Introduction: The implementation of futile nursing interventionsseems to be a persistent problem in adult intensive care units. Understandingthis phenomenon can contribute to its prevention and all deleterious effectsassociated with it. Objective: To identify the perceptions ofexpert nurses from adult intensive care units about therapeutic futility innursing. Methods: This study consists of a conventional contentanalysis. Data was collected through a focus group interview that included fiveexpert nurses in adult intensive care, with a minimum of fifteen years ofprofessional experience in intensive care. To analyze the information, thetechnique of thematic categorical analysis was used, according to Bardin.Results: Four central categories were identified for the topicunder study, for which several subcategories were identified that allow a betterunderstanding of this phenomenon. Conclusion: Adult intensive careexpert nurses advocate that therapeutic futility in nursing is a realityperceived by teams and families, which should be avoided due to the risk ofpotentiating the implementation of ethically reprehensible care. Intensive care units are highly advanced and organized systems dedicated to providingcare to critically ill patients. Thanks to a wide monitoring capacity and multiplemodalities of physiological organ support, these units enable the provision of careto people with highly complex critical illness. These units are equipped with amultidisciplinary team that is systematically dedicated to the care of people whohave developed, or are at risk of developing, acute organic dysfunction that putstheir lives at risk. However, despite the noble availability of resources, there aresituations of high vulnerability and irreversibility that are impossible to reverseeven in these environments .Therapeutic futility has been studied for a long time, with evidence from recordsdating to the time of Hippocrates. However, the term futile care only emerged in thehealth literature in the 80s of the last century . Since tIn general, nurses are healthcare professionals who demonstrate a high level of moralsensitivity to ethical issues in clinical practice . IntensiAlthough it is consensual that therapeutic futility occurs frequently, especially incertain environments that are characterized by the existence of technological andhuman resources that make it possible to prolong life, such as intensive care units,this practice continues to be verified frequently through the implementation ofinappropriate interventions that do not contribute to the improvement of theprognosis or to the relief of symptoms, aiming exclusively at prolonging life .The underlying reasons for therapeutic futility can be varied, but in general theyfall into three main categories, such as patients and family members request forcontinuing life-sustaining treatments, personal reasons of health professionals,cultural and organizational structure . SomeauTherapeutic futility has been subject of discussion all over the world. However,despite several studies carried out by nurses, there is still a lack of consensusregarding the definition and early identification of therapeutic futility, whichcontributes to the persistence of this phenomenon. In Portugal, the debate on thetopic of therapeutic futility has become more evident in the last decade, which hascontributed to the increase in scientific publications by national authors,especially in the areas of intensive care . Most stTo identify the perceptions of expert nurses from adult intensive care units abouttherapeutic futility in nursing.Focus group interview conducted in November 2021, by videoconference, moderatedby the principal investigator and supervised by an ethical decision specialist.A conventional content analysis was carried out through a thematic categoricalanalysis. This approach allowed the direct identification of categoriesextracted from the data collection. The study occurred between August 2021 andJuly 2022.Data were collected using a focus group interview, carried out to stimulateparticipation and to enhance the quantity and quality of the narratives. Thisfocus group interview, carried out in November 2021, lasted 127 min and includedthe following questions: (1) Tell us about a situation in which you think youprovided nursing care (or attended the provision of nursing care) more than whatwas necessary for the specific person; (2) What did you do in that situation,what did you consider to have been futile or too much, that is, beyond what wasnecessary? (3) Why did you consider/think that what you did was too much? Was itjust your perception, or was it a generalized appreciation? (4) When you thinkof therapeutic futility in nursing, what terminology/terms do you think of?The focus group interview was carried out using videoconferencing. Despite thatthe most used strategy for this method is still face-to-face, recent studiespoint to benefits associated with videoconferencing, namely, the possibility ofbringing together participants from significantly dispersed geographical areasand the ease of proceeding with the full recording of all discussions provided,provided that with the express authorization of all participants .What are the perceptions of expert nurses from adult intensive care units abouttherapeutic futility in nursing.For this study, a non-probabilistic sampling method was used, specifically,convenience sampling. Study participants were intentionally selected andconsisted exclusively of nurses who are experts in adult intensive care. Theintention of the sample for a study of a qualitative nature is justified by theselection of expert participants whose anticipated richness and depth ofcontribution could not be neglected. Inclusion criteria were: (1) adultintensive care nurses; (2) nurses with a minimum of fifteen years ofprofessional experience in an adult intensive care unit; (3) advanced knowledgeof the topic under study and interest in participating.A total of five nurses  participThe study was approved by the Scientific Committee and the Ethics Committee of aUniversity in Portugal (148_CES-UCP). Before conducting the focus groupinterview, confidentiality and anonymization were guaranteed and allparticipants in the focus group interview consented to their authorization. Inaddition, all participants were informed about all characteristics of the study,objectives, and the reasons behind the study. Voluntary participation wasemphasized and during the focus group interview, anticipating that the narrativeof delicate and complex situations could imply some negative emotion in theparticipants, a specialist in ethical decision was present for the eventual needto provide assistance in the field of moral suffering.The analysis of the data collected was carried out between November 2021 andMarch 2022, in a first phase independently by two authors, after transcriptionof the audio to text. For the qualitative analysis of the information obtained,the content analysis technique was used, an information treatment techniquecommonly used in empirical research, particularly thematic categorical analysis,with thThe operations to be carried out during the content analysis included thedefinition of categories, the definition of the units of analysis, and thequantification centered on the recording units of each indicator. The text, oncetranscribed, was analyzed using the NVivo® software.Each of the authors listened and analyzed the transcript several times, toextract the categories identified according to the subcategories that emerged.All similar subcategories were classified into the same category andsignificantly similar categories were merged. Subsequently, the authors comparedtheir results and whenever differences were found in the analysis, a discussionwas promoted with the third author until a final consensus was reached. Thisanalysis was performed exclusively by the authors. It should be noted that, bothduring the data collection phase and in the data analysis phase, the researcherswere able to identify and keep in abeyance their convictions, beliefs, andopinions about the phenomenon under study, excluding all prepositions andconvictions to confront the narratives obtained in the purest form .To confirm the credibility of the data obtained, the principal investigator ofthis study established several contacts with the participants. Additionally,exhaustive research was carried out on the subject and a constant evaluation waspromoted by experts on the subject under study. After transcription, the focusgroup interview was returned to all participants to confirm a true transcript.After identifying the codes, categories, and subcategories extracted, to confirmthe reliability an evaluation was carried out by two experts.The content analysis performed on the content extracted from the focus groupinterview made it possible to identify four general categories related to the topicunder study of therapeutic futility in nursing, specifically, the situation ofdeclared futility in nursing, futile nursing interventions, the recognition oftherapeutic futility in nursing and the scope of therapeutic futility in nursing. For eacPatients who arrive in refractory septicshock…” (P.1); “Patients who essentially have a pH lowerthan seven…and in addition they have lactates that sometimes go as high as15 and 20 mmol/ L.” (P.1); “People with severe, refractoryhypotension, despite unreasonable administrations of vasoactiveamines.” (P.2). Persistence of care that results directly from theculture of intensive care that only aims to prolong life: “We end upprolonging life in some situations…” (P.4); “Weintensivists are a little accused of taking our attitude ofinterventionists." (P.4); "…Use of some abused drugs toprolong this state of life…we nurses know, we clinicians know that we willnot be able to have the quality of life in that person, we will just prolongit life.” (P.4); “The margin in which we have to interveneis very short and we only prolong this life a little…” (P.4).People with surgical situations of high irreversibility associated with severecomorbidities: “They are essentially surgical situations, often linkedto comorbidities and that we quickly realize that they are situations thatare not controllable.” (P.3); “Surgical situations of greatcomplexity and gravity, which we quickly realize are irreversible.”(P.3). Contexts in which, according to scientific evidence, results areunattainable and do not justify the implementation of interventions:“Situations … with everything that has no positive purpose for thepatient we are caring for.” (P.5).In this category, four subcategories were identified in which nurses who areexperts in adult intensive care recognize the existence of therapeutic futilityin nursing in adult intensive care units. Situations in which the implementationof interventions is maintained despite evidence of biophysiological indicatorsincompatible with life: “There was almost general consensus in the category in which the participantsidentified the futile nursing interventions that they most frequently perceive,from which four subcategories stand out: participation in some interdependentnursing interventions, that are prescribed by other health professionals and inwhich the nurse assumes responsibility for their implementation, with particularemphasis on the placement of invasive clinical devices; autonomous nursinginterventions, in which the nurse assumes responsibility for its prescriptionand implementation; interventions implemented exclusively by norms andprotocols, routines or scores; the provision of care in complementary diagnosticexams that aim exclusively at a diagnosis and that do not offer any contributionto the improvement of the prognosis/outcome.The most penetrating ones and the ones that leave a lot ofreservations are not the independent interventions, they are theinterdependent ones.” (P.3); “The placement or change ofcatheters, central catheters, arterial lines, and that sometimes we thinkwhat is this, what is this for? Because putting a catheter in is highlyfutile in a patient, we know is going to die.” (P.1). With regardto autonomous nursing interventions, despite some initial controversy among someparticipants of the focus group, regarding some specific nursing care with adirect relationship with basic needs, some testimonies emerged that gatheredconsensus: “Some independent interventions /autonomous, in certaincontexts, can be futile: positioning a person who is already in the processof end-of-life, unconscious, without any evidence in terms of monitoringthat shows suffering, is futile for me.” (P.5); “Placingnasogastric tubes, if it is exclusive to prolong life, is futile. Hydratinga person to prolong life when the outcome is pointless is futile.”(P.5).Regarding interdependent nursing interventions, some of the nurses’ statementsincluded: “Interventions that are extremely futile are changes daily, interminally ill patients, of catheters, probes… This makes no sense,including the monitoring of vital signs.” (P.1); “…routinepositioning." (P.1); “Defensive nursing…it is prescribed,and the nurse has to do it!” (P.2); “…decubitus changebecause it is time to do it, regardless of the inexistence ofbenefit." (P.2); “Interventions because there is a score tomeet… And scores can be used and manipulated…” (P.3).In the subcategory of interventions implemented by preestablished routines, bynorms or protocols, by scores, there were several statements in which it waspossible to identify different situations that fall into this subcategory, suchas: “What bothers me most are the excessive diagnosticaids that we provide to patients when they don't need them foranything.” (P.4); “…which are of no use, for absolutelynothing, because they do not alter the decision-making process in anyway.” (P.4); “we use the nurses’ work a lot when carryingout additional diagnostic exams that I think are not an asset for decisionmaking and benefit…” (P.4); “More and more people in theirintensive care unit use and abuse complementary exams that are exclusivelydiagnostic, increasingly differentiated, and the futility of thesediagnostic means of diagnosis is something that afflicts me.”(P.3).The last subcategory identified in this topic proved to be the one with the mostregistration units, with a broad consensus among all nurses who considered thatnursing interventions associated with complementary diagnostic exams that aimexclusively at a diagnosis, when the inevitability of death is confirmed, arefutile interventions: “Our conversation, isn't it, our shift changes, our dailyreflections.” (P.4); “for the sharing of opinions among thegroup." (P.4); “our experience that sometimes gives us, orrather, the experience is something that we bring from the fact that we havebeen working in the units for many years and we identify similar situations,and we see and know that the future of that person will be very identical tocountless cases that have already passed us.” (P.1).From the participants’ narratives, it is possible to identify two subcategoriesthat refer to the recognition of therapeutic futility in nursing, namely,recognition by the nursing team and recognition by family members. Sometestimonies of the participants include, regarding the recognition by thenurses: “The family itselfsays: look, isn't it time to stop? Sometimes it is at this point that theteam clicks that we are actually making too many approaches.”(P.1); “Sometimes it is the family itself that tells us: I do not wantit anymore, it's not worth it.” (P.1); “The family itselfsays: I don't want it anymore, don't make my father or mother sufferanymore.” (P.1); “It is the family member who says: look,maybe it's been too much, is not it, and I do not want to cause pain, Idon't want to cause my father suffering.” (P.2); “They seethat the time that passes, the person in the unit, and that there is noimprovement in them and the fact that we are improving treatment anddiagnosis techniques makes the family itself aware.” (P.2);“Don't you think it is good to stop because my father is suffering?And I am even a little astonished and wondering if that person is okay, butmaybe he's correct.” (P.1). This assessment of family members isattributed, by some participants, to the increase in health literacy, to which,according to nurses, the enormous ease of obtaining information contributesgreatly.With regard to the family's recognition of futility, it was a considerationpresented by the participants that deserved significant emphasis, with severalrecording units identified in testimonies such as: “Initially, some difficulty was recognized on the part of the participants inidentifying elements to characterize the extent and scope of therapeuticfutility in nursing, including some reservations when nurses were asked topresent suggestions for terms/associated terminology to this conception. Fromthe responses presented by the participants, four subcategories are recognized,particularly, ridicule of care, transposition of the limits of intervention andcare, lack of benefit, and therapeutic incarceration.When we talk about futility, I talk about ridicule, ridiculousthings." (P.4); “It is something that isridiculous." (P.4); “…it's ridiculous that we're doingsomething like that because it's unthinkable…” (P.4); “Lookhow ridiculous the situation is!” (P.4). Regarding the transposition of thelimits of intervention and care, the second subcategory identified theexpression “to exceed the limit.” . Concerning thethird subcategory, which refers to the lack of benefit, several registrationunits were identified, with emphasis on the following statement: “It iseverything that goes beyond the benefit for the patient.” (P.2).Finally, on the last subcategory, which was called therapeutic incarceration,there were several statements made by nurses who are experts in adult intensivecare, which include: “For me, futility is incarceration.”(P.3); “… futility is therapeutic incarceration, it is a hopelessinvestment.” (P.3); “continue to make a series ofinterventions to the patient, knowing that the end is in sight.”(P.3); “…systematic surgeries… vasopressors in doses incompatible withlife… continuous dialysis techniques knowing that the end is in sight, allthis, and more, are therapeutic incarceration.” (P.2).In the first subcategory that was identified, ridicule of care, statements suchas: “Foreseeingthat this could happen and thinking it was futile and that I would never doit, but when the time came I did it all because it was my mother.”(P.3). On the contrary, in a situation that also involved a family member,another participant revealed a remarkable ability, in a situation of declarednursing therapeutic futility, not to persist in the implementation ofinterventions, declaring: “I knew it was futile, that it was not overthere… I do not, I didn't make my brother's comfort worse, and I know it.However, above all, I gave comfort to the family.” (P.2).On this issue of the scope of therapeutic futility in nursing, it is important tonote that one of the participants mentioned the difficulty in identifying thelimit of their performance in a personal situation, saying: “The realization of this study made it possible to identify some of the perceptionsthat underlie and/or dominate the daily action that nurses in adult intensive careunits have about therapeutic futility in nursing. The narratives of theparticipants, all experts in adult intensive care, with a minimum time ofprofessional experience in these contexts of care practice of fifteen years, allowedthe identification of four situations in which it is possible to recognizetherapeutic futility in nursing, namely: situations in which the implementation ofinterventions is maintained despite the evidence of biophysiological indicatorsincompatible with life; persistence of care that results directly from the cultureof intensive care that only aims at prolonging life; people with highly irreversiblesurgical situations associated with severe comorbidities; contexts in which, in thelight of science and scientific evidence, results are unattainable and do notjustify the implementation of interventions. Nurses confirmed, with consensus, thatthese are the four situations in which they have already recognized situations oftherapeutic futility in nursing in the context of an adult intensive care unit.In the category of futile nursing interventions, it was possible to recognize theexistence of four subcategories, interdependent nursing interventions, autonomousnursing interventions, interventions implemented exclusively by norms or protocols,routines or scores, interventions associated with exclusively diagnosticcomplementary exams. It was with some surprise that one of the subcategories thatthe experts identified in this category was recognized, specifically, thesubcategory of autonomous nursing interventions. It was anticipated thatinterdependent nursing interventions would be identified almost exclusively, thatis, interventions that are prescribed by other professionals, namely, by thedoctors, but that are implemented by the nurse, who assumes responsibility only forits implementation, highlighting the participation of invasive techniques, in theadministration of therapy, among others. Notwithstanding the fact that theidentification of autonomous nursing interventions was unexpected, the participantsjustified their acknowledgment stating that they are futile autonomous nursinginterventions that are implemented when death is irreversible, presenting as examplethe placement of some clinical devices, such as nasogastric tubes exclusively tofeed/hydrate the person, or the replacement of some devices such as peripheralcatheters. This point generated a heated controversy, with three nurses vehementlyspeaking out against the argument presented regarding the therapeutic futility offood/hydration, regardless of the circumstances. Although some clinical objectiveswere not consensual among the participants, it was clear that in some circumstancesthere are autonomous nursing interventions that can be futile, such as therespective placement/replacement of clinical devices. Participants also mentionedthat nursing interventions associated with complementary exams are exclusivelydiagnostic, that is, they do not contribute to decision making, and interventionsand care provided exclusively by virtue of norms or protocols, routines, or scores,can be futile, reinforcing the importance of a personalized, regular, and systematicassessment.The recognition of therapeutic futility in nursing, and inevitably of futile nursinginterventions, was an aspect that gathered consensus among all participants, whoidentified that situations of therapeutic futility in nursing arerecognized/identified in these contexts, with relative ease by the nursing team,mostly by more experienced nurses, and by family members. Nurses recognize thetherapeutic futility of their interventions in the situations mentioned above andwhen there is a prolonged stay of the person in the intensive care unit withoutimprovement or recovery. It should be noted that one of the participants made apoint of mentioning that he cannot associate the identification of pain with therecognition of therapeutic futility because, according to this nurse, currently theteams are highly trained to detect pain and can anticipate potential discomfortsituations with relative ease, so these are very infrequent situations. Regardingthe family, nurses report that this recognition is, above all, associated with thelength of stay and the lack of results. According to them, most family members areperspicacious in identifying these situations and there is an increase in literacythat facilitates the recognition of these situations of futility.In what concerns to the scope of therapeutic futility in nursing, the nurses’difficulty in characterizing the dimension and extension of this conception wassignificant, with the participants showing some reservations, especially in thepresentation of proposals for terms/terminology for this dimension. Thesedifficulties seemed to be associated, above all, with the complexity of the topicunder study, and not exactly with the inexperience of the participants, whoconfessed to having experienced numerous situations that they manage to associatewith therapeutic futility in nursing.The analysis of the few national studies carried out with nurses on therapeuticfutility made it possible to identify some results that are in line with thefindings of this study. These studies, carried out in intensive care and palliativecare, which analyze this phenomenon in end-of-life situations, conclude thattherapeutic futility is a recurrent event that includes the implementation ofexcessive interventions that are not associated with benefits, which should beavoided at all costs, for the implications it may have in prolonging suffering anddiminishing human dignity (Aiming to reduce the occurrence of therapeutic futility, the authors emphasize, as inmost of the available studies, the relevance of carrying out more studies on thisphenomenon and the importance of education and training of health professionals onthis phenomenon (The limitations identified for this study are all related to the data collectionmethod, especially with the option of carrying out remotely. Holding an online focusgroup runs the risk of harming communication, because of the risk of inhibitingparticipants to participate. Additionally, given the possible stay in a familiarplace during the focus group, such as the participants’ own home, where theenvironment and external stimuli cannot always be controlled, the possibility ofsome distraction cannot be excluded. Nevertheless, the authors consider that theadvantages and benefits of conducting the focus group at a distance outweigh thedisadvantages, with particular emphasis on the possibility of including participantsfrom dispersed geographical areas.This study contributes to the scientific knowledge of nurses in intensive care unitsabout therapeutic futility in nursing and helps these professionals to reflect inadvance and systematically about its occurrence in these environments. Thedevelopment of nurses’ skills in this area is valuable contribution to preventingthe occurrence of this phenomenon and all the negative consequences associated withit.Therapeutic futility in nursing is a reality perceived by nurses in adult intensivecare units and four declared situations are associated with this phenomenon, namely,biophysiological indicators incompatible with life, intensive care culture of lifeextension, surgical situations of high irreversibility, uncontrollable, associatedwith severe comorbidities, contexts in which, according to scientific evidence, theresults are unattainable and do not justify the implementation of interventions.These situations, which may include futile nursing interventions that fall into fourcategories, specifically, interdependent interventions, autonomous interventions,complementary diagnostic tests, and care implemented due to scores, can be perceivednot only by the nursing team, but also by the family. Four subcategories for thescope of therapeutic nursing interventions are identified, which include ridicule ofcare, transposing the limits of intervention and care, no benefit, and therapeuticincarceration.


The study’s 3 × 3  ×  design revealed disordinal interactions for being away, fascination, preference, mental fatigue, and stimulating and activating effects associated with cities. This implies that humans’ place perceptions are more complex than previously assumed. Both city and nature relatedness were relevant covariates of these findings. Surprisingly, the construct ‘activating effects’, was found to be mostly perceived as more positive for mixed and built environments compared to natural environments. Thus, complementing restorative environments research by introducing a measure for city relatedness significantly enhances understanding of the potential of urban public spaces for promoting human health and well-being.The present study aims to investigate whether a sense of relatedness to a city helps to broaden understanding of the restorative potential of urban public spaces. Findings based on a sample of German adults ( It is expected that in 2050 more than 68 percent of the world’s population will live in cities . AccordiPerceived restorativeness can be understood as the perceived degree to which depleted cognitive resources needed for directed attention over the course of a day become renewed or replenished. Whether (and to what degree) restoration is initiated was found to be strongly associated with features of the environment, e.g., . AccordiIn addition to well-designed urban environments , other sChoosing and describing places that either exhibit or do not exhibit livability is useful as it allows elements of a place to be categorized and practical implications to be derived . HoweverThe extent to which an environment is perceived as restorative depends not only on physical features of the environment, but also on individual differences such as connections to nature ,33, as tAs humanity already has years of experience living in (or with) cities, it is reasonable to assume that humans have also developed a connectedness to the city. Cities provide certain amenities, such as opportunities for social interaction and cultural engagement, and health care facilities. Therefore, drawing upon theory and research on connectedness to nature, we developed a measure to assess city relatedness see . In lineSD = 11.62, range = 18–76 years) participated in the online study. This sample size is close to Schönbrodt and Perugini’s [A total of 249 adults  with a mean age of 26.83 years  over city trips  = −3.53, 2-tailed, p < 0.05, d = 0.30; 1 − ß > 0.80). They then filled out the Nature Relatedness Scale NRS [Participants were first asked to answer questions regarding their socio-demographics and whether they enjoy nature trips . To To assess further characteristics of natural and urban places besides perceived restorativeness, preference, and mental fatigue, we referred back to the six dimensions of place memories: activities within the place, cognitive and emotional responses, social context, environment, time, and self (note that we excluded the ‘activities within the place’ dimension because of its descriptive character ); and toWe thought activities within the place and functional possibilities share a common underlying idea and therefore formulated the corresponding item as follows: ‘This place provides a broad scope for action’. Likewise, social aspects are assumed to play a role in both theories (as well as others mentioned above). We thus formulated the corresponding item as follows: ‘This place encourages social life’. As both of these items share a common idea of what a place can offer, we added two further items in this direction, ‘This place provides amenities’ and ‘At this place, you are at the cutting edge’, followed by the time aspect and the two CRS items ‘Even in the middle of nature, I think about the amenities in the city’ and ‘My ideal vacation spot would be a vibrant metropolis’. In line with this vibrancy aspect, as well as the emotional response of vitality to a known place, we added the following item: ‘This place has something invigorating’. Moreover, we formulated one item for each motivational reason for interior design, as well as the self, cognitive, and emotional response dimensions as follows: ‘In this place, I recognize myself’ (identity claim to self), ‘I would meet my friends at this place, so that they can learn more about me’, (identity claim to others), ‘This place regulates my emotions in a positive sense’ (emotion regulation), and ‘This place regulates my thoughts in a positive sense’ (thought regulation). As the aesthetic aspect of a place is part of the environment dimension and a happiness factor, we formulated a corresponding item as follows: ‘This place creates a pleasant atmosphere’. With regard to the appearance aspect, the corresponding item was: ‘This place has a stimulating appearance’. Besides appearance, the characteristics of a place also play an important role. We therefore added the item: ‘This place has stimulating characteristics’. Finally, addressing the recreational aspect, we formulated the item: ‘This place invites relaxation’ , root mean squared error of approximation (RMSEA), and standardized root mean squared residual (SRMR) were considered. Hu and Bentler’s recommendation that a good model fit is reflected by a CFI close to 0.95, a SRMR smaller than 0.08 and a RMSEA smaller than 0.06 should be seen as desirable values rather than strict cut-off criteria [Statistical analyses were performed using R  and R Stcriteria . To detecriteria . To evalcriteria . Tukey mr = 0.39), the model fits were acceptable. The correlation between nature-related self and nature-related experience amounted to r = 0.87. Because of the small difference in effect, we decided to consider nature relatedness in the subsequent analyses. Acceptable model fits were also observed for city-related self and city-related experience. The correlation between these facets amounted to r = 0.85. The correlations between nature and city were close to zero on both the domain and facet level. Moderate differences were observed between nature and city relatedness and self, with higher means and thus manifestation for nature. No difference was observed when comparing nature and city experience , we always depicted the smaller value. The p-value only differed for mental fatigue in the detailed condition, but in both cases the finding was not significant) consistently revealed small to moderate significant main effects for the types condition , small significant main effects for the detailed condition , and small significant effects for the interaction terms for all of the considered scales except for mental fatigue, where the detailed condition was not significant . We therefore decided to report the ANCOVA values, as at least one of the covariates was significant for each construct considered. ɳcant see .Nature relatedness was a significant covariate for fascination, activating effects, and mental fatigue, but always to a very small extent. City relatedness was a significant covariate for all of the scales considered; all effect sizes were comparable to those for nature relatedness with the exception of preference, where the effect size was small. Thus, higher scores for city relatedness are associated with higher scores for preference. Interaction effects for nature and city relatedness were generally also very small, yet mostly significant. Only for activating effects in the types condition were the effect sizes small and significant.Post-hoc comparisons for the types condition were significant for all scales considered . While the means for being away, fascination, stimulating effect, preference, and mental fatigue were higher  in the nature condition, followed by the mixed and built conditions, it was exactly the opposite for activating effects. Moreover, activating effects were positively associated with both restorative facets. The same applies for stimulating effects and preference, while mental fatigue seems to be unrelated to these variables see .The post-hoc comparisons for the detailed condition revealed significant differences between the average and livability conditions and between the average and bird’s-eye perspective conditions for all scales considered except for mental fatigue, where none of the post-hoc tests were significant. The comparison between the livability and bird’s-eye view conditions was only significant for fascination. As can be seen in The present study provides several new insights into people’s relationship to natural, mixed, and built environments. First, it could be shown that people can experience relatedness not only to nature , but alsThe present study also has some limitations that must be considered. Although participants lived in a different city than the city where the photographs were taken, one hundred of them indicated being familiar with at least one place used in the study. However, in the open answer format for the mental fatigue item, some participants wrote the name of the place or the area where they thought the picture had been taken. None of the participants were right, as they all thought the pictures had been taken in Hamburg. Nevertheless, those participants stated that they recognized the place. Hence, future research should employ an open response format for each place, in order to verify whether participants are actually familiar with the place and to control for socially desirable responses, as some participants might have had the impression that they should recognize the place. Moreover, participants should be asked whether they have ever been to this place and if so, whether they have place memories, in order to appropriately control for such place memories . The parThese limitations notwithstanding, the present findings have implications for theory and practice. Our initial findings confirm the city relatedness construct and call for future research to determine the factors that affect it. Moreover, as city relatedness was shown to be associated with how we perceive an environment, an increase in city relatedness probably also leads to increased positive perceptions of urban environments. Finally, these findings imply a change in approach to urban happiness, as the location-specific focus would shift to a more interactionist perspective. An examination of further individual differences would shed light onto different perceptions of a place ,62 and m


Furthermore, Moderation analysis suggests that the preschoolers’ age, gender, and instruments affected the association between the executive functions and mathematical competence. The implications of these findings for theory and practice deserve further discussion.Numerous studies have been conducted on the correlation between preschool children’s executive functions and mathematical competence, the findings of those studies are inconsistent. This study used meta-analysis to investigate the correlation between executive functions and mathematical competence of preschool children in China, and then explored the moderating effects of age, gender, and instruments. The researchers conducted an extensive search of CNKI, Web of Science, Google Scholar and used screening criteria to identify 22 studies of Chinese preschoolers aged 3–7 years from 2007 to 2021. The findings indicated that there was a positive correlation between Chinese preschool children’s executive functions and mathematical competence ( Mathematical competence is a very important basic ability in modern society, and it is also a vital component of academic competency and development foundation, particularly in preschool and school-age children . For manExecutive functions are also considered a critical advanced cognitive activity that influences individual development . In otheIn China, influenced by traditional values which focus on the cultivation of children’s competitiveness at an early age, parents tend to place a high value on the development of children’s mathematical competence in the preschool stage . Some paFor this purpose, we employed a meta-analytic approach to synthesize the extant literature examining the interrelations between executive functions and preschool children’s mathematical competence in China. We also examined whether the associations between executive functions and preschool children’s mathematical competence varied as a result of some study moderators. Specifically, we addressed two research questions: (1) What is the overall strength of the relationship between executive functions and preschool math competence when the study conceptualizes executive functions as a multidimensional structure? (2) Does the direction and strength of the association between executive functions and preschool math competence differ on account of the child’s gender, grade level, age, or the measurement method of executive functions?According to In recent years, there have been some differences in the division of the core elements of executive functions. While The Guidelines on Learning and Development for Children Aged 3–6 (2012) issued by the Ministry of Education of the People’s Republic of China set two clear goals for mathematical cognitive development from an educational perspective: to preliminarily perceive the usefulness and fun of mathematics in life and to perceive and understand quantities and relations between and among quantities.On the one hand, the National Council of Teachers of Mathematics (NCTM) divided children’s mathematical competence into the ability to master mathematical learning content and the ability shown in the process of mathematical learning in an American Context . SpecifiIn terms of mathematical competence, Some researchers have pointed out that executive functions and mathematical competence may share a common physiological basis, which involves the prefrontal lobe, orbitofrontal lobe, medial thalamic system of the brain, etc. . HoweverThere are differences in children’s mathematical cognition of different genders. Studies have shown that gender differences in children’s mathematical development begin to appear at the ages of 5–6 . CompareWith the growth of children’s age, especially when children enter kindergarten, due to the stimulation and reinforcement of the external environment such as the interaction with their teachers and peers, children’s ability in inhibition control has been continuously strengthened . In addiFinally, some studies have implied that instruments may influence the association between executive functions and mathematical competence , since tAs shown above, the association between executive functions and mathematical competence remains unclear in Chinese preschool children. What is the real relationship between executive functions and mathematical competence? How do subcomponents of executive functions impact early childhood math abilities? These fundamental problems have not been well resolved. However, as the research shows, the relationship between the two is complex . One is Articles that met the following criteria were included: (a) The research subjects were Chinese preschool children, aged 3–7 years; (b) The study was required to report the difference between executive functions  and mathematics; (c) The research does not include special groups of children, such as children with learning disabilities; (d) The research needs to report basic information such as the gender, age, and instruments of the subjects; and (e) The research also includes master’s and doctoral dissertations.Firstly, through the retrieval of CNKI, Wanfang Data, VIP, Google Scholar, Web of Science, ProQuest, Scopus, etc., with “Executive Functions” “Inhibition control” “Working Memory” “Cognitive Flexibility” and “Mathematics” “Chinese” as keywords, 1,452 search results were initially obtained, and the retrieval time was from December 1, 2021, to February 1, 2022. Secondly, after the titles and abstracts of these literatures were studied, those that did not meet the inclusion criteria were excluded, and the abstracts and full texts of the literatures with potential research value were read. In the end, a total of 22 studies in line with the established research purpose were obtained, involving 2,730 subjects, with a total of 65 effect sizes, and the time span was 2007–2021. The specific screening process is as follows:Each study was coded according to the following characteristics: authors’ information, year of publication, source of subjects, sample size, number of boys and number of girls, their ages, instruments, and correlation coefficients between executive functions and mathematical competence see . For them−1)r¯xx  the corrr value, that is, Z = 0.5× Log((1 + r)/(1-r)), SE = 1/√((n-3)). As suggested by In this study, the correlation coefficient between variables was used as an indicator of the effect size. To exclude the influence of the sample size on the effect size results, the study performed Fisher’s Z transformation on the r between variables was used as the effective value for correlation calculation, and the meta-analysis software Comprehensive Meta-Analysis Version 3.3 was used for data processing and analysis. In addition, the study calculated weights and 95% confidence intervals based on the sample size.Some studies reported the correlation coefficient between a sub-dimension of executive functions and mathematical competence, some studies reported the correlation coefficient between three sub-dimensions  and mathematics, and some studies’ correlation coefficients between preschool children’s executive functions overall and mathematical competence were reported. In this study, all the above correlation coefficients were included in the statistics, the Pearson correlation coefficient p - value of Egger’s test is less than 0.05, there is publication bias , indicating that the effect values selected in the study were all heterogeneous, so a random effect model was used for further analyses.Due to differences in research methods, objects, tools, evaluation criteria, etc., there may be heterogeneity in research. Therefore, a test for heterogeneity is required to determine the appropriate effect model for the study. The heterogeneity test generally uses the Iogeneity . When I2We identified 65 effect sizes from 23 independent studies involving a total of 2,370 children from China, of whom 55.6% are female. The main effect results of the meta-analysis are shown in female > Rmale, and at the same time, the difference between groups is significant . In terms of inhibition control, the effect size of between executive functions and mathematical competence of female preschool children is greater than that of male preschoolers Rfemale = 0.391  > Rmale = 0.338 . There is a significant difference between groups ; in terms of working memory, the effect size between male preschool children’s executive functions and mathematical competence is greater than that of female preschoolers Rmale = 0.462  > R female = 0.385 . The difference between groups is significant ; in terms of cognitive flexibility, the effect size of the association between executive functions and mathematical is greater in male than female Rmale = 0.369  > Rfemale = 0.335 . The difference between groups is significant . In conclusion, the results of the heterogeneity test between groups showed significant differences between each group, and therefore, gender played a moderating role in the association between executive functions and mathematical competence in preschool children.There are some differences in the association between executive functions and mathematical competence in preschool children of different genders. As shown in p < 0.001, and I2 = 77.279). Second, in terms of inhibition control, the effect sizes between executive functions and mathematical competence differed across age groups. For example, the effect size was 0.370  between 3 and 4 year olds, 0.424  for 4–5 year olds, and 0.279  for 5–6 year olds, and the difference between them was significant . Similarly, there were significant differences in the association between executive functions and mathematical competence in children of different ages in terms of inhibitory control  and cognitive flexibility . In conclusion, the link between executive functions and mathematical competence in preschoolers is moderated by age differences.The age of the subjects is further divided into three groups: 3–4 years old, 4–5 years old, and 5–6 years old, and their moderating effects on the association between executive functions and mathematical competence of preschool children were discussed, respectively. The analysis results are shown in p < 0.001, and I2 = 89.319). In terms of working memory, the Fixed Box Task had a significant effect on the executive functions and mathematical competence of preschool children. The effect size between the two groups is 0.413 ; the effect size of the Digit-Span Task between preschool children’s executive functions and mathematical competence is 0.298 ; the effect size of Digit Backwards Task between executive functions and mathematical competence of preschool children is 0.524 ; and the difference between groups was significant ; In terms of cognitive flexibility, the effect size of FIST Task between executive functions and mathematical competence of preschool children is 0.392 ; the effect size of WCST Task between executive functions and mathematical competence of preschool children is 0.329 ; and the difference between groups is significant . According to the heterogeneity test results between each group, the differences among the groups are all significant, which indicated that the instruments had a moderating effect between the executive functions and mathematical competence of preschool children.The measurement of executive functions is mainly to measure the sub-components of executive functions, and the instruments selected in different studies vary. So, after statistics processing, several typical instruments were selected in each aspect of executive functions to explore the moderating effect of different instruments on the executive functions and mathematical competence of preschool children. The analysis results are shown in The findings of this meta-analysis led us to conclusions regarding relations between executive functions and mathematical competence in Chinese cultural background. The overall research results indicated that executive functions and sub-dimensions of EFs  were positively associated with mathematical competence. The correlation coefficients for these findings were both medium. Furthermore, preschoolers’ age, gender, and instruments moderated these relations.The meta-analysis results indicated that there was a moderately positive correlation between executive functions and mathematical competence in preschool children in the Chinese context, which is consistent with previous studies . HoweverPreschool children’s gender plays a role in determining the level of correlation between executive functions and mathematical competence varied which is consistent with some previous research results . Here arAnother factor—children’s age would also impact how correlated they are between executive functions and mathematical competence. The main reason is that the development of executive functions is staged, and the influence of executive functions of preschool children of different ages on children’s mathematical competence is different. Specifically, inhibition control is the ability to consciously suppress dominant responses in the first place, and this ability increases with age. Studies have shown that inhibition control reaches a stage of rapid development when children are 4 years old . Second,According to the results of the meta-analysis, there are significant differences in the association between executive functions and mathematical competence of preschool children under different instruments. The main reason is that the content of the test tasks is quite different. For instance, the Stroop Task, which tests children’s inhibition control ability, let children quickly say “night” when they see a picture of the “sun” and say “day” when they see a picture of the “moon.” Also, a blue-red task that examines inhibition control has children say “blue” when they see red, and “red” when they see blue. Although there is not much difference between the two instruments, they are quite different in content. Children’s cognition of the objective objects “sun” and “moon” is different from the cognition of “red” and “blue” colors, and there are also great differences in essence. Therefore, there are significant differences in the results measured by different instruments.There are several limitations to this study. Firstly, the effect mechanism of preschool children’s executive functions on mathematical competence needs further clarification. At present, it is uncertain how executive functions affect mathematical competence, and the issue in terms of how the subcomponents of executive functions are related also needs further studies. As some studies have shown, there may be other factors  at play between executive functions and mathematical competence. Therefore, issues such as how executive functions (including each sub-component) affect children’s mathematical competence, what is the association between the sub-components, and whether there is some interaction mechanism need further research. Secondly, the demonstration of the causal relationship between the two in the existing research is insufficient. Future study should deepen the discussion on this aspect to further prove the existence of the causal association between the two through experimental research and longitudinal research. Finally, our sample only considered preschool children between 3 and 7 under the Chinese cultural background, and thus did not include older children. Future research should expand the sample group to verify the validity of research conclusions from a broader sample group.This study used meta-analysis research methods to explore the real association between executive functions and mathematical competence in preschool children in the Chinese context. The research results showed that there was a moderately positive correlation between the executive functions and mathematical competence of Chinese preschool children. Among them, the association between working memory and mathematical competence was the strongest. In addition, the association was also moderated by gender, age, and instruments. Our findings have clarified the debate on existing research viewpoints, illustrated the real association between preschool children’s executive functions (including each sub-component) and mathematical competence, and provided a research basis and reference for subsequent scientific research.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.ZZ: conceptualization, methodology, writing—original draft, and review and editing. YX: conceptualization, formal analysis, and writing—review and editing. RJ, MZ, and HZ: writing—review and editing. CY: writing—review and editing, and supervision. All authors contributed to the article and approved the submitted version.This work was supported by the National Ethnic Affairs Commission of the People’s Republic of China “Research on Early Childhood Education and Development in Minority Areas (2021-GMI-010) Ethnic Research Project.”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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: The nursing perspectives on suicidal behaviors may influence the quality of assistance and suicidal prevention. This phenomenon is scarcely investigated among nursing students. Aims: The aim of this study is to understand the meanings of suicidal behavior for Portuguese undergraduate students. Methods: This qualitative study utilized Grounded Theory and Symbolic Interactionism. We collected data in Portugal in 2017–2018 with 13 undergraduate students. Results: Students compared suicidal behavior to “A complex and close haze” and considered it “A neglected phenomenon”. Suicidal behavior was predominantly perceived as an emotional distress that requires assistance. The students compared the person and society as “The car and the road: behavior influenced by communication and interaction” and valorized social dimensions and repercussions of suicidal behavior. Limitations: Lack of triangulation in the data and the sampling restricted to nursing students of a single institution are considered limitations of this study. Conclusions: This study can contribute to the development of academic education strategies and psychosocial support for nursing students. Suicide is a global concern that must be given priority in the public health and policy agenda. It is estimated that over 700 thousand people die by suicide every year c In Portugal, in 2019, the suicide mortality rate was 11.5 per 100,000 inhabitants, a higher rate than other types of violent deaths. These numbers are probably underestimated, as suicide is underreported in Portugal for several reasons, and the country is one of the countries with the highest number of violent deaths from undetermined causes in the European Union  it’s a mixture of things, it’s not just one thing.” “Suicidal behavior can have many reasons, they are variables […] I can’t give you a specific definition, they are actions intended to hurt themselves.” “I never thought about it, but in my view, suicide is always different because of the people, because each person is different.” Suicidal behavior was also considered common in society, something that can occur at any stage in life, associated with regular, everyday pressures and hardships, and present in the social circle of many respondents.“I had a schizophrenic uncle, and last year he committed suicide. And two years ago, an aunt with the same problem committed suicide and my grandmother attempted suicide […] suicide is a major part of my life.” “I think it’s rare to meet people who don’t know someone who attempted [suicide].” Suicidal behavior was considered essentially interactional and communicative. It was not seen by the students as an isolated or individual event. Social dimensions were strongly present in representations of the risk factors, protective factors, and effects or consequences of suicide. A metaphor of a car  and a road  was used to describe the social dimensions of well-being or suicidal behavior.“It’s like I [person with suicidal behavior] was a car and the people who support me were the road. I am the one who is in movement, but if the road goes away, I fall.” “We do not live alone in the world; we have the people around us, who affect us in several ways, including this one.” The statements revealed the belief that suicidal behavior and communication or interaction could exert a mutual and heavily influence in terms of prevention and support , neglect  or pro-suicidal effects .“They [closer people] will know better how the person [vulnerable to suicide] is and what they need […] they can help this person better.” “Sometimes we are only looking at ourselves and we forget about the others, we are not there for them, we stop thinking and knowing what we should do [to help people who are suffering].” “In fact, the media can influence people. The media influences everything and everyone. […] people can read and get this idea for themselves.” The students believed that the person who suffers from suicidal thinking and behaviors, intentionally or not, could be sending messages, “a cry for help” and “a cry for attention”, or trying to provoke feelings or influence others.“One person can make a cry for attention just to get support or as a cry for help”. “It’s selfish, with the intent to hurt others. […] they are attention-seeking behaviors.” “When she is thinking about suicide, she is thinking: ’m going to relieve the burden, the weight that I mean for other people. If people get rid of me, they will be happier. I won’t be missed here.” The consequences of suicidal behavior were also deeply linked to social dimensions that include the feelings, reactions, judgments, and impact on the history of lives. Death by suicide can have a profound effect on the people who are close to the deceased. Respondents who knew someone close who died by suicide claimed suicide leaves “permanent marks” and “affects mainly the people who remain”. “When there is a suicide, people usually analyze the social context involving the person.” “I feel that suicide doesn´t happen to the person who dies, it happens to the other people (…) he or she stops feeling anything, while great suffering begins for the bereaved people.” Suicidal behavior was considered a difficult phenomenon to identify and prevent effectively in the present moment. According to the participants, these difficulties were related to the characteristics of the psychological states of suicidality, and to society’s responses to this phenomenon. Thus, prevailed in society, reactive actions regarding the suicidal behavior  than proactive actions .“When it happens, the person is not expecting it. […] They only realize they could have done something after it already occurred.” The difficulties with identifying a suicide state and, therefore, being unable to prevent it were the covert, non-specific, or not evident symptoms, the recurrence of crises with unforeseeable consequences, lack of hope and assistance to seek help, and the possibility of an abrupt suicide attempt.“Suicide is a process that begins with negative thoughts, and it can go unnoticed by people who are not very close or attentive […] and it may be recurrent […] and when we’re at that stage we don´t want anyone’s help.” “ […] It is difficult to distinguish things and we cannot always see clearly if a person is suffering. Some think there are fewer better days, because fewer good days exist and we neglect them, but sometimes I think it is very hard to see.” The limited proactivity of society in preventing suicide could also be related to ignorance, lack of preparation and difficulties approaching the subject, stigma, discrimination, and condemnatory attitudes towards suicidal behavior. Participants also mentioned the generalization and trivializing of other people’s suffering, the conventional and impersonal way of supporting them, a limited bond with the person at risk, and personal attitudes or beliefs. “Just yesterday I had a meeting with a lecturer and with my colleagues. There was this colleague of mine, and we started talking about it [suicide], but he didn’t feel comfortable so we chose to remain silent because no one knew what to say.” “I think that the prevailing concept, in general, is, for example: “He´s just sad”, “You have to be strong to get through this”. I think it’s something along those lines. […] they don’t pay attention, they neglect it, because they know other people have been there and overcame the situation.” According to the respondents, suicidal behavior was an attenuated or deconstructing taboo in society. However, participants say that the demystification process is still superficial, insufficient to promote changes, and the discussion about suicide is yet restricted to certain groups. The social responses to suicidal behavior were associated with geographic locations , level of education, access to knowledge about mental health, social isolation, and personality factors .“I think it’s not discussed very much. […] but my generation, I think they have a new approach. It is becoming more and more common and easier to talk about.” “The end of life is a sensitive topic, and in Portugal they [health professionals] still try to keep the person alive, regardless of the circumstances.” “There’s the social stigma. What they say in the villages and out there is that the person who commits suicide is weak […] my mother is from a village and she would say psychologists are for crazy people […]. In the village, people are less literate, they rarely go to the city and their only means of communication are the TV and the radio, they are very isolated inside themselves.” The current study aimed to investigate the meaning of suicidal behavior from the perspective of Portuguese nursing students. Suicidal behavior was considered complex and diverse, intriguing, and multifactorial. It was represented as a neglected risk due to its characteristics  and social issues that impair suicide prevention . Suicidal behavior was considered essentially interactional and communicative. Individual, relational and social dimensions were present in risk and protection factors, in prevention, functions, intentionality, and consequences of suicidal behavior. The most accepted theoretical models regarding suicidal behavior have a multifactorial perspective and reinforce the relevance of individual, interactional and communicative dimensions ,5,6.In this study, suicidal behavior was perceived by the participants as a complex, but a common and neglected phenomenon. Previous research suggests that suicide is frequent in Portuguese society although notoriously underreported ,8. The sIn this study, the students had difficulties describing suicidal behavior, stated by themselves, still as something obscure. At the same time, they also know they will be working with this uncommon phenomenon whose understanding is limited. In the literature, suicide is often described as a complex phenomenon with different connotations, hardly comparable to other potentially fatal conditions, and overshadowed by the lack of a clear and publicly stated definition ,19,21.Previous studies revealed that many health professionals, students, and a large proportion of the general population believe that people suffering from suicidal thinking and behavior are responsible and aware of the consequences of their suicidal actions. In addition, suicidal behavior is often associated with stigmatized and negative attitudes, and misunderstanding and is considered a transgression or reprehensible act ,21,23,30In another study with nursing students, suicidal behavior was considered an act that could be communicative when associated with manipulation or a request for help . In the According to nursing students, the quality of social interactions could be related to prevention, neglect, or pro-suicidal effects. They vehemently criticized the predominance of reactive rather than proactive (preventive) attitudes related to suicidal behavior. Nursing care for people with suicidal behavior demands interaction, engagement, and connection with the person, understanding them, and establishing a therapeutic bond. This bond needs to have authenticity, trust, reflexivity, proximity, empathic assessment, and construction of collaborative care capable of favoring openness, building a support network, and better coping with crises ,13.Regarding the reactions to suicide, studies with students and health professionals point out that suicide can provoke reactions of emotional distress, concerns, doubts, fear, frustration, and shock ,17,18,19Studies indicate that suicide risk can be assessed by nursing students based on personal judgments and beliefs ,20. In aThe students believed that the taboo surrounding suicide is in a process of deconstruction, but they also pointed out that the ongoing demystification is slow because people avoid talking about suicide. They also stated that the younger generation was more understanding than the previous ones. According to the Directorate General of Health in Portugal, stigma, and taboos related to suicide are still important problems in Portugal ,8. HowevThe limitations of this study involve a lack of triangulation in the data, the small sample size, and the sampling restricted to nursing students of a single educational institution within a restricted geographic territory. However, investigations that use GT can be adapted and expanded, from the emergence of new data or new sample groups. To our knowledge, this is the first study to address the perceived meanings of suicidal behavior amongst Portuguese nursing students.Suicidal behavior was predominantly represented as emotional distress that requires assistance, and it was considered diverse, intriguing, and multifactorial. It was considered essentially interactional and communicative. Individual, relational, and social dimensions were present in risk and protection factors, in prevention, functions, intentionality, and consequences of suicidal behavior.Suicidal behavior was perceived as a neglected risk due to its characteristics  and social issues that impair suicide prevention . It is relevant to investigate the elements that can harm prevention  among other health professional students. Additionally, it is important to promote deep and open discussion about suicide and investigate the cultural issues and other characteristics  apparently related to stigma and taboos regarding suicide in Portugal.


Traditional Chinese medicine (TCM) includes over ten thousand herbal medicines, some of which were introduced from outside countries and territories. The Silk Road enabled the exchange of merchandise such as teas, silks, carpets, and medicines between the East and West of the Eurasia continent. During this time, the ‘Compendium of Materia Medica’ (CMM) was composed by a traditional medicine practitioner, Shizhen Li  of the Ming Dynasty. This epoch-making masterpiece collected knowledge of traditional medical materials and treatments in China from the 16th century and before in utmost detail, including the origin where a material was obtained. Of 1892 medical materials from the CMM, 46 came from Persia (now Iran). In this study, the basic information of these 46 materials, including the time of introduction, the medicinal value in TCM theory, together with the current status of these medicines in China and Iran, are summarized. It is found that 20 herbs and four stones out of the 46 materials are registered as medicinal materials in the latest China Pharmacopoeia. Now most of these herbs and stones are distributed in China or replacements are available but saffron, ferula, myrrh, and olibanum are still highly dependent on imports. This study may contribute to the further development, exchange, and internationalization of traditional medicine of various backgrounds in the world, given the barriers of transportation and language are largely eased in nowadays. Persia (present Iran) was an important territory along the ancient Silk Road. The Silk Road was first officially proposed by a German geographer Ferdinand von Richthofen in 1877 . The SilThe record of Iran in China can be dated back to before Christ (BC), corresponding to the Arsa Dynasty of the Parthian Empire (247 BC–226 AD) in Iran . In 138 The Compendium of Materia Medica  provides a body of medicinal products and agents that was compiled by Shizhen Li  in the Ming Dynasty. He devoted his entire life and spent 30 years to complete the masterpiece. The book is divided into 16 sections . With a total of 1.9 million Chinese characters, the book collected 1892 medicines, 11,096 medical prescriptions, and 1,160 illustrations. The book systematically describes the knowledge of each CMM medicine in detail and provides an explanation of the names and background of each medicinal material and it discusses quality, taste, indications, explication, prescriptions, etc. The number of medicinal herbs recorded and the details of the content in the CMM are vast and during the preparation of CMM, Shizhen Li visited a wide range of regions and consulted many people in order to ensure authenticity and accuracy in the recording of ethnobotanical information. He summarized and criticized herbal books written by previous scholars, corrected errors in these books, and then invented a comparative system of drug classification methods. In classifying medicinal materials, he established a system from low level to advanced, from simple to complex, which was a very advanced classification method at that time. The first edition CCM was published over 400 years ago. Since then, it has been translated into other languages, making it accessible to the rest of the world. As a world’s documentary heritage, the CMM was successfully selected in the Memory of the World Register in 2011 . Being aIt has a long history of cultivating medicinal plants in China. These plants account for a major part of traditional Chinese medicine (TCM), however, not all of these herbs are native to China. As exotic plants, they were incorporated and developed into the TCM system despite being introduced to China from overseas. These exotic plants have become naturalized, gradually adapting to local environments and are now widely recognized by Chinese people. According to www.mpns.science.kew.org) was used to check the correctness of the nomenclature of the reported plant species.All original information on the medicinal materials was based on a Chinese version of the Compendium of Materia Medica , of whicA total of 46 TCMs documented in the CMM were clearly mentioned to have an origin linked to Persia. The name and current distribution of these TCMs are included in Strobilanthes cusia (Nees) Kuntze and this is used as a single medicine or in combination with Persicaria tinctoria (Aiton) Spach and Isatis tinctoria subsp. tinctoria. On the other hand, two different parts of one herb might be separately registered in the PPRC. The leaf and root of Isatis tinctoria subsp. tinctoria are separately registered in the PPRC as two medicines and their formulations are different. It is worth noting that one stone is not grouped in a formula but most of these materials are still in use with as many as 75 formulae being utilized. According to the CMM method, the TCM from Persia was divided into categories of herbs, vegetables, fruits, woods, metal/stone/mineral, and fowls. The following sections provide details in terms of these medicinal products.A detail of the basic information of the TCM with a registry of China Pharmacopoeia, is organized in Natural indigo/Strobilanthes cusia (Nees) Kuntze, Persicaria tinctoria (Aiton) Spach, or Isatis tinctoria subsp. tinctoria/“Qing Dai,”“青黛”Strobilanthes cusia (Nees) Kuntze, Persicaria tinctoria (Aiton) Spach, or Isatis tinctoria subsp. tinctoria. Natural indigo was commonly used as a dye for cloth and paint in old times but it has been adopted as an important TCM for a long time. It is now included in the 2020 edition of the Pharmacopoeia of People’s Republic of China (PPRC), which is used for reducing body heat and detoxification of the body. I. tinctoria subsp. tinctoria produces a large variety of chemicals including terpenoids, alkaloids, organic acids, and others, which are the chemical foundation of multiple pharmacological effects including anti-inflammation, anti-tumor, anti-allergy, and anti-microbes . Shizhen Li in the CMM said that a soup made from boiling long pepper together with milk was excellent in treating headaches, rhinorrhea, and toothache. Long pepper is now included in the PPRC, with functions of warming the interior body, dissipating cold, and for stopping pain. Modern studies have shown that the main components of long pepper are amide alkaloids and volatile oils that have caryophyllene and pentadecane (both about 17.8%) and bisaboline (11%), as well as amino acids and inorganic elements  D. Y. Hong/“Hu Huanglian,” “胡黄连”Neopicrorhiza scrophulariiflora (Pennell) D.Y. Hong, a plant of the Scrophulariaceae. It is now predominantly distributed in Tibet and is thus an important Tibetan medicine. There are no records of the plant being grown in Iran. It was listed as a national tertiary protection plant and recorded in the PPRC. In TCM theory, N. scrophulariiflora is used as a tonic for the liver and gallbladder and is said to improve the eyesight. It can also be utilized for treating fevers and it has a reputation as being used for diabetes. Apart from this, it may be used for treating convulsions in pregnant women. It stops diarrhea and dysentery and treats five types of hemorrhoids. Studies showed that its main chemical components are iridoids, cucurbitol, phenylethanol glycosides, and phenol glycosides  Skornick. and A.D. Poulsen or Wurfbainia villosa var. xanthioides (Baker) T.L. Wu and S.J. Chen/“Sushami,”“缩砂蔤”W. villosa or W. villosa var. xanthioides. It is included in the PPRC with the name of Sharen. Both wild and cultivated W. villosa are distributed in China but there are currently no records that indicate it being grown in Iran. The main components of W. villosa are volatile essential oils, such as borneol acetate, camphor, borneol, β-bisabolene, nerolidol, and cubeno . Many studies have indicated that betel has a potential for treatment of Leishmania donovani– induced parasitic disease  Medik./“Buguzhi,” “补骨脂”Cullen corylifolium (L.) Medik plants. The fruit is harvested and dried after it matures in autumn, and the fruit is used as a medicine. It is included in PPRC for treating skin diseases such as psoriasis. C. corylifolia also has a long history in Ayurvedic medicine. It is widely distributed in India. Babchi contains various chemical components including coumarins, monoterpenoids, flavonoids, and benzofurans, and has a wide range of pharmacological effects, including anti-tumor, anti-oxidant, anti-inflammatory, anti-fungal, anti-bacterial, and immunomodulatory properties (Babchi is produced from the dry ripening fruits of operties . In a reoperties .Jasmine/Jasminum sambac (L.) Aiton/“Moli,” “茉莉”Jasminum sambac (L.) Aiton, are an important component of TCM with the effect of clearing heat and removing excessive water. Jasmine has strong historical and cultural implications in China. Traditionally, flowers of jasmine can be ground into a powder that is used as a mask for detoxification, acne, and facial nourishment. Perfumes made of essential oils from jasmine are popular. Petals of jasmine can be used to make tea with a fragrant smell. Studies have indicated that jasmine exhibits activities of gastroprotective , Cichorium intybus L. (5%), Fumaria parviflora Lam (5%), and Citrus × aurantiifolia (Christm.) Swingle (4%)  .Spinach/Spinacia oleracea L./“Boleng,” “菠薐”Spinach is a common vegetable rich in carotene, vitamin C, protein, calcium, iron, and other minerals. In TCM, it has the functions of heat clearing, dryness moistening, and invigorating of the blood circulation. Although spinach is widely used as a vegetable worldwide, some studies have shown its pharmacological actions as it may help with some diseases, such as metabolic syndrome , cartilaPhoenix date/Phoenix dactylifera L./“Wulouzi,” “无漏子”Phoenix dactylifera L, which grows in the high temperature and arid desert areas, such as Iraq and Iran. It tonifies the interior and reinforces the qi, eliminates phlegm, and stops coughing. Phoenix date has a high nutritional and medicinal value, and it is rich in vitamin A and vitamins B1 and B2. It has the function of protecting visual acuity, strengthening nerves, and softening blood vessels. In addition, other studies have shown that date also has a certain sedative effect, which has a certain effect on psychological panic and fear, as well as neurological disorders caused by hyperthyroidism  DC./“Ganlan”, “橄榄”Olea europaea L, which is a common tree in the Mediterranean Basin for olive oil or food. The dried ripe fruit of Canarium album (Lour.) DC. was included in PPRC. In TCM, olive helps produce body fluid, relieves restlessness, and quenches thirst and it is good for relieving throat pain. Chewing the fruit and swallowing the juice also helps to detoxify toxins from all kinds of fishes and turtles. Studies have proven that the chemicals of the fruits exert efficacy against some diseases, such as benzofuran neolignans for anti-inflammation . In TCM theory, it has the effect of supplementing qi and blood, benefiting the kidney and liver, generating liquid, strengthening muscles and bones, stopping cough and eliminating vexation, and promoting urination. In addition to being used as a fruit, there are huge varieties of grapes for wine and beverage. The rich phytochemical composition of grape makes it an attractive object for pharmacological exploration. Through a systematic review, grape seed extract, which contains resveratrol and other anti-oxidant chemicals, may be beneficial for people with cardiovascular diseases . The seeAgarwood/Aquilaria malaccensis Lam./“Mixiang,” “蜜香”Agarwood is regarded as being precious as it is favored by many fragrance enthusiasts because of its special fragrance. Shizhen Li in the CMM concluded that Mixiang is one species of Chenxiang (Chinese Eaglewood). It has similar therapeutic functions to Chenxiang. The name of Chenxiang is derived from its characteristics of sinking in water. When the resin content in Chinese eaglewood is higher than 25%, regardless of its form , it will sink into water. The agarwood mainly contains volatile chemicals such as sesquiterpenes, 2-(2-phenylethyl) chromone, aromatic, and flavonoids. Although it is believed that the agarwood has analgesic, anti-diarrhea, neuroprotective, anti-inflammatory, and anti-bacterial activities , thorougMarking nut tree/Semecarpus anacardium L. f [Anacardiaceae]/“Poluode,” “婆罗得”Ricinus communis L.). It is also an important Ayurvedic medicine. In TCM theory, it warms the interior, tonifies the waist and kidney. It can dye hair and beard in black. It is not included in PPRC. Pharmacological studies have disclosed the medicinal values of the marking nut tree. The stem barks, or the nuts of the tree have been shown to possess potential against diabetes and inflammation in a rat study  Engl./“Moyao,”“没药”Commiphora myrrha (T.Nees) Engl. As an important TCM with a long history, however, myrrh is not produced in China. According to our research, myrrh was used as a component in 75 formulas out of 1605 TCM formulas registered in the current PPRC, proving its importance in TCM (data not published). In TCM theory, myrrh removes blood stasis, eliminates swelling, relieves pain, and promotes muscle growth. It falls within two categories in PPRC: natural myrrh and colloidal myrrh. Natural myrrh is of irregular granular clump with different sizes, the larger diameter can up to 6 cm or more. Natural myrrh has a special aroma with a bitter taste and slightly pungent smell. The colloidal myrrh is made of irregular lumps and granules with a brown surface, which stick into lumps of different sizes. Colloidal myrrh is opaque, solid or loose in texture with a specific aroma. The main chemical constituents of myrrh are monoterpene, ploidy, triterpenoids, steroids, and lignin  Craib ex Hartwich/“Anxixiang,” “安息香”Styrax tonkinensis (Pierre) Craib ex Hartwich, a semi-deciduous tropical tree that can grow up to 20 m high. The outgoing resin is collected and dried when the tree stem is naturally damaged or cut apart in the summer or autumn. Benzoin is included in the PPRC. It is divided into two types: Thai benzoin and Sumatra benzoin. The resin content of benzoin is as high as 70–80%, and the main component of the resin is volatile vanillic acid. In addition, lignins, terpenoids, and steroids were obtained from the studies on the chemical compositions of the genus Bemberine  H. Karst, which is native to Iran. In Iran, Ferula is used to treat spasmodism, helminth, carmination, and constipation  Burm. f. or Aloe ferox Mill./“Luhui,” “卢会”Aloe vera (L.) Burm. f., Aloe ferox Mill., or other close species. Aloe is used to treat skin diseases, constipation, indigestion, and worms in TCM. The thick juice from A. barbadensis leaves is a good moisturizer, especially in cosmetics. A study has disclosed that a compound, aloin A, might be the bioactive agent that prevents infection of skin wounds when aloe is applied as a topical treatment  parasitized on the young branches of Quercus infectoria G. Olivier. Unpierced cecidum is mainly used for medicinal purposes. Nutgalls are rich in gallotannin (50–70%), followed by gallic acid (2–4%), propionic acid, and resin. It has the effect of strengthening teeth and fixing gums, clearing blood and relieving pain, and inhibiting bacteria. It is a common medicine used in Uyghur as an enema in the treatment of chronic ulcerative colitis  J. Presl/“Longnaoxiang,” “龙脑香”Cinnamomum camphora (L.) J. Presl. Borneol is a common Chinese medicinal material, and there are four kinds of borneol contained in the National Drug Standards of China  Engl., and T. chebula was comparable to metformin in treating diabetic rats, suggesting its potential remedy in diabetes , Huangfan , Lvfan , Heifan , and Jiangfan . Presently, the PPRC contains Alumen and Melanteritum. In TCM, the alumen treats itching and worms for topical treatment and it stops bleeding by oral administration.Sulfur/“Shiliuhuang,” “石硫磺”The massive sulfur is a light yellow crystal that has an unpleasant stench. In TCM, sulfur for external use can kill worms to stop itching, treat scabies, eczema, and skin pruritus. For internal use, it is indicated to nourish fire and invigorate Yang, in addition to strengthening sinews and bones, and to relieving constipation. Sulfur benefits qi and stops bleeding, dispels phlegm and reduces panting. However, sulfur is toxic so it is suggested not to be taken in large quantities or for a long period. Sulfur is not contained in the PPRC. Limited cases of sulfur are used in the TCM formula. Sulfur is a very efficient fumigation reagent and is widely adopted in the TCM material treatment. However, the excessive residue of sulfur is forbidden and it is a monitored substance in the quality control of TCM material.Salt/“Guangmingyan,” “光明盐”Salt is a natural crystal that mainly contains sodium chloride. In TCM, it is primarily used for dispelling pathogenic wind for improving eyesight, digestion and accumulation, and detoxification. It is now only a food additive and not a medicine in China. It is not often to be used in TCM formulas but is used in some applications of moxibustion or massage. Although currently sodium chloride is commonly used as an essential condiment for the maintenance of concentration and osmotic pressure crossing cell membrane, treatment with additional sodium chloride is necessary for diseases characterized by lack of salt including cystic fibrosis , congeniLitharge/“Mituoseng,” “密陀僧”Litharge is a red oxide mineral of lead, belonging to the tetrahedral system. Litharge mainly contains lead oxide, which has certain toxicity. Internal use causes lead poisoning. In TCM, litharge treats regurgitation, diabetes, malaria, and dysentery. It also stops bleeding, kills parasites, and removes food retention. It is good for treating sores, eliminating swelling and attacks of noxious agents, dispersing bromhidrosis, and dyeing the hair black. Litharge was externally used to treat eczema, sore poison, burns, scalds, injuries from falls and other surgical diseases. Internal use includes treating diarrhea, malaria, epilepsy, and other diseases. Litharge is currently not included in the PPRC. No report of using it in the current TCM.Iron/Ferrum/“Tie”, “铁”Iron is a grayish-black metal, mainly produced from hematite, limonite, and magnetite. The CMM claimed that iron could dissipate extravasated blood and eliminate erysipelas. Iron is used as the main medicinal treatment for incised  wounds, chest and diaphragm pain due to being blocked by gas, and retention of food. However, the CMM also stated that it could damage the lung and injure the liver and kidney. Iron is not included in the current PPRC, but in the previous version of PPRC; red, yellow, brown, purple, and black ferric oxides were included. No reports of any use are included in the current TCM.Gold/“Jin,” “金”Gold was recorded in many Chinese ancient books as a medicine. However, the gold needs to be made into gold foil before it can be used as medicine. The internal use of gold foil has the effect of leading to tranquility and protecting the liver. The external use is said to detoxify and treat furuncle. Clinically, it is mostly used for treating convulsive epilepsy and insane and disquieted heart spirit. Gold is not included in the PPRC. No report of its current use is now indicated in TCM.Silver/“Yin,” “银”Silver has been a medicine in China for thousands of years. The needles for acupuncture and moxibustion were made of silver. In terms of medicinal materials, silver flakes were mainly used for epilepsy and mania, palpitation and trance, treating pox sores, and sudden loss of consciousness in children. Nowadays, silver is mostly used for anti-infection, anti-bacterial, and anti-inflammation purposes. Sliver is not included in the PPRC.Copper/“Chitong,” “赤铜”In the CMM, it is noted that the debris of red copper falling off during forging was used for medicinal purposes, and it has the effect of connecting bones and tendons, dispersing blood stasis and relieving pain. Internal treatment can cure blood stasis obstructing the collaterals, and external treatment is implicated in curing bleeding wounds and for eyelid ulcerations. Copper has also been used as a dye to make hair black and remove odors. However, internal use is not necessarily advised as this can lead to stomach and kidney damage and so, copper is suggested not to be taken in large quantities or for a long time. Natural copper  is recorded in the PPRC for treating injuries that may be associated with falls, fractures, contusions and strains, and pain due to stasis swelling.Lead/“Qian,” “铅”In TCM, lead is good for eliminating scrofula, carbuncles, and swelling. It improves eyesight, stabilizes the teeth, and blackens the hair. It is effective for female suffering absence or atresia of the vagina (a birth defect). It kills parasites and eliminates phlegm. It is also good for treating dysphagia, diabetes, and acute infantile convulsions. Consequently, drugs containing lead should be used carefully in clinical practice to ensure the safety. It is not included in the PPRC. Lead is a poisonous element and a high level of lead in the blood affects brain function and development. Currently lead is monitored in TCM material due to its poisonous nature.Coral/Corallium/“Shanhu,” “珊瑚”In TCM theory, coral has a similar medicinal efficacy to that of gold. Due to the specificity of the marine environment, corals have a variety of secondary metabolites and a wide range of biological activities. There are thus opportunities for the development of new pharmaceutical coral–derived ingredients in marine natural drug research. It is not included in the PPRC. At present, it is not common to use coral in TCM treatments.Cinnabar/“Dansha,” “丹砂”Cinnabar is a mercuric sulfide mineral, which played a major role in old Chinese alchemy to increase longevity. In TCM it clears the heart, calms the mind, brightens the eyes, and detoxifies the body. When used externally, it can inhibit skin fungi. Mercury is a heavy metal element that is highly toxic. Its presence in common TCM material is thus rigorously monitored and concentrations have to be exceedingly low and limited to ensure quality control aspects linked to safety and toxicity. Cinnabar is included in the PPRC; however, no formula is registered with it.Calamine/“Luganshi,” “炉甘石”According to the CCM, calamine is produced in Persia and is similar to gold in appearance. Calamine is a carbonate mineral calcite rhombozite, mainly containing zinc carbonate. It has a sweet and neutral taste and is non-toxic. Calamine is frequently used in ophthalmology and surgery. It has the effect of detoxifying, improving eyesight and removing nebula, dispelling excessive water, relieving itching, and healing sores. It is included in the PPRC. Many modern proprietary medicines contain calamine components, such as medicament for the eyes . Calamine is not suitable for internal use and is frequently made into liniment or lotion with other drugs.Fibroferrite/“Huangfan,” “黄矾”The CMM mentioned that fibroferrite ore produced in Persia has a golden thread when cut open. Fibroferrite was used as medicine before the Song Dynasty but was rarely used after that, and it is not included in the PPRC.Ostrich/Struthio camelus/“Tuoniao,” “鸵鸟”Ostrich originally lived in the semi-arid desert areas of Africa. According to historical records, in 101 AD, the Sabbath Dynasty presented lions, ostriches, and other animals as gifts to Chinese emperors. It is not included in the PPRC. It is a zoo animal in China and there is no report of using it in the current TCM.Taiping Guangji (first edition in 978 of Song Dynasty), recorded a large number of Persian merchants who settled down in Chang’an to trade the jewelry and spice. At the same time, China’s ceramics, paper, silk, tea, porcelain, sericulture, and other expertise were also introduced to Persia, which greatly impact the empire. Yunsheng Hu  Some foreign drug resources spread to China, over time, they have gradually adapted to the cultivation environment in China and have been included in the “Chinese herbal medicines,” becoming China’s localized medicine. Saffron, myrrh, and olibanum are as such medicines that are all included in the PPRC for treating diseases even though these medicines are still largely dependent on imports from Iran or other countries. 2) Some medicinal materials are no longer included as TCM materials, but are treated as common food through long-term of experiencing, recognition, and understanding. As mentioned earlier, dill and spinach became common vegetables not only in China but also in the rest of the world. Fig, grape, jackfruit, phoenix date, and pistachio are popular fruits with good taste and nutrition. Jasmine, olives, and other fragrant medicines are primarily being used as raw materials for processing into many products including perfume, essential oil, and skin care products, which can not only make full use of the value of these plants, but also meet the diverse needs of people. Based on the theory of TCM, the aforementioned fruit and vegetables can be classified in a group of food and also medicine due to their tonic factors. 3) In addition, some medicinal materials, due to excessive toxicity, are listed outside the range of commonly used medicinal materials. This part of the medicinal materials is mostly concentrated in the category of metals, stones, and minerals. For example, lead and litharge are no longer used as medicinal materials. Cinnabar, copper, and calamine are also extremely restricted in clinical use. Lead and mercury are closely monitored in the standardization of quality control of all TCM materials for contamination of heavy metals.S. cusia, P. tinctoria, and I. tinctoria subsp. tinctoria show similar treatments and people treat them the same but it might be I. tinctoria subsp. tinctoria which was the only one introduced from Persia to China. Second, some of the medicinal plants from Persia might have been replaced by the ones that were naturally found in China. When plants have close pharmacological effects, harvesting from nearby areas is more economical than obtaining plant materials from faraway places that are ten thousand of kilometers away. If this is the case, some of species that are naturally distributed in Iran might be valuable for drug discovery as they have found use in China, such as close species of Cullen corylifolia (L.) Medik., and Terminalia chebula Retz., are all found in Iran. Another example is of the Ferula species. F. sinkiangensis or F. fukanensis are the two species listed in the PPRC but these two plants were discovered in the 1950s in China and now they are endangered with limited production. For a long time, the Ferula imported from Persia must be the close species Ferula assa-foetida L. or other species in Iran. Re-connection of the China–Iran bilateral authentification of the medicine may help to utilize the rich resources of Ferula in Iran. Third, some of the medicinal plants are not distributed in Iran or even in old Persia, but they were introduced by the Persia businessmen and brought to China. It is confirmed that Iran does not produce myrrh and for a long time and the great demand of the Chinese market might be provided by Persian commercial men, who obtained it from other places. It was until recent decades that China started importing the myrrh from Ethiopia and nearby countries. In this way, the Silk Road in the old times may have extended to Africa by Persia (Of interest, 25 of the 38 TCM medicinal plants now are cultivated or wild growing in China but they are not found in Iran. There are some possible explanations for this. First, the authentification of material used in TCM is changing with time. In old days without scientific names, it is possible that different plant species could easily be confused, especially if they share similar medicinal efficacy. For example, natural indigo, the three plants, namely, y Persia . We are There are 24 TCMs, consisting of 38 medicinal plants and four stones, studied in this study and were included in the 2020 edition of the Pharmacopoeia of the People’s Republic of China. The pharmacopoeia is a drug code established by the state to ensure the quality and safety of the medicine. Drugs recorded in the pharmacopoeia are commonly used as medicinal materials and are permitted in use in the clinical practice. In The introduction and cultivation of exotic drugs is an important part of the development history of Chinese herbal medicines. Persia was an important country on the Silk Road. Looking back to the date when Shizhen Li was writing the book and even earlier, the introduction of traditional medicine benefited both sides. With saffron as an example, even though it is now sporadically cultivated in China, much more is imported to China from Iran, perhaps continuously lasting over two thousand years. It is not because it cannot grow in China. It is because in the Chinese medicinal culture Persia produces the best quality saffron even though it is treated as a native medicine. The peaceful development of China and Persia has a positive impact on the politics, economy, and culture of the two territories. It is the best example and most valuable legacy of the Silk Road on the sharing of traditional medicinal resources. It shall inspire us to peacefully develop a collaborative relationship to share the advancement of the human civilization.