention to whether the patient has abdominal pain, vomiting of coffee-like substances, or tar-like black stool. if this occurs, the patient should promptly come to the emergency department and be treated with acid-suppressing stomach and other drugs. 3) investigators will observe the patient's neuropsychiatric symptoms closely, such as euphoria, excitement, mania, and insomnia. if necessary, advise patients to seek medical help. the designated monitor will visit each investigational site once a month. the monitor will check that if the regulatory binder is complete and all that associated documents is stored well or not, including crf, informed consent forms, and adverse events reports. and the monitor will help the investigational site resolve the issues happened in the trial. plans for communicating important protocol amendments to relevant parties (e.g., trial participants, ethical committees) {25} any modification to the protocol which may impact the conduct of the study and the potential benefit of the patients will be reported to ethic committee. the amendments will be approved by the ethics committee before it is announced to each investigational site. and an investigator training about new protocol will be held through wechat video meeting. participants will be informed of the new protocol. participant information will not be released outside of the study without the permission of individuals except for monitoring. blood samples, data collection, and administrative forms will be identified with the same code and stored separately in a locked place. all data will be uploaded to the resman original data sharing platform (ipd sharing platform) http://www.medresman. org of the china clinical trial registry, which is available to outside investigators when the trial ends. the result will be published in peer-reviewed journals and shared at conferences. the findings of the trial will be released to the participating physicians and patients. with the design of tcm as an adjunct to systemic glucocorticoids to treat copd exacerbation in this randomized trial, we will test the non-inferiority of two different treatment terms of systemic glucocorticoids in copd exacerbation. the finding will bring new proofs to the controversial applications of glucocorticoids. in addition, we will clarify a pragmatic method to identify the efficacy of classic description based on tcm syndrome differences despite limitations like bias of measurement and the subjectivity of the questionnaire assessment which may be exacerbated by the loss of some participant during follow-up. the difference between the four groups will indicate that tcm reduces the suppression of the hpa axis and strengthens the anti-inflammation effect of glucocorticoids. tcm may strongly support and enrich the management of copd exacerbation. however, there are some limitations in this protocol. firstly, we choose one of the specific tcm syndromes as the criteria. the result is hard to be extended to the whole patients with copd exacerbation. in addition, we use the chinese guideline to evaluate the degree of copd exacerbation, which relies on the subjective assessment of symptoms of the enrolled participants by the physician. hopefully, an objective method will be proposed to assess the copd exacerbation. our trial has enrolled 10 volunteers in shanghai from 07 august 2019 up to today. we have modified protocol according to the practice and standard protocol items [42, 43] . in the meantime, we proposed amendment to ethics commitment and chinese clinical trial registry in july of 2019. the protocol version is ky 2019-299,03,03, july, 2019. the new protocol was reported to all subcenter pis in a group meeting. due to covid-19, we expect to complete the recruitment process around october 2020 and report the results as soon as possible. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04669-5. additional file 1. burden of copd prevalence and risk factors of chronic obstructive pulmonary disease in china (the china pulmonary health cph study): a national cross-sectional study prevention and management of copd in china: successes and major challenges chronic obstructive pulmonary disease in china: a nationwide prevalence study mortality, morbidity, and risk factors in china and its provinces, 1990-2017: a systematic analysis for the global burden of disease study international variation in the prevalence of copd (the bold study): a population-based prevalence study copd exacerbations: defining their cause and prevention symptom variability in patients with severe copd: a pan-european cross-sectional study acute copd exacerbations expert consensus on acute exacerbation of chronic obstructive pulmonary disease in the people's republic of china treatment with systemic steroids in severe chronic obstructive pulmonary disease exacerbations: use of short regimens in routine clinical practice and their impact on hospital stay copd clinical practice guideline of the korean academy of tuberculosis and respiratory disease: a summary diagnosis, prevention and treatment of stable copd and acute exacerbations of copd: the swiss recommendations use of glucocorticoids in patients with copd exacerbations in china: a retrospective observational study controlled trial of oral prednisone in outpatients with acute copd exacerbation oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease oral or iv prednisolone in the treatment of copd exacerbations -a randomized, controlled, double-blind study efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support systemic corticosteroids in acute exacerbation of copd: a metaanalysis of controlled studies with emphasis on icu patients prednisone in copd exacerbation requiring ventilatory support: an open-label randomised evaluation global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the gold science committee report 2019 susceptibility to exacerbation in chronic obstructive pulmonary disease acute exacerbations of chronic obstructive pulmonary disease identification of biologic clusters and their biomarkers blood eosinophils to direct corticosteroid treatment of exacerbations of chronic obstructive pulmonary disease: a randomized placebo-controlled trial effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of fev (1) -the lung health study zheng: a systems biology approach to diagnosis and treatments oral chinese herbal medicine for improvement of quality of life in patients with stable chronic obstructive pulmonary disease: a systematic review efficacy and safety of indacaterol 150 and 300 mu g in chronic obstructive pulmonary disease patients from six asian areas including japan: a 12-week, placebo-controlled study bu-fei yi-shen granule combined with acupoint sticking therapy in patients with stable chronic obstructive pulmonary disease: a randomized, double-blind, double-dummy, active-controlled, 4-centre study effects of comprehensive therapy based on traditional chinese medicine patterns in stable chronic obstructive pulmonary disease: a four-centre, open-label, randomized, controlled study effects of yupingfeng granules on acute exacerbations of copd: a randomized, placebo-controlled study effects of two chinese herbal formulae for the treatment of moderate to severe stable chronic obstructive pulmonary disease: a multicentre, double-blind, randomized controlled trial important action of improving adrenocortical function for certain diseases recovery effect and mechanism of several traditional chinese medicine components on inflammatory response of chronic obstructive pulmonary disease caused by exposure to cigarette smoke scutellaria baicalensis attenuates airway remodeling via pi3k/akt/nf-kappab pathway in cigarette smoke mediated-copd rats model paeonol attenuates cigarette smoke-induced lung inflammation by inhibiting ros-sensitive inflammatory signaling a real-world evidence study for distribution of traditional chinese medicine syndrome and its elements on respiratory disease short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the reduce randomized clinical trial spirit 2013 statement: defining standard protocol items for clinical trials spirit 2013 explanation and elaboration: guidance for protocols of clinical trials publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank dr. yiyuan zeng and dr. waijiao cai from school of public health, boston university, for their linguistic assistance during the preparation of this manuscript. qing kong and shuming mo drafted the manuscript. wenqian wang, zihui tang, baojun liu, yijie du and lingwen kong participated in the design of the study. zihui tang participated in the statistic plan. ying wei, yubao lv and jingcheng dong conceived the study, participated in its design and coordination, and drafted the manuscript. all authors read and approved the final manuscript. all named authors adhere to the authorship guidelines of trials; no professional writers have been involved. the enrolled participants who sign the informed consent forms about clinical data and bio-sample collection are provided with free medication of jwby formulas and prednisone for 9 days as needed. participants' information will not be released outside of the study without the permission of individuals except for monitoring. blood samples, data collection, and administrative forms will be identified with the same code and stored separately in a locked place. all data will be uploaded to the resman original data sharing platform (ipd sharing platform) http://www.medresman.org of the china clinical trial registry, which is available to outside investigators when the trial ends. the result will be published in peer-reviewed journals and shared at conferences. the findings of the trial will be released to the participating physicians and patients. central ethics committee approval has been obtained from ethics committee of huashan hospital affiliated to fudan university in shanghai, china (id: ky-2019299). the local ethics committee of other ten hospitals has approved the protocol, too. the trial was registered on www.chictr.org.cn (id: chictr1900023364) on may 24, 2019. the investigator will make safety and progress reports to the ethics committee monthly. protocol amendment will be approved by the ethics committee prior to the implementation of amended protocol at the sub-centers. all investigators are trained to carry out the new protocol. there is no conflict of interests among the subcenters. informed consent will be obtained from all study participants. these are available from the corresponding author upon request. there are no competing interests in this work.author details key: cord-024111-7yrftdp4 authors: zhang, runzhi; gao, xi; bai, hong; ning, kang title: traditional chinese medicine and gut microbiome: their respective and concert effects on healthcare date: 2020-04-22 journal: front pharmacol doi: 10.3389/fphar.2020.00538 sha: doc_id: 24111 cord_uid: 7yrftdp4 advances in systems biology, particularly based on the omics approaches, have resulted in a paradigm shift in both traditional chinese medicine (tcm) and the gut microbiome research. in line with this paradigm shift, the importance of tcm and gut microbiome in healthcare, as well as their interplay, has become clearer. firstly, we briefly summarize the current status of three topics in this review: microbiome, tcm, and relationship of tcm and microbiome. second, we focused on tcm's therapeutic effects and gut microbiome's mediation roles, including the relationships among diet, gut microbiome, and health care. third, we have summarized some databases and tools to help understand the impact of tcm and gut microbiome on diagnosis and treatment at the molecular level. finally, we introduce the effects of gut microbiome on tcm and host health, with two case studies, one on the metabolic effect of gut microbiome on tcm, and another on cancer treatment. in summary, we have reviewed the current status of the two components of healthcare: tcm and gut microbiome, as well as their concert effects. it is quite clear that as the holobiont, the maintenance of the health status of human would depend heavily on tcm, gut microbiome, and their combined effects. with the rapid advancement of research in traditional chinese medicine (tcm) and gut microbiome, studies involving both fields have significantly accelerated around the world. tcm and gut microbiome are closely related to human health. therefore, exploring the relationship between tcm and gut microbiome is essential for healthcare. the microbiome is a novel research field related to human health, bioenergy, agriculture, and the environment. it has recently emerged as a crucial factor in human physiology and disease. taking the microbiome into consideration, human beings could be considered "super organisms," with around 10% human cells and 90% microbial cells, most of which can be found in the gut (lederberg, 2000) . the human gut is a biological niche, home to a variety of microbes that affect nearly all aspects of human biology through their interactions with their hosts (blaser, 2014) . the human intestinal flora is a complex micro-ecosystem, containing approximately 10 14 microbes from more than 1,000 microbial species, of which the phyla firmicutes, bacteroidetes, and actinobacteria (gill et al., 2006) account for more than 90% of the species above. in addition, the genetic factors, dietary habits, and various environmental factors of the host lead to the diversity and the specificity of the human intestinal flora, while human intestinal flora in turn would play important roles in exerting host's physiological functions, such as metabolism, energy intake, and immune regulation. under normal circumstances, the intestinal flora is in a state of homeostasis. environment, drugs, and the other factors that destroy the structure of intestinal flora will cause dysbiosis, which may influence human health. recent studies have already accumulated ample evidences that the gut microbiome plays pivotal roles in many forms of chronic diseases. for example, inflammatory bowel disease (ibd) is a chronic bowel disease with clinical symptoms of abdominal pain, diarrhea, and unknown etiology, it includes ulcerative colitis and crohn's disease (cd) . the fecal microbiome of cd patients contains a significant reduction of firmicutes diversity, and it's worth mentioning that the clostridium leptum phylogenetic group has less abundance in cd patients than healthy (manichanh et al., 2006) . constipation is a common health problem with high mortality, as well as a predisposing factor for many conditions. bifidobacterium adolescentis exhibited strain-specific effects in alleviation of constipation . obesity is a global problem in that nearly 12% of the people worldwide are obese. obese mice had 50% fewer bacteroidetes and more correspondingly firmicutes than their lean littermates (ley et al., 2005) . besides, they reached similar conclusions for obese people (ley et al., 2007) . dietary interventions might lead to the modulation of gut microbiome, which will contribute to weight loss, enhance the integrity of the intestinal barrier, and reduce the antigenic load in the circulation, ultimately improving the inflammatory and metabolic phenotypes (xiao et al., 2014) . type 2 diabetes (t2d) is a complex disorder affected by genetic and environmental components (wellen and hotamisligil, 2005; risé rus et al., 2009) , and become a major public health problem on a global scale. a protocol has been developed for the metagenome-wide association study (mgwas) and a two-phase approach has been taken based on high-throughput sequencing of the intestinal microbiome of 345 chinese individuals. mgwas analysis revealed that the intestinal microbiome of patients with t2d was mal-regulated, which was manifested by the decrease in the abundance of certain universal butyrate-producing bacteria and the increase of pathogenic bacteria in various conditions (qin et al., 2012) . metformin is a widely used drug in the treatment of t2d. a recent study discovered the mechanism of metformin by regulating the composition of gut microbiome (wu et al., 2017) , indicating a close relation between the gut microbiome and t2d. human gut microbiome are structurally dynamic over time and plastic under different conditions, as the bacterial composition as well as the collection of genes varied with xenobiotics and the environment (zhao et al., 2012) . due to the close relevance between the microbiome and the human genome, the taxonomic and functional composition changes of the intestinal microbiome inevitably regulate gene expression and host immunity, which may lead to the occurrence of diseases, in particular, chronic diseases. in recent years, with the launching of various international projects on human microecology [e.g., hmp: http://www. hmpdacc.org/, metahit: http://www.metahit.eu/ and ihmp (proctor et al., 2014) ], gut microbiome have become the hotspot research between chronic diseases and the gut microbiome has steadily increased, promoting the most significant paradigm shifts in modern medicine. tcm is in constant development and inheritance along the long chinese traditional culture. it has been developed in clinics over thousands of years and has accumulated abundant clinical experience, forming a field with unique experiences and specific theories. the tcm system is complex, as it contains components of natural plants, animals, and mineral materials. tcm uses therapeutic herbs to treat the disease and restore the balance of physical function according to the patient's syndrome, based on the combination principle of "king, vassal, assistant and delivery servant" (yi and chang, 2004) . each prescription combination of these herbs is called a tcm preparation or prescription, such as liuweidihuangwan (lwdhw) pills. many chinese herbal medicines are known for their therapeutic effects compared to chemical and biological agents (chan, 1995; corson and crews, 2007; qiu, 2007) , which contain not only bioactive components but also various nutrients such as proteins and polysaccharides. for example, glycyrrhiza uralensis fisch., also called "gan-cao" in china, as a health-preserving and therapeutic agent, it has been widely utilized for more than 2,000 years. it is one of the most broadly used ingredients in tcm preparations in china, exerting a wide range of pharmacological efficacies. glycyrrhiza uralensis fisch. contains many bioactive ingredients, including glycyrrhizin, glycyrrhetinic acid, glycyrol, coumarin, and alkaloids. in addition, previous studies have shown that glycyrrhiza uralensis fisch. has a variety of pharmacological effects, including antitumor (shibata et al., 1991) , antiviral (nakashima et al., 1987) , and anti-inflammatory effects (kimura et al., 1988) . the traditional discovery pathway for most new drugs is to identify or design pharmacologically effective agents that specifically stimulate or inhibit a specific set of target receptors. nevertheless, the influence of the gut microbiome on humans has been largely ignored in this process. therefore, the pharmacological effects of these single target drugs on chronic diseases are limited. in contrast, since one of the characteristics of tcm is oral administration, the drug will interact with the intestinal flora inevitably. previous studies have proven that tcm is conductive to maintain the homeostasis of the intestinal flora (chang et al., 2015; zhou et al., 2016) , and the gut microbiome could also exert pharmacological effects of the tcm on host (park et al., 2006) , which render tcm a potential new drug in the western markets. thus, research about relationship between tcm and gut microbiome is significant, which helps researchers to further study the pharmacological effects of tcm on the human body and the causal links among intestinal microbiome with disease. in this review, we summarize the current status of microbiome, tcm, relationship of tcm and microbiome, as well as the therapeutic effects of tcm and gut microbiome's mediation roles. among them, databases and tools that contribute to the molecular understanding of tcm and the role of the gut microbiome in diagnosis and treatment are also presented. finally, we introduce the impacts of gut microbiome on tcm and host health, with two case studies, one on the metabolic effect of gut microbiome on tcm, and another on cancer treatment (figure 1 ). an increasing number of studies have been conducted on tcm, gut microbiome, and their interplay. statistics on the published papers in "public medicine (pubmed)" (https://pubmed.ncbi. nlm.nih.gov) and "china national knowledge infrastructure (cnki)" (https://www.cnki.net) showed that the number of literature on tcm and gut microbiome continued to rise in recent years ( figure 2 ). most importantly, due to the standardization of tcm, research on tcm and gut microbiome has received more and more attention around the world, and the tcm-related research outputs have shown explosive growth in 2019. to maintain the health of humans under various physiological conditions and environments, tcm and the gut microbiome must coordinate with each other to cope with the challenges. the interactions between tcm and the gut microbiome can mainly be categorized into four types ( figure 3 ): the regulatory effects of tcm on gut microbial communities are mainly reflected in treatment of dysbiosis to restore homeostasis of the intestinal flora. ganoderma lucidum (g. lucidum), called "ling-zhi" in china, has been widely used as a health-preserving and therapeutic agent. a water extract of g. lucidum has antiobesogenic effects, as it could modulate the taxonomical composition of the gut microbiome (chang et al., 2015) . the water extract of g. lucidum mycelium can reverse high-fat diet (hfd)-induced gut dysbiosis, indicated by the decreased firmicutes-bacteroidetes ratios and endotoxin-bearing proteobacteria levels. it can also maintain intestinal barrier integrity and reduce metabolic endotoxemia. in addition, it can reduce the expression and secretion of the proinflammatory cytokines tumour necrosis factor (tnf), interleukin-1-beta (il-1b), and interleukin-6 (il-6). the glucose tolerance and insulin sensitivity are improved by the extract as well. these effects are especially mediated by the gut microbiome, as it has already been observed from experiments on mice that the weight loss effect induced by g. lucidum is transmissible via transfer of feces from g. lucidum-treated mice to hfd-fed mice. the study has also demonstrated that the antiobesogenic effect of the g. lucidum water extract is mainly owing to its high molecular weight polysaccharide fraction (>300 kda). g. lucidum polysaccharide can inhibit colon expansion of colorectal cancer (crc) mice and reduce mortality by 30%, by alteration of reduced the relative abundance (ra) of cecal oscillospirawhich was first observed in crc mice, and down-regulation of four cancer-related genes (acaa1b, fabp4, mgll, and scd1) expression of colonic epithelial cells (luo et al., 2018) . gegen qinlian decoction (gqd), a traditional prescription, could effectively alleviate t2d by modulating the gut microbiome (xu et al., 2013) . in their study, compared to the patients with a low dose gqd and the placebo, patients who received high dose and moderate dose gqd showed remarkable reductions in adjusted mean changes from baseline fasting blood glucose (fbg) and glycated hemoglobin (hba1c). faecalibacterium prausnitzii was a species enriched significantly by gqd; the species was negatively correlated with hba1c and fbg, while 2-h postprandial blood-glucose levels were positively correlated with homeostasis model assessment of b-cell function, which suggests that the structure of gut microbiome was changed by gqd. furthermore, the amounts of beneficial bacterium, such as faecalibacterium spp., could be enriched by gqd treatment. it has been reported that another tcm, polygonatum kingianum, is effective in the treatment of diabetes and related diseases (deng et al., 2012) . a phytochemistry investigation demonstrated that the major types of active chemical constituents of p. kingianum were total saponins (tspk) and total polysaccharides (pspk). tspk and pspk could prevent the increase of fasting blood glucose after oral administration, and tspk could increase the content of fasting insulin. since tspk and pspk improved the intestinal microecology by increasing the abundance of firmicutes and decreasing that of bacteroidetes and proteobacteria, tspk and pspk could prevent t2d by changing the regulation of the gut microbiome (yan et al., 2017) . huang-qin decoction (hqd) is widely used to alleviate gastrointestinal disorders such as inflammatory bowel disease. hqd significantly inhibited the weight loss, tissue damage, colon shortening, and inflammatory cytokine changes caused by dextran sulfate sodium (dss). the relative abundance of lactococcus in the dss + hqp group was higher than that in the dss group, while desulfovibrio and helicobacter were decreased, indicating that hqd can improve dss-induced inflammation through its regulation in the gut microbiome. in addition to tcm directly acting on gut microbiome to ameliorate diseases, some tcms exert indirect effects on the intestinal flora . ginsenosides and polysaccharides in du-shen-tang made from panax ginseng are used to investigate their pharmacological effects on acute cold stress and overfatigue. it was demonstrated that the intestinal metabolism and absorption of certain ginsenosides were improved by polysaccharides. in addition, in recovery of the disordered gut microbiome, polysaccharides especially boost the growth of two important probiotics, lactobacillus spp. and bacteroides spp. (zhou et al., 2016) . glycyrrhiza uralensis fisch., also named licorice, has been commonly used for sore throat and gastrointestinal diseases. after administering different doses of licorice aqueous extracts to mice, they found that the proportion of bacteroides gates decreased significantly, and the proportion of phylum firmicutes increased and became dominant. bacteroides was reported to be associated with iga in humans and may cause colitis, and more phylum firmicutes than bacteroides lead to more efficient absorption of food calories. therefore, it is speculated that licorice aqueous extract can promote intestinal absorption, anti-inflammatory effect, and treatment of abdominal pain . diammonium glycyrrhizinate (dg), the main component of licorice root extracts, is a compound of the natural bioactive pentacyclic triterpenoid glycoside, can protect against nonalcoholic fatty liver disease (nafld) in mice through the decreasing of firmicutes-to-bacteroidetes ratio and endotoxin-producing bacteria such as desulfovibrio, and elevate the abundance of probiotics such as proteobacteria and lactobacillus. dg can also augment the levels of short-chain fatty acid (scfa)-producing bacteria such as ruminococcaceae to promote scfa production, and restoration of intestinal barrier . the regulation of tcm on human health can also be reflected in other microbial communities, including saliva and tongue coating (jiang et al., 2012; liang et al., 2014; li, 2015) . for figure 2 | number of published papers related to tcm-gut microbiota in pubmed and cnki. papers in pubmed were searched using keywords "gut/intestinal microbiota," "chinese," and "medicine"; papers in cnki were searched by chinese name of "tcm" and "gut microbiota/microbiome." the red bar chart represents the papers in chinese; the blue bar chart represents the papers in english. instance, through a network pharmacology approach (li, 2015) , the tongue coating microbiome have been found to be associated with various diseases including colorectal cancer (liang et al., 2014) and "cold-disease" (jiang et al., 2012) . therefore, the regulation of tcms can be reflected in microbial communities of various human body habitats, including gut and oral habitats, indicating quite diverse microbial-based approaches for noninvasive probing of human health status. in recent years, with the widespread use of synthetic and semisynthetic antibiotics, the problem of bacterial resistance has become increasingly serious in clinical fields. pathogenic bacterial infections are critical factors that may affect the development and severity of the disease. tcm was reported to possess a broad-spectrum antibacterial effect. therefore, systematic study on the antibacterial activity of tcm and the further development of new drugs have become the focus of more and more researchers. currently, more and more research indicate that tcm has antibacterial effect ( table 1) . in the long history of tcm treatment, diet has always been considered as an important category of resources. development of the research of gut microbiome involves not only the drug and tcm but also the daily diet of humans. recently, a rapidly increasing number of studies have indicated the crucial role of the diet for the treatment of disease (leboeuf et al., 2020; li et al., 2020b; moayyedi et al., 2020; naudin et al., 2020; yu et al., 2020) . in addition, studies about the close relationship between the diet and the intestinal flora have gradually aroused attention, which may offer us some new perspective for disease prevention. carbohydrates are important components of the daily diet and include monosaccharides, disaccharides, and polysaccharides. both fructooligosaccharide (fos) and polyphenols can be transferred directly into the large intestine of mammals alone, reshaping the composition of gut microbiome, which is beneficial to human health. the combination of different phenolic compounds and fos had a distinct impact upon the host, and gut microbiome improved by using prebiotics can delay the onset of senescencerelated health problems (zheng et al., 2017; tanabe et al., 2019) . adding catechin to an fos diet could inhibit firmicutes and enhance bacteroidetes. in addition, it turns out that antibiotic treatment influences the diversity and composition of the gut microbial community. furthermore, the use of probiotics or prebiotics to modulate antibiotic-induced gut microbiome destruction has been considered a desired treatment or prophylaxis (bron et al., 2011) . cefixime can reduce the diversity of the microbial community and lead to a significant decrease in the relative abundance of firmicutes. the composition of gut microbiome of lactobacillus and fos probiotic mixture treatment group was much more diverse than that of the natural recovery group, indicating a better recovery effect of the probiotic cocktails on the gut microbiome (shi et al., 2017) . moreover, the composition of the gut microbiome significantly changed in the hfd + fructose (hff)-fed and the hfd + sucrose (hfs)-fed rats compared with the control diet (c)-fed rats; body-fat mass, metabolic inflexibility, glucose intolerance, lipopolysaccharide (lps), insulin, renal reactive oxygen species (ros), malondialdehyde (mda), nadphox, and srebp-1 were significantly higher, and antioxidant enzymes and lean body masses were significantly lower in the hfs group with respect for the hff group (rosas-villegas et al., 2017) , indicating the harmful effect on the hfs group and the hff group on gut microbiome as well as the health of humans. carrageenan, agarose, and alginate are algae-derived undigested polysaccharides that have been used as food additives for hundreds of years. bacteroides uniforms l8 could degrade agarose completely, and the major enzyme secreted was b-agarase. the enzyme produced by isolate 38f6 (bacteroides xylanisolvens and escherichia coli), which degrades k-carrageenan oligosaccharides, is b-carrageenase, and alginate, guluronic acid oligosaccharides, and mannuronic acid oligosaccharides could be degraded by two enzymes from bacteroides ovatus g19 . vitamin d is an important pro-hormone for optimal intestinal calcium absorption for mineralization of bone (khazai et al., 2008) , which is common in high-fat food such as cream and salmon. vitamin d deficiency is a disease caused by air pollution, insufficient sunlight exposure, and altered dietary composition, which have also been associated with other diseases, including autoimmune diseases, hepatitis, and cancer (holick et al., 2011) . the functionality of the vitamin d-vitamin d receptor (vdr) axis in up-regulating and the activation/process of ileal a-defensins was identified. conversely, dietary vitamin d deviancy resulted in the loss of paneth cellspecific a-defensins, which may consequently lead to intestinal dysbiosis and endotoxemia, indicating that vitamin d is essential for the homeostasis of intestinal flora (su et al., 2016) . acetate has been widely distributed in nature, such as in fruits or vegetable oils. a recent study showed that acetate produced by protective bifidobacteria could improve intestinal defense that is mediated by epithelial cells, and this could protect the host against negative infection (fukuda et al., 2011) . in addition, moderate consumption of wine has shown the potential to delay the onset of neurodegenerative diseases: after drinking, microbial metabolites may effectively protect neuroblastoma cells from nitrosative stress injury (esteban-fernandez et al., 2017) . with the application of network pharmacology and related databases and tools, the research on tcm and gut microbiome has been further developed (figure 4) . commonly used databases of tcm gut microbiome research include the tcm database [tcm-mesh , tcmsp (ru et al., 2014) , tcmid , and hit (ye et al., 2011) ], as well as pathogen-host databases [phi-base (winnenburg et al., 2006) and ehfpi ]. tcm-mesh has integrated information about tcm ingredients, compound-protein interactions, as well as protein-disease relationships, to establish the largest resource for tcm target genes and diseases. based on the biological databases and clinical trial results, a researcher can analyze the "tcm-host-gut microbiome" interaction network from a holistic perspective. virtual metabolic human database (noronha et al., 2018) contains information on human and gut microbial metabolism, which is linked to hundreds of diseases and nutritional data by mathematical models. many tools are usually used for analysis and visualization as well. for example, qiime (caporaso et al., 2010 ) is a software that provides an open-source bioinformatics pipeline for performing microbiome analysis from raw dna sequencing data. it includes demultiplexing, quality filtering, operational taxonomic units (otu) picking, taxonomic assignment, phylogenetic reconstruction, diversity of analyses and visualizations. picrust (langille et al., 2013) is designed to predict microbiome functional content from marker gene (e.g., 16s rrna) surveys and full genomes. metaphlan (segata et al., 2013 ) is a computational tool for microbial communities analysis based on metagenomic sequencing data, in which the data were compared with the markers of each species obtained from the known database to determine the species category. muscle (edgar, 2004) and clustalw (thompson et al., 1994) are two algorithms used for multiple sequence alignments; muscle is a computer program for creating multiple alignments of protein sequences. mega (kumar et al., 2016 ) is a computer program package for estimating evolutionary distances, reconstructing phylogenetic trees, and computing basic statistical quantities from molecular data. additionally, itol (letunic and bork, 2016) is an online tool for visualization, annotation, and management of phylogenetic trees. furthermore, with the development of deep learning, many methods have been used for studying the gut microbiome and diseases. for example, a model was constructed to predict responses to anti-integrin biologic therapy for inflammatory bowel diseases through gut microbiome function (ananthakrishnan et al., 2017) . although many approaches are not currently used in tcm study on gut microbiome, related methods will become a future trend. therefore, additional investigations are warranted. furthermore, interactive visualization tools are of equal importance. cytoscape is an open-source platform that could be used for complex network analysis and visualization (shannon et al., 2003) , which is useful for analyzing the network in network pharmacology studies. similar functions are also offered by the web services of many databases. the involvement of the gut microbiome in maintaining the health status of every person will undoubtedly affect the effectiveness of drug treatments, including tcm treatment. here, we provide two case studies to illustrate this, one on the metabolic effect of gut microbiome on tcm, and the other on cancer treatment, to illustrate the mediation role of the gut microbiome in medicinal treatment in general. previous studies have found that many of the chemical constituents of tcm can be transformed and metabolized by the intestinal flora, making it easier for the body to absorb. in other words, the gut is like a processing factory of tcm. the effects of the intestinal flora on different kinds of chemical constituents vary: flavonoids represent a major class of secondary metabolites of plants and can be classified into 12 subclasses: anthocyanins, chalcones, dihydrochalcones, flavanols, flavanones, flavones, flavonols, isoflavones, flavan-3-ols, flavan-3,4-diols, aurones, and proanthocyanidins (crozier et al., 2009) . the effects of these polyphenols in the prevention of cancer, cardiovascular disease, t2d, and cognitive dysfunction are supported by an increasing number of studies (del et al., 2013; rodriguez-mateos et al., 2014) . to exert their effects, flavonoids are metabolized by the gut microbiome, and the resulting compounds may have bioactivity. such bacterial conversion and potential health consequences for the human host (chiou et al., 2014) are hardly unique: baicalin, puerarin, and daidzin, which are widely found in tcm prescriptions, can also be metabolized by gut microbiome (kim et al., 1998) . as baicalin is difficult to be absorbed in the gut, it has to be hydrolyzed by gut microbiome to baicalein to exert its effect. metabolism of baicalin was hardly detected in germ-free rats compared to conventional rats, indicating that gut microbiome play a key role in the metabolism of baicalin (akao et al., 2001) . (mochizuki et al., 1995; sun et al., 2008; shi et al., 2013) . ginsenoside compounds k (ck) is one of the metabolites of ginsengoside, which exerts various pharmacological effects, including antiallergic (shin and kim, 2005) , antidiabetic (kim et al., 2014) , anticarcinogenic (zhou et al., 2010; zhang et al., 2013) , anti-inflammatory (joh et al., 2011; chen et al., 2014) , and antiaging effects (kim et al., 2004) . the occurrence of ck in rat plasma is required for intestinal bacterial hydrolysis after oral administration of ginsengosides (akao et al., 1998) . when human intestinal flora was cultured anaerobically with ginsengosides rb1, rb2, and rc, these ginsengosides were metabolized into ck, where the transformation of rc is conducted by the concert efforts of bacteroides spp., eubacterium spp., and bifidobacterium spp. (bae et al., 2000; bae et al., 2002) . in addition, intestinal bacterial metabolism of ginsengosides was mainly dependent on the composition of intestinal flora, such as bacteroides spp., ruminococcus spp., and bifidobactetium spp. (kyung-ah kim et al., 2013) . additionally, the metabolism of panax notoginseng saponins (pnss) was influenced by gut microbiome, of which proteobacteria may have an effect on the deglycosylated metabolism of pnss by regulating the activities of glycosidases (xiao et al., 2016) . up-regulation of bacteroidetes may increase the activity of redox metabolic enzymes in intestinal flora and accelerate the redox metabolism of pnss (xiao et al., 2016) . oxymatrine and matrine are two main alkaloids in the radix sophorae flavescentis, and oxymatrine could be transformed into matrine by intestinal bacteria when taken orally, and both can be absorbed by the blood . scopolamine was incubated with rat intestinal flora in vitro under limited oxygen conditions, and scopolamine was transformed by gut microbiome into scopine (chen et al., 2006) . anthraquinones have widespread applications throughout industry and medicine, and are naturally distributed in many plants, including rheum officinale baill., fallopia multiflora (thunb.) harald., catsia tora linn., folium sennae, and aloe vera (linn.) n. l. burman var. chinensis (haw.) berg. through a chemical constituent study on the metabolism of rhubarb extract by rat intestinal bacteria, a total of 14 components, including emodin-o-glucosides, aloe-emodin-o-glucosides, physcion-oglucosides, chrysophanol-o-glucosides, and their aglycones were found to be biotransformed by rat intestinal bacteria. twelve major metabolites were identified in the incubation sample, suggesting the importance of the intestinal flora during the metabolism of anthraquinones (song et al., 2011) . carcinogenesis may be mediated by microbiome influencing cellular metabolism, inflammation, and proliferation (zitvogel et al., 2017) . the microbiome regulate cancer at the level of predisposing conditions, initiation, genetic instability, susceptibility to host immune response, progression, comorbidity, and response to therapy. several examples are as follows: there is an increasing number of studies involving mice and humans on the role of intestinal flora in cancer treatments. in mice, the procarcinogenic phenotype expressed by genetically mutated mice has been shown to be transferred to wild-type mice by microbiome transfer (garrett et al., 2009; couturier-maillard et al., 2013; hu et al., 2013) , and transfer of fecal microbiome from patients who are sensitive to cancer treatment into germfree mice has been found to endow these animals with an ability to respond efficiently to therapy (vetizou et al., 2015) , indicating that changes in the composition of intestinal flora indirectly affect carcinogenesis and response to cancer treatment through lifestyle and host genetic. furthermore, the intestinal flora affects anticancer activity, toxicity, as well as pharmacokinetics of drugs at various levels (dzutsev et al., 2015; spanogiannopoulos et al., 2016) . several anticancer drugs have experimentally been shown to be affected by the intestinal flora , including the hydrolysis of methotrexate, the nitroreduction of misonidazole, and the deconjugation of irinotecan. in germfree mice or mice in which gut commensals were exhausted by broad-spectrum antibiotics, the antitumor effect of cisplatin or oxaliplatin treatment on subcutaneous transplantable tumors was decreased evidently (lida et al., 2013) . probiotics lactobacillus acidophilus in antibiotic-treated mice restored cisplatin-induced inflammatory gene expression (gui et al., 2015) , indicating the mediation role of gut microbiome on drug efficacy. additionally, oral administration with bifidobacterium bifidum and l. acidophilus, a probiotic combination, was found to prevent intestinal toxicity in cancer patients who were treated with both cisplatin and radiotherapy (chitapanarux et al., 2010) . in addition to the direct effects on the enzymes and microbiome on the absorption and metabolism of drugs (maurice et al., 2013; feng et al., 2015; montassier et al., 2015) , the indirect effects of gut microbiome on the metabolism of drugs were reported to occur through regulation of gene expression and the physiological function of the local mucosal barrier and of distant organs, such as the liver (bjorkholm et al., 2009; selwyn et al., 2015; selwyn et al., 2016) . radiotherapy is one of the traditional methods for cancer treatment. because radiotherapy alters the microbiome composition and destroys the intestinal barrier (barker et al., 2015) , pathobionts can easily access the intestinal immune system (belkaid and hand, 2014) . with the development of research on cancer and microbiome, probiotics have been reported to be beneficial in prevention of radiation-induced enteropathy in some clinical studies. for example, patients 2 | recent studies on the close relationship between colorectal cancer (crc) and the gut microbiome. year reference fecal metabolomic signatures are associated with gut microbiome and colorectal cancer pathogenesis: (1) the levels of polyunsaturated fatty acids and sphingolipids are further increased in patients with crc, which may represent early changes in crc. (2) regardless of disease status, age, or gender, there is a strong overall correlation between microbiome and metabolomics data, and the correlation is higher in women than in men. (3) the abundance of multiple bacteria in firmicutes, actinobacteria, and bacteroides is strongly correlated with elevated metabolite pathways in patients. 2020 (kim et al., 2020) non-nucleatum fusobacteria common in southern chinese populations are associated with colorectal cancer: (1) irrespective of crc disease status, the prevalence, relative abundance, and diversity of fusobacterium in southern chinese populations are higher than those in other regions. (2) in addition to non-nucleatum fusobacteria, fusobacterium varium and fusobacterium ulcerans and other fusobacterium groups are also enriched in crc patients. (3) several non-nucleatum taxa possess fada homologues and were enriched in crc cohorts. 2020 (yeoh et al., 2020) a pathological imbalance of the gut microbiome (dysbiosis) is present in colorectal cancer patients: (1) bacteria affect crc directly or indirectly, by secreting metabolites, by invading tissues, and by modulating the host immune response. (2) fusobacterium, peptostreptococcus, porphyromonas, prevotella, parvimonas, bacteroides, and gemella are among the most prominent crc-associated bacteria. 2020 (ternes et al., 2020) changes in gut microbiome can reduce the carcinogenic effect of colitis-related colorectal cancer: (1) enterobacter strains are associated with molybdenum-dependent metabolic pathways in the colitis model. oral sodium tungstate can inhibit the activity of e. coli molybdenum and reduce the colonization of e. coli in the intestine. (2) limiting the growth of enterobacteriaceae can control intestinal inflammation and reduce the incidence of colorectal cancer. (3) oral sodium tungstate treatment can reduce intestinal inflammation and inhibit tumorigenesis caused by colicin. 2019 (zhu et al., 2019) colorectal cancer can be diagnosed by lachnoclostridium as a marker: (1) metagenomic analysis identified "m3" from a lachnoclostridium sp., fusobacterium nucleatum (fn), and clostridium hathewayi (ch) to be significantly enriched in crc. (2) the combination of m3 with fn, ch, bacteroides, and fit can diagnose crc most accurately. 2019 (liang et al., 2019) intestinal fungal disorders in colorectal cancer, expected to be used for diagnosis: (1) crc intestinal fungal disorders, increased ratio of basidiomycetes/ascomycetes, increased malassezia, decreased yeast and pneumocystis, 6 genus enrichment, 38 species abundance changes. (2) the co-occurrence association between fungi and the mutual exclusion of bacteria-fungi in crc increased, and the positive interaction between proteobacteria and ascomycota became mutually exclusive in crc. 2019 (coker et al., 2019) different intestinal flora species increased or decreased the effectiveness of drugs: (1) bacterial nucleotide metabolism genes in caenorhabditis elegans affect drug efficacy. (2) 5-fluorouracil and 5-fluoro-2'-deoxyuridine act through bacterial ribonucleotide metabolism to exert their cytotoxic effects in c. elegans rather than by thymineless death or dna damage. two-way bacterial mediation effects of fluoropyrimidine on host metabolism may contribute to drug efficacy: (1) microbes can bolster or suppress the effects of fluoropyrimidines through metabolic drug interconversion involving bacterial vitamin b 6 , b 9 , and ribonucleotide metabolism. (2) disturbances in bacterial deoxynucleotide pools amplify 5-fu-induced autophagy and cell death in host cells. 2017 (scott et al., 2017) levels of p. anaerobius are higher in human colon tumor tissues and adenomas compared with nontumor tissues; this bacterium increases colon dysplasia in a colorectal cancer mouse model. p. anaerobius interacts with tlr2 and tlr4 in colon cells to increase the abundance of reactive oxidative species, which promotes cholesterol synthesis and cell proliferation. 2017 (tsoi et al., 2017) f. nucleatum plays a key role in colorectal carcinogenesis through suppression of the hosts' immune response to tumor. a diet rich in whole grains and dietary fiber is associated with a lower risk of f. nucleatum-positive colorectal cancer. 2017 (mehta et al., 2017) key microbial markers are critical in the classification of crc cases and are commonly used in the diagnosis of disease. 2017 (shah et al., 2017) (1) aim2-deficient mice are hypersusceptible to colonic tumor development. (2) susceptibility of aim2-deficient mice to colorectal tumorigenesis is enhanced by dysbiotic gut microbiome compared with healthy wildtype mice. 2015 (man et al., 2015) zhang et al. with head and neck cancer received lactobacillus brevis cd2 lozenges during chemotherapy and radiation, and the incidence of treatment-induced mucositis decreased while the treatment completion rate increased (sharma et al., 2012) . immunotherapy is another approach that has shown potential in treating solid cancers and hematopoietic (couzin-frankel, 2013) . the proliferation and antitumor cytotoxic activity of transferred t cells in the tumor were increased by the total-body irradiationinduced translocation of intestinal flora into the mesenteric lymph nodes (paulos et al., 2007) . moreover, many studies have revealed the crucial role of intestinal flora in colorectal cancer treatment recently ( table 2) , indicating the close relationship between gut microbiome and cancer treatment. in recent years, with the modernization of tcm and the development of systems biology, our understanding of tcm has been significantly advanced. tcm has gradually transformed from an experience-based approach to an evidence-based medicinal system, of which chinese scientists have made great contributions. we modify this sentence to "for example, it was discovered that arsenic induces the degradation of a key leukemogenic protein and exerts a pharmacological effect on the treatment of acute promyelocytic leukemia (zhang et al., 2001) . youyou tu, the nobel prize winner, has also focused on tcm research and research on the combination of western medicine and tcm for many years (tu et al., 1981; tu et al., 1982) . the trend has become clear that more and more tcm researches use molecular biology approach. however, with the systems biology approach enabled, the potential of tcm studies at the molecular level remains to be better exploited. on the other hand, research about the microbiome, in particular the gut microbiome, has made enormous progress during recent years. with the launch of various international projects on the human microbiome, research on the gut microbiome has become a hot research area. studies have proven that tcm could be used as a perfect agent to treat many kinds of diseases, many of which were mediated by gut microbiome. therefore, combination of the research of tcm and gut microbiome is important to maintain the healthy status of the host-microbiome holobiont. in addition, with the advancement of biological big data research, databases can now provide a more holistic perspective for tcm research and intestinal flora research. however, with the regulation or mediation principles of gut microbiome on human health still lacking except for a few diseases, more microbiome experiments, sequencing data, and analytical methods have yet to be conducted, collected, or developed to better understand these principles. it has become urgent that several problems remain to be solved for both tcm and gut microbiome research areas, especially in the era of biological big-data. with the constant increase in research in related fields, various experimental data have been generated. these all require better ways to curate, analyze, and interpret the concerted effects of tcm and the microbiome on human health. first, a more comprehensive database on tcm and gut microbiome is needed, which should not only include the interaction between the tcm and the gut microbiome but should also represent the advantages of tcm databases and microbiome databases in accelerating the application of tcm on a global scale. second, analytical methods must keep pace with the rapid development of modern systems biology. a more powerful data mining tool is required to investigate the complex and multi-scale "tcm-hostmicrobiome" network. third, investigations on the mechanisms of mutual regulation between tcm and gut microbiome are limited. how do various tcms regulate dysbiotic microbiome in concert? what kinds of enzymes produced by gut microbiome are responsible for metabolizing tcm and exerting the effect of tcm? these only represent a few questions that are to be answered. fourth, the microbiome has been indicated as a precision medicine frontier (kuntz and gilbert, 2017) , as interindividual differences in microbiome patterns have been reported, even between co-raised twins. finally, it is only when enough time-series samples are collected can we answer questions about dynamic patterns for the "tcm-host-microbiome" network. such dynamic pattern is the basis for the "shelf life" and "personalized medicine" for the microbiome-mediated tcm treatment, and could push for the modernization of tcm. in summary, researchers might take advantage of tcm and microbiome for better health care and treatment, as both possess the great potential in health care. this might lead to another paradigm shift: from genome-centric precision medicine to systems biology approach enabled holobiont-centric precision medicine. kn and hb conceived and proposed the idea. kn, hb, and rz jointly designed the main idea of this work. kn, rz, and xg contributed to the interpretation of data for the work. kn, hb, xg and rz drafted the manuscript, kn, hb, xg, and rz revised it critically for important intellectual content. all authors read and approved the final manuscript to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. drug metabolism: intestinal bacterial hydrolysis is required for the appearance of compound k in rat plasma after oral administration of ginsenoside rb1 from panax ginseng balicalin, the predominant flavone glucuronide of scutellariae radix, is absorbed from the rat gastrointestinal tract as the aglycone and restored to its original form gut microbiome function predicts response to anti-integrin biologic therapy in inflammatory bowel diseases constitutive beta-glucosidases hydrolyzing ginsenoside rb1 and rb2 from human intestinal bacteria metabolism of ginsenoside r(c) by human intestinal bacteria and its related antiallergic activity the in vitro growth-inhibitory effect of euphorbia humifusa willd. 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purification, partial characterization, and bioactivity of polysaccharides from panax ginseng impact and consequences of polyphenols and fructooligosaccharide interplay on gut microbiota in rats studies on the preparation, crystal structure and bioactivity of ginsenoside compound k gut microbiotainvolved mechanisms in enhancing systemic exposure of ginsenosides by coexisting polysaccharides in ginseng decoction editing of the gut microbiota reduces carcinogenesis in mouse models of colitis-associated colorectal cancer anticancer effects of the microbiome and its products the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 zhang, gao, bai and ning. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-256838-8rzibpbl authors: eng, yi shin; lee, chien hsing; lee, wei chang; huang, ching chun; chang, jung san title: unraveling the molecular mechanism of traditional chinese medicine: formulas against acute airway viral infections as examples date: 2019-09-27 journal: molecules doi: 10.3390/molecules24193505 sha: doc_id: 256838 cord_uid: 8rzibpbl herbal medicine, including traditional chinese medicine (tcm), is widely used worldwide. herbs and tcm formulas contain numerous active molecules. basically, they are a kind of cocktail therapy. herb-drug, herb-food, herb-herb, herb-microbiome, and herb-disease interactions are complex. there is potential for both benefit and harm, so only after understanding more of their mechanisms and clinical effects can herbal medicine and tcm be helpful to users. many pharmacologic studies have been performed to unravel the molecular mechanisms; however, basic and clinical studies of good validity are still not enough to translate experimental results into clinical understanding and to provide tough evidence for better use of herbal medicines. there are still issues regarding the conflicting pharmacologic effects, pharmacokinetics, drug interactions, adverse and clinical effects of herbal medicine and tcm. understanding study validation, pharmacologic effects, drug interactions, indications and clinical effects, adverse effects and limitations, can all help clinicians in providing adequate suggestions to patients. at present, it would be better to use herbs and tcm formulas according to their traditional indications matching the disease pathophysiology and their molecular mechanisms. to unravel the molecular mechanisms and understand the benefits and harms of herbal medicine and tcm, there is still much work to be done. it is common to initiate the therapy of orthodox western medicine by fitting the pharmacologic characteristics of a drug, including pharmacokinetic and pharmacodynamic effects, to the disease pathophysiology. physicians further validate the clinical application according to evidence-based medicine (ebm); however, this is not the case for tcm. tcm developed in ancient china, and at that time, physicians managed diseases with herbs only by clinical experience, without any knowledge of disease pathophysiology, nor the pharmacologic activities of herbs, to say nothing of the molecular mechanisms of herbs. to unravel the molecular mechanism of tcm formulas, it would be better to understand how physicians prescribe them first. tcm includes herbal therapy, acupuncture, massage, and dietary therapy. in the current work, tcm will be simply defined as herbal and dietary therapies. tcm is widely popular in east asia and forms the kampo medicine in japan, as well as traditional korean medicine; importantly, traditional medicines form the mainstream of healthcare in these countries. in ancient china, several famous tcm textbooks summarized the clinical experiences of using tcm formulas against various diseases, including endemic diseases, and each formula has its indication, including specific symptoms of patients. this is quite different from using tcm formulas based on the yin-yang theory (two opposite, but complementary forces) and five elements theories (everything in the world can be classified into the natural five elements. these elements promote as well as feedback each other to keep everything in balance). kampo medicine in japan classified tcm theories into ancient formula sect and recent formula sect for prescribing tcm formulas. the physicians of the ancient formula sect (a-physicians) use the indications of formula formed before formula can have active molecules that are pharmacologically different from that ingredient or the tcm formula. obversely, the pharmacological activities of a tcm formula may differ from those of their active ingredient or active molecules of ingredients. as a consequence, unraveling the molecular mechanism of a tcm formula needs comparison of the pharmacological activities between the formula, its ingredients, and the active molecules in the ingredients. the amount of most bioactive compounds in the herbs is very low. combination of herbs to form a tcm formula can further decrease their concentrations. is it possible that herbs and tcm formulas can be effective in this low concentration of bioactive compounds? is it possible that little amount of bioactive molecules can cause interactions? in orthodox western medicine, vitamins of little amount can show their clinical effects. the molecular mechanisms are the key, instead of their amount. in the real world practice, herbs and tcm formulas are bioactive. several side effects of tcm formulas have been reported [11] [12] [13] [14] [15] [16] [17] that raise the safety issue of tcm formula. natural products and tcm formulas might not be safe; however, some a-physicians suppose that the side effects may come from the misuse of tcm formulas without fulfilling their indications, while r-physicians consider the side effects developing from the misinterpretation of the disharmony. most tcm physicians do not agree that these side effects come from tcm formulas themselves, although with the same indications or disharmony, it is common to find that some patients respond well while others do not-while some patients develop side effects, some show responses opposite to the in vitro pharmacological effects. for example, panax quinquefolius prolongs thromboplastin time, prothrombin time (pt) and thrombin time in vitro [18] . however, in combination therapy with warfarin, panax quinquefolius actually decreases seral concentration of warfarin and has shortened inr in a clinical trial [19] . with therapy using panax ginseng, one can develop thrombosis [20] , bleed [21, 22] , or remain without any particular response [23] . several factors may affect the molecular mechanisms and subsequent clinical effects of tcm formulas, including individual gene-based response, composition and amount of active molecules in tcm formulas, complex interactions, and appropriateness of use of tcm formulas. individual genetic basis is unique to metabolize tcm formulas and produces different responses. from the results of pharmacokinetic study of gan-lu-siao-du-yin, a tcm formula (submitted data), the blood concentrations of structurally-related index molecules, baicalin and baicalein, wogonin, and wogonoside, are highly variable between participants. the different patterns of blood concentrations support the unique pharmacokinetic profile based on individual genes. different concentrations of active molecules may affect the pharmacologic activities. therefore, individual gene-based metabolism could be one of the major factors affecting the molecular mechanisms and subsequent clinical effects of tcm formulas. to provide insights into action mechanisms of tcm formulas, metabolomic technologies might be helpful. a metabolomics integrative approach accepts a 'top-down' strategy to express the function of organisms through terminal symptoms of metabolic network and will gain a revolution in understanding of the holistic concept of tcm [24, 25] . such technologies have been used to investigate the biological mechanisms of different syndromes of patients by studying the functional activities of the human body from a system-wide perspective. for example, the overall biological characterization of the urine of psoriasis patients with tcm blood stasis syndrome was performed to investigate the therapeutic metabolomic mechanism of the optimized yinxieling formula [26] . in addition, metabolomics have been considered a powerful tool in diagnosis and treatment of primary dysmenorrhea by supporting information on changes of metabolites and changes in endocrinal, neural, and immune pathways [27] . the xiang-fu-si-wu formula has been demonstrated to affect some significant perturbations in sphingolipid and glycerophospholipid metabolism as well as steroid hormone biosynthesis to make the metabolic discrepancy return to the normal level [28] . tcm formulas are complex with numerous active chemical molecules in variable amounts. among these molecules with different pharmacologic activities, it is unclear which one mainly accounts for the clinical effect of a tcm formula, as the most abundant molecule might not be the most important one for a specific activity. the amount of an active molecule can be easily changed in different batches of product, or by different agriculture and collection of medicinal plants, therefore, understanding the molecular mechanisms of a tcm formula requires analysis not only of the mechanisms of the tcm formula as a whole, but those of individual active molecules and ingredient respectively as well. understanding the molecular mechanisms of an active molecule can facilitate its development into an investigational new drug (ind). meanwhile, unraveling the molecular mechanisms of a tcm formula can help to validate its traditional use and avoid its misuse and side effects. to keep a relatively constant amount of active molecules and pharmacologic activities, several things should be paid attention to, including use of right specie, use of right part of a plant, and use of a plant harvested in the right season. both use of closely related but wrong species and use of wrong part of herbs might lead to different active molecules with different pharmacologic activities, and various clinical effects and side effects. plants harvested in different seasons might contain variable amounts of active molecules thereby affecting their activities. some active molecules are secondary metabolites of plants against physical, chemical, or biological stimulants. active molecules of some plants can vary from year to year and place to place. therefore, confirmation of its authenticity is the cornerstone. in addition to this, fingerprints of the active molecules are needed to confirm the authenticity of a plant or a formula and to confirm the amount of active molecules via high-performance liquid chromatography (hplc) or liquid chromatography coupled with mass spectrometry (lcms). this is highly necessary for quality control and efficacy assessment. to have quality control of the products of tcm formulas, good manufacturing practice (gmp) procedure should be followed to avoid (a) inadequate processing that might lead to different chemical compositions of the final product; (b) inadequate storage conditions or prolonged storage that might lead to microbial contamination and early decay of the active molecules; and (c) adulteration of formulas and accidental contamination creating serious uncertainty in quality. adulteration is a plant or formula containing active pharmaceuticals or other bioactive agents for the purpose of claiming better efficacy or broader indications. accidental contamination is the plant raw materials containing heavy metals or other toxic substances from the manufacturing process due to ecological collapse. lead, mercury, and arsenic contamination in traditional chinese herbs has been reported [29] [30] [31] [32] 3.3. complex interplays between herb-drug, herb-food, herb-herb, herb-microbiome, and herb-disease in the clinical practice of orthodox medicine, the more drugs used, the more adverse drug reaction (adr) occurred [33] . this is commonly caused by drug-drug interactions. tcm formulas are mixtures of several ingredients. each ingredient has several bioactive compounds, so a tcm formula has numerous bioactive compounds. thinking of dozens or even hundreds of active molecules in a tcm formula been taken at once implies that the probability of drug interaction could be high. such interactions may be found between herb and drug, herb and food, herb and herb, herb and microbiome, and even between herb and disease. for example, in herb-drug interaction, scutellariae baicalensis is a common ingredient in tcm formulas. s. baicalensis contains baicalin, a flavonoid, as one of its major molecules. interactions between s. baicalensis and drugs are found due to baicalin affecting metabolic enzymes of drugs, displacing plasma protein binding, and regulating various transporters involved in the pharmacokinetics [34] . baicalin may inhibit the expression and hydroxylation activity of cyp3a in the liver to change the pharmacokinetics of drugs [35] . co-administration of extract of s. baicalensis, and mefenamic acid, a kind of nsaid, can potentiate its anti-inflammatory effect [36] . co-administration of baicalin and rosuvastatin, a hmg-coa reductase inhibitor commonly used to reduce serum cholesterol level, might find reduced plasma concentration of rosuvastatin in certain patients with certain genomes [37] . as for herb-food and herb-food-drug interactions, baicalin can potentiate the antioxidant activity of β-carotene, which is a terpenoid of red-orange color, abundant in plants and fruits [38] . the intakes of flavonoid-rich foods and beverages, containing baicalin and rutin, might compete with the binding site of calcium channel blockers on human serum albumin to affect their clinical effects [39, 40] . by contrast, baicalin and rutin will increase the binding affinity of curcumin on human serum albumin to change its bioavailability [41] . herbs may also interact with each other. for example, baicalin and berberine are important coexisting molecules of the combination of s. baicalensis and coptidis chinensis. berberine, but not baicalin, can increase glucose consumption. co-administration of berberine and baicalin had a synergetic effect on glucose utilization [42] . additionally, tcm herbs are commonly used as food supplements and dietary therapy. foods have been reported to modify the intestinal microbiome [43] . commensal microbiota have been thought to be involved in the development of the innate and adaptive immunity, nutrient metabolism of humans, and protection from the overgrowth of intestinal pathogens [44] . herbs can change pharmacokinetics of drugs by intestinal microbiota [34] . the intestinal microbiome is metabolically active to play an important role in the absorption of certain active molecules and change their bio-availabilities, particularly in those containing glycosidic linkages [34, 45] . therefore, change of intestinal microbiome by herbs-containing foods may affect human health care and drug therapy. as for interactions between disease and herb, more absorption of active molecules of maxing shigan decoction (mxgst), including liquiritin, glycyrrhizin, amygdalin, prunasin, ephedrine, pseudoephedrine, and methylephedrine, can be found in rsv pneumonia-infected rats vis-à-vis normal rats by reducing the clearance rates of these active molecules [46] . there are highly complex interactions between herbs and drugs, foods, herbs, microbiome, and diseases, and most of these complex interactions are not completely discovered or remain unseen, just like the submerged part of an iceberg. therefore, there are still insufficient data to completely understand the molecular mechanisms, pharmacokinetics, pharmacodynamics, and interactions of tcm formulas. acute airway infections, including acute bronchitis, viral pneumonia, and acute exacerbation of chronic obstructive pulmonary disease (copd), are commonly caused by viruses of different families, including rhinovirus, influenza, and parainfluenza virus, enteroviruses, coronavirus, adenovirus, respiratory syncytial virus, etc. [47, 48] . these viruses infect epithelia, produce inflammation, induce immune response, and cause symptoms. from the viewpoint of pathophysiology, tcm formulas used to manage airway viral infections need to have antiviral activity against such viruses listed above, and/or to induce antiviral cytokines, and/or anti-inflammatory effect, and/or to relieve symptoms commonly presented in airway infections ( figure 1 ). to simplify the molecular mechanisms and to correlate the pharmacologic activities with their clinical effects, five formulas of a-physicians will be used as examples against airway infections: ge-gen-tang (ggt; table 1 ) [49] has been reported to be effective in the treatment of common colds, chronic sinusitis, allergic rhinitis, and pneumonia. the indication to use ggt is patients with symptoms of headache, fever without sweating, and particularly stiffness of neck and shoulders. ggt can successfully reduce various symptoms of dogs infected with common cold viruses [50] . ggt has antiviral activities against respiratory syncytial virus (rsv) [51] and influenza virus [52] . ggt can reduce the mortality of influenza virus-infected mice [53] . among its active molecules, uralsaponins from glycyrrhiza uralensis [54] and procyanidin from cinnamomum cassia [55] may effectively inhibit the replication of the influenza virus. allicin in ginger (zingiber officinale) and coumarin in cinnamomum cassia might have the activity to inhibit influenza neuraminidase [56] . paeonol and 1,2,3,4,6-penta-o-galloyl-β-d-glucopyranose from paeonia lactiflora show antiviral activity against rhinovirus [57] . of its anti-inflammatory effects, ggt can suppress the interleukin-1α (il-1α) production induced by interferons (ifn) in influenza [58] . ggt was found to decrease cigarette smoking-(cs-) and lipopolysaccharide (lps)-induced elevated counts of inflammatory cells, and expression of inflammatory cytokines and proteins (il-6, tnf-α, inos, and cox-2) [59] . ggt can stimulate il-12 and ifn-β to counteract viral infection [53] , and can also enhance the phagocytic activity of macrophages [50] . among its active molecules, paeoniflorin, a major constituent of paeonia lactiflora, exerts anti-inflammatory and immunomodulatory effects by balancing the function of th1/th2 [60] . glycyrrhizin, a major constituent of glycyrrhiza uralensis, ge-gen-tang (ggt; table 1 ) [49] has been reported to be effective in the treatment of common colds, chronic sinusitis, allergic rhinitis, and pneumonia. the indication to use ggt is patients with symptoms of headache, fever without sweating, and particularly stiffness of neck and shoulders. ggt can successfully reduce various symptoms of dogs infected with common cold viruses [50] . ggt has antiviral activities against respiratory syncytial virus (rsv) [51] and influenza virus [52] . ggt can reduce the mortality of influenza virus-infected mice [53] . among its active molecules, uralsaponins from glycyrrhiza uralensis [54] and procyanidin from cinnamomum cassia [55] may effectively inhibit the replication of the influenza virus. allicin in ginger (zingiber officinale) and coumarin in cinnamomum cassia might have the activity to inhibit influenza neuraminidase [56] . paeonol and 1,2,3,4,6-penta-o-galloyl-β-d-glucopyranose from paeonia lactiflora show antiviral activity against rhinovirus [57] . of its anti-inflammatory effects, ggt can suppress the interleukin-1α (il-1α) production induced by interferons (ifn) in influenza [58] . ggt was found to decrease cigarette smoking-(cs-) and lipopolysaccharide (lps)-induced elevated counts of inflammatory cells, and expression of inflammatory cytokines and proteins (il-6, tnf-α, inos, and cox-2) [59] . ggt can stimulate il-12 and ifn-β to counteract viral infection [53] , and can also enhance the phagocytic activity of macrophages [50] . among its active molecules, paeoniflorin, a major constituent of paeonia lactiflora, exerts anti-inflammatory and immunomodulatory effects by balancing the function of th1/th2 [60] . glycyrrhizin, a major constituent of glycyrrhiza uralensis, suppresses nuclear factor-kappa b (nf-κb) via the phosphoinositide 3-kinase (pi3k) pathway, inhibits the production of nitric oxides (no), prostaglandin e2 (pge2), and reactive oxygen species (ros), and reduces the protein and mrna levels of inducible no synthase (inos) and cyclooxygenase-2 (cox-2) [61]( figure 2 ). meanwhile, glycyrrhiza polysaccharide, isolated from glycyrrhiza uralensis, significantly induces no production and inos transcription in peritoneal macrophages [62] . however, this study design uses intraperitoneal injection to show the induction of no [62] , instead of the traditional oral route. polysaccharides will be normally digested in the gastrointestinal tract into monosaccharide, so that polysaccharides can hardly reach intraperitoneal macrophages in the regular oral route, so this pharmacologic activity has been questioned. isoliquiritigenin, a flavonoid from glycyrrhiza uralensis, inhibits nf-κb activation to suppress inflammatory response [63] . cinnamaldehyde, from cinnamomum cassia, inhibits the secretion of pge2, il-1β and tumor necrosis factor-α (tnf-α), and the activation of nf-κb to show the anti-inflammatory effect [64] [65] [66] . particularly, e-cinnamaldehyde and o-methoxy-cinnamaldehyde down-regulate no and tnf-α production to show anti-inflammatory activity [67] . although it can mediate antiviral activity, tnf-α plays only a minor role in clearance of various airway viruses; rather, it is the major contributor of t-cell-mediated lung injury [68] . for enhancement of antiviral immunity, puerarin, an isoflavonoid from pueraria lobate, increased ifn-γ [69] . 6-gingerol (6-g), the main bioactive component of ginger (zingiber officinale), increases ifn-γ and il-12, but decreases il-10 and transforming growth factor-β1 (tgf-β1) levels [70] . on the contrary, gingerol was also reported to suppress t cell response and inhibit ifn-γ synthesis [71] (figure 2 ). these conflicting data may come from different study designs and raise questions about the actual pharmacological activity in humans. (ros), and reduces the protein and mrna levels of inducible no synthase (inos) and cyclooxygenase-2 (cox-2) [61] (figure 2 ). meanwhile, glycyrrhiza polysaccharide, isolated from glycyrrhiza uralensis, significantly induces no production and inos transcription in peritoneal macrophages [62] . however, this study design uses intraperitoneal injection to show the induction of no [62] , instead of the traditional oral route. polysaccharides will be normally digested in the gastrointestinal tract into monosaccharide, so that polysaccharides can hardly reach intraperitoneal macrophages in the regular oral route, so this pharmacologic activity has been questioned. isoliquiritigenin, a flavonoid from glycyrrhiza uralensis, inhibits nf-κb activation to suppress inflammatory response [63] . cinnamaldehyde, from cinnamomum cassia, inhibits the secretion of pge2, il-1β and tumor necrosis factor-α (tnf-α), and the activation of nf-κb to show the antiinflammatory effect [64] [65] [66] . particularly, e-cinnamaldehyde and o-methoxy-cinnamaldehyde downregulate no and tnf-α production to show anti-inflammatory activity [67] . although it can mediate antiviral activity, tnf-α plays only a minor role in clearance of various airway viruses; rather, it is the major contributor of t-cell-mediated lung injury [68] . for enhancement of antiviral immunity, puerarin, an isoflavonoid from pueraria lobate, increased ifn-γ [69] . 6-gingerol (6-g), the main bioactive component of ginger (zingiber officinale), increases ifn-γ and il-12, but decreases il-10 and transforming growth factor-β1 (tgf-β1) levels [70] . on the contrary, gingerol was also reported to suppress t cell response and inhibit ifn-γ synthesis [71] (figure 2 ). these conflicting data may come from different study designs and raise questions about the actual pharmacological activity in humans. ma-huangtang (mht; table 2 ) [49] have been reported to be effective in the treatment of influenza, upper respiratory tract infection, acute and chronic bronchitis, and asthma [72, 73] . the indication to use mht is patients with chills, fever without sweating, headache, shortness of breath, and joint pain. clinically, mht can effectively reduce fever and flu symptoms, including myalgia, headache, arthralgia, fatigue and cough, in patients with seasonal influenza type a [74] . among its active molecules, l-ephedrine from ephedra sinica and amygdalin from prunus armeniacae, possess the antitussive effect [75] , so co-administration of ephedra sinica and prunus armeniacae shows a better antitussive effect than use singly [76] . mht clearly shows anti-inflammatory activity via suppressing the no/pge2 pathway [77] , reducing inflammatory cells infiltration and reducing pro-inflammatory cytokine, including tnf-α, il-1β, and il-6, in lung experiments [78] . in an acute bronchial asthma mice model, mht can also mitigate the pathological changes of acute asthma-like syndrome through inhibition of the toll-like receptor 9 (tlr9) pathway [79] . mht can modulate th1/th2 cytokines via decreasing il-4 & il-17 and increasing ifn-γ levels. mht can inhibit th17 cells [80] , and decreases il-4, il-5, tnf-α, cd3+, cd8+ t cell levels (th2 response), but increases il-2, ifn-γ, and cd4+ t cell levels (th1 response) to increase cd4+/cd8+ ratio [81] . among its active ingredients, ephedra sinica inhibits pge2 biosynthesis, reduces ige-mediated histamine release, reduces the mrna or protein levels of il-1β, il-6, tnf-α, cox2, and nf-κb [82] and inhibits complement activation of both classical and alternative pathways [83] . additionally, ephedra sinica can directly activate both alpha-and beta-adrenergic receptors to reduce bronchial mucosal edema and to dilate the bronchus respectively [75, 84] . to understand the molecular mechanism, several active molecules have been identified. ephedrannin a and b, from ephedra sinica, effectively suppressed the transcription of tnf-α, il-1β, and nf-κb, and the phosphorylation of p38 mitogen-activated protein (map) kinase to exert their anti-inflammatory actions on lps-stimulated macrophages [85] . glycyrrhiza uralensis and cinnamomum cassia contain active molecules mediating anti-inflammatory and immunomodulatory effects mentioned in the ggt section. for its antiviral activity, mht was initially thought to inhibit airway viruses through inducing antiviral ifn. however, herbacetin from ephedrine alkaloid-free extract of ephedra sinica might have anti-influenza activity similar to its extract containing ephedrine and pseudoephedrine [86] . the study of ephedra sinica is relative rare owing to it containing ephedrine and pseudoephedrine, which are illegal in several countries. glycyrrhiza uralensis and cinnamomum cassia also have active antiviral constituents mentioned in the ggt section ( figure 3 ). ma-xing-gan-shitang (mxgst; table 3 ) [49] , a similar formula to ma-huang-tang, is effective against influenza virus infection [87] . mxgst has only one ingredient different from that of mht, i.e., using gypsum instead of cinnamomum cassia, so their pharmacologic effects and active molecules are similar, except that gypsum possesses a more powerful anti-pyretic effect by decreasing the pge2 level in the hypothalamus [88] . co-treatment with ephedra sinica and gypsum can have synergistic effects to manage fever and asthma than single use [89] . mxgst add-on therapy may improve pulmonary function indicies, such as forced expiratory volume in one second (fev1), forced vital capacity (fvc), and fev1/fvc in patients with acute exacerbation of copd [90] . additionally, at higher cumulative doses, mxgst might reduce the incidence of pneumonia and protect against admission [91] . the indication to use mxgst is patients with fever, cough with yellow and sticky sputum, chest pain, and shortness of breath. mxgst has been found to have antitussive and anti-pyretic effects in an lps-induced hyperthermia rat model [92] . mxgst has bronchodilation effect mediated by stimulation of β2-adrenoceptors in pigs [93] and can block acetyl-cholinergic and histaminergic receptor-induced bronchial contraction in rats [92] , reduce neutrophilic inflammation [93] , and in a copd rat model, can decrease il-4, il-8, and tnf-α, but increase ifn-γ [94] . these effects may be beneficial to manage airway viral infections with cough. the molecular mechanism of mxgst is summarized (figure 4 ). molecules 2019, 24, x; doi: www.mdpi.com/journal/molecules ma-xing-gan-shitang (mxgst; table 3 ) [49] , a similar formula to ma-huang-tang, is effective against influenza virus infection [87] . mxgst has only one ingredient different from that of mht, i.e., using gypsum instead of cinnamomum cassia, so their pharmacologic effects and active molecules are similar, except that gypsum possesses a more powerful anti-pyretic effect by decreasing the pge2 level in the hypothalamus [88] . co-treatment with ephedra sinica and gypsum can have synergistic effects to manage fever and asthma than single use [89] . mxgst add-on therapy may improve pulmonary function indicies, such as forced expiratory volume in one second (fev1), forced vital capacity (fvc), and fev1/fvc in patients with acute exacerbation of copd [90] . additionally, at higher cumulative doses, mxgst might reduce the incidence of pneumonia and protect against admission [91] . the indication to use mxgst is patients with fever, cough with yellow and sticky sputum, chest pain, and shortness of breath. mxgst has been found to have antitussive and antipyretic effects in an lps-induced hyperthermia rat model [92] . mxgst has bronchodilation effect mediated by stimulation of β2-adrenoceptors in pigs [93] and can block acetyl-cholinergic and histaminergic receptor-induced bronchial contraction in rats [92] , reduce neutrophilic inflammation [93] , and in a copd rat model, can decrease il-4, il-8, and tnf-α, but increase ifn-γ [94] . these effects may be beneficial to manage airway viral infections with cough. the molecular mechanism of mxgst is summarized (figure 4 ). xiao-qing-longtang (xqlt; table 4 ) [49] is one of the most common prescriptions used against allergic rhinitis [95] . xqlt, at higher cumulative doses, might reduce the incidence of pneumonia and protect against admission [91] . xqlt with/without ma-xing-gan-shi-tang (mxgst) is the most frequently prescribed tcm formula for copd [96] , and is also commonly used in the treatment of patients with respiratory diseases, such as common cold, flu, bronchitis, asthma, bronchiectasis, and emphysema. the indication to use xqlt is patients with cough, watery rhinorrhea or watery sputum, but without thirst. to manage airway viral infection, xqlt is effective against human respiratory syncytial virus (rsv) infection by preventing viral attachment, internalization, syncytial formation, and by stimulating ifn-β secretion [97] , and has been proven beneficial against influenza virus in vivo through the augmentation of antiviral iga antibody [98, 99] . xqlt can reduce the airway inflammation with the decrease of eosinophils count, the ovalbumin (ova)-specific immunoglobulin e (ige) antibody, and histamine release [100] [101] [102] , can also modulate th1/th2 balance thereby reducing il-4 and restoring ifn-γ levels [101, 103] . among its active molecules, schisandrin a, a bioactive lignin of schisandra sphenanthera, inhibits the il1β-induced inflammation via suppression of mitogen-activated protein kinase (mapk) and nf-κb signal pathways [104] , and can also inhibit the nf-κb, mapk and pi3k/akt pathways, partially mediated by the activation of the nuclear factor erythroid 2-related factor 2/heme oxygenase-1 (nrf2/ho-1) pathway to manage inflammatory and oxidative disorders caused by over-activation of macrophages [105] . schisandrin b, another bioactive lignin of schisandra sphenanthera, increases the expression of nrf2 and ho-1 and blocks the activation of nf-κb induced by lps to suppress the production of vascular cell adhesion molecule 1 (vcam-1), intercellular adhesion molecule 1 (icam-1), tnf-α, and il-8 expressions in human umbilical vein endothelial cells (huvecs) [106] . α-cubebenoate, isolated from schisandra chinensis, can block the increase of il-1β and il-6 during inflammation [107] , and inhibit lps-induced expression of inos and cox-2 [108] . oral polysaccharide from schisandra chinensis showed antitussive effect in a guinea pig model [109] . the active molecules of common ingredients, including ephedra sinica, cinnamomum cassia, paeonia lactiflora, glycyrrhiza uralensis, and zingiber officinale, have several pharmacologic activities mentioned in the above sections. most of these activities aim at inhibiting inflammation induced by airway infection, however, lectin from pinellia ternate may activate macrophages, induce neutrophil migration, cytokine release, ros overproduction and the activation of the nf-κb signaling pathway to produce pro-inflammatory activity [110] (figure 5 ). therefore, interactions, including both synergistic and antagonistic between active molecules in a tcm formula could be so complex as to affect the final effects. from more than two thousand years ago in china and japan, ye-gan-ma-huangtang (ygmht; table 5 ) [49] has been used to manage flu-like symptoms. a meta-analysis shows that ygmht can improve the total effective rate, fev1, and asthma control test (act) score of refractory asthmatic patients [111] . when combined with salbutamol aerosol, ygmht can obviously improve their pulmonary functions, including act score, pef, fev1, and fev1% predicted value. the indication to use ygmht is patients with chill and fever, hyperinflation of lung, cough with stridor and rales associated with frothy or whitish sputum [112] . ygmht has been reported effective against enterovirus infection, including coxsackievirus [113] and ev71 [114] . it can regulate the serum levels of tnf-α, il-10, and il-13 to show clinical effect in management of cough and variant asthmatic symptoms in children [115] . additionally, a modified ygmht (also named san-long-ping-chuan-decoction; slpcd) can significantly inhibit airway inflammation, reduce inflammatory cells in bronchoalveolar lavage fluid (balf), and decrease the serum total ige levels [116] . slpcd can significantly down-regulate the mrna expression levels of th2 cytokines (il-4, il-5, il-10, and il-13) and up-regulate those of th1 cytokines (il-2 and ifn-γ) in lungs of asthmatic mice [116] . for this anti-inflammatory activity, aster tataricus can protect from lps-induced acute lung injury mainly through inhibiting the release of inflammatory cells (wbc, macrophage, neutrophil, lymphocyte), regulating the pro-inflammatory cytokines (il-1β, il-6, tnf-α), and attenuating the pulmonary edema [117] . among its active molecules, irigenin, a major active constituent of belamcanda chinensis, can reduce no and pge2 production by decreasing the mrna and protein expression of inos and cox-2, respectively, as well as by suppressing nf-κb activation [118] (figure 6 ). molecules 2019, 24, x; doi: www.mdpi.com/journal/molecules from more than two thousand years ago in china and japan, ye-gan-ma-huangtang (ygmht; table 5 ) [49] has been used to manage flu-like symptoms. a meta-analysis shows that ygmht can improve the total effective rate, fev1, and asthma control test (act) score of refractory asthmatic patients [111] . when combined with salbutamol aerosol, ygmht can obviously improve their pulmonary functions, including act score, pef, fev1, and fev1% predicted value. the indication to use ygmht is patients with chill and fever, hyperinflation of lung, cough with stridor and rales associated with frothy or whitish sputum [112] . ygmht has been reported effective against enterovirus infection, including coxsackievirus [113] and ev71 [114] . it can regulate the serum levels of tnf-α, il-10, and il-13 to show clinical effect in management of cough and variant asthmatic symptoms in children [115] . additionally, a modified ygmht (also named san-long-ping-chuan-decoction; slpcd) can significantly inhibit airway inflammation, reduce inflammatory cells in bronchoalveolar lavage fluid (balf), and decrease the serum total ige levels [116] . slpcd can significantly down-regulate the mrna expression levels of th2 cytokines (il-4, il-5, il-10, and il-13) and up-regulate those of th1 cytokines (il-2 and ifn-) in lungs of asthmatic mice [116] . for this anti-inflammatory activity, aster tataricus can protect from lps-induced acute lung injury mainly through inhibiting the release of inflammatory cells (wbc, macrophage, neutrophil, lymphocyte), regulating the pro-inflammatory cytokines (il-1β, il-6, tnf-α), and attenuating the pulmonary edema [117] . among its active molecules, irigenin, a major active constituent of belamcanda chinensis, can reduce no and pge2 production by decreasing the mrna and protein expression of inos and cox-2, respectively, as well as by suppressing nf-κb activation [118] (figure 6 ). to unravel the molecular mechanism of tcm formulas, several issues need to be solved. many pharmacologic activities are obtained from in vitro and animal studies. could these activities be extrapolated into humans? there are so many active molecules with various pharmacologic activities in a tcm formula or herbs. are these molecules specific for that specific activity of a tcm formula or herbs? could they reach a minimal serum level to exert that particular pharmacologic activity in humans? active molecules may have the same activity with different potency. the most abundant one may not be the most important one for a particular activity. is it possible that there might be unidentified active molecules that actually account for a particular pharmacologic activity? several pharmacologic activities of a tcm formula cannot find a corresponding active molecule. is it possible that interactions between active molecules, e.g., synergism, but not active molecules themselves, account for a specific activity? is it possible that new active molecules are generated during preparation of the tcm formula? the genetic basis will affect the drug pharmacokinetics. is there a specific gene or single nucleotide polymorphism (snp) largely affecting the pharmacokinetic profile? does publication bias exist so that undesired pharmacologic effects are not published? is it possible that a particular gene is prone to a specific adr of a tcm formula or herbs? could a specific adr come from interactions between specific active molecules? several tcm formulas clearly show that some ingredients are not active in managing their traditional applications. could these inactive ingredients be omitted? all these questions need many studies to determine valid answers. at this moment, it would be better to use herbs and tcm formulas according to their traditional indications and the disease pathophysiology by matching their molecular mechanisms. as the world population has continued to age, the elderly have become associated with chronic diseases requiring multiple medications. increasing dissatisfaction with orthodox medicine and/or preference for alternative therapists and/or naturopathy has meant people continue to seek alternatives to maintain or improve their health, and this has spurred the growth of complementary and alternative medicine (cam) therapies. the validity of pharmacologic studies, safety issues, and validation of clinical effects of herbal medicine and tcm are limitations that should be highly considered; however, most clinicians are not familiar with herbal medicine and tcm so they do not recommend herbal therapies. more effort should be placed on unraveling the molecular mechanisms in order to solve the above issues. the reasons that limit clinicians from becoming more familiar with herbal medicine and for not recommending herbal therapies are explored below. herbal medicine and tcm form a part of complementary and alternative medicine (cam). however, evidence-based research in the field of cam therapies is still limited. there is a wrong perception that a naturally derived product is relatively safe. it is highly important to identify both usefulness and safety of cam and integrate these health approaches with orthodox medicine through rigorous scientific investigation to improve health care. it is also important for medical educators and providers to recognize the trend, the evidence, the benefits, and the risks of herbal medicine and tcm to educate clinicians for appropriate patient management and education. tcm studies published in chinese are usually not translated into english. the terminology of tcm is also difficult to translate, particularly those used by r-physicians, so medical education of herbal medicine and tcm has been neglected worldwide, except in germany and china. with their increasing use since the 1960s, understanding the molecular mechanisms, benefits, and limitations by physicians has become increasingly important to monitor their benefits and harmfulness. most of the evidence supporting clinical claims of herbs and natural products come from studies of inadequate design that do not provide tough evidence of the effects. relatively few well-designed studies support their clinical claims. sometimes, adequately powered, double-blinded, placebo-controlled clinical trials come to conclusions against previous reports, such as echinacea for upper respiratory infection [119] , or ginkgo for dementia or mild cognitive impairment [120] . additionally, the amounts of most bioactive compounds in herbs and tcm formulas are very low. is it possible that the clinical effects of herbs and tcm formulas can be effective with such a small amount of bioactive compounds? one study discussed the clinical effect of ma-huang-tang (mht) against seasonal influenza [121] . mht showed an equivalent clinical effect as neuraminidase inhibitors. however, not every tcm formula can provide such evidence. several tcm formulas, such as ma-xing-gan-shi-tang (mxgst), ge-gen-tang (ggt), and xiao-qing-long-tang (xqlt), are among the top ten most common tcm prescriptions for patients with upper respiratory tract infections (urtis) in taiwan [122] . they are commonly used for urtis, but more research is required to validate their clinical effects and mechanisms. without tough clinical evidence and clear molecular mechanisms, physicians tend to avoid herbal therapies. most clinical claims of herbal therapies are based on bench studies that do not possess external validity to support their conclusions; for example, using animal-derived cancer cell lines to study antiviral effects in humans; using cancer cell lines to study physical changes; using intraperitoneal injection to study oral medications; and using high-dose pharmacological designs to study physiological responses, etc. therefore, there is still much space for improvement of our understanding of the mechanisms of herbal medicine. herbs are pharmacologically active and can positively or negatively affect patient's health. with increasing use of herbs as dietary supplements and alternative therapy, there is an increased risk of negative impacts, such as adverse effects and interactions. herbal medicine is among the most common causes of drug-induced liver injury (dili) [123] . additionally, several adverse effects of commonly used herbs have been reviewed, including hypoglycemic or hyperglycemic effect, hypolipidemic or hyperlipidemic effect, hormonal activities, hypertensive, cardioactive [124] , and hepatotoxic effects [125] . some of them are serious even in recommended dosage, such as ephedra alkaloids (derived from ephedra sinica or ma huang) [126] [127] [128] . however, most of the molecular mechanisms causing side effects are unknown. plants containing pyrrolizidine alkaloids can lead to hepatotoxicity and venoocclusive disease, possibly by the accumulation of toxic metabolites produced via the cytochrome system [129] . some herbal treatments containing aristolochic acid (aa), including aristolochia fangchi, aristolochia debilis sieb. et zucc., aristolochia manshuriensis, aristolochia debilis, can cause aa nephropathy requiring renal replacement therapy [130, 131] ; additionally, aa is associated with urothelial cancers [132] . although most of the above issues have been identified, the unrecognized issues are just the tip of the iceberg. tcm formulas have numerous bioactive compounds to form a kind of cocktail therapy. however, the amounts of each bioactive compound in herbs and tcm formulas are very low. this may raise questions about the likelihood of their interactions with others during administration in a decoction. ginseng, a common natural product used among adults [4] , has about 30 ginsenosides as its major bioactive compounds [133] , although the actual amount of each ginsenoside is small. after oral administration, ginsenosides are metabolized and transformed by intestinal microbiota. diet can markedly influence the transformation of ginsenosides. they exert pharmacologic effects in animals, and also show various clinical effects in randomized controlled trials, including several side effects and drug interactions [133] , so small amounts of bioactive compounds do have clinical effects and side effects, which might come from the individual pharmacological activity of bioactive compounds or their synergism. the side effects may also come from individual unfavorable bioactivity or from interactions. additionally, herbal medicine and tcm therapy are commonly used in combination with orthodox medicine by patients, sometimes unknown to their doctors. the complex and unknown interactions, including herb-drug, herb-herb, herb-food, herb-microbiome, and herb-disease interactions, make use of herbal medicine more complicated and requiring frequent monitoring. the mechanisms of these interactions can be divided into molecular mimicry and pharmacologic interactions, such as pharmacodynamic and pharmacokinetic interactions. for example, with molecular mimicry, several herbs naturally has coumarin or salicylate analogue that may potentiate the bleeding risk of warfarin and salicylate, respectively. for pharmacodynamic interactions, ephedra sinica (ma huang) should not be used with sedative or anti-hypertensive agents. for pharmacokinetic interactions, st john's wort and several tcm formulas have been noted to affect the cyp450 system of liver, which may increase or decrease the effects of other drugs [134] . additionally, the herb-drug interaction may be individualized, e.g., in combination with warfarin, panax ginseng may cause thrombotic event [20] , bleeding [21, 22] , or neither [23] . currently, most of the molecular mechanisms of these identified interactions are not fully understood, to say nothing of the unrecognized interactions. quality uncertainty impacts the reproducibility of clinical efficacy and safety of commercially available natural products. variability of the quality of natural products may come from a lack of standardization of manufacturing, including misidentification of authenticity, inadequate processing, inadequate storage, adulteration of formulas, and accidental contamination [135] . most of those quality problems can be gradually solved by following the who guidelines on good agriculture and collection practices for medicinal plants [136] and botanical drug development guidance for industry of fda [137] . several health benefits of herbal medicine and tcm are claimed; for example, herbs and tcm formulas, including those discussed above, are believed to have anti-oxidative activities helpful against several diseases. this idea is based on reactive oxygen and nitrosative species (ros/rns) as metabolic byproducts that can cause damage to cellular macromolecules; thus, many diseases can be triggered by oxidative stress under high levels of ros/rns. these diseases include cancer, inflammation, and degenerative diseases. oxidative stress causes damage either with an overwhelming production of ros/rns or under insufficient levels of antioxidants or repair mechanisms, so blocking the generation of ros/rns might prevent and/or manage these diseases [138] . however, ros/rns are also signaling molecules for several physiological functions, including regulation of vascular tone, control of ventilation, and erythropoietin production, etc. actually, ros-mediated responses may protect against oxidative stress [139] . additionally, ros/rns may play a dual role in different diseases, i.e., ros/rns might contribute to, or counteract, the disease progression. it remains unclear that more dosage of antioxidants is not better and may even worsen a medical condition [138] . there are insufficient data to establish the ability of tcm to decrease ros/rns levels and establish its effects on the disease, and this affects the interpretation of any claims of benefit. to validate such claims of the benefits of herbal medicine and tcm, much work remains to be done. only when these limitations can be minimized, can the molecular mechanisms of herbs and tcm formulas be understood. consequently, clinicians can help patients by giving adequate prescriptions and suggestions to minimize the harmfulness and maximize the benefits to healthcare. herbal medicine, including tcm, is commonly used worldwide. herbal remedies contain numerous active molecules to form a kind of cocktail therapy. these active molecules may interact with each other to affect the therapeutic effects and produce side effects. understanding their pharmacological effects, interactions, side effects, clinical effects, and the underlying molecular mechanisms is very important to provide benefits, but avoid harm, to the patient. to unravel the molecular mechanisms, much work remains to be done. the abc clinical guide to herbs trends in 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guinea pigs changes in the level of cytokine in rats with chronic obstructive pulmonary disease of phlegm heat cumber lung type after treatment of maxing shigan decoction. chin the prescriptions frequencies and patterns of chinese herbal medicine for allergic rhinitis in taiwan the use of chinese herbal medicine in the treatment of chronic obstructive pulmonary disease (copd) xiao-qing-long-tang (sho-seiryu-to) inhibited cytopathic effect of human respiratory syncytial virus in cell lines of human respiratory tract in vivo anti-influenza virus activity of kampo (japanese herbal) medicine "sho-seiryu-to" to indicate a break in thought or interpretation and its mode of action in vivo anti-influenza virus activity of kampo (japanese herbal) medicine "sho-seiryu-to"-effects on aged mice, against subtypes of a viruses and b virus, and therapeutic effect proteomic analysis of anti-inflammatory effects of a kampo (japanese herbal) medicine "shoseiryuto (xiao-qing-long-tang)" on airway inflammation in a mouse model xiao-qing-long-tang attenuates allergic airway inflammation and remodeling in repetitive dermatogoides pteronyssinus challenged chronic asthmatic mice model effects of xiaoqiongtang decoction on airway inflammation and airway remodeling in patients with copd anti-allergic activity of a kampo (japanese herbal) medicine "sho-seiryu-to (xiao-qing-long-tang)" on airway inflammation in a mouse model schisandrin a inhibits the il-1beta-induced inflammation and cartilage degradation via suppression of mapk and nf-kappab signal pathways in rat chondrocytes schisandrin a suppresses lipopolysaccharide-induced inflammation and oxidative stress in raw 264.7 macrophages by suppressing the nf-kappab, mapks and pi3k/akt pathways and activating nrf2/ho-1 signaling schisandrin b inhibits lps-induced inflammatory response in human umbilical vein endothelial cells by activating nrf2 anti-septic activity of alpha-cubebenoate isolated from schisandra chinensis identification of a novel anti-inflammatory compound, alpha-cubebenoate from schisandra chinensis antitussive activity of the schisandra chinensis fruit polysaccharide (scfp-1) in guinea pigs models pinellia ternata lectin exerts a pro-inflammatory effect on macrophages by inducing the release of pro-inflammatory cytokines, the activation of the nuclear factor-kappab signaling pathway and the overproduction of reactive oxygen species meta-analysis on shegan mahuang tang for refractory asthma clinical observation on therapeutic effect of traditional chinese medicine granules made by formula of shegan mahuang decoction for patients with asthma yakammaoto inhibited human coxsackievirus b4 (cvb4)-induced airway and renal tubular injuries by preventing viral attachment, internalization, and replication yakammaoto inhibits enterovirus 71 infection by reducing viral attachment, internalization, replication, and translation effect of modified shegan mahuang decoction on cytokines in children patients with 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plants drug development guidance for industry positive or negative actors? biomolecules free radicals in the physiological control of cell function the authors would like to thank teachers of the center for languages and culture of kaohsiung medical university for the technical support. the authors declare no conflict of interest. key: cord-273941-gu6nnv9d authors: chandran, uma; mehendale, neelay; patil, saniya; chaguturu, rathnam; patwardhan, bhushan title: chapter 5 network pharmacology date: 2017-12-31 journal: innovative approaches in drug discovery doi: 10.1016/b978-0-12-801814-9.00005-2 sha: doc_id: 273941 cord_uid: gu6nnv9d abstract the one-drug/one-target/one-disease approach to drug discovery is presently facing many challenges of safety, efficacy, and sustainability. network biology and polypharmacology approaches gained appreciation recently as methods for omics data integration and multitarget drug development, respectively. the combination of these two approaches created a novel paradigm called network pharmacology (np) that looks at the effect of drugs on both the interactome and the diseasome level. ayurveda, the traditional system of indian medicine, uses intelligent formulations containing multiple ingredients and multiple bioactive compounds; however, the scientific rationale and mechanisms remain largely unexplored. np approaches can serve as a valuable tool for evidence-based ayurveda to understand the medicines’ putative actions, indications, and mechanisms. this chapter discusses np and its potential to explore traditional medicine systems to overcome the drug discovery impasse. drug discovery, the process by which new candidate medications are discovered, initially began with random searching of therapeutic agents from plants, animals, and naturally occurring minerals (burger, 1964) . for this, they depended on the materia medica that was established by medicine men and priests from that era. this was followed by the origin of classical pharmacology in which the desirable therapeutic effects of small molecules were tested on intact cells or whole organisms. later, the advent of human genome sequencing revolutionized the drug discovery process that developed into targetàbased drug discovery, also known as reverse pharmacology. this relies on the hypothesis that the modulation of the activity of a specific protein will have therapeutic effects. the protein that the drug binds to or interacts with is also referred to as a "target." in this reductionist approach, small molecules from a chemical library are screened for their effect on the target's known or predicted function (hacker et al., 2009) . once the small molecule is selected for a particular target, further modifications are carried out at the atomic level to ameliorate the lock-and-key interactions. this one-drug/onetarget/one-therapeutic approach was followed for the last several decades. the information technology revolution at the end of 20th century metamorphosed the drug discovery process as well (clark and pickett, 2000) . advancements in omics technologies during this time were used to develop strategies for different phases of drug research (buriani et al., 2012) . computational power was implemented in the discovery process for predicting a drug-likeness of newly designed or discovered compounds and ligandprotein docking for predicting the binding affinity of a small molecule with a protein three-dimensional structure. in silico tools were developed to predict other pharmacological properties of the drug molecules such as absorption, distribution, metabolism, excretion, and toxicity-abbreviated together as admet (van de waterbeemd and gifford, 2003; clark and grootenhuis, 2002) . the technological advancements triggered discovery efforts in a direction to discover more specific magic bullets that were completely against the holistic approach of traditional medicine. this magic bullet approach is currently in decline phase. the major limitations of this drug discovery approach are side effects and the inability to tackle multifactorial diseases. this is mainly due to the linearity of this approach. during the peak, historical time of drug discovery and development of natural productsàbased drugs had played a significant role due to their superior chemical diversity and safety over synthetic compound libraries (zimmermann et al., 2007) . currently, it is estimated that more than one hundred new, natural productàbased leads are in clinical development (harvey, 2008) . many active compounds (bioactives) from traditional medicine sources could serve as good starting compounds and scaffolds for rational drug design. natural products normally act through modulation of multiple targets rather than a single, highly specific target. but in drug discovery and development, technology was used to synthesize highly specific mono-targeted molecules that mimic the bioactives from natural compounds rather than understanding the rationale behind their synergistic action and developing methods to isolate the bioactives from natural resources. researchers understand that most diseases are due to dysfunction of multiple proteins. thus, it is important to address multiple targets emanating from a syndrome-related, metabolic cascade, so that holistic management can be effectively achieved. therefore, it is necessary to shift the strategy from one that focuses on a single-target, new chemical entity to one of a multiple-target, synergistic, formulation-discovery approach . this tempted the research world to go back and extensively explore natural sources, where modern pharmacology had begun. this renewed research focus indicates the need to rediscover the drug discovery process by integrating traditional knowledge with state-of-the-art technologies (patwardhan, 2014a) . a new discipline called network pharmacology (np) has emerged which attempts to understand drug actions and interactions with multiple targets (hopkins, 2007) . it uses computational power to systematically catalogue the molecular interactions of a drug molecule in a living cell. np appeared as an important tool in understanding the underlying complex relationships between botanical formula and the whole body berger and iyengar, 2009) . it also attempts to discover new drug leads and targets and to repurpose existing drug molecules for different therapeutic conditions by allowing an unbiased investigation of potential target spaces (kibble et al., 2015) . however, these efforts require some guidance for selecting the right type of targets and new scaffolds of drug molecules. traditional knowledge can play a vital role in this process of formulation discovery and repurposing existing drugs. by combining advances in systems biology and np, it might be possible to rationally design the next generation of promiscuous drugs (cho et al., 2012; hopkins, 2008; ellingson et al., 2014) . np analysis not only opens up new therapeutic options, but it also aims to improve the safety and efficacy of existing medications. the postgenomic era witnessed a rapid development of computational biology techniques to analyze and explore existing biological data. the key aim of the postgenomic biomedical research was to systematically catalogue all molecules and their interactions within a living cell. it is essential to understand how these molecules and the interactions among them determine the function of this immensely complex machinery, both in isolation and when surrounded by other cells. this led to the emergence and advancement of network biology, which indicates that cellular networks are governed by universal laws and offer a new conceptual framework that could potentially revolutionize our view of biology and disease pathologies in the 21st century (barabási and oltvai, 2004) . during the first decade of the 21st century, several approaches for biological network construction were put forward that used computational methods, and literature mining especially, to understand the relation between disease phenotypes and genotypes. as a consequence, lmma (literature mining and microarray analysis), a novel approach to reconstructing gene networks by combining literature mining and microarray analysis, was proposed (li et al., 2006; huang and li, 2010) . with this, a global network was first derived using the literatureàbased, cooccurrence method and then refined using microarray data. the lmma biological network approach enables researchers to keep themselves up to date with relevant literature on specialized biological topics and to make sense of the relevant large-scale microarray dataset. also, lmma serves as a useful tool for constructing specific biological network and experimental design. lmmaàlike representations enable a systemic recognition for the specific diseases in the context of complex gene interactions and are helpful for studying the regulation of various complex biological, physiological, and pathological systems. the significance of accumulated-data integration was appreciated by pharmacologists, and they began to look beyond the classic lock-and-key concept as a far more intricate picture of drug action became clear in the postgenomic era. the global mapping of pharmacological space uncovered promiscuity, the specific binding of a chemical to more than one target (paolini et al., 2006) . as there can be multiple keys for a single lock, in the same way, a single key can fit into multiple locks. similarly, a ligand might interact with many targets and a target may accommodate different types of ligands. this is referred to as "polypharmacology." the concept of network biology was used to integrate data from drugbank (re and valentini, 2013) and omim (hamosh et al., 2005) , an online catalog of human genes and genetic disorders to understand the industry trends, the properties of drug targets, and to study how drug targets are related to disease-gene products. in this way, when the first drug-target network was constructed, isolated and bipartite nodes were expected based on the existed one-drug/one-target/onedisease approach. rather, the authors observed a rich network of polypharmacology interactions between drugs and their targets (yildirim et al., 2007 ). an overabundance of "follow-on" drugs that are drugs that target already targeted proteins was observed. this suggested a need to upgrade the singletarget single-drug paradigm, as single-protein single-function relations are limited to accurately describing the reality of cellular processes. advances in systems biology led to the realization that complex diseases cannot be effectively treated by intervention at single proteins. this made the drug researchers accept the concept of polypharmacology which they previously thought as an undesirable property that needs to be removed or reduced to produce clean drugs acting on single-targets. according to network biology, simultaneous modulation of multiple targets is required for modifying phenotypes. developing methods to aid polypharmacology can help to improve efficacy and predict unwanted off-target effects. hopkins (hopkins, 2007 (hopkins, , 2008 observed that network biology and polypharmacology can illuminate the understanding of drug action. he introduced the term "network pharmacology." this distinctive new approach to drug discovery can enable the paradigm shift from highly specific magic bulletàbased drug discovery to multitargeted drug discovery. np has the potential to provide new treatments to multigenic complex diseases and can lead to the development of e-therapeutics where the ligand formulation can be customized for each complex indication under every disease type. this can be expanded in the future and lead to customized and personalized therapeutics. integration of network biology and polypharmacology can tackle two major sources of attrition in drug development such as efficacy and toxicity. also, this integration holds the promise of expanding the current opportunity space for druggable targets. hopkins proposed np as the next paradigm in drug discovery. polypharmacology expands the space in drug discovery approach. hopkins had suggested three strategies to the designers of multitarget therapies: the first was to prescribe multiple individual medications as a multidrug combination cocktail. patient compliance and the danger of drugàdrug interactions would be the expected drawbacks of this method. the second proposition was the development of multicomponent drug formulations. the change in metabolism, bioavailability, and pharmacokinetics of formulation as well as safety would be the major concerns of this approach. the third strategy was to design a single compound with selective polypharmacology. according to hopkins, the third method is advantageous, as it would ease the dosing studies. also, the regulatory barriers for the single compound are fewer compared to a formulation. an excellent example of this is metformin, the first-line drug for type ii diabetes that has been found to have cancerinhibiting properties (leung et al., 2013) . the following years witnessed the application research of np by integrating network biology and polypharmacology. a computational framework, based on a regression model that integrates human proteinàprotein interactions, disease phenotype similarities, and known geneàphenotype associations to capture the complex relationships between phenotypes and genotypes, has been proposed. this was based on the assumption that phenotypically similar diseases are caused by functionally related genes. a tool named cipher (correlating protein interaction network and phenotype network to predict disease genes) has been developed that predicts and prioritizes disease-causing genes (wu et al., 2008) . cipher helps to uncover known disease genes and predict novel susceptibility candidates. another application of this study is to predict a human disease landscape that can be exploited to study the related genes for related phenotypes that will be clustered together in a molecular interaction network. this will facilitate the discovery of disease genes and help to analyze the cooperativity among genes. later, cipher-hit, a hitting-time-based method to measure global closeness between two nodes of a heterogeneous network, was developed (yao et al., 2011) . a phenotypeàgenotype network can be explored using this method for detecting the genes related to a particular phenotype. a net-workàbased gene clustering and extension were used to identify responsive gene modules in a conditionàspecific gene network aimed to provide useful resources to understand physiological responses (gu et al., 2010) . np was also used to develop mirnaàbased biomarkers (lu et al., 2011) . for this, a network of mirna and their targets was constructed and further refined to study the data for specific diseases. this process integrated with literature mining was useful to develop potent mirna markers for diseases. np was also used to develop a drug geneàdisease comodule (zhao and li, 2012) . initially, a drug-disease network was constructed by information gathered from databases followed by the integration of gene data. the gene closeness was studied by developing a mathematical model. this network inferred the association of multiple genes for most of the diseases and target sharing of drugs and diseases. these kinds of networks give insight into new drug-disease associations and their molecular connections. during the progression period of network biology, natural products were gaining importance in the chemical space of drug discovery, as these have been economically designed and synthesized by nature for the benefit of evolution (wetzel et al., 2011) . researchers began analyzing the logic behind traditional medicine systems and devised computational ways to ease the analysis. a comprehensive herbal medicine information system that was developed integrates information of more than 200 anticancer herbal recipes that have been used for the treatment of different types of cancer in the clinic, 900 individual ingredients, and 8500 small organic molecules isolated from herbal medicines (fang et al., 2005) . this system, which was developed using an oracle database and internet technology, facilitates and promotes scientific research in herbal medicine. this was followed by the development of many databases that serve as a source of botanical information and a powerful tool that provides a bridge between traditional medicines and modern molecular biology. these kinds of databases and tools made the researchers conceive the idea of np of botanicals and their formulations to understand the underlying mechanisms of traditional medicines. we refer to such networks as "ethnopharmacological networks" and the technique as "network ethnopharmacology (nep)" (patwardhan and chandran, 2015) . shao li pioneered this endeavor and proposed this network as a tool to explain the zheng (syndrome of traditional chinese medicine (tcm)) and the multiple-targets' mechanism of tcm (li, 2007) . li et al. tried to provide a molecular basis for 1000-year-old concept of zheng using a neuro-endocrine-immune (nei) network . zheng is the basic unit and key concept in tcm theory. it is also used as a guideline in disease classification in tcm. the hot (hans zheng in mandarin) and cold (re zheng) are the two statuses of zheng which therapeutically directs the use of herbs in tcm. chinese herbs are classified as hotàcooling and are used to remedy hot zheng and coldàwarming herbs that are used to remedy cold zheng. according to the authors, hormones may be related to hot zheng, immune factors may be related to cold zheng, and they may be interconnected by neurotransmitters. this study provides a methodical approach to understand tcm within the framework of modern science. later they reconstructed the nei network by adding multilayer information including data available on the kegg database related to signal transduction, metabolic pathways, proteinàprotein interactions, transcription factor, and micro rna regulations. they also connected drugs and diseases through multilayered interactions. the study of cold zheng emphasized its relation to energy metabolism, which is tightly correlated with the genes of neurotransmitters, hormones, and cytokines in the nei interaction network ma et al., 2010) . another database, tcmgenedit, provides information about tcms, genes, diseases, tcm effects, and tcm ingredients mined from a vast amount of biomedical literature. this would facilitate clinical research and elucidate the possible therapeutic mechanisms of tcms and gene regulations (fang et al., 2008) . to study the combination rule of tcm formulae, an herb network was created using 3865 collaterals-related formulae . they developed a distance-based, mutual-information model (dmim) to uncover the combination rule. dmim uses mutual-information entropy and "between herb distance" to measure the tendency of two herbs to form an herb pair. they experimentally evaluated the combination of a few herbs for angiogenesis. understanding the combination rule of herbs in formulae will help the modernization of traditional medicine and also help to develop a new formulae based on the current requirement. a network targetàbased paradigm was proposed for the first time to understand the synergistic combinations , and an algorithm termed "nims" (network tar-getàbased identification of a multicomponent synergy) was also developed. this was a step that facilitated the development of multicomponent therapeutics using traditional wisdom. an innovative way to study the molecular mechanism of tcm was proposed during this time by integrating the tcm experimental data with microarray gene expression data (wen et al., 2011) . as a demonstrative example, si-wu-tang's formula was studied. rather than uncovering the molecular mechanism of action, this method would help to identify new health benefits of tcms. the initial years of the second decade of the 21st century witnessed the network ethnopharmacological exploration of tcm formulations. the scope of this new area attracted scientists, and they hoped nep could provide insight into multicompound drug discoveries that could help overcome the current impasse in drug discovery (patwardhan, 2014b; . nep was used to study the antiinflammatory mechanism of qingfei xiaoyan, a tcm . the predicted results were used to design experiments and analyze the data. experimental confirmation of the predicted results provides an effective strategy for the study of traditional medicines. the potential of tcm formulations as multiple compound drug candidates has been studied using tcm formulations based np. tcm formulations studied in this way are listed in table 5 .1. construction of a database containing 19,7201 natural product structures, followed by their docking to 332 target proteins of fda-approved drugs, shows the amount of space shared in the chemical space between natural products and fda drugs (gu et al., 2013a) . molecular-docking technique plays a major role in np. the interaction of bioactives with molecular targets can be analyzed by this technique. molecular dockingàbased nep can be a useful tool to computationally elucidate the combinatorial effects of traditional medicine to intervene disease networks (gu et al., 2013c ). an approach that combines np and pharmacokinetics has been proposed to study the material basis of tcm formulations (pei et al., 2013) . this can be extrapolated to study other traditional medicine formulations as well. in cancer research, numerous natural products have been demonstrated to have anticancer potential. natural products are gaining attraction in anticancer research, as they show a favorable profile in terms of absorption and metabolism in the body with low toxicity. in a study all of the known bioactives were docked for their property to interact with 104 cancer targets (luo et al., 2014) . it was inferred that many bioactives are targeting multiple ejiao slurry regulates cancer cell differentiation, growth, proliferation, and apoptosis, and shows an adjuvant therapeutic effect that enriches the blood and increases immunity xu et al. (2014b) xiao-chaihu decoction and da chaihu-decoction xchd treats diseases accompanying symptoms of alternating fever and chills, no desire for food or drink, and dry pharynx, while dchd treats those with symptoms of fullness, pain in abdomen, and constipation. dragon's blood used in colitis and acts through interaction with 26 putative targets xu et al. (2014a) protein targets and thus are linked to many types of cancers. np coupled to sophisticated spectroscopical analysis such as ultra-performance liquid chromatographyàelectrospray, ionizationàtandem mass spectroscopy (uplc-esi-ms/ms) is a useful approach to study the absolute molecular mechanism of action of botanical formulations based on their constituent bioactives (xu et al., 2014a) . bioactiveàtarget analysis has shown that some of the botanical formulations are more effective than their corresponding marketed drugàtarget interactions . this indicates the potential of np to better understand the power of botanical formulations and to develop efficient and economical treatment options. the holistic approach of botanical formulations can be better explained by np. a study has reported this property by exemplifying a tcm formulation against viral infectious disease . not only does the formulation target the proteins in the viral infection cycle, but it also regulates the proteins of the host defense system; thus, it acts in a very distinctive manner. this unique property of formulations is highly efficient for strengthening the broad and nonspecific antipathogenic actions. thus, network-based, multitarget drugs can be developed by testing the efficacy of the formulation, identifying, and isolating the major bioactives and redeveloping a multicomponent therapeutic using the major bioactives based on synergism (leung et al., 2013) . np also serves to document and analyze the clinical prescriptions of traditional medicine practitioners . a traditional medicine network that links bioactives to clinical symptoms through targets and diseases is a novel way to explore the basic principles of traditional medicines (luo et al., 2015) . the network-based approaches provide a systematic platform for the study of multicomponent traditional medicine and has applications for its beneficial modernization. this platform not only recovers traditional knowledge, but it also provide new findings that can be used for resolving current problems in the drug industry . this section explains a handful of ethnopharmacological networks that were developed to understand the scientific rationale of traditional medicine. dragon's blood (db) tablets, which are made of resins from dracaena spp., daemonorops spp., croton spp., and pterocarpus spp., is an effective tcm for the treatment of colitis. in a study, an np-based approach was adopted to provide new insights relating to the active constituents and molecular mechanisms underlying the effects of db (xu et al., 2014a) . the constituent chemicals of the formulation were identified using an ultraperformance liquid chromatography-electrospray ionization-tandem mass spectrometry method. the known targets of those identified 48 compounds were mined from literature and putative targets that were predicted with the help of computational tools. the compounds were further screened for bioavailability followed by the systematic analysis of the known and putative targets for colitis. the network evaluation revealed the mechanism of action of db bioactives for colitis through the modulation of the proteins of the nod-like receptor signaling pathway (fig. 5.1) . the antioxidant mechanism of zhi-zi-da-huang decoction as an approach to treat alcohol liver disease was elucidated using np an and feng, 2015 ). an endothelial cell proliferation assay was performed for an antiangiogenic alkaloid, sinomenine, to validate the network targetàbased identification of multicomponent synergy (nims) predictions. the study was aimed at evaluating the synergistic relationship between different pairs of therapeutics, and sinomenine was found to have a maximum inhibition rate with matrine, both through the network and in vitro studies. the discovery of bioactives and elucidation of the mechanism of action of the herbal formulae, qing-luo-yin and the liu-wei-di-huang pill, using np, has given insight to the design validation experiments that accelerated the process of drug discovery . validation experiments based on the network findings regarding cold zheng and hot zheng on a rat model of collagenàinduced arthritis showed that the cold zhengàoriented herbs tend to affect the hub nodes in the cold zheng network, and the hot zheng-oriented herbs tend to affect the hub nodes in the hot zheng network . np was used to explain the addition and subtraction theory of tcm. two decoctions: xiao chaihu and da chaihu were studied using np approach to investigate this theory. according to the addition and subtraction theory, the addition or removal of one or more ingredients from a traditional formulation resulted in a modified formula that plays a vital role in individualized medicine. compounds from additive herbs were observed to be more efficient on diseaseàassociated targets (fig. 5.2) . these additive compounds were found to act on 93 diseases through 65 drug targets (li et al., 2014a) . experimental verification of the antithrombotic network of fufang xueshuantong (fxst) capsule was done through in vivo studies on lipopoly-saccharideàinduced disseminated intravascular coagulation (dic) rat model. it was successfully shown that fxst significantly improves the activation of the coagulation system through 41 targets from four herbs (sheng et al., 2014) . np analysis of the bushenhuoxue formula showed that six components-rhein, tanshinone iia, curcumin, quercetin and calycosin-acted through 62 targets for the treatment of chronic kidney disease. these predictions were validated using unilateral ureteral obstruction models, and it was observed that even though the individual botanicals showed a significant decrease in creatinine levels, the combination showed lower blood creatinine and urea nitrogen levels (shi et al., 2014) . the antidiabetic effects of ge-gen-qin-lian decoction were investigated using an insulin secretion assay, and an insulinàresistance model using 13 of the 19 ingredients showed antidiabetic activity using np studies (li et al., 2014b) . to confirm the predictions of the network of liu-wei-di-huang pill, four proteins-pparg, rara, ccr2, and esr1-that denote different functions and are targeted by different groups of ingredients were chosen. the interactions between various bioactives and their effect on the expression of the proteins showed that the np approach can accurately predict these interactions, giving hints regarding the mechanism of action of the compounds (liang et al., 2014) . experimental results confirmed that the 30 core ingredients in modified simiaowan, obtained through network analysis, significantly increased huvec viability and attenuated the expression of icam-1 and proved to be effective in gout treatment (zhao et al., 2015) . the role of anthraquinone and flavanols (catechin and epicatechin) in the therapeutic potential of rhubarb in renal interstitial fibrosis was examined using network analysis and by conventional assessment involving serum biochemistry, histopathological, and immunohistochemical assays (xiang et al., 2015) . in silico analysis and experimental validation demonstrated that compound 11/12 of fructus schisandrae chinensis targets gba3/shbg . np is a valuable method to study the synergistic effects of bioactives of traditional medicine formulation. this was experimentally shown on the sendeng-4 formulation for rheumatoid arthritis (fig. 5.3 ). data and network analysis have shown that the formulation acts synergistically through nine categories of targets (zi and yu, 2015) . another network that studied three botanicals, salviae miltiorrhizae, ligusticum chuanxiong, and panax notoginseng for coronary artery disease (cad), displayed their mode of action through 67 targets, out of which 13 are common among the botanicals (fig. 5.4) . these common targets are associated with thrombosis, dyslipidemia, vasoconstriction, and inflammation . this gives insight to how these botanicals are managing cad. another approach using np is the construction of networks based on experimental data followed by literature mining. this method is very effective for large space data analysis, which will help to derive the mechanism of action of the formulation. a network of qishenyiqi formulation having cardioprotective effects, constructed based on the microarray data and the published literature, showed that 9 main compounds were found to act through 16 pathways, out of which 9 are immune and inflammation-related (li et al., 2014c) . the mechanism of action for the bushen zhuanggu formulation was proposed based on lc-ms/ms standardization, pharmacokinetic analysis, and np (pei et al., 2013) . the efficacy of shenmai injection was evaluated using a rat model of myocardial infarction, genome-wide transcriptomic experiment, and then followed by a np analysis. the overall trends in the ejection fraction and fractional shortening were consistent with the networkàrecovery index (nri) from the network . in order to develop an ethnopharmacological network, exploring the existing databases to gather information regarding bioactives and targets is the first step. further information such as target-related diseases, tissue distribution and pathways are also to be collected depending on the type of study that is going to be undertaken. the universal natural products database (unpd) (gu et al., 2013a ) is one of the major databases that provides bioactives information. other databases that provide information regarding bioactives include cvdhd (gu et al., 2013b) , tcmsp (ru et al., 2014) , tcm@taiwan (sanderson, 2011) , supernatural (banerjee et al., 2015) , and dr. dukes's phytochemical and ethnobotanical database (duke and beckstrom-sternberg, 1994) . the molecular structures of bioactives are usually stored as "sd" files and chemical information as smiles and inchkeys in these databases. any of these file formats can be used as inputs to identify the targets in protein information databases. binding database or "binding db" (liu et al., 2007) and chembl (bento et al., 2014) are databases for predicting target proteins. binding db searches the exact or similar compounds in the database and retrieves the target information of those compounds. the similarity search gives the structurally similar compounds with respect to the degree of similarity as scores to the queried structure. the information regarding both annotated and predicted targets can be collected in this way. this database is connected to numerous databases, and these connections can be used to extract further information regarding the targets. the important databases linked to binding db are uniprot (bairoch et al., 2005) , which gives information related to proteins and genes; reactome, a curated pathway database (croft et al., 2011) ; and the kyoto encyclopedia of genes and genomes (kegg), a knowledge base for systematic analysis of gene functions and pathways (ogata et al., 1999) . therapeutic targets database (ttd) (zhu et al., 2012) gives fully referenced information of targeted diseases of proteins, their pathway information, and the corresponding drug directed to each target. disease and gene annotation (dga), a database that provides a comprehensive and integrative annotation of human genes in disease networks, is useful in identifying the disease type that each indication belongs to (peng et al., 2013) . the human protein atlas (hpa) database (pontén et al., 2011) is an open database showing the spatial distribution of proteins in 44 different normal human tissues. the information of the distribution of proteins in tissues can be gathered from hpa. the database also gives information regarding subcellular localization and protein class. an overall review of the methods to implement np for herbs and herbal formulations is also available, including a systematic review of the databases that one could use for the same (kibble et al., 2015; lagunin et al., 2014) . integration of knowledge bases helps data gathering for network pharmacological studies, and its knowledge base shows the inter-relationships among these databases (fig. 5 .5) . the counts of entities, such as bioactives, targets, and diseases, can vary based on the knowledge bases that are relied on for data collection. an integration of knowledge bases can overcome this limitation. another factor that affects the counts of these entities is the time frame for data collection. this change occurs due to the ongoing, periodic updates of the databases. a network is the schematic representation of the interaction among various entities called nodes. in pharmacological networks, the nodes include bioactives, targets, tissue, tissue types, disease, disease types, and pathways. these nodes are connected by lines termed edges, which represent the relationship between them (morris et al., 2012) . building a network involves two opposite approaches: a bottom-up approach on the basis of established biological knowledge and a top-down approach starting with the statistical analysis of available data. at a more detailed level, there are several ways to build and illustrate a biological network. perhaps the most versatile and general way is the de novo assembly of a network from direct experimental or computational interactions, e.g., chemical/gene/protein screens. networks encompassing biologically relevant nodes (genes, proteins, metabolites), their connections (biochemical and regulatory), and modules (pathways and functional units) give an authentic idea of the real biological phenomena (xu and qu, 2011) . cytoscape, a java-based open source software platform (shannon et al., 2003) , is a useful tool for visualizing molecular interaction networks and integrating them with any type of attribute data. in addition to the basic set of features for data integration, analysis, and visualization, additional features are available in the form of apps, including network and molecular profiling analysis and links with other databases. in addition to cytoscape, a number of visualization tools are available. visual network pharmacology (vnp) , which is specially designed to visualize the complex relationships among diseases, targets, and drugs, mainly contains three functional modules: drug-centric, target-centric, and disease-centric vnp. this disease-target-drug database documents known connections among diseases, targets, and the usfda-approved drugs. users can search the database using disease, target, or drug name strings; chemical structures and substructures; or protein sequence similarity, and then obtain an online interactive network view of the retrieved records. in the obtained network view, each node is a disease, target, or drug, and each edge is a known connection between two of them. the connectivity map, or the cmap tool, allows the user to compare gene-expression profiles. the similarities or differences in the signature transcriptional expression profile and the small molecule transcriptional response profile may lead to the discovery of the mode of action of the small molecule. the response profile is also compared to response profiles of drugs in the cmap database with respect to the similarity of transcriptional responses. a network is constructed and the drugs that appear closest to the small molecule are selected to have better insight into the mode of action. other software, such as gephi, an exploration platform for networks and complex systems, and cell illustrator, a java-based tool specialized in biological processes and systems, can also be used for building networks . ayurveda, the indian traditional medicine, offers many sophisticated formulations that have been used for hundreds of years. the traditional knowledge digital library (tkdl, http://www.tkdl.res.in) contains more than 36,000 classical ayurveda formulations. approximately 100 of these are popularly used at the community level and also as over-the-counter products. some of these drugs continue to be used as home remedies for preventive and primary health care in india. until recently, no research was carried out to explore ayurvedic wisdom using np despite ayurveda holding a rich knowledge of traditional medicine equal to or greater than tcm. our group examined the use of np to study ayurvedic formulations with the wellknown ayurvedic formulation triphala as a demonstrable example (chandran et al., 2015a, b) . in this chapter, we demonstrate the application of np in understanding and exploring the traditional wisdom with triphala as a model. triphala is one of the most popular and widely used ayurvedic formulations. triphala contains fruits of three myrobalans: emblica officinalis (eo; amalaki) also known as phyllanthus emblica; terminalia bellerica (tb; vibhitaka); and terminalia chebula (tc; haritaki). triphala is the drug of choice for the treatment of several diseases, especially those of metabolism, dental, and skin conditions, and treatment of cancer (baliga, 2010) . it has a very good effect on the health of heart, skin, eyes, and helps to delay degenerative changes, such as cataracts (gupta et al., 2010) . triphala can be used as an inexpensive and nontoxic natural product for the prevention and treatment of diseases where vascular endothelial growth factor aàinduced angiogenesis is involved . the presence of numerous polyphenolic compounds empowers it with a broad antimicrobial spectrum (sharma, 2015) . triphala is a constituent of about 1500 ayurveda formulations and it can be used for several diseases. triphala combats degenerative and metabolic disorders possibly through lipid peroxide inhibition and free radical scavenging (sabu and kuttan, 2002) . in a phase i clinical trial on healthy volunteers, immunostimulatory effects of triphala on cytotoxic t cells and natural killer cells have been reported (phetkate et al., 2012) . triphala is shown to induce apoptosis in tumor cells of the human pancreas, in both in vitro and in vivo models (shi et al., 2008) . although the anticancer properties of triphala have been studied, the exact mechanism of action is still not known. the beneficial role of triphala in disease management of proliferative vitreoretinopathy has also been reported (sivasankar et al., 2015) . one of the key ingredients of triphala is amalaki. some studies have already shown the beneficial effect of amalaki rasayana to suppress neurodegeneration in fly models of huntington's and alzheimer's diseases (dwivedi et al., 2012 (dwivedi et al., , 2013 . triphala is an effective medicine to balance all three dosha. it is considered as a good rejuvenator rasayana, which facilitates nourishment to all tissues, or dhatu. here we demonstrate the multidimensional properties of triphala using human proteome, diseasome, and microbial proteome targeting networks. the botanicals of triphala-eo, tb, and tc-contain 114, 25, and 63 bioactives, respectively, according to unpd data collected during june 2015. of these, a few bioactives are common among the three botanicals. thus, triphala formulation as a whole contains 177 bioactives. out of these, 36 bioactives were score-1, based on binding db search carried out during june 2015. eo, tb, and tc contain 20, 4, and 20 score-1 bioactives, respectively ( fig. 5.6 ). the score-1 bioactives that are common among three plants are chebulanin, ellagic acid, gallussaeure, 1,6-digalloyl-beta-d-glucopiranoside, methyl gallate, and tannic acid. this bioactive information is the basic step toward constructing human proteome and microbial proteome targeting networks. thirty-six score-1 bioactives of triphala are shown to interact with 60 human protein targets in 112 combinations (fig. 5.7) . quercetin, ellagic acid, 1,2,3,4,6-pentagalloylglucose and 1,2,3,6-tetrakis-(o-galloyl)-beta-d-glucose are the four bioactives that interact with the maximum number of targets: 21, 16, and 7, respectively. the other major bioactives that have multitargeting property include catechin; epicatechin; gallocatechin; kaempferol; and trans-3,3',4',5,7-pentahydroxylflavane. the major protein targets of triphala include alkaline phosphatase (alpl); carbonic anhydrase 7 (ca7); coagulation factor x (f10), dna repair protein rad51 homolog 1 (rad51); gstm1 protein (gstm1); beta-secretase 1 (bace1); plasminogen activator inhibitor 1 (serpine1), prothrombin (f2); regulator of g-protein signaling (rgs) 4, 7, and 8, tissue-type plasminogen activator (plat); and tyrosineprotein phosphatase nonreceptor type 2 (ptpn2). the 60 targets of triphala are associated with 24 disease types, which include 130 disease indications (fig. 5.8) . the major disease types in which triphala targets are associated include cancers, cardiovascular diseases, nervous system diseases, and metabolic diseases. analysis of existing data indicates that targets of triphala bioactives are involved in the 40 different types of cancers making it the largest group of diseases, involving triphala targets. this linkage is through the interaction of 25 bioactives and 27 target proteins in 46 different bioactiveàtarget combinations. the types of cancers which are networked by triphala include pancreatic, prostate, breast, lung, colorectal and gastric cancers, tumors, and more. quercetin, ellagic acid, prodelphinidin a1, and 1,2,3-benzenetriol are the important bioactives; and rad51, bace1, f2, mmp2, igf1r, and egfr are the important targets that play a role in cancer. triphala shows links to 18 indications of cardiovascular diseases through 12 bioactives and 11 targets. the cardiovascular diseases that are covered in the triphala network include atherosclerosis, myocardial ischemia, infarction, cerebral vasospasm, thrombosis, and hypertension. the bioactives playing a major role in cardiovascular diseases are quercetin, 1,2,3,4,6-pentagalloyoglucose, 1,2,3,6-tetrakis-(o-galloyl)-beta-d-glucose, bellericagenin a1, and prodelphinidin a1, whereas the targets playing an important role are serpine1, f10, f2, and fabp4. triphala's network to nervous system disorders contains 13 diseases in which the significant ones are alzheimer's disease, parkinson's disease, diabetic neuropathy, and retinopathy. in this subnetwork, 14 bioactives interact with 11 targets through 21 different interactions. quercetin, 1,2,3,4,6-pentagalloyoglucose, 1,2,3,6-tetrakis-(o-galloyl)-beta-d-glucose, and epigallocatechin-3-gallate are the most networked bioactives whereas the most networked targets are bace1, serpine1, plat, aldr, ca2. the association of triphala with metabolic disorders is determined by six bioactives that interact with seven targets. the major metabolic diseases come in this link are obesity, diabetic complications, noninsulin-dependent diabetes, hypercholesterolemia, hyperlipidemia, and more. the bioactives having more interactions with targets are ellagic acid, quercetin, and bellericagenin a1, whereas the highly networked targets are igf1r, fabp5, aldr, and akr1b1. triphala bioactives are also linked to targets of other diseases comprising autoimmune diseases, ulcerative colitis, mccuneàalbright syndrome, psoriasis, gout, osteoarthritis, endometriosis, lung fibrosis, glomerulonephritis, and more. the proteome-targeting network of triphala, thus, shows its ability to synergistically modulate 60 targets that are associated with 130 disease indications. this data is generated with the available information that included only one-fifth of the total number of bioactives. further logical analysis and experimental studies based on the network result are needed to explore the in-depth mechanism of action of triphala. for researchers in this area, these kind of networks can give an immense amount of information that can be developed further to reveal the real mystery behind the actions of traditional medicine. triphala is also referred to as a "tridoshic rasayana," as it balances the three constitutional elements of life. it tonifies the gastrointestinal tract, improves digestion, and is known to exhibit antiviral, antibacterial, antifungal, and antiallergic properties (sharma, 2015; amala and jeyaraj, 2014; sumathi and parvathi, 2010) . triphala mashi (mashi: black ash) was found to have nonspecific antimicrobial activity, as it showed a dose-dependent inhibition of gram-positive and gram-negative bacteria (biradar et al., 2008) . hydroalcoholic, aqueous, and ether extracts of the three fruits of triphala were reported to show antibacterial activity against uropathogens with a maximum drug efficacy recorded by the alcoholic extract (bag et al., 2013; prasad et al., 2009) . the methanolic extract of triphala showed the presence of 10 active compounds using gc-ms and also showed potent antibacterial and antifungal activity (amala and jeyaraj, 2014) . triphala has been well studied for its antimicrobial activity against gram-positive bacteria, gram-negative bacteria, fungal species, and different strains of salmonella typhi (amala and jeyaraj, 2014; sumathi and parvathi, 2010; gautam et al., 2012; srikumar et al., 2007) . triphala showed significant antimicrobial activity against enterococcus faecalis and streptococcus mutans grown on tooth substrate thereby making it a suitable agent for prevention of dental plaque (prabhakar et al., 2010 (prabhakar et al., , 2014 . the application of triphala in commercial antimicrobial agents has been explored. a significant reduction in the colony forming units of oral streptococci was observed after 6% triphala was incorporated in a mouthwash formulation (srinagesh et al., 2012 ). an ointment prepared from triphala (10% (w/w)) showed significant antibacterial and wound healing activity in rats infected with staphylococcus aureus, pseudomonas aeruginosa, and streptococcus pyogenes (kumar et al., 2008) . the antiinfective network of triphala sheds light on the efficacy of the formulation in the simultaneous targeting of multiple microorganisms. also, this network provides information regarding some novel bioactiveàtarget combinations that can be explored to combat the problem of multidrug resistance. among the bioactives of triphala, 24 score-1 bioactives target microbial proteins of 22 microorganisms. the botanicals of triphala-eo, tb, and tccontain 19, 3, and 8 score1 bioactives respectively which showed interactions with microbial proteins. they act through modulation of 35 targets which are associated with diseases such as leishmaniasis, malaria, tuberculosis, hepatitis c, acquired immunodeficiency syndrome (aids), cervical cancer, candidiasis, luminous vibriosis, yersiniosis, skin and respiratory infections, severe acute respiratory syndrome (sars), avian viral infection, bacteremia, sleeping sickness, and anthrax ( fig. 5.9 ). the microorganisms captured in the triphala antiinfective network includes candida albicans, hepatitis c virus, human immunodeficiency virus 1, human papillomavirus type 16, human sars coronavirus leishmania amazonensis, mycobacterium tuberculosis, staphylococcus aureus, plasmodium falciparum, and yersinia enterocolitica. in mycobacterium tuberculosis, dtdp-4-dehydrorhamnose 3,5-epimerase rmlc is one of the four enzymes involved in the synthesis of dtdp-l-rhamnose, a precursor of l-rhamnose (giraud et al., 2000) . the network shows that triphala has the potential to modulate the protein through four bioactives such as punicalins, terflavin b, 4-o-(s)-flavogallonyl-6-o-galloylbeta-d-glucopyranose, and 4,6-o-(s,s)-gallagyl-alpha/beta-d-glucopyranose. research on new therapeutics that target the mycobacterial cell wall is in progress. rhamnosyl residues play a structural role in the mycobacterial cell wall by acting as a linker connecting arabinogalactin polymer to peptidoglycan and are not found in humans, which gives them a degree of therapeutic potential (ma et al., 2001) . triphala can be considered in this line to develop novel antimycobacterial drugs. the network shows the potential of gallussaeure and 3-galloylgallic acid to modulate human immunodeficiency virus type 1 reverse transcriptase. inhibition of human immunodeficiency virus at the initial stage itself is crucial and thus, targeting human immunodeficiency virus type 1 reverse transcriptase, at the preinitiation stage is considered to be an effective therapy. protein e6 of human papillomavirus 16 (hpv16) prevents apoptosis of figure 5.9 the microbial proteomeàtargeting network of triphala. dark green verus are the botanicals of triphala and oval green nodes are the score1 bioactives. targets, diseases, and microorganisms are represented by blue diamond nodes, red triangle nodes, and pink octagon nodes, respectively. infected cells by binding to fadd and caspase 8 and hence being targeted for development of antiviral drugs (yuan et al., 2012) . kaempferol of triphala is found to target protein e6 of hpv16, which is a potential mechanism to control the replication of the virus. the network also shows triphala's potential to act on plasmodium falciparum. enoyl-acyl carrier protein reductase (enr) has been investigated as an attractive target due to its important role in membrane construction and energy production in plasmodium falciparum (nicola et al., 2007) while the parasite interacts with human erythrocyte spectrin and other membrane proteins through protein m18 aspartyl aminopeptidase (lauterbach and coetzer, 2008) . trans-3,3',4',5,7-pentahydroxylflavane, epigallocatechin, and epicatechin can modulate both while epigallocatechin 3-gallate can regulate enoyl-acyl carrier protein reductase and, quercetin and vanillic acid can act on m18 aspartyl aminopeptidase. epigallocatechin 3-gallate can also target 3-oxoacyl-acyl-carrier protein reductase which is a potent therapeutic target because of its role in type ii fatty acid synthase pathway of plasmodium falciparum (karmodiya and surolia, 2006) . epigallocatechin 3-gallate and quercetin are the bioactives that have shown maximum antimicrobial targets interaction. while epigallocatechin 3-gallate shows interaction with 3-oxoacyl-(acyl-carrier protein) reductase, cpg dna methylase, enoyl-acyl-carrier protein reductase, glucose-6phosphate 1-dehydrogenase, hepatitis c virus serine protease, ns3/ns4a and yoph of plasmodium falciparum, saccharomyces cerevisiae, and spiroplasma monobiae; quercetin acts on 3c-like proteinase (3cl-pro), arginase, beta-lactamase ampc, glutathione reductase, m18 aspartyl aminopeptidase, malate dehydrogenase and tyrosine-protein kinase transforming protein fps of escherichia coli, fujinami sarcoma virus, human sars coronavirus (sars-cov), leishmania amazonensis, plasmodium falciparum, saccharomyces cerevisiae, and thermus thermophiles. np has gained impetus as a novel paradigm for drug discovery. this approach using in silico data is fast becoming popular due to its cost efficiency and comparably good predictability. thus, network analysis has various applications and promising future prospects with regard to the process of drug discovery and development. np has proven to be a boon for drug research, and that helps in the revival of traditional knowledge. albeit there are a few limitations of using np for nep studies. this is because the bioactives form the foundation of any traditional medicine network. 2. absorption, distribution, metabolism, excretion, and toxic effects (admet) parameters associated with the bioactives/formulation when they are administered in the form of the medicine need to be considered in order to extrapolate in silico and cheminformatics data to in vitro and in vivo models. in silico tools that offer the prediction of these parameters can be depended on for this. but traditional medicines are generally accompanied by a vehicle for delivery of the medicine. these vehicles, normally various solvents-water, milk, lemon juice, butter, ghee (clarified butter), honey-that alter the solubility of the bioactives, play a role in regulating admet parameters. experimental validation studies are required to evaluate this principle of traditional medicine. 3. target identification usually relies on a single or a few databases due to the limited availability of databases with free access. this can occasionally give incomplete results. also, there may be novel targets waiting to be discovered that could be a part of the mechanism of action of the bioactives. to deal with this discrepancy in the network, multiple databases should be considered for target identification. integration of databases serving similar functions can also be a solution for this problem. in addition to this, experimental validation of the target molecules using proteinàprotein interaction studies or gene expression studies will provide concrete testimony to the network predictions. 4. a number of traditional medicines act through multiple bioactives and targets. synergy in botanical drugs helps to balance out the extreme pharmacological effects that individual bioactives may have. the interactions of bioactives with various target proteins, their absorption into the body after possible enzyme degradation, their transport, and finally their physiological effect are a crucial part of traditional medicine (gilbert and alves, 2003) . however, in vitro assays or in silico tools are unable to give a clear idea as to the complete and exact interactions in a living organism. np is only the cardinal step toward understanding the mechanism of bioactives/formulations. but this gives an overview of the action of traditional medicine which can be used to design in vivo experiments and clinical trials. this saves time and cost of research and inventions. 5. it is observed that formulations are working by simultaneous modulation of multiple targets. this modulation includes activation of some targets and inhibition of other. in order to understand this complex synergistic activity of formulation, investigative studies regarding the interactions of ligands with targets are to be carried out. this can be achieved by implementing high-throughput omics studies based on the network data. network pharmacological analysis presents an immense scope for exploring traditional knowledge to find solutions for the current problems challenging the drug discovery industry. nep can also play a key role in new drug discovery, drug repurposing, and rational formulation discovery. many of the bioactiveàtarget combinations have been experimentally studied. the data synthesis using np provides information regarding the mode of action of traditional medicine formulations, based on their constituent bioactives. this is a kind of reverse approach to deduce the molecular mechanism of action of formulations using modern, integrated technologies. the current network analysis is based on the studies that have been conducted and the literature that is available. hence, the data is inconclusive as a number of studies are still underway and novel data is being generated continuously. despite its limitations, this still is a favorable approach, as it gives insight into the hidden knowledge of our ancient traditional medicine wisdom. np aids the logical analysis of this wisdom that can be utilized to understand the knowledge as well as to invent novel solutions for current pharmacological problems. determination of antibacterial, antifungal, bioactive constituents of triphala by ft-ir and gc-ms analysis antibacterial potential of hydroalcoholic extracts of triphala components against multidrug-resistant uropathogenic bacteria--a preliminary report triphala, ayurvedic formulation for treating and preventing cancer: a review super natural ii--a database of natural products network biology: understanding the cell's functional organization the chembl bioactivity database: an update network analyses in systems pharmacology exploring of antimicrobial activity of triphala mashi-an ayurvedic formulation. evidence-based complement 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heart disease in vivo effects of traditional ayurvedic formulations in drosophila melanogaster model relate with therapeutic applications ayurvedic amalaki rasayana and rasa-sindoor suppress neurodegeneration in fly models of huntington's and alzheimer's diseases tc;mgenedit: a database for associated traditional chinese medicine, gene and disease information using text mining antifungal potential of triphala churna ingredients against aspergillus species associated with them during storage rmlc, the third enzyme of dtdp-l-rhamnose pathway, is a new class of epimerase identification of responsive gene modules by networkbased gene clustering and extending: application to inflammation and angiogenesis use of natural products as chemical library for drug discovery and network pharmacology cvdhd: a cardiovascular disease herbal database for drug discovery and network pharmacology understanding traditional chinese medicine antiinflammatory herbal formulae by simulating their regulatory functions in the human arachidonic acid metabolic network evaluation of anticataract potential of triphala in selenite-induced cataract: in vitro and in vivo studies pharmacology: principles and practice online mendelian inheritance in man (omim), a knowledgebase of human genes and genetic disorders network pharmacology: the next paradigm in drug discovery vnp: interactive visual network pharmacology of diseases, targets, and drugs detection of characteristic sub pathway network for angiogenesis based on the comprehensive pathway network analyses of co-operative transitions in plasmodium falciparum beta-ketoacyl acyl carrier protein reductase upon co-factor and acyl carrier protein binding network pharmacology applications to map the unexplored target space and therapeutic potential of natural products triphala promotes healing of infected full-thickness dermal wound chemo-and bioinformatics resources for in silico drug discovery from medicinal plants beyond their traditional use: a 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of traditional chinese herbal formulae network target for screening synergistic drug combinations with application to traditional chinese medicine analysis on correlation between general efficacy and chemical constituents of danggui-chuanxiong herb pair based on artificial neural network network pharmacology study on major active compounds of fufang danshen formula a network pharmacology study of chinese medicine qishenyiqi to reveal its underlying multi-compound, multitarget, multi-pathway mode of action herb network analysis for a famous tcm doctor' s prescriptions on treatment of rheumatoid arthritis. evidence-based complement a novel network pharmacology approach to analyse traditional herbal formulae: the liu-wei-di-huang pill as a case study bindingdb: a web-accessible database of experimentally determined protein-ligand binding affinities network pharmacology study on major active compounds of siwu decoction analogous formulae for treating primary dysmenorrhea of gynecology blood stasis syndrome computational pharmacological comparison of salvia miltiorrhiza and panax notoginseng used in the therapy of cardiovascular diseases triphala and its active constituent chebulinic acid are natural inhibitors of vascular endothelial growth factor-a mediated angiogenesis computational identification of potential microrna network biomarkers for the progression stages of gastric cancer systems pharmacology strategies for anticancer drug discovery based on natural products multiscale modeling of druginduced effects of reduning injection on human disease: from drug molecules to clinical symptoms of disease drug targeting mycobacterium tuberculosis cell wall synthesis: genetics of dtdp-rhamnose synthetic enzymes and development of a microtiter plate-based screen for inhibitors of conversion of dtdp-glucose to dtdp-rhamnose bridging the gap between traditional chinese medicine and systems biology: the connection of cold syndrome and nei network analysis and visualization of biological networks with cytoscape discovery of novel inhibitors targeting enoyl-acyl carrier protein reductase in plasmodium falciparum by structure-based virtual screening global mapping of pharmacological space rediscovering drug discovery network ethnopharmacology approaches for formulation discovery integrative approaches for health: biomedical research, ayurveda and yoga material basis of chinese herbal formulas explored by combining pharmacokinetics with network pharmacology the disease and gene annotations (dga): an annotation resource for human disease significant increase in cytotoxic t lymphocytes and natural killer cells by triphala: a clinical phase i study. evid. based complement alternat the human protein atlas as a proteomic resource for biomarker discovery evaluation of antimicrobial efficacy of herbal alternatives (triphala and green tea polyphenols), mtad, and 5% sodium hypochlorite against enterococcus faecalis biofilm formed on tooth substrate: an in vitro study evaluation of antimicrobial efficacy of triphala (an indian ayurvedic herbal formulation) and 0.2% chlorhexidine against streptococcus mutans biofilm formed on tooth substrate: an in vitro study potent growth suppressive activity of curcumin in human breast cancer cells: modulation of wnt/beta-catenin signaling tcmsp: a database of systems pharmacology for drug discovery from herbal medicines anti-diabetic activity of medicinal plants and its relationship with their antioxidant property databases aim to bridge the east-west divide of drug discovery cytoscape: a software environment for integrated models of biomolecular interaction networks network pharmacology analyses of the antithrombotic pharmacological mechanism of fufang xueshuantong capsule with experimental support using disseminated intravascular coagulation rats a network pharmacology approach to understanding the mechanisms of action of traditional medicine: bushenhuoxue formula for treatment of chronic kidney disease triphala inhibits both in vitro and in vivo xenograft growth of pancreatic tumor cells by inducing apoptosis aqueous and alcoholic extracts of triphala and their active compounds chebulagic acid and chebulinic acid prevented epithelial to mesenchymal transition in retinal pigment epithelial cells, by inhibiting smad-3 phosphorylation evaluation of the growth inhibitory activities of triphala against common bacterial isolates from hiv infected patients antibacterial efficacy of triphala against oral streptococci: an in vivo study antibacterial potential of the three medicinal fruits used in triphala: an ayurvedic formulation dissection of mechanisms of chinese medicinal formula realgar-indigo naturalis as an effective treatment for promyelocytic leukemia a network study of chinese medicine xuesaitong injection to elucidate a complex mode of action with multicompound, multitarget, and multipathway phytochemical and pharmacological review of da chuanxiong formula: a famous herb pair composed of chuanxiong rhizoma and gastrodiae rhizoma for headache in silico analysis and experimental validation of active compounds from fructus schisandrae chinensis in protection from hepatic injury discovery of molecular mechanisms of traditional chinese medicinal formula si-wu-tang using gene expression microarray and connectivity map biology-oriented synthesis a network pharmacology approach to evaluating the efficacy of chinese medicine using genome-wide transcriptional expression data identifying roles of "jun-chen-zuo-shi" component herbs of qishenyiqi formula in treating acute myocardial ischemia by network pharmacology network-based global inference of human disease genes the study on the material basis and the mechanism for anti-renal interstitial fibrosis efficacy of rhubarb through integration of metabonomics and network pharmacology a systems biology-based approach to uncovering the molecular mechanisms underlying the effects of dragon's blood tablet in colitis, involving the integration of chemical analysis, adme prediction, and network pharmacology study on action mechanism of adjuvant therapeutic effect compound ejiao slurry in treating cancers based on network pharmacology alternative medicine. intech network pharmacological research of volatile oil from zhike chuanbei pipa dropping pills in treatment of airway inflammation navigating traditional chinese medicine network pharmacology and computational tools modularity-based credible prediction of disease genes and detection of disease subtypes on the phenotype-gene heterogeneous network small molecule inhibitors of the hpv16-e6 interaction with caspase 8 an integrative platform of tcm network pharmacology and its application on a herbal formula network understanding of herb medicine via rapid identification of ingredient-target interactions dbnei2.0: building multilayer network for drug-neidisease systems pharmacology dissection of the anti-inflammatory mechanism for the medicinal herb folium eriobotryae network pharmacology study on the mechanism of traditional chinese medicine for upper respiratory tract infection a network pharmacology approach to determine active ingredients and rationality of herb combinations of modifiedsimiaowan for treatment of gout a co-module approach for elucidating drug-disease associations and revealing their molecular basis deciphering the underlying mechanisms of diesun miaofang in traumatic injury from a systems pharmacology perspective network pharmacology-based prediction of the multi-target capabilities of the compounds in taohong siwu decoction, and their application in osteoarthritis a network-based analysis of the types of coronary artery disease from traditional chinese medicine perspective: potential for therapeutics and drug discovery therapeutic target database update 2012: a resource for facilitating target-oriented drug discovery multi-target therapeutics: when the whole is greater than the sum of the parts studying traditional medicine that would hopefully get resolved in the future. the major limitations and possible solutions are listed:1. nep currently relies on various databases for literature and bioactive mining. databases, though curated, may show discrepancies due to numerous sources of information, theoretical, and experimental data. moreover, the botanicals that undergo certain preparatory procedures during the formulation of the medicine may have its constituents that have chemically changed due to the procedures; like boiling, acid/ alkali reactions, interactions between the bioactives, etc. a way to navigate around this problem is to make use of modern, high-throughput chemical identification techniques like ultra-performance liquid chromatogra-phyàelectrospray ionizationàtandem mass spectroscopy (uplc-esi-ms/ms). this technique will help to identify the exact bioactives or the chemical constituents of the formulation, and will enrich the subsequent key: cord-274141-vujx538o authors: chinsembu, kazhila c. title: coronaviruses and nature’s pharmacy for the relief of coronavirus disease 2019 date: 2020-10-06 journal: rev bras farmacogn doi: 10.1007/s43450-020-00104-7 sha: doc_id: 274141 cord_uid: vujx538o [image: see text] coronaviruses (covs) cause acute and chronic respiratory, enteric, and central nervous system diseases in many species of animals including humans. while the history of covs dates as far back as the 1940s, identification of the first human covs (hcovs) as causative agents of mild respiratory infections was reported in the 1960s. these hcovs were named human cov 229e (hcov-229e) and hcov-oc43 (pillaiyar et al. 2020) . the replication and pathogenesis of covs were actively studied by virologists in the 1970s, leading to the discovery of four other human covs, namely hcov-hong kong university 1 (hcov-hku1), human coronavirus-nl63 (hcov-nl63), severe acute respiratory syndrome (sars)-cov, and middle east respiratory syndrome (mers)-cov (pillaiyar et al. 2020) . sars is a highly contagious and often fatal respiratory infection. hcov-229e, hcov-oc43, hcov-nl63, and hcov-hku1 are ubiquitous and cause approximately onethird of common cold in humans. hcov-229e, hcov-oc43, hcov-nl63, and hcov-hku1 strains are usually associated with mild, self-limiting upper respiratory tract infections, such as the common cold (andersen et al. 2020) . however, subtypes hcov-229e, hcov-oc43, hcov-hku1, and hcov-nl63 can cause life-threatening pneumonia and bronchitis in the elderly and immunologically compromised individuals including those undergoing chemotherapy and persons living with hiv/aids. indeed, before the discovery of sars-cov, two coronaviruses, hcov-229e and hcov-oc43, were known to infect humans, but they caused only selflimiting upper respiratory tract infections (30% of the common colds), and had never been reported to cause severe illness (kuba et al. 2005) . sars-cov caused a global epidemic from november 2002 to 2003; about 8422 people were infected in 32 countries, 916 persons died, and the fatality rate was 10-15%. analysis of the full sequence of sars-cov, which is about 29.7 kb in length, reveals that it is a large, single-stranded, positivesense rna virus . in 2013, mers-cov also triggered an epidemic in the middle east and a major outbreak in south korea occurred in may-june 2015 (kim et al. 2017a) . with a case-fatality rate of 35.5%, mers-cov is heavily endemic in dromedary camels and causes lower respiratory tract infections in humans (kim et al. 2017a) . although the sars-cov epidemic had been under control for years, wang et al. (2017) warned that re-emergence of this threatening infection posed a possible global risk as potentially new strains of sars-cov would be more dangerous than the previous ones. toward the end of 2019 and the beginning of 2020, multiple human cases of a new viral infection were reportedly linked to the huanan seafood wholesale "wet" market (south china seafood city food market) in wuhan, china zhang et al. 2020 ). on 7 january 2020, the new virus was identified as a novel coronavirus and officially named by the world health organization as 2019-ncov ). on 20 january 2020, the national health commission of china confirmed the human-to-human transmission of 2019-ncov with its presenting common symptoms such as fever, tiredness, dry cough, shortness of breath, and pneumonia (elfiky 2020) , and less common signs as diarrhea, conjunctivitis, headache, loss of taste or smell, and rash on skin or discoloration of fingers and toes. the world health organization also recognized 2019-ncov as the causative agent of the coronavirus disease 2019 . the 2019-ncov was later named severe acute respiratory syndrome coronavirus 2 (sars-cov-2) by the international committee on taxonomy of viruses, coronaviridae study group (ling 2020) . a phylogenetic analysis found a bat origin for the sars-cov-2 (lu et al. 2020; wan et al. 2020) . yang et al. (2020) reported that sars-cov-2, formerly known as 2019-ncov, the causative pathogen of covid-19, had rapidly spread across china and around the world, causing an outbreak of acute infectious pneumonia. the spread of sars-cov-2, a new highly contagious and lethal strain of hcovs, has now caused a global pandemic (remuzzi and remuzzi 2020) . in the morning of 7 september 2020, johns hopkins university reported that there were over 26,994,442 total confirmed cases and 880,994 deaths globally; over 6,189,488 cases and 187,541 deaths were in the united states of america (usa). covid-19 has spread more rapidly due to increased global travel and adaptation of sars-cov-2 in every environment (vellingiri et al. 2020) . currently, the seven identified human coronaviruses (hcovs) are sars-cov-2, mers-cov, sars-cov, hcov-229e, hcov-oc43, hcov-nl63, and hcov-hku1 strains (andersen et al. 2020 ). molecular evolutionary analysis shows that all hcovs originate in animals; sars-cov, mers-cov, hcov-nl63, and hcov-229e are derived from bats; hcov-oc43 and hcov-hku1 are sourced from rodents (forni et al. 2017) . the 229e and nl63 strains of hcovs belong to alpha coronaviruses while oc43, hku1, sars, mers, and sars-cov-2 belong to beta coronaviruses (elfiky 2020) . most people infected with sars-cov, mers-cov, and sars-cov-2 present with severe respiratory distress, and many of the infected succumb to coronavirus infection (andersen et al. 2020) . pillaiyar et al. (2020) reviewed recent developments in the discovery and development of synthetic drugs to treat hcovs. however, these drugs have not achieved extended distribution for clinical application because they have not yet been tested in rigorous randomized controlled clinical trials (ford et al. 2020) . zhou et al. (2020a, b) reported that there were no effective drugs targeting sars-cov-2. yang et al. (2020) also stated no efficacious and safe antiviral drugs or vaccines were available for the treatment of this sudden and lethal disease. supportive care and non-specific treatment to ameliorate covid-19 symptoms of the patient are the main options available. remdesivir, produced by the company gilead, shows ec 90 of 1.76 μm against sars-cov-2 in vitro (elfiky 2020). on 1 may 2020, remdesivir was granted approval by the us food and drug administration for emergency use in the treatment of covid-19 patients. an inhibitor of the enzyme rnadependent rna polymerase (rdrp) involved in hcov replication, the drug reduced mortality from 11 to 8% and duration of symptoms from 15 to 11 days. however, in comparison with the placebo, remdesivir's reduction of patient mortality was not significantly different. due to the absence of conventional therapies, yang et al. (2020) reported that more than 85% of sars-cov-2-infected patients in china were treated with traditional chinese medicine (tcm). during the 2002 to 2003 outbreak, tcm was also used as a supplementary treatment of severe laboratoryconfirmed conditions of sars (hsu et al. 2006a) . along this trajectory, the aim of the current review is to provide an update on the bioactivity functions of medicinal plants and other natural products that have previously been used to treat coronaviruses. in the short term, knowledge of these natural products may be significant in the relief of covid-19 symptoms. in the long term, natural products that alleviate covid-19 symptoms may be used in the search for novel drugs against sars-cov-2. in the face of current challenges to the treatment of covid-19, data presented in this review may help to reimagine a new future where natural products are the new frontier for more efficacious and low-cost sars-cov-2 inhibitors. the goal is to create a strong bioprospecting pipeline from which pharmaceutical companies can advance the discovery and repurposing of covid-19 drugs from current medicinal plants and other natural products. to prevent author bias, this review was carried out using a comprehensive and systematic data mining approach similar to that used by chinsembu (2019) . to obtain pertinent literature, the key words "sars" and "medicinal plants" were concomitantly searched in google scholar, elsevier's payto-view service science direct, scopus, scielo, and pubmed central, the us national library of medicine's digital archive of biomedical and life sciences journal literature. literature sources included peer-reviewed journal articles and refereed books. medicinal plants, mushrooms, algae, and sponges with anti-sars activity were included. wherever possible, active compounds and anti-sars profiles mainly half maximal inhibitory concentration (ic 50 ) and effective concentration (ec 50 ) were recorded. inclusion criteria included plants, fungi, and marine organisms, namely algae and sponges. exclusion criteria included animal products. countries reported in the review were those where primary data were collected; hence, geographical scope was not deliberately selected. the international plant names index (http://www.ipni.org) and the plant list (http://www.theplantlist.org) were used to verify names of plant species. the spike protein, a type i membrane-bound protein, is essential for sars-cov attachment to the host cell receptor angiotensin-converting enzyme 2 (ace2). in general, sars-cov entry starts with the attachment of the virus to its specific receptor ace2 on the host cell surface (keyaerts et al. 2007 ). binding of ace2 then induces the viral envelope protein to undergo conformational changes that mediate fusion between sars-cov and host cell membranes. the spike protein is responsible for these two steps in the coronavirus entry process (keyaerts et al. 2007) . a member of the c-type lectin superfamily, dendritic cell (dc)-specific icamgrabbing non-intergrin (dc-sign), a molecule designated as cd209, binds to surface proteins of sars-cov, consequently facilitating viral entry (liu et al. 2015) . sars-cov spike protein contains a number of n-linked glycosylation sites that modulate binding to the dc-sign receptor on dc (zhang et al. 2007 ). sars-cov binding to dc-sign is required for dc infection and target cell trans-infection. dc-sign plays an important role in mediating dc adhesion and internalization of sars-cov. antiviral agents from plants generally block virus entry and membrane fusion (hsieh et al. 2004 ). de clercq (2005 suggested that it was feasible to develop sars-cov fusion inhibitors analogous to enfuvirtide, a linear 36-amino acid synthetic peptide marketed under the trade name fuzeon, an approved anti-hiv drug that inhibits the entry of the virus into cells. sars-cov entry inhibitors fall into several categories. the first group consists of inhibitors that bind to the ace2 receptor, the second class comprises entry inhibitors that bind to the virus and prevent it from interacting with its receptors, and the third set of inhibitors can obstruct the conformational changes thus thwarting sars-cov fusion with the target cells (keyaerts et al. 2007 ). an effective inhibitor of sars-cov, the medicinal basidiomycete ganoderma lucidum (curtis) karst. contains ganoderic acid f, a lanostane triterpene that acts as an inhibitor of ace2 receptor (ic 50 4.7 × 10 −6 m) (morigiwa et al. 1986 ). lee (2019) asserts that lectins have emerged as a new class of antiviral biologic drugs or biologics by taking advantage of a unique glycosylation pattern only found on the surface of viruses. lectins, a group of proteins with carbohydrate recognition activity, recognize the sars-cov spike protein (liu et al. 2015) . keyaerts et al. (2007) found prominent anti-sars-cov activity among mannose-specific plant lectins. one of the most potent lectins against the sars-covinduced cytopathicity is the mannose-specific plant lectin isolated from leek (allium porrum l.) with an ec 50 of 0.45 μg/ml and a selectivity index of > 222. the n-acetyl glucosamine-specific lectins isolated from the stinging nettle (urtica dioica l.) and from the tobacco plant (nicotiana tabacum l.) were also markedly active against the sars-cov with a selectivity index of > 77 and > 59, respectively (kumaki et al. 2011) . a mannose-specific lectin (agglutinin) of hippeastrum striatum (lam.) h.e.moore prevented the penetration of sars-cov into vero e6 cells (ec 50 2.5 μg/ml at 4°c) (keyaerts et al. 2007 ). sars-cov spike protein contains 12 n-glycosylation sites and the sugars attached to four of these n-glycosylation sites have been identified (zhou et al. 2010) . two of the four sugars were found to be high-mannose-type glycans and the other two showed complex glycan structures . the potent anti-sars-cov activity of mannose-specific plant lectins is therefore attributable to the presence of high-mannose-type glycans in the sars-cov spike protein (keyaerts et al. 2007; zhou et al. 2010 ). many lectins from algae have antiviral activity. a highly potent broad-spectrum antiviral, griffithsin is a 121-amino acid red alga-derived lectin that binds to the terminal mannose residues of the asparagine(n)-linked man 5-9 glcnac2 structures found on the envelope of sars-cov (lee 2019). initially identified as an anti-hiv-1 agent with ec 50 of 0.43-0.98 nm, griffithsin isolated from the aqueous extract of the red algae griffithsia corallinoides (l.) trevisan found off the eastern shore of chatham island, new zealand, is a 12.7-kda lectin that also inhibits sars-cov (ec 50 0.048-960 nm), various avian cov subtypes (ec 50 0.032-0.57 nm), bovine cov (ec 50 0.057 nm), puffinosis cov (ec 50 0.57 nm), and hcov mutants with ec 50 of 0.16 nm (mitchell et al. 2017 ). some viruses such as ebola and sars-cov use cathepsins, a family of proteases, to infect host cells (huang et al. 2006) . inhibitors of cathepsin l prevent entry of sars-cov into target cells (simmons et al. 2005) . unfortunately, many cathepsin inhibitors are non-selective (zhou et al. 2016) . leupeptin (1), also known as n-acetyl-l-leucyl-l-leucyl-l-argininal, is protease inhibitor produced by actinomycetes and isolated from a strain of streptomyces exfoliatus (waksman and curtis) waksman and henrici, which can inhibit cysteine, serine, and threonine peptidases. simmons et al. (2005) showed that inhibitors of proteases such as leupeptin act as potent inhibitors of sars-cov entry into host cells. sars-cov spike protein-driven virus-cell fusion is inhibited by 1 , which exhibited a dose-dependent inhibition of sars-cov infection ) (ic 95 15.2 μm). this inhibition is the result of an absolute requirement in cell lines for endosomal processing of the sars-cov spike protein by cathepsin l during entry into the target cell ). the oligopeptide antipain (2), an inhibitor of trypsin and papain, isolated from actinomycetes inhibited sars-cov entry into host cells (simmons et al. 2005 ). (dong et al. 2016; zhou et al., 2020a, b) , and cassia tora l. emodin inhibited sars-cov via the blockage of viral entry by binding to the spike proteins and interfering with sars-cov 3cl pro activity (hyun et al. 2009 ). in assays involving sars-cov and hcov-oc43, emodin in a dose-dependent manner significantly blocked the interaction between the sars-cov spike protein and ace2 (a functional sars-cov receptor), inhibited the 3a ion channel (k 1/2 value of about 20 μm), and stopped new coronavirus release (dong et al. 2016; ho et al. 2007 ). sars-cov-2 spike protein directly binds to the host cell surface ace2 receptor facilitating virus entry and replication . corollary, emodin can be considered a potential lead therapeutic agent in the treatment of sars-cov-2 infection. experimental data now suggest that combining emodin and the drug toremifene, a first-generation non-steroidal selective estrogen receptor modulator for the treatment of metastatic breast cancer, provides a potential therapeutic approach for sars-cov-2 (zhou et al., 2020a, b) . terpenoids isolated from medicinal plants have attracted attention because many of them exhibit specific in vitro antiviral effect against sars-cov (wen et al. 2007 ). triterpenoids inhibit the entry of ebola, marburg, hiv, and influenza a viruses with distinct structure-activity relationships (si et al. 2018 ). these natural agents modulate a broad range of virus-host fusion functions via wrapping the heptad repeat 2 domain prevalent in viral envelopes. euphorbia neriifolia l. produces 22 triterpenoids with stronger activity against hcovs than actinomycin d (chang et al. 2012) . saikosaponins represent a group of oleanane derivatives, usually as glucosides, found in medicinal plants in the genera bupleurum l., heteromorpha cham. & schltdl., and scrophularia l. (cheng et al. 2006) . saikosaponins a, b 2 , c, and d demonstrated anti-hcov-229e activity at concentrations of 0.25-25 μm, with the strongest activity being noted for saikosaponin b 2 (4) (ic 50 1.7 ± 0.1 μm) (cheng et al. 2006 ). since saikosaponin b 2 blocks hcov-229e attachment and penetration, it could be a novel lead for the development of a potential chemo-preventive agent for sars-cov infection (cheng et al. 2006) . yang et al. (2020) reported that saikosaponins and glycyrrhizin from toona sinensis (juss.) m.roem. had potent anti-sars-cov effects by inhibition of viral cellular entry, adsorption, and penetration. the licorice plant, glycyrrhiza glabra l., was reported to have specific anti-sars effects (polansky and lori 2020) . constituents of licorice include triterpenoids such as glycyrrhizin or glycyrrhizic acid (5). glycyrrhizin (5) exerted very high antiviral activity and in vitro inhibition of sars-cov (ec 50 300 μg/ml) (cinatl et al. 2003) . glycyrrhizin and its derivatives inhibited sars-cov replication in vitro (baltina et al. 2015) . ryu et al. (2010a) reported that 95% methanolic extracts of the bark of tripterygium regelii sprague & takeda remarkably inhibited sars-cov 3cl pro activity (> 70% inhibition at 30 μg/ml) (ryu et al. 2010a) . the active compounds of t. regelii are four quinone-methide triterpenoid derivatives: celastrol, pristimerin, tingenone, and iguesterin (6) with ic 50 values of 10.3, 5.5, 9.9, and 2.6 μm, respectively, against sars-cov 3cl pro (ryu et al. 2010a ). the seeds of aesculus turbinata blume, a medicinal plant found in china, japan, and south korea, contain a natural saponins called escins, constituents with strong virucidal effects against sars-cov (ec 50 of 6 μm, selectivity index value of 2.5) (kim et al. 2017b; salinas et al. 2019) . betulin and betulinic acid, the main antiviral components of the betula l. plants, inhibit hiv fusion and one of the steps in hiv maturation (chinsembu 2016a) . a methanolic extract of betula papyrifera marshall exerted antiviral activity against bovine coronavirus (rastogi et al. 2015) . many natural polyphenols, with antioxidant properties, possess antiviral activity and some of them, for example, myricetin (7), an inhibitor of coronavirus helicase nsp13 (ic 50 value of 2.71 μm), are already being used against coronaviruses (semwal et al. 2016; yu et al. 2012) . naturally occurring flavonoids such as quercetin, naringin, hesperetin, and catechin, the most abundant polyphenols in the human diet, are usually found in fruit and vegetables as glycosides and sometimes as acylglycosides. luteolin and quercetin can interfere with adsorption of the virus to its host cells. it was hypothesized that specific flavonoids, such as quercetin, hesperetin, and myricetin (7) and their glycosylated derivatives, may play an effective role in inhibiting sars-cov entry into host cells, specifically by binding with high affinity to the spike protein, helicase, and protease sites on the ace receptor (ngwa et al. 2020) , in addition to acting against fatty acid synthase (wen et al., 2011) . extracted from tcm herbal formulae used to treat sars, the following active polyphenols inhibited various steps during sars-cov entry and replication: baicalin, emodin, epigallocatechin, gallate, gallocatechin gallate, herbacetin, isobavaschalcone, kaempferol derivatives, luteolin, myricetin, quercetin, 3-β-d-glucoside, rhoifolin, pectolinarin, scutellarein, and tetra-o-galloyl-β-d-glucose ). quercetin (8) is an aglycone present at high concentration in onions. this compound has virucidal activity against enveloped viruses such as mengovirus, herpes simplex, parainfluenza type 3, pseudorabies, respiratory syncytial, and sindbis viruses ). quercetin is able to inhibit h + -atpase of lysosomal membrane and thus prevents virus coat removal and blocks viral replication and competitively inhibits sars-cov 3cl pro with ic 50 of 42.79 ± 4.97 μm (chen et al. 2006) . torreya nucifera (l.) siebold & zucc. is a traditional medicinal plant in asia. the ethanol leaf extract of t. nucifera exerts good sars-cov 3cl pro inhibitory activity (62% at 100 μg/ml) (ryu et al. 2010b ). following the bioactivityguided fractionation of t. nucifera, the biflavone amentoflavone (9) showed the most potent sars-cov 3cl pro inhibitory effect with ic 50 of 8.3 μm (ryu et al. 2010b) . apigenin, luteolin, and quercetin inhibited sars-cov 3cl pro activity with ic 50 values of 280.8, 20.2, and 23.8 μm, respectively (ryu et al. 2010b ). zhong et al. (2013) found that jinchai, a capsule of tcm consisting of plants such as lonicera japonica thunb., bupleurum chinense dc., astragalus membranaceus (fisch.) bunge, and codonopsis pilosula subsp. tangshen (oliv.) d.y.hong inhibited sars-cov. jinchai blocks sars-cov infection by weakening adsorption of viruses to cells and reduces the ability of sars-cov to infect surrounding tissues (zhong et al. 2013) . the main active constituents of jinchai are chlorogenic acid and baicalin (10) whose ec 50 (μg/ml) at 48 h was 12.5 to 25, ec 50 (μg/ml) at 72 h was 25 to 50, cc 50 (μg/ml) was > 100, and si calculated as cc 50 /ec 50 at 48 h was > 4 to 8 . camellia sinensis (l.) kuntze (black tea) polyphenol epigallocatechin gallate (egcg) inhibited bovine coronavirus propagation; egcg interfered with the adsorption of bovine coronavirus to madin-darby bovine kidney cells (bansal et al. 2013) . although sanguisorba officinalis l. extract inhibits hiv-1 infection by binding to the viral envelope and blocking entry of the virus, it did not inhibit sars-cov entry (liang et al. 2013) . in oriental herbal medicine, the bark of cinnamon plant cinnamomum cassia (l.) j. presl has been used as a spice, infusion, and prime component of herbal remedies for common cold, gastrointestinal infections, cancer, chronic cardiovascular disease, and gynecological disorders. zhuang et al. (2009) found that cinnamon bark extract has anti-rna viral effects. the cinnamon extract inhibited wild-type sars-cov infection in vitro with an ic 50 of 43 μm; and the proposed mechanism of action for cinnamon bark extract was blocking cell entry via endocytosis (polansky and lori 2020) . whereas the antiviral, anti-bacterial, and anti-cancer effects were attributable to essential oils such as cinnamaldehyde (11), the anti-inflammatory actions of cinnamon water extract were due to the presence of polyphenols such as flavonoids and tannins. molecular docking studies show that 11 may block the attachment of sarc-cov-2, though detailed in vitro and in vivo studies are required to confirm its efficacy (asif et al. 2020) . compound 11 had the lowest electronegativity value among the phytochemicals with a score of − 4.34; binding affinity in kilocalorie per mole was − 5 (asif et al. 2020; kulkarni et al. 2020 ). stilbene derivatives displayed antiviral activities against sars-cov ). the stilbenoid resveratrol (12) exists widely in different plants including grape vitis vinifera l., polygonum cuspidatum, and cranberry vaccinium macrocarpon aiton (lin et al. 2017) . resveratrol inhibits various viral infections, including the inhibition of hiv and sars-cov replication . compound 12 was a potent in vitro inhibitor of sars-cov (at ≤ 0.5 mg/ml) and mers-cov, at ≤ 62.5 μm within 24 h of infection lin et al. 2017) . it was predicted that resveratrol (12) could be a potential agent against new hcovs in the near future (lin et al. 2017 ). polysaccharides isolated from tcm herb astragalus mongholicus bunge have been widely used to boost immunity against viruses. a study by zhang et al. (2018) showed that supplementation with a. mongholicus polysaccharides can inhibit the replication of avian coronaviruses. extracts of acanthopanax gracilistylus var. trifoliolatus c.b. shang, the root of sophora flavescens aiton, and the dried root of sanguisorba officinalis and torilis elata spreng. reduced the in vitro replication of sars-cov more potently than the ribavirin drug control (kim et al. 2010) . cimicifuga racemosa (l.) nutt., melia azedarach l., coptis chinensis franch., phellodendron chinense c.k.schneid., and sophora tonkinensis var. polyphylla x.c.huang & z.c.zhou decreased mouse hepatitis virus a59 (mhv-a59) production and intracellular viral rna and protein expression with ec 50 values ranging from 2 to 27.5 μg/ml (kim et al. 2008) . cimicifuga racemosa, m. azedarach, c. chinensis, p. chinense, and s. tonkinensis were good candidates for the treatment of coronaviral infections in both humans and animals (kim et al. 2008 ). the underlying antiviral mechanism was most likely due to the inhibition of rna-dependent rna polymerase or proteases that are crucial for coronavirus rna replication. melia azedarach and c. chinensis may also affect virus assembly or release. silvestrol (13), a natural cyclopenta[b]benzofuran, isolated from the fruits and twigs of aglaia foveolata pannell, at 0.6-2 μm, inhibited cap-dependent viral mrna translation of hcov-229e with an ic 50 of 40 nm (müller et al. 2018) . ouabain (14), also known as g-strophanthin, is a toxic cardiac glycoside that was traditionally used as an arrow poison for both hunting and warfare in eastern africa. however, this substance, in lower doses, can be used medically to treat hypotension and some arrhythmias. in addition, ouabain diminishes sars-cov titers and the number of sars-cov rna copies at 0-3000 nm (yang et al. 2018) . wu et al. (2020) described drug names, chemical structures, pharmacological functions, and sources of 20 potential rdrp inhibitors from an in-house natural product database. their results were based on computer virtual screening because no in vitro and in vivo experiments were conducted. andrographolide has been studied for its effects on cell signaling, immunomodulation, and stroke. using computational approaches, enmozhi et al. (2020) showed that andrographolide (15), an extremelly bitter labdane diterpenoid isolated from andrographis paniculata (burm.f.) wall. ex nees, docked successfully in the binding site of sars-cov-2 m pro . the molecule obeys lipinski's rule making it a promising compound to treat covid-19 (enmozhi et al. 2020) . omacetaxine mepesuccinate (trade names synribo), formerly named as homoharringtonine (16), is a plant alkaloid derived from cephalotaxus fortunei hook that was approved by the us fda in october 2012 for the treatment of chronic myeloid leukemia in adults. homoharringtonine has been reported to exhibit potent inhibitory activity against coronaviruses, namely porcine epidemic diarrhea virus, murine hepatitis virus (dong et al. 2018; andersen et al. 2019) , and sars-cov-2 with ec 50 at 2.10 μm (choy et al. 2020 ). tylophorine (17), a phenanthraindolizidine alkaloid, has anti-hcov activity in the nanomolar concentrations, up to 1000 nm . tylophorine derivatives, including naturally occurring and synthetic phenanthroindolizidines and phenanthroquinolizidines, have been identified as potent in vitro inhibitors of enteropathogenic coronavirus transmissible gastroenteritis virus (tgev). this class of potent compounds showed ec 50 values ranging from 8 to 1468 nm as determined by immunofluorescent assay of the expression of tgev spike and nucleocapsid proteins and by real-time qrt-pcr analysis of viral yields. tylophorine compounds could be novel leads for further drug development on their own or as templates for drug design . tylophorine and related alkaloids, isolated from tylophora indica merr., inhibit tgev replication for anti-coronavirus activity and suppress nitric oxide production in raw264.7 cells, a measure of antiinflammation (lee et al., 2012a, b) . additionally, a pharmacokinetic study demonstrated high and comparable oral bioavailabilities of tylophorine (65.7%) in rats (lee et al., 2012a, b) . the chymotrypsin-like protease (3cl pro ) is vital for sars-cov replication and is therefore a promising drug target. the active site of sars-cov 3cl pro has a catalytic dyad with the sulfur of cys145 as a nucleophile and the imidazole ring of his41 as a general base (ryu et al. 2010a) . also called main protease (m pro ), the 3cl pro of sars-cov mediates the proteolytic processing of replicase polypeptides 1a and 1ab into functional proteins; thus, it is an important target for drug development . curcumin inhibits sars-cov 3cl pro (ic 50 value of 23.5 μm) (ryu et al. 2010a ). the extracts of cibotium barometz (l.) j.sm. and dioscorea batatas decne. also inhibited sars-cov 3cl pro activity with ic 50 values of 39 μg/ml and 44 μg/ml, respectively (cuong et al. 2009; wen et al. 2011) . tannic acid, 3-isotheaflavin-3-gallate, and theaflavin-3,3′digallate, three phenolic compounds from black tea, inhibit sars-cov 3cl pro with ic 50 values of 3, 7, and 9.5 μm, respectively . isatis indigotica fortune root extracts were frequently used as a remedy during the 2002/2003 sars outbreak in china. a water extract of i. indigotica had anti-sars-cov 3cl pro activity . the root extract of i. indigotica contains indigo, indirubin, indican (indoxyl-β-d-glucoside), β-sitosterol, γ-sitosterol, and sinigrin (18). the ic 50 in the cell-free assays was 115 μm for β-sitosterol, 121 μm for sinigrin, and 300 μm for indigo. the cell-based assay indicated that the antioxidant sinigrin (ic 50 217 μm) was more efficient in blocking the cleavage processing of the 3cl pro than indigo (ic 50 752 μm) and β-sitosterol (ic 50 1210 μm) . compound 18 is a glucosinolatetype compound also found in some plants of the family brassicaceae such a brussels sprouts, broccoli, and the seeds of black mustard (brassica nigra (l.) andrz. echinaforce® is a standardized preparation extracted from freshly harvested herb (herba tintura 2580 mg/125 drops) and roots (radix tintura 135 mg/125 drops) of echinacea purpurea (l.) moench plants (purple coneflower) with a 65% alcoholic solution (schapowal 2020) . echinaforce® reduces the infectivity of hcov-229e in a dose-dependent manner. it inhibits hcov-229e infection of respiratory epithelial cells (schapowal 2020) . hcov-229e was irreversibly inactivated when exposed to echinaforce® (ic 50 of 3.2 μg/ml) (schapowal 2020) . echinaforce® showed a dosedependent reduction of hcov 229e infectivity with an ic 50 = 9 ± 3 μg/ml (engler et al. 2017) . complete neutralization was achieved with 50 μg/ml (engler et al. 2017) . similar inhibition was observed for mers-cov when 10 μg/ml of echinaforce® reduced infectivity by 99.9% and 50 μg/ml of echinaforce fully blocked infectivity (engler et al. 2017 ). extracts of echinacea purpurea have been used traditionally in north america for the treatment of various infections and wounds, and they have become very popular herbal medicines globally (hudson 2012) . rondanelli et al. (2018) found that a combination of e. purpurea, vitamin d, vitamin c, and zinc was useful in the treatment of the common cold. vitamin d supplementation also lessens the risk of covid-19 infection and deaths (grant et al. 2020) . echinacea angustifolia dc., echinacea pallida (nutt.) nutt., and echinacea purpurea are the most common echinacea moench species recognized for treating common cold and sars (hudson 2012) . coronavirus infection in humans is characterized by uncontrolled replication of the virus and a prominent proinflammatory response (wong and yuen 2008) . still, in the management of coronavirus disease, the role of immunomodulators to decrease excessive inflammation remains elusive (wong and yuen 2008) . the immunomodulatory compounds tomentins a-e (19-23), geranylated flavonoids, isolated from paulownia tomentosa (thunb.) steud. lower the concentration of pro-inflammatory cytokines interleukin-1β and tumor necrosis factor alpha . these tomentins could be useful in allaying the multisystem inflammatory syndrome, also known as the cytokine storm, seen in many covid-19 patients. a n t i -i n f l a m m a t o r y a n d a n t i n e o p l a s t i c bisbenzylisoquinoline alkaloids isolated from stephania tetrandra s.moore, namely cepharanthine (24), fangchinoline, and tetrandrine, acted as immunomodulators and inhibited the expression of hcov-oc43 spike and nucleocapsid proteins (kim et al. 2019) . after the cells were infected with hcov-oc43, each compound (5 μm) was added to the wells, and cytokine mrna was qantified by real-time qrt-pcr. compound treatment following virus infection reduced the mrna expression levels of ifn-α1 by almost 20-fold at 4 days post infection, and about 100-fold reduction for ifn-β1 at 3 days post infection (kim et al. 2019 ). according to islam et al. (2020) , natural products with anticoronavirus activity are major constituents of common dietary supplements and can therefore be used to improve the immunity of the general population in pandemics such as covid-19. according to kwon et al. (2013) , five phlorotannins of the edible brown algae ecklonia cava kjellman competitively inhibit the binding of sars-cov spike protein to sialic acids at a concentration of less than 36.6 μm. two phlorotannins caused the inhibition of sars-cov rna and sars-cov protein synthesis in late stages, with ic 50 values of 12.2 ± 2.8 and 14.6 ± 1.3 μm, respectively . the results suggest that compounds isolated from e. cava have strong antiviral activity and may be developed into natural therapeutic drugs against sars-cov infection . a commercially available e. cava extract, seapolynol™, was approved as a new dietary ingredient (ndi) by the us food and drug administration in 2008 (fda-1995-s-0039-0176) (lee et al., 2012a, b) . an ethanol extract of the edible brown algae ecklonia cava, laminariaceae, contained eight phlorotannins that exhibited a dose-dependent (competitive) inhibitory effect on sars-cov 3cl pro with ic 50 values ranging from 2.7 to 164.7 μm . dieckol showed the most potent sars-cov 3cl pro trans/cis-cleavage inhibitory effects. isolated from the marine alga halimeda tuna (j.ellis & solander) j.v.lamouroux, halitunal is a novel diterpene aldehyde with a unique cyclopentadieno[c]pyran ring system. halitunal displayed antiviral activity against murine coronavirus a59 in vitro (gustafson et al. 2004) . dercitin, an acridine alkaloid isolated from a marine sponge in the genus dercitus gray, inhibited the coronavirus a59 strain (ec 50 1.8 μm). mycalamides a and b, protein synthesis inhibitors and antiviral compounds isolated from a sponge mycale incrustans burton, also inhibited coronavirus a59 (laport et al. 2009 ). in vivo activity against coronavirus a59 was observed in mice treated with a 2% mycalamide mixture at a dosage of 0.2 μg/kg daily with 100% survival over a 2-week period (gallimore 2017) . triterpenes (thyrsiferol, thyrsiferol acetate, venustatriol) isolated from the red alga laurencia venusta yamada inhibit coronaviruses, and orthosterol disodium sulfates from the sponge petrosia weinbergi van soest inhibit coronavirus a59 (el sayed 2000) . spirulina platensis (gomont) geitler is a microscopic filamentous alga rich in proteins, vitamins, essential amino acids, minerals, and essential fatty acids like γ-linolenic acid. it is produced commercially and sold as a food supplement in health food stores around the world. spirulina platensis (15 g) enhances the immune status and inflammatory and oxidative markers of covid-19 patients (mccarty and dinicolantonio 2020). china xiao et al. (2003) provided leading insights into the use of fourteen chinese herbal medicines in the prevention and treatment of sars. tcm played an important role in the fight against sars and it was reported by practitioners to be very effective (lau et al. 2005) . the state administration of tcm of the people's republic of china formed a panel of tcm specialists to draw up a technical scheme for the prevention and treatment of sars-cov using tcm . scutellaria baicalensis is one of the most widely used tcms and its roots are used to treat inflammation, cancer, and viral and bacterial infections. baicalin, baicalein, wogonin, and oroxylin a are the main active components in s. baicalensis. the most abundant active compound, baicalin, exhibits anti-sars-cov properties. yeh et al. (2013) affirmed that licorice (glycyrrhiza uralensis fisch. ex dc.) is a common ingredient in prescriptions of tcm. licorice has antiviral activity against various dna and rna viruses including hiv and sars-cov. chinese multi-plant remedy consisting of houttuynia cordata thunb., chrysanthemum morifolium ramat., artemisia scoparia waldst. & kit., eupatorium fortunei turcz., and amomum tsao-ko crevost & lemarié was effective in the prevention and treatment of sars-cov (zhang and chen 2008) . extracts of lonicera japonica are a common tcm used to treat sars-cov (wang et al. 2014) . to control sars-cov in 2003, l. japonica was widely used in prescriptions publicly published by the state administration of tcm. panax ginseng c.a.mey., commonly known as ginseng, is a known natural antiviral agent with protective effects against sars-cov (im et al. 2016) . extracts of t. sinensis inhibit sars-cov replication wu et al. 2014 ). extracts of plants lycoris radiata miq., artemisia annua l., pyrrosia lingua (thunb.) farw., and lindera aggregata (sims) kosterm. displayed anti-sars-cov actions with ec 50 values of 2.4 ± 0.2, 34.5 ± 2.6, 43.2 ± 14.1, and 88.2 ± 7.7 μg/ml, respectively (li et al. 2005 ). an ethanol stem cortex extract of l. radiata was very potent against sars-cov (ec 50 of 2.1 ± 0.2 nm against the bj-006 viral strain) (li et al. 2005) . the active compound lycorine was identified as the anti-sars-cov component (ec 50 value of 15.7 ± 1.2 nm). lycorine shows moderate to potent antiviral activity and reduces viral titers of sars-cov (roy et al. 2018) . jinchai is a widely used tcm that deters sars-cov entry, replication, and lung inflammation induced by viral infection (zhong et al. 2013) . roots and rhizomes of glycyrrhiza glabra, a natural sweetener that contains glycyrrhizin, inhibit virus growth and inactivate virus particles. glycyrrhizic acid, a major triterpene glycoside isolated from glycyrrhiza species, has activity against several enveloped viruses including sars-cov and hiv . diammonium glycyrrhizinate, extracted and purified from g. uralensis, inhibited sars-covs . ho et al. (2007) found that two widely used tcm plants in the family polygonaceae inhibited the interaction of sars-cov spike protein and ace2; the ic 50 values for extracts of the root tubers of rheum officinale baill. and the root tubers/vines of polygonum multiflorum ranged from 1 to 10 μ/ml (ho et al. 2007 ). chen et al. (2020) stated that the mortality of covid-19 patients in china was markedly reduced because of effective combination therapy of tcm and western medicines. at least 20 patent tcms were recommended by government guidelines in the treatment of covid-19 patients in china . several tcm plant formulae for treating sars-cov and covid-19 were reported by yang et al. (2020) . in lebanon, the oil of laurus nobilis cav. exerted remarkable activity against sars-cov with an ic 50 value of 120 μg/ml and a selectivity index of 4.16 (loizzo et al. 2008 ). an ornamental tree and a member of the cupressaceae family, cupressus sempervirens l. contains flavonoid derivatives, dit e r p e n e s , c a t e c h i n s a n d f l a v o n o l i c o l i g o m e r s , proanthocyanidins, phenolic acids, fatty acids, and essential oils (orhan and tumen 2015) . the essential oil of c. sempervirens had a mild inhibitory outcome on sars-cov activity (700 ± 2.3 μg/ml) (orhan and tumen 2015; loizzo et al. 2008) . volatile oils are potential agents for treatment of sars-cov (pasdaran et al. 2016 ). an ethanolic extract of thymus vulgaris sm. found in lebanon inhibits sars-cov (bekut et al. 2018) . lebanese essential oils have also been evaluated for their inhibitory activity against sars-cov replication in vitro by visually scoring the virus-induced cytopathogenic effect post infection. the papain-like protease (pl pro ) encoded by sars-cov cleaves the viral replicase polyprotein. since this enzymatic activity is important for viral infection, pl pro is a target of interest in the development of antiviral therapies. nine diarylheptanoids from the bark of alnus japonica (thunb.) steud. were evaluated for their inhibitory activities against sars-cov pl pro . hirsutenone was found to be the most potent inhibitor of sars-cov pl pro (ic 50 of 4.1 ± 0.3 μm). seven tanshinones isolated from salvia miltiorrhiza bunge. were selective inhibitors of sars-cov 3cl pro and pl pro viral cysteine proteases with ic 50 values from 0.8 to 30 μm (park et al. 2012b) . cryptotanshinone was the most potent inhibitor of sars-cov pl pro . cho et al. (2013) obtained 12 flavonoids from the fruits of paulownia tomentosa that function as sars-cov pl pro inhibitors. these flavonoids resulted in significant inhibition of sars-cov pl pro in a dose-dependent manner. tomentin e exhibited the highest inhibitory effect with an ic 50 of 5 ± 0.06 μm . tomentin isolated from sphaeralcea angustifolia (cav.) g.don inhibited pl pro with ic 50 values ranging from 5 to 14.4 μm. singapore chiow et al. (2016) conducted in vitro virus neutralization assays where an ethyl acetate (ea) fraction of houttuynia cordata and three of its constituent flavonoids were tested on murine coronavirus. with no cytotoxicity, the ea fraction of h. cordata, added before the viral adsorption stage, inhibited murine coronavirus (ic 50 0.98 μg/ml) (chiow et al. 2016) . the flavonoid quercetin weakly inhibited murine coronavirus with a minimum inhibitory concentration of 125 μg/ml, cytotoxicity cc 50 value of 116.50 μg/ml, and selectivity index of 0.93. the ea fraction and quercetin yielded a long-lasting anti-murine coronavirus effect of up to 6 days. overall, this study demonstrated that the ea fraction of h. cordata and its flavonoid component, quercetin, neutralizes murine coronavirus in vitro (chiow et al. 2016 ). the eps® 7630 liquid herbal drug umckaloabo®, a 100 μg/ml extract of pelargonium sidoides dc., exerts antiinfluenza virus activity in vitro and in vivo (theisen and muller 2012) . discovered in south africa, umckaloabo, a decoction of the roots of pelargonium sidoides, was originally used by zulu traditional healers as a remedy for acute bronchitis. umckaloabo® is known to inhibit the entry and replication of hcov-229e (michaelis et al. 2011) . it is a common medication for acute bronchitis in south africa and germany. although uncontrolled human trials for sars-cov anti-infectives have been reported, no randomized controlled trials with a specific anti-coronavirus agent had been conducted with respect to therapy or prophylaxis (wong and yuen 2008) . there had not been any clinical trials for drugs of infections caused by hcov-oc43, hcov-229e, hcov-nl63, and hcov-hku1 (wong and yuen, 2008) . urged that randomized placebo control trials should assess the efficacy of intravenous baicalin (10) for the treatment of sars especially in developing countries where such formulations were available and affordable. in a randomized double-blinded placebo controlled trial, quercetin supplementation in doses of 500 and 1000 mg/day for 12 weeks significantly increased plasma quercetin levels with no reported side effects, but neither decreased total number of upper respiratory tract infection sick days nor reduced symptomatology in all subjects (heinz et al. 2010) . liu et al. (2012) reviewed 12 randomized controlled trials and one quasirandomized controlled trial where 12 herbal remedies were administered on 640 sars patients. case reports, case series, controlled observational studies, and randomized clinical trials provided compelling data that tcm had beneficial effects in the treatment or prevention of sars (lau et al. 2005) . for example, the rate of fatality in hong kong and singapore was approximately 18%, while the rate for beijing was initially more than 52% until the 5th may 2003 when it decreased to 4%, and then to 1% after 20th may 2003 . the dramatic reduction in fatality in beijing was associated with the use of tcm as a supplement to conventional therapy (chen and nakamura 2004) . lau et al. (2005) reported that during the sars outbreak of 2002/2003, 1063 volunteers including 926 hospital workers and 37 laboratory technicians working in high-risk virus laboratories used tcm, namely sang ju yin plus yu ping feng san. compared with the 0.4% of infection in the placebo group, none of the tcm users was infected. in a controlled clinical study, hsu et al. (2006b) reported that supplementary treatment with tcm resulted in marked relief of symptoms and truncated the disease course. the clinical benefits of tcm were supported by laboratory studies especially for the use of glycyrrhizin (5), baicalin (10), and mol376, an inhibitor of cathepsin l that could become a lead compound for sars therapy . after a review of eight randomized controlled trials, liu et al. (2004) resolved that a combination of tcm with conventional medicine had beneficial effects such as decrease of mortality, relief of symptoms, and control of fungal infections in patients with sars. however, the trial evidence was not sufficient enough due to the lack of methodological rigour. in a review of 90 peer-reviewed chinese publications after the sars epidemic of 2002 , leung (2007 concluded that tcm used together with conventional treatment had positive effects including better control of fever and quicker amelioration of chest infection. wu et al. (2008) urged a rerun of clinical trials involving tcm for the treatment of sars because the validity of results was jeopardized by questionable trial designs and experimental biases. tcm should be evaluated in carefully designed clinical trials, either used alone or integrated with western medicine, to cover the prevention and treatment of patients suffering from covid-19 pneumonia (ling 2020) . by mid-march 2020, at least 14 tcm clinical trials with a total of 2714 patients were ongoing for the treatment of sars-cov-2 infection . chinese treatment data showed that patented tcm had good therapeutic efficacy in the treatment of covid-19, with minimal adverse reactions (zhuang et al. 2020 ). empirical data on sars-cov treatments are scarce (wong and yuen 2008) , and the majority of viral diseases do not have targeted drugs or vaccines (mahapatra et al. 2019) . although the ongoing sars-cov-2 global pandemic should remind scientists that current options for treating life-threatening zoonotic coronavirus infections are very limited , medicinal plants offer a strong pipeline for the discovery of novel lead compounds that can be converted into new drugs to treat covid-19. medicinal plants hold great promise for drug development against sars-cov-2, but there is paucity of research on the development of anti-sars-cov-2 drugs from natural products. in addition, most of the data on natural products with activity against hcovs are from non-clinical and pre-clinical studies . potential anti-coronavirus therapies can be divided into two categories depending on their target: those that act on the human immune system or human cells, and those that interfere with the coronavirus itself . the unmet need for pharmacologically potent and safe antivirals ought to be fulfilled by thinking out of the box and indigenous knowledge of medicinal plants may be a masterstroke against deadly infectious diseases such as covid-19 (mahapatra et al. 2019) . vellingiri et al. (2020) postulated that medicinal plants are potential sources of drugs for the treatment of covid-19. ling (2020) also submitted that traditional plant medicines are a good source of natural compounds for the discovery and development of drugs against sars-cov-2. so, the mortality of covid-19 patients in china was limited by the use of tcm. as the growing covid-19 global pandemic reformats the classical norms of pharmaceutical and clinical interventions, this review is a poignant reminder that repurposing of current medicinal plants and other natural products to treat covid-19 should become part of our new vernacular health system. comparative genomics lends credence to the repurposing of current anti-sars natural products for the treatment of covid-19. this is because the genome sequence of sars-cov is very similar to that of sars-cov-2 (tahir ul qamar et al. 2020) . phylogenetic analysis of whole genomes reveals that sars-cov-2 shares 79.7% nucleotide sequence identity with sars-cov zhou et al., 2020a, b) . compared with sars-cov, the envelope and nucleocapsid proteins of sars-cov-2 share sequence identities of 96% and 89.6%, respectively (zhou et al., 2020a, b) . the virion of sars-cov-2 consists of a similar structure as sars-cov and mers-cov. like sars-cov, sars-cov-2 also uses ace2 as its cellular receptor to enter host cells (zhou et al., 2020a, b) . the chymotrypsin-like protease (3cl pro ) of sars-cov is conserved and shares 99.02% sequence identity with sars-cov-2 3cl pro (tahir ul qamar et al. 2020 ). these comparative genomic similarities signify one epic biomedical prospect: if medicinal plants used against sars-cov and mers-cov are carefully repurposed, they could be effective against sars-cov-2. in this new normality, natural products should become part of the covid-19 survival kit. in the absence of an effective and safe drug that inhibits sars-cov-2, the use of antimalarial plants and synthetic drugs has gained traction in the treatment of covid-19. the notion that antimalarial plants in the genus artemisia l. can be repurposed to prevent and treat covid-19 has often been associated with experimental data that chloroquine inhibits the replication of viruses. chloroquine inhibits chikungunya virus replication in vero a cells (ic 50 7 μm, ic 90 15 μm, selectivity index = 37.14) in a dose-dependent manner. chloroquine, whose chemical structure mimics nucleoside analogues, has in vitro activity against sars-cov and sars-cov-2 ). an antimalarial drug known since 1934, chloroquine blocks hiv-1 and hcovs at a very early stage; it also inhibits the replication of mers-cov in a dose-dependent mode (ec 50 of 3 μm) (de wilde et al. 2014 ). chloroquine exerts antiviral as well as immunomodulatory properties. chloroquine (ec 50 of 1.13 μm against sars-cov-2) blocks viral infection by increasing the endosomal ph required for viral fusion (vellingiri et al. 2020) . a 9-aminoquinoline, chloroquine inhibits sars-cov replication and downregulates ifn-γ and tnf-α production in mice (prinsloo et al. 2018 ). in the first half of 2020, clinical t r i a l s ( n c t 0 4 2 6 1 5 1 7 a n d n c t 0 4 3 0 7 6 9 3 ) o f hydroxychloroquine treatment for covid-19 were underway in china (wang et al. 2020b ). the world health organization announced it would resume its halted randomized controlled trials to find out whether hydroxychloroquine was able to prevent covid-19. this was after the lancet on 4 june 2020, due to concerns with respect to the veracity of the data and analyses, retracted an influential article which had earlier reported that hydroxychloroquine increased the mortality of covid-19 patients. on 15 june 2020, the us food and drug administration revoked the emergence use of hydroxychloroquine to treat covid-19 patients after reports that the drug increases the risk of cardiovascular side effects including cardiomyopathy and cardiac arrest. taken together, these developments signify that many countries should carefully evaluate the efficacy and safety of natural antimalarial agents for the possible treatment of covid-19. rich in flavonoids such as acacetin, genkwanin, and 7-methoxyacacetin, leaf extracts of artemisia afra jacq., a common antimalarial remedy in kenya, rwanda, and zambia (chinsembu 2015) , should be carefully evaluated in covid-19 patients. the need for medicinal plants and other natural products to treat covid-19 patients is urgent especially in africa where health systems grapple with high caseloads of hiv/aids and malaria in addition to being heavily underresourced in terms of funding and staff. overall, plants with antiplasmodial (chinsembu 2015) , anti-tuberculosis (chinsembu 2016b) , and anti-hiv replication (chinsembu 2019 ) activities may present good prospects for the discovery of new active compounds with anti-sars-cov-2 action. pechuel-loeschea leubnitziae o. hoffm. (asteraceae), an indigenous plant used to "steam" patients suffering from pneumonia and coughs in namibia mofolo et al. 2020) , should also be evaluated for anti-covid-19 function. high-throughput screening of these plants should be conducted, and computational techniques can quicken the process. moreover, plant active compounds should be subjected to absorption, distribution, metabolism, and excretion (adme) evaluation to verify that oral administration would be effective ). analysis of structure-activity relationships may be helpful in understanding the mechanisms of certain active compounds such as myricetin (5), baicalein (6), and quercetin. further studies including in silico molecular docking simulations should be done to investigate the binding affinities of plant active compounds to sars-cov-2. a docking analysis can test whether the active compound has the potential to directly interact with sars-cov-2 proteins ). application of structure-based drug design strategies may aid in the development of novel sars-cov-2 inhibitors from natural compounds. to predict the general in vivo effects of the natural compounds, network pharmacology analysis can be carried out. only 0.0004% plant samples may directly lead to a commercial drug (chinsembu 2016a) . thus, there are few plantderived anti-sars agents in clinical trials. from 2012 to 2017, only twelve new antivirals were approved by the us food and drug administration; eight were for the treatment of pathologies related to hepatitis c virus and two were combinations of anti-hiv drugs (mercorelli et al. 2018) . since less than 15% of plant diversity has been explored for pharmaceutical purposes (chinsembu, 2016a) , the transition from natural product to anti-sars-cov-2 drug prototypes is a daunting reality as much as it is a beautiful prospect. this review shows that plants, fungi, and marine organisms have anti-sars-cov properties. many of these plants, fungi, and marine organisms have other pharmacological benefits because structural diversity and adaptation to various environmental conditions induce them to synthesize defensive compounds with assorted biological activities (prinsloo et al. 2018) . corollary, diverse plant secondary metabolites are an important library of novel lead compounds that may be functional against sars-cov-2. bio-assay-guided fractionation of medicinal plant extracts may provide a quicker pipeline for the discovery of novel compounds against sars-cov-2. an examination of the research publications on anti-sars natural products cited in this review shows that about 8 out of 10 are authored by the chinese. since the chinese represent about 80% of all research efforts and publications on anti-sars natural products, there is 80% chance that the next big discovery of novel natural products to treat covid-19 will be from tcm. china is the world leader in research and development for innovative anti-sars agents from natural products. by all intents and purposes, the first wellresearched and clinically proven herbal remedy for covid-19 will most likely be discovered and developed in china. the most notable gap identified in the current literature is that many countries in africa, asia (except china), australia/ oceania, europe, north america, and south america lag behind in terms of research efforts on anti-coronavirus remedies from medicinal plants and other natural products. in many countries all over the world, there is need to conduct detailed ethnobotanical studies to establish putative anti-sars-cov-2 medicinal plants and their active compounds. the search for new anti-sars-cov-2 agents should be rigorously extended to marine organisms. this review shows that there is a dearth of experimental data on posology and cytotoxicity of plant extracts and active compounds with in vitro activity against sars-cov-2. more studies on pan-assay interference compounds (pains) and sars-cov-2 immunomodulatory agents from plants and other natural products should be conducted. there is also lack of pharmacological and rigorous human clinical trial data in relation to natural products for treating covid-19. the world is in the middle of a covid-19 pandemic. although the deadly threat posed by the current covid-19 pandemic requires the development of new therapeutic agents, there are currently no efficacious and safe vaccines or drugs to prevent or treat this highly infectious disease. even in developed nations, blockbuster vaccines or drugs have not yet been developed or approved for the prevention and treatment of covid-19. only one synthetic drug (remdesivir) has been approved for emergency use in the usa. compared with placebo, remdesivir did not significantly reduce the mortality of covid-19 patients in clinical trials. against this backdrop, this review provides a modest but insightful snapshot of medicinal plants, fungi, and marine organisms that contain putative active compounds that inhibit sars-cov-2. data in this review show two recurring motifs. the first one is that the search for herbal remedies against covid-19 is more intense in china than in any other part of the world. the second is that most putative anti-sars-cov-2 remedies contain active compounds that inhibit hcovs at the cellular and molecular levels. since structure dictates function, many of these compounds inhibit sars-cov replication because their chemical structures mimic nucleoside analogues. while many of the natural products possess anti-sars-cov properties, their extracts and active compounds should be evaluated for human cytotoxicity and dosage. putative anti-sars-cov-2 extracts and active compounds should be rigorously tested in animal and randomized placebo clinical trials. due to the current lack of effective and safe drugs, natural products presented in this review may form part of the health beliefs, self-medication choices, and selfefficacy practices that people may use to manage covid-19. natural products presented in this paper 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in the treatment of coronavirus disease 2019 (covid-19) in china procyanidins and butanol extract of cinnamomi cortex inhibit sars-cov infection acknowledgments the author is grateful to the anonymous reviewers and to professor rogelio pereda-miranda, editor-in-chief of revista brasileira de farmacognosia, for their help in improving the original manuscript. 