Does Danshen improve disability after acute ischaemic stroke?

Intracisternal administration of tanshinone IIA-loaded nanoparticles leads to reduced tissue injury and functional deficits in a porcine model of ischemic stroke

Background

The absolute number of new stroke patients is annually increasing and there still remains only a few Food and Drug Administration (FDA) approved treatments with significant limitations available to patients. Tanshinone IIA (Tan IIA) is a promising potential therapeutic for ischemic stroke that has shown success in pre-clinical rodent studies but lead to inconsistent efficacy results in human patients. The physical properties of Tan-IIA, including short half-life and low solubility, suggests that Poly (lactic-co-glycolic acid) (PLGA) nanoparticle-assisted delivery may lead to improve bioavailability and therapeutic efficacy. The objective of this study was to develop Tan IIA-loaded nanoparticles (Tan IIA-NPs) and to evaluate their therapeutic effects on cerebral pathological changes and consequent motor function deficits in a pig ischemic stroke model.

Results

Tan IIA-NP treated neural stem cells showed a reduction in SOD activity in in vitro assays demonstrating antioxidative effects. Ischemic stroke pigs treated with Tan IIA-NPs showed reduced hemispheric swelling when compared to vehicle only treated pigs (7.85 ± 1.41 vs. 16.83 ± 0.62%), consequent midline shift (MLS) (1.72 ± 0.07 vs. 2.91 ± 0.36 mm), and ischemic lesion volumes (9.54 ± 5.06 vs. 12.01 ± 0.17 cm³) when compared to vehicle-only treated pigs. Treatment also lead to lower reductions in diffusivity (-37.30 ± 3.67 vs. -46.33 ± 0.73%) and white matter integrity (-19.66 ± 5.58 vs. -30.11 ± 1.19%) as well as reduced hemorrhage (0.85 ± 0.15 vs 2.91 ± 0.84 cm³) 24 h post-ischemic stroke. In addition, Tan IIA-NPs led to a reduced percentage of circulating band neutrophils at 12 (7.75 ± 1.93 vs. 14.00 ± 1.73%) and 24 (4.25 ± 0.48 vs 5.75 ± 0.85%) hours post-stroke suggesting a mitigated inflammatory response. Moreover, spatiotemporal gait deficits including cadence, cycle time, step time, swing percent of cycle, stride length, and changes in relative mean pressure were less severe post-stroke in Tan IIA-NP treated pigs relative to control pigs.

Conclusion

The findings of this proof of concept study strongly suggest that administration of Tan IIA-NPs in the acute phase post-stroke mitigates neural injury likely through limiting free radical formation, thus leading to less severe gait deficits in a translational pig ischemic stroke model. With stroke as one of the leading causes of functional disability in the United States, and gait deficits being a major component, these promising results suggest that acute Tan IIA-NP administration may improve functional outcomes and the quality of life of many future stroke patients.

Salvianolic Acid B Improves Postresuscitation Myocardial and Cerebral Outcomes in a Murine Model of Cardiac Arrest: Involvement of Nrf2 Signaling Pathway

Survival and outcome of cardiac arrest (CA) are dismal despite improvements in cardiopulmonary resuscitation (CPR). Salvianolic acid B (Sal B), extracted from Salvia miltiorrhiza, has been investigated for its cardioprotective properties in cardiac remodeling and ischemic heart disease, but less is known about its role in CA. The aim of this study was to learn whether Sal B improves cardiac and neurologic outcomes after CA/CPR in mice. Female C57BL/6 mice were subjected to eight minutes of CA induced by an intravenous injection of potassium chloride (KCl), followed by CPR. After 30 seconds of CPR, mice were blindly randomized to receive either Sal B (20 mg/kg) or vehicle (normal saline) intravenously. Hemodynamic variables and indices of left ventricular function were determined before CA and within three hours after CPR, the early postresuscitation period. Sal B administration resulted in a remarkable decrease in the time required for the return of spontaneous circulation (ROSC) in animals that successfully resuscitated compared to the vehicle-treated mice. Myocardial performance, including cardiac output and left ventricular systolic (dp/dt_max) and diastolic (dp/dt_min) function, was clearly ameliorated within three hours of ROSC in the Sal B-treated mice. Moreover, Sal B inhibited CA/CPR-induced cardiomyocyte apoptosis and preserved mitochondrial morphology and function. Mechanistically, Sal B dramatically promoted Nrf2 nuclear translocation through the downregulation of Keap1, which resulted in the expression of antioxidant enzymes, including HO-1 and NQO1, thereby counteracted the oxidative damage in response to CA/CPR. The aforementioned antiapoptotic and antioxidant effects of Sal B were impaired in the setting of gene silencing of Nrf2 with siRNA in vitro model. These improvements were associated with better neurological function and increased survival rate (75% vs. 40%, p < 0.05) up to 72 hours postresuscitation. Our findings suggest that the administration of Sal B improved cardiac function and neurological outcomes in a murine model of CA via activating the Nrf2 antioxidant signaling pathway, which may represent a novel therapeutic strategy for the treatment of CA.

Oxidative metabolism of typical phenolic compounds of Danshen by electrochemistry coupled to quadrupole time-of-flight tandem mass spectrometry

An electrochemistry coupled to online quadrupole time-of-flight tandem mass spectrometry (EC/Q-TOF/MS) was applied to investigate the oxidative transformation and metabolic pathway of five phenolic acids in Danshen sample. Simulation of the phase I oxidative metabolism was carried out in an electrochemical reactor equipped with a glassy carbon working electrode. The phase II reactivity of the generated oxidative products towards biomolecules (such as glutathione) was investigated by ways of covalent adduct formation experiments. The results obtained by EC/MS were compared with well-known in vitro studies by conducting rat liver microsome incubations. Structures of the electrochemically produced metabolites were identified by accurate mass measurement and previously results in vivo metabolites. It was indicated that the electrochemical oxidation was in good accordance with similar products found in vivo experiments. In conclusion, this work confirmed that EC/Q-TOF/MS was a promising analytical tool in the prediction of metabolic transformations of functional foods.

Efficacy and Safety of Chinese Herbal Medicine for Primary Intracerebral Hemorrhage: A Systematic Review of Randomized Controlled Trials

Background: Primary intracerebral hemorrhage (ICH) is the most harmful subtype of stroke, but there have yet been no specific proven therapies. Chinese herbal medicine (CHM) has been used for ICH for more than a thousand years; however, currently it is still lacking of available evidence. The objective of this study is to assess the current available evidence of CHM for acute ICH according to randomized controlled trials. Methods: Eight databases were searched from the year of their respective inception to November 2017. Only the studies that assessed at least four domains with "yes" according to the Cochrane risk of bias tool were selected for analysis. All the data were analyzed by using Review Manager 5.3 software. P < 0.05 was considered to be statistically significant. Results: Forty-five studies with 4,517 individuals were identified. CHM paratherapy can improve dependency, neurological function deficit, volume of hematoma, clinical effective rate, and volume of perihematomal edema compared with CHM alone or placebo (all P < 0.05). By contrast, it was not significant for improving the mortality rate of ICH patients (P > 0.05). In addition, adverse events were reported in 16 studies, whereas 29 studies did not mention it. The frequency of adverse events was 70/972 in the trial group and 48/944 in the control group. Conclusion: The present study provided supportive evidence of CHM for improving dependency of ICH and showed generally safety; however, there is still lack of evidence for improving mortality rate, and it opens for further study.

The Beneficial Effects of Raffinee in Permanent Occulted Stroke Mice

Ischemic stroke is a major cause of disability and mortality globally. Although thrombolytic therapy is routinely adopted in cases of ischemic stroke, various alternative natural neuroprotectants are also used as effective adjuvant therapies to recover neurofunction following ischemic stroke. Raffinee, a natural fermented product with strong antioxidant and neuroprotective activities, has antiatherogenic effects in animals and has exhibited neuroprotective effects in a clinical trial by recovering motor and sensory function following spinal cord lesion. This study reveals the advantageous effects of Raffinee on PC12 cells by decreasing hypoxia-induced apoptosis in mice with permanent middle cerebral artery occlusion (pMCAO) by increasing the levels of neurotrophic factors such as S100β, reducing serum inflammatory factors such as matrix metalloproteinases (MMP)-9/MMP-2 ratio, tumor necrosis factor-α, and interleukin (IL)-6 level, and increasing IL-10 levels. Significantly reduced brain infarct volume along with a favorable survival ratio was observed for pMCAO mice that received Raffinee, suggesting a neuroprotective potential of Raffinee in cases of acute ischemic stroke by suppressing apoptosis.

Meta-Analysis for Clinical Evaluation of Xingnaojing Injection for the Treatment of Cerebral Infarction

Objective: Xingnaojing injection (XNJ) is derived from An-Gong-Niu-Huang pill, a well-known traditional Chinese patent medicine, which is widely used for stroke. To evaluate the therapeutic effect of XNJ on cerebral infarction, an extensive meta-analysis was used.

Methods: Six major electronic databases including the Chinese Biomedical Database (CBM), Wanfang, the VIP medicine information system (VMIS) and the China National Knowledge Infrastructure (CNKI), PubMed, Embase, and the Cochrane Library were examined to retrieve randomized controlled trials designed to evaluate the clinical efficacy of XNJ in treating CI before November 26, 2016.

Results: There were 53 randomized controlled trials with 4915 participants in this study. The results reflected that compared with the conventional therapy (CT) alone, XNJ could significantly improve the overall response rate (OR = 3.56, 95% CI [2.94, 4.32], P < 0.00001), and clinical symptom (including increasing activities of daily living (ADL, MD = 10.23, 95% CI [9.47, 10.99], P < 0.00001), and reduce infarction size (MD = -1.83, 95% CI [-2.49, -1.16], P < 0.00001)). However, there was no significant difference between the XNJ treatment and conventional therapy in Glasgow Coma Scale (GCS, P = 0.32). Neurological deficit score demonstrated that XNJ could significantly reduce the score in two different evaluation criterions as National Institutes of Health Stroke Scale (NIHSS, MD = -3.44, 95% CI [-4.52, -2.36], P < 0.00001), and the Chinese Stroke Scale (CSS, MD = -5.72, 95% CI [-6.94, -4.50], P < 0.00001). Additionally, serum MMPs, including MMP-2 and MMP-9 were significantly reduced by XNJ treatment compared with conventional therapy (MD = -11.24, 95% CI [-20.83, -1.65], P = 0.02; MD = -25.08, 95% CI [-35.49, -14.67], P < 0.00001, respectively). Moreover, XNJ was able to improve hemorrheology in reducing whole blood viscosity, plasma viscosity, and hematocrit (MD = -1.44, 95% CI [-2.18, 0.70], P = 0.001; MD = -0.22, 95% CI [-0.37, -0.07], P = 0.003; MD = -3.63, 95% CI [-6.23, -1.03], P = 0.006, respectively). The therapeutic efficacy of XNJ was found associated with improving hemodynamics (increasing peak-flow rate, and average velocity) (MD = 12.66, 95% CI [10.50, 14.81], P < 0.00001; MD = 9.90, 95% CI [8.63, 11.17], P < 0.00001). XNJ was also related to reducing cholesterol and triglyceride (MD = -1.06, 95% CI [-1.21, -0.92], P < 0.00001; MD = -1.05, 95% CI [-1.12, -0.97], P < 0.00001).

Conclusion: Despite the sample size and the poor quality of the included studies of this review, the results of the research showed that XNJ might be a beneficial therapeutic method for the treatment of cerebral infarction.

Adjuvant Chinese Herbal Products for Preventing Ischemic Stroke in Patients with Atrial Fibrillation

OBJECTIVE

Chinese herbal products (CHPs) are widely used for atrial fibrillation (AF) in Taiwan. We investigated the effect of adjuvant CHPs in preventing ischemic stroke in patients with AF.

METHODS

Taiwanese patients in the Health Insurance Database newly diagnosed with AF during 2000-2011 were enrolled. Medication treatment with/without CHPs was administered within 7 days after the AF diagnosis. The clinical endpoint was an ischemic stroke. The Chi-square test, Fisher's exact test, and Student t test were used to examine differences between the traditional Chinese medicine (TCM) and non-TCM cohorts. Cox proportional hazard regression was used to assess the risk for ischemic stroke between two cohorts.

RESULTS

Three hundred and eleven patients underwent TCM treatment and 1715 patients did not. Compared to non-TCM users, TCM users had a lower incidence of stroke (12.59% vs. 1.93%, respectively) and lower risk of stroke [CHA2DS2-VASc score = 0-2 (hazard ratio = 0.20; 95% confidence interval = 0.06-0.65)]. Compared to non-TCM users, the stroke risk was significantly lower in TCM users with AF who were female or younger than 65 years, but not in males, people more than 65 years old, or people with comorbidities. Compared to TCM users, non-TCM users who received conventional treatment had a higher ischemic stroke risk. The risk for AF-related hospitalization was significantly lower in TCM users (0.64%) than in non-TCM users (38.1%).

CONCLUSIONS

Users of TCM with AF have a lower risk of new-onset ischemic stroke. Therefore, adjuvant CHP therapy may have a protective effect and may be used in AF patients to prevent ischemic stroke.

Ligustrazine for the Treatment of Unstable Angina: A Meta-Analysis of 16 Randomized Controlled Trials

Ligustrazine is a principal ingredient of chuanxiong. Concerns regarding the evaluation of the effectiveness of ligustrazine in the treatment of UA have resulted in a meta-analysis combined with recent clinical evidence. Seven computer databases that included the China hospital knowledge database (CHKD), Wanfang Med Online, the Chinese medical journal database (CMJD), PubMed, Cochrane, Embase (Ovid), and Medline (Ovid) were systematically searched. We included randomized controlled trials and quasi-randomized controlled trials. Our systematic review identified 16 RCTs that met our eligibility criteria. Ligustrazine combined with conventional medicine was associated with an increased rate of marked improvement in symptoms and an increased rate of marked improvement of ECG compared with conventional Western medicine alone. Additionally, the use of ligustrazine was associated with significant trends in the reduction of the consumption of nitroglycerin and the level of fibrinogen when compared with conventional Western medicine alone. No firm results were found between the intervention and the control method groups in the reduction of the time of onset or the frequency of acute attack angina due to the high level of heterogeneity. In conclusion, our meta-analysis found that ligustrazine was associated with some benefits for people with unstable angina.

Characterization of metabolites in rats after intravenous administration of salvianolic acid for injection by ultra-performance liquid chromatography coupled with quadrupole-time-of-flight mass spectrometry

It is an essential requirement to clarify the metabolites of traditional Chinese medicine (TCM) injections, which contain numerous ingredients, to assess their safe and effective use in clinic. Salvianolic acid for injection (SAFI), made from hydrophilic phenolic acids in Salvia miltiorrhiza Bunge, has been widely used for the treatment of cerebrovascular diseases, but information on its metabolites in vivo is still lacking. In the present study, we aimed to holistically characterize the metabolites of the main active ingredients in rat plasma, bile, urine and feces following intravenous administration of SAFI. An ultra-performance liquid chromatography coupled with quadrupole-time-of-flight mass spectrometry (UPLC/Q-TOF-MS) method was developed. Combining information on retention behaviors, multistage mass spectra and literature data, a total of eight prototypes and 52 metabolites were tentatively characterized. Metabolites originated from rosmarinic acid and salvianolic acid B comprised the majority of identified compounds. Meanwhile, four metabolites derived from salvianolic acid D and five from salvianolic acid B are reported for the first time. This study revealed that methylation, sulfation and glucuronidation were the major metabolic pathways of phenolic acids in SAFI in vivo. Furthermore, the developed UPLC/Q-TOF-MS method could also benefit the metabolic investigation of extracts and preparations in TCM with hydrophilic ingredients. Copyright © 2016 John Wiley & Sons, Ltd.

Chinese Herbal Products for Ischemic Stroke

Traditional Chinese herbal products (CHPs) have been described in ancient medicine systems as treatments for various stroke-associated ailments. This study is aimed to investigate the prescription patterns and combinations of CHPs for ischemic stroke in Taiwan. Prescriptions of CHPs for ischemic stroke were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan. Every prescription with a leading diagnosis of ischemic stroke made during 2000-2010 was analyzed. Descriptive statistics were applied to the pattern of co-prescriptions. Multiple logistic regression models were used to assess demographic and risk factors that are correlated with CHP use. The dataset of inpatient claims data contained information on 15,896 subjects who experienced ischemic stroke from 2000 to 2010. There was an average of 5.82 CHPs in a single prescription for subjects with ischemic stroke. Bu-yang-huan-wu-tang (BYHWT) (40.32%) was by far the most frequently prescribed formula CHP for ischemic stroke, and the most commonly used combination of two-formula-CHP was BYHWT with Shu-jin-huo-xue-tang (SJHXT) (4.40%). Dan Shen (16.50%) was the most commonly used single CHP for ischemic stroke, and the most commonly used combination of two single CHPs was Shi Chang Pua with Yuan Zhi (4.79%). We found that BYHWT and Dan Shen were the most frequently prescribed formula and single CHP for ischemic stroke, respectively. These results provide information about individualized therapy and may contribute to further pharmacologic experiments and clinical trials.

Preparation of przewalskinic acid A from salvianolic acid B using a crude enzyme from an Aspergillus oryzae strain

Przewalskinic acid A is a rare, water-soluble, and highly biologically active ingredient found, thus far, only in the Salvia przewalskii Maxim herb; however, the content in S. przewalskii herb is very low. In order to obtain useful quantities of przewalskinic acid A, the biotransformatin of salvianolic acid B from Salvia miltiorrhiza root (danshen in Chinese) into przewalskinic acid A was studied using a crude enzyme produced from Aspergillus oryzae D30s strain. The crude enzyme from the A. oryzae strain hydrolyzed salvianolic acid B into przewalskinic acid A and danshensu. The preparation afforded 31.3 g przewalskinic acid A (91.0 % purity) and 13.1 g danshensu (95 % purity) from 75 g salvianolic acid B. The preparation of przewalskinic acid A was therefore very successful with a yield of over 86 %, but the yield of danshensu was only 33 %. The product przewalskinic acid A was identified using ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) and NMR.

Systematic review and meta-analysis of randomized controlled trials of xingnaojing treatment for stroke

Objective. Xingnaojing injection (XNJ) is a well-known traditional Chinese patent medicine (TCPM) for stroke. The aim of this study is to assess the efficacy of XNJ for stroke including ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Methods. An extensive search was performed within using eight databases up to November 2013. Randomized controlled trials (RCTs) on XNJ for treatment of stroke were collected. Study selection, data extraction, quality assessment, and meta-analysis were conducted according to the Cochrane standards, and RevMan5.0 was used for meta-analysis. Results. This review included 13 RCTs and a total of 1,514 subjects. The overall methodological quality was poor. The meta-analysis showed that XNJ combined with conventional treatment was more effective for total efficacy, neurological deficit improvement, and reduction of TNF-α levels compared with those of conventional treatment alone. Three trials reported adverse events, of these one trial reported mild impairment of kidney and liver function, whereas the other two studies failed to report specific adverse events. Conclusion. Despite the limitations of this review, we suggest that XNJ in combination with conventional medicines might be beneficial for the treatment of stroke. Currently there are various methodological problems in the studies. Therefore, high-quality, large-scale RCTs are urgently needed.

Scalp acupuncture for acute ischemic stroke: a meta-analysis of randomized controlled trials

Scalp acupuncture (SA) is a commonly used therapeutic approach for stroke throughout China and elsewhere in the world. The objective of this study was to assess clinical efficacy and safety of SA for acute ischemic stroke. A systematical literature search of 6 databases was conducted to identify randomized controlled trials (RCTs) of SA for acute ischemic stroke compared with western conventional medicines (WCMs). All statistical analyses were performed by the Rev Man Version 5.0. Eight studies with 538 participants were included in the studies. The studies were deemed to have an unclear risk of bias based on the Cochrane Back Review Group. Compared with the WCM, 6 RCTs showed significant effects of SA for improving neurological deficit scores (P < 0.01); 4 RCTs showed significant effects of SA for favoring the clinical effective rate (P < 0.01) However, the adverse events have not been documented. In conclusion, SA appears to be able to improve neurological deficit score and the clinical effective rate when compared with WCM, though the beneficial effect from SA is possibly overvalued because of generally low methodology of the included trials. No evidence is available for adverse effects. Rigorous well-designed clinical trials are needed.

Chinese medicine shenfu injection for heart failure: a systematic review and meta-analysis

Objective. Heart failure (HF) is a global public health problem. Early literature studies manifested that Shenfu injection (SFI) is one of the most commonly used traditional Chinese patent medicine for HF in China. This article intended to systematically evaluate the efficacy and safety of SFI for HF. Methods. An extensive search was performed within 6 English and Chinese electronic database up to November 2011. Ninety-nine randomized controlled trails (RCTs) were collected, irrespective of languages. Two authors extracted data and assessed the trial quality independently. RevMan 5.0.2 was used for data analysis. Results. Compared with routine treatment and/or device support, SFI combined with routine treatment and/or device support showed better effect on clinical effect rate, mortality, heart rate, NT-proBNP and 6-minute walk distance. Results in ultrasonic cardiography also showed that SFI combined with routine treatment improved heart function of HF patients. There were no significant difference in blood pressure between SFI and routine treatment groups. Adverse events were reported in thirteen trails with thirteen specific symptoms, while no serious adverse effect was reported. Conclusion. SFI appear to be effective for treating HF. However, further rigorously designed RCTs are warranted because of insufficient methodological rigor in the majority of included trials.

History and mechanism for treatment of intracerebral hemorrhage with scalp acupuncture

Intracerebral hemorrhage (ICH) is an important public health problem with high rates of mortality, morbidity, and disability, but no clinically proven treatment strategy is available to date. Scalp acupuncture (SA) refers to a therapy for treating diseases by needling and stimulating the specific areas of the scalp. The evidence from clinical studies suggested that SA therapy may produce significant benefits for patients with acute ICH. However, the therapeutic mechanisms are yet not well addressed. Therefore, in this paper, we provide a comprehensive overview on the history and mechanisms of SA therapy on acute ICH. Although SA has been practiced for thousands of years in China and could date back to 5 BC, SA therapy for acute ICH develops only in the recent 30 years. The possible mechanisms associated with the therapeutic effects of SA on ICH include the influence on hematoma, brain edema, and blood brain barrier, the products released from haematoma, the immune and inflammatory reaction, focal perihemorrhagic hypoperfusion and hemorheology, neuroelectrophysiology, and so on. At last, the existence of instant effect of SA on acute ICH and its possible mechanisms are presented.

Investigation of the binding of Salvianolic acid B to human serum albumin and the effect of metal ions on the binding

The studies on the interaction between HSA and drugs have been an interesting research field in life science, chemistry and clinical medicine. There are also many metal ions present in blood plasma, thus the research about the effect of metal ions on the interaction between drugs and plasma proteins is crucial. In this study, the interaction of Salvianolic acid B (Sal B) with human serum albumin (HSA) was investigated by the steady-state, synchronous fluorescence and circular dichroism (CD) spectroscopies. The results showed that Sal B had a strong ability to quench the intrinsic fluorescence of HSA through a static quenching mechanism. Binding parameters calculated showed that Sal B was bound to HSA with the binding affinities of 10(5) L mol(-1). The thermodynamic parameters studies revealed that the binding was characterized by positive enthalpy and positive entropy changes, and hydrophobic interactions were the predominant intermolecular forces to stabilize the complex. The specific binding distance r (2.93 nm) between donor (HSA) and acceptor (Sal B) was obtained according to Förster non-radiative resonance energy transfer theory. The synchronous fluorescence experiment revealed that Sal B cannot lead to the microenvironmental changes around the Tyr and Trp residues of HSA, and the binding site of Sal B on HSA is located in hydrophobic cavity of subdomain IIA. The CD spectroscopy indicated the secondary structure of HSA is not changed in the presence of Sal B. Furthermore, The effect of metal ions (e.g. Zn(2+), Cu(2+), Co(2+), Ni(2+), Fe(3+)) on the binding constant of Sal B-HSA complex was also discussed.

Anti-inflammatory effects of Chinese medicinal herbs on cerebral ischemia

Abstracts

Recent studies have demonstrated the importance of anti-inflammation, including cellular immunity, inflammatory mediators, reactive oxygen species, nitric oxide and several transcriptional factors, in the treatment of cerebral ischemia. This article reviews the roles of Chinese medicinal herbs as well as their ingredients in the inflammatory cascade induced by cerebral ischemia. Chinese medicinal herbs exert neuroprotective effects on cerebral ischemia. The effects include inhibiting the activation of microglia, decreasing levels of adhesion molecules such as intracellular adhesion molecule-1, attenuating expression of pro-inflammatory cytokines such as interleukin-1β and tumor necrosis factor-α, reducing inducible nitric oxide synthase and reactive oxygen species, and regulating transcription factors such as nuclear factor-κB.

Studies on the interaction of salvianolic acid B with human hemoglobin by multi-spectroscopic techniques

The interaction between salvianolic acid B (Sal B) and human hemoglobin (HHb) under physiological conditions was investigated by UV-vis absorption, fluorescence, synchronous fluorescence and circular dichroism spectroscopic techniques. The experimental results indicate that the quenching mechanism of fluorescence of HHb by Sal B is a static quenching procedure, the binding reaction is spontaneous, and the hydrophobic interactions play a major role in binding of Sal B to HHb. Based on Förster's theory of non-radiative energy transfer, the binding distance between Sal B and the inner tryptophan residues of HHb was determined to be 2.64 nm. The synchronous fluorescence experiment revealed that Sal B can not lead to the microenvironmental changes around the Tyr and Trp residues of HHb, and the binding site of Sal B on HHb is located at α(1)β(2) interface of HHb. Furthermore, the CD spectroscopy indicated the secondary structure of HHb is not changed in the presence of Sal B.

The effect of tanshinone IIA on the cardiovascular system in ovine fetus in utero

This was the first study to determine the effect of tanshinone IIA (an active ingredient in herb Danshen) on fetuses in utero under unstressed condition. Tanshinone IIA or 0.9% NaCl as control was intravenously (i.v.) administrated into pregnant ewes. Both maternal and fetal blood were analyzed for PO(2), PCO(2), SO(2)%, hemoglobin, hemotecrit, glucose, lactic acid, Na(+), K(+), and Cl(-) concentrations. Maternal and fetal heart functions were assessed by examining cardiac enzymes and cardiovascular responses. The results showed that tanshinone IIA did not alter the blood values in ewes and fetuses. Cardiac enzyme activities related to the heart remained unchanged. In cardiovascular experiments, no alternation in maternal blood pressure by tanshinone IIA was observed. However, fetal systolic pressure was slightly and significantly increased following i.v. tanshinone IIA into the mothers, while fetal diastolic pressure, mean arterial pressure, and heart rate were not changed. The results demonstrated that tanshinone IIA used during the last third of gestation did not cause the biochemical changes related to cardiac functions in both maternal and fetal sheep. Fetal oxygen metabolism remained stable in utero, providing new information for clinical use of the herb in pregnancy. That tanshinone IIA increased fetal systolic pressure may open new opportunities to study the herb in fetal medicine.

The Quality of Randomized Controlled Trials on DanShen in the Treatment of Ischemic Vascular Disease

BACKGROUND AND OBJECTIVES

Many randomized controlled trials (RCTs) were conducted to evaluate the efficacy of DanShen (Salvia miltiorrhizae, an herbal medicine) on ischemic vascular diseases (IVD). However, there has been no systematic evaluation of the quality of DanShen RCTs so far. The aims of this study were (1) to assess the quality of DanShen RCTs on IVD published in mainland China from 1998 to 2007 and (2) to explore the factors correlating with the quality.

DESIGN

A number of Chinese databases were searched, and most of DanShen RCTs on IVD were collected. According to CONSORT for TCM (Consolidated Standards for Reporting of Trials for Traditional Chinese Medicine) and the Jadad scale, the quality assessment and data abstraction were performed independently by two reviewers. One-way analysis of variance and Pearson correlation analysis were applied to explore the association between basic characteristic and the quality of the RCTs.

RESULTS

One hundred and fifty (150) DanShen RCTs were identified finally. The mean (standard deviation) score of 150 DanShen RCTs assessed by CONSORT for TCM was 23.87 (3.68), and 1.94 (0.82) by the Jadad scale, respectively. Only 6.7% (10/150) of RCTs were identified with high quality (Jadad score > or =4). Authors' affiliation, publication journal, sample size, and follow-up time were correlated with the quality of DanShen RCTs.

CONCLUSIONS

The quality of DanShen RCTs in mainland China has not been improved significantly over recent years, and the overall quality of DanShen RCTs is still poor.

Role of P-glycoprotein in restricting the brain penetration of tanshinone IIA, a major active constituent from the root ofSalvia miltiorrhizaBunge, across the blood–brain barrier

Tanshinone IIA (TSA) is a major constituent of Salvia miltiorrhiza Bunge widely used in the treatment of stroke. This current study aimed to investigate the nature of brain penetration of TSA using several in vitro and in vivo models. The uptake and efflux of TSA in primary rat brain microvascular endothelial cells (RBMVECs) were altered in the presence of a PgP inhibitor or multidrug-resistance-associated protein (Mrp1/2) inhibitor. A polarized transport of TSA was found in RBMVEC monolayers with facilitated efflux from the abluminal to the luminal side. The polarized transport of TSA was attenuated by PgP or Mrp1/2 inhibitors. In an in situ rat brain perfusion model, TSA crossed the blood-brain barrier at a greater rate than that for sucrose, and the brain penetration was increased in the presence of a PgP or Mrp1/2 inhibitor. The brain levels of TSA were only about 31% of that in the plasma and it increased to 74-77% of plasma levels when verapamil or quinidine was coadministered in rats. The entry of TSA to the central nervous system (CNS) significantly increased in rats subjected to middle cerebral artery occlusion or treatment with quinolinic acid. The normalized brain penetration of TSA in mdr1a((-/-)) mice was much higher than the wild-type mice. Taken collectively, these findings provide evidence that TSA has limited brain penetration through the blood-brain barrier owing to the contribution of PgP and possibly Mrp1/2.

Preclinical factors affecting the pharmacokinetic behaviour of tanshinone IIA, an investigational new drug isolated from Salvia miltiorrhiza for the treatment of ischaemic heart diseases

Tanshinone IIA (TSIIA) is a major active triterpenoid isolated from Salvia miltiorrhiza. The purposes of this study were to investigate various preclinical factors that determined the pharmacokinetics of TSIIA. After oral dosing at 6.7, 20, and 60 mg kg(-1), TSIIA was detected mainly as glucuronidated conjugate (TSIIAG) with only small amounts of the unchanged in the plasma. TSIIA was predominantly excreted into the bile and faeces as TSIIAG, and urine to a minor extent. The C(max) and AUC(0-)(t) of TSIIAG after i.p. administration were significantly lower than those after intragastric administration. The plasma concentration-time profiles of TSIIA following oral dosing of TSIIA showed multiple peaks. The C(max) and AUC(0-)(t) of TSIIA and its glucuronides in rats with intact bile duct were significantly lower than those of rats with bile duct cannulation. Studies from the linked-rat model and intraduodenal injection of bile containing TSIIA and its metabolites indicate that TSIIA glucuronides underwent hydrolysis and the aglycone was reabsorbed from the gut and excreted into the bile as conjugates. TSIIA had a wide tissue distribution, with a very high accumulation in the lung, but very limited penetration into the brain and testes. TSIIA was metabolized by rat CYP2C, 3A and 2D, as ticlopidine, ketoconazole and quinidine all inhibited TSIIA metabolism in rat liver microsomes. Taken collectively, these findings indicate that multiple factors play important roles in determining the pharmacokinetics of TSIIA.

Tanshinone IIB, a primary active constituent from Salvia miltiorrhza, exhibits neuro-protective activity in experimentally stroked rats

Tanshinone IIB (TSB) is a major active constituent of the root of Salvia miltiorrhiza (Danshen) used in the treatment of acute stroke. Danshen extracts and TSB have shown marked neuron-protective effects in mouse studies but there is a lack of clinical evidence for the neuron-protective effects of Danshen and its active ingredients. This study investigated the neuron-protective effects of TSB in experimentally stroked rats. TSB at 5 and 25 mg/kg by intraperitoneal injection significantly reduced the focal infarct volume, cerebral histological damage and apoptosis in rats subjected to middle cerebral artery occlusion (MCAO) compared to MCAO rats receiving vehicle. This study demonstrated that TSB was effective in reducing stroke-induced brain damage and may represent a novel drug candidate for further development. Further mechanistic studies are needed for the neuron-protective activity of TSB.

Meta-analysis of traditional Chinese patent medicine for ischemic stroke

BACKGROUND AND PURPOSE

A large number of traditional Chinese patent medicine (TCPM) are widely used for ischemic stroke in China. The aim of this study was to systematically review the existing clinical evidence on TCPM for ischemic stroke.

METHODS

We identified all TCPM that were listed in the Chinese National Essential Drug list of 2004 and those commonly used TCPM in current clinical practice for ischemic stroke. Fifty-nine TCPM were identified for further evaluation. We applied Cochrane systematic review methods. We searched for reports of randomized controlled trials and controlled clinical trials on any of the 59 TCPM for ischemic stroke comparing one TCPM with control. PRIMARY OUTCOMES included death or dependency at the end of follow-up (at least 3 months) and adverse events. Effects on neurological impairments were a secondary outcome.

RESULTS

One-hundred ninety-one trials (19,338 patients) on 22 TCPM were available and included, of which 120 were definite or possible randomized controlled trials and 71 were controlled clinical trials. The methodological quality of included trials was generally "poor." Few trials reported methods of randomization. Three trials were randomized, double blind, and placebo-controlled.

PRIMARY OUTCOMES

one trial on Puerarin and one trial on Shenmai injection assessed death or dependency at the end of long-term follow-up (at least 3 months) and found no statistically significant difference between 2 groups. The reported adverse events including allergic reaction, headache, nausea, diarrhea, bellyache, blood pressure change, and subcutaneous ecchymosis. Most of the adverse events were not severe.

SECONDARY OUTCOMES

analysis of the secondary outcome, "marked improvement in neurological deficit," showed apparent benefits of about the same magnitude for all the TCPM studied. Of the 22 TCPM, 8 drugs (Milk vetch, Mailuoning, Ginkgo biloba, Ligustrazine, Danshen agents, Xuesetong, Puerarin, and Acanthopanax) had relatively more studies and patient numbers.

CONCLUSIONS

There was insufficient good quality evidence on the effects of TCPM in ischemic stroke on the primary outcome (death or dependency). We considered the apparent benefit on neurological impairment was as likely to be attributable to bias from poor methodology as to a real treatment effect. However, because the agents assessed appeared potentially beneficial and nontoxic, further randomized controlled trials are justified. Eight drugs could be further research priorities.

Dan Shen agents for acute ischaemic stroke

BACKGROUND

Based mainly on experimental data that indicates improvement to the cerebral microcirculation, Dan Shen, a herbal medicine, is widely used in the treatment of acute ischaemic stroke in China.

OBJECTIVES

To assess the effects of Dan Shen agents in patients with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched July 2006), the register of the Cochrane Complementary Field (last searched July 2006) and the Chinese Stroke Trials Register (last searched August 2006). In addition, we searched the following bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2006), MEDLINE (1996 to August 2006), EMBASE (1980 to August 2006), CINAHL (1982 to August 2006), AMED (1985 to August 2006), and the China Biological Medicine Database (CBM-disc) (1979 to August 2006). We handsearched 10 Chinese journals, searched clinical trials and research databases, scanned reference lists and contacted the pharmaceutical company manufacturing Dan Shen. We also attempted to contact trial authors to obtain further data.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing Dan Shen agents with placebo or open control in patients with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data.

MAIN RESULTS

Six trials involving 494 patients were included. Three trials are awaiting assessment. Numbers of deaths and dependent patients at the end of follow up of at least three months were not reported in the six included trials. Only two trials reported adverse events. All trials measured the outcome 'significant improvement in neurological deficit at the end of treatment'. Dan Shen agents were associated with a significant increase in the number of patients with the outcome (Peto odds ratio 3.02, 95% confidence interval 1.73 to 5.26). No deaths were reported within the first two weeks of treatment or during the whole follow-up period. The trials did not include any assessment of quality of life.

AUTHORS' CONCLUSIONS

The methodological quality of all included studies was poor, and reliable conclusions could not be drawn from the present data. Further high-quality randomised controlled trials should be performed.

Cardiovascular effects of Danshen

Danshen is one of the most versatile Chinese herbal drugs that have been used for hundred of years in the treatment of numerous ailments. Because of its properties of improving microcirculation, causing coronary vasodilatation, suppressing the formation of thromboxane, inhibiting platelet adhesion and aggregation, and protecting against myocardial ischemia, it is widely used either alone or in combination with other herbal ingredients for patients with coronary artery disease and other cardiovascular diseases, in both China and other countries including the United States. This article provides an overview of its history, pharmacology, pharmacokinetics, clinical applications, side effects, interactions with Western drugs, and future prospects in the management of cardiovascular diseases.

Bioavailability of salvianolic acid B in conscious and freely moving rats

Salvianolic acid B is an herbal ingredient isolated from Salvia miltiorrhiza. The aim of this study was to apply an automated blood sampling system coupled to a simple liquid chromatographic system to determine the bioavailability of salvianolic acid B in stress-free rats. The plasma sample (25 microl) was vortex-mixed with 50 microl of internal standard solution (chloramphenicol 10 microg/ml in acetonitrile) to achieve protein precipitation. Salvianolic acid B in the rat plasma was separated using a reversed-phase C18 column (250 mm x 4.6 mm, 5 microm) with a mobile phase of acetonitrile-methanol-20mM NaH(2)PO(4) (adjusted to pH 3.5 with H(3)PO(4)) (20:10:70 v/v/v) containing 0.1mM 1-octanesulfonic acid, and the flow-rate of 1 ml/min. The UV detection wavelength was 286 nm. The concentration-response relationship from the present method indicated linearity over a concentration range of 0.5-200 microg/ml. Intra- and inter-assay precision and accuracy of salvianolic acid B fell well within the predefined limits of acceptability (<15%). The plasma sample of salvianolic acid B was further identified by LC-MS/MS in the negative ion mode using mass transition m/z 358.2 to the product ion m/z 196.9. After salvianolic acid B (100mg/kg, i.v.; 500 mg/kg, p.o.) was given in conscious and freely moving rats, the AUC were 5030+/-565 and 582+/-222 min microg/ml for intravenous (100 mg/kg) and oral (500 mg/kg) doses, respectively. The oral bioavailability of salvianolic acid B in freely moving rats was calculated to be 2.3%.

Preclinical and clinical examinations of Salvia miltiorrhiza and its tanshinones in ischemic conditions

Salvia miltiorrhiza (Labiatae, Laminaceae), danshen, is an annual sage mainly found in China and neighboring countries. The crude drug (dried root) and its preparations are currently used in China to treat patients suffering from heart attack, angina pectoris, stroke and some other conditions. The use of S. miltiorrhiza has been increasing in the management of stroke. Pharmacological examinations showed that the plant and its active ingredients, tanshinones and salvianolic acids, have anticoagulant, vasodilatory, increased blood flow, anti-inflammatory, free radical scavenging, mitochondrial protective and other activities. This review discusses the pharmacology, medicinal chemistry and clinical studies published, especially in China, for danshen and tanshinone preparations. Clinical examinations are evaluated in terms of S. miltiorrhiza preparation, dose, double blinding, control, clinical assessments of outcomes and other parameters. Meta-analyses of S. miltiorrhiza are also discussed.

Danshen: an overview of its chemistry, pharmacology, pharmacokinetics, and clinical use

Danshen, the dried root of Salvia miltiorrhiza, has been widely used in China and, to a lesser extent, in Japan, the United States, and other European countries for the treatment of cardiovascular and cerebrovascular diseases. In China, the specific clinical use is angina pectoris, hyperlipidemia, and acute ischemic stroke. The current review covers its traditional uses, chemical constituents, pharmacological activities, pharmacokinetics, clinical applications, and potential herb-drug interactions based on information obtained in both the English and Chinese literature. Although numerous clinical trials have demonstrated that certain Danshen products in China are effective and safe for the treatment of cardiovascular diseases, most of these lack sufficient quality. Therefore, large randomized clinical trials and further scientific research to determine its mechanism of actions will be necessary to ensure the safety, effectiveness, and better understanding of its action.

Insights from molecular investigations of traditional Chinese herbal stroke medicines: implications for neuroprotective epilepsy therapy

Traditional Chinese herbal medicine is the most widely practiced form of herbalism worldwide. It is based on a sophisticated system of medical theory and practice that is distinctly different from orthodox Western scientific medicine. Most traditional therapeutic formulations consist of a combination of several drugs. The combination of multiple drugs is thought to maximize therapeutic efficacy by facilitating synergistic actions and ameliorating or preventing potential adverse effects while at the same time aiming at multiple targets. Orthodox drug therapy has been subject to critical analysis by the "evidence-based medicine" movement, and demands have been made that herbal medicine should be subject to the same kind of scrutiny. However, evaluation of the effectiveness of herbal medicines can be challenging, as their active components are often not known. Accordingly, it may be difficult to ensure that an herbal preparation used in clinical trials contains the components underlying its purported therapeutic effect. We reasoned that the identification of actions of herbal medicines at well-defined molecular targets and subsequent identification of chemical compounds underlying these molecular effects might serve as surrogate markers in the hypothesis-guided evaluation of their therapeutic efficacy. A research program was initiated to characterize in vitro molecular actions of a collection of 58 traditional Chinese drugs that are often used for the treatment of stroke. The results indicate that these drugs possess activity at disparate molecular targets in the signaling pathways involved in N-methyl-d-aspartate (NMDA) receptor-mediated neuronal injury and death. Each herbal drug contains diverse families of chemical compounds, where each family comprises structurally related members that act with low affinity at multiple molecular targets. The data appear to support the multicomponent, multitarget approach of traditional Chinese medicine. Glutamate release and excessive stimulation of NMDA receptors cause status epilepticus-induced neuronal death and are involved in epileptogenesis. Therefore, these results are also relevant to the development of antiepileptogenic and neuroprotective therapy for seizures. The combination of principles of modern molecular medicine with certain ideas of traditional empirical Chinese medicine may be beneficial in translational medicine in general.