Arnebia. At present, there is no systematic analysis of its mechanism. Therefore, we used the method of network pharmacology to analyze the mechanism of RosA. In our study, PubChem database was used to search for the chemical formula and the Chemical Abstracts Service (CAS) number of RosA. Then, the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform (TCMSP) was used to evaluate the pharmacodynamics of RosA, and the Comparative Toxicogenomics Database (CTD) was used to identify the potential target genes of RosA. In addition, the Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis of target genes were carried out by using the web-based gene set analysis toolkit . At the same time, we uploaded the targets to the STRING database to obtain the protein interaction network. Then, we carried out a molecular docking about targets and RosA. Finally, we used Cytoscape to establish a visual protein-protein interaction network and drug-target-pathway network and analyze these networks. Our data showed that RosA has good biological activity and drug utilization. There are 55 target genes that have been identified. Then, the bioinformatics analysis and network analysis found that these target genes are closely related to inflammatory response, tumor occurrence and development, and other biological processes. These results demonstrated that RosA can act on a variety of proteins and pathways to form a systematic pharmacological network, which has good value in drug development and utilization.Rosmarinic acid (RosA) is a natural phenolic acid compound, which is mainly extracted from Labiatae and  Arnebia plants such as Rosmarinus officinalis, Melissa officinalis, and Hyssopus cuspidatus Boriss [Traditional Chinese medicine and natural compounds contain a large number of active components. This provides more possibilities and opportunities for the development and the use of drugs. Rosmarinic acid (RosA) is one of the water-soluble natural phenolic acid compounds . It is ws Boriss . Increass Boriss –7. Moreos Boriss –10. So Rs Boriss , 12. ThiIn consequence, we systematically analyzed the pharmacological effects of RosA by using the method of network pharmacology. Firstly, the server of TCMSP was used to evaluate the biological characteristics of RosA. In addition, we predicted the potentially related target genes by chemical-gene interaction analysis. Furthermore, these potential target genes were used for GO enrichment analysis, KEGG enrichment analysis, and molecular docking. Finally, we systematically explained the potential targets and mechanism of RosA by constructing the pharmacological relationship network of RosA. https://pubchem.ncbi.nlm.nih.gov/) is an open and accessible database resource, which contains important information resources such as drug discovery and chemical biology research [PubChem database  is one of the phytochemical databases. The database includes pharmacokinetic characteristics of natural compounds, such as oral bioavailability (OB), drug similarity (DL), blood-brain barrier (BBB), and water solubility [TCMSP Database and Analysis Platform (lubility . Most ofhttp://ctdbase.org/) is a database that aims to clarify the relationship between genes, drugs, and diseases. It provides key information about the interrelation between genes, gene interactions, disease, and chemical phenotype. The information in the database is selected from peer-reviewed scientific literature [CTD  is one of the online databases that can collect, score, and integrate all publicly available sources of information about protein-protein interactions. It can use computational predictions to supplement the existing information on protein-protein interactions. It achieves a comprehensive and objective global network, including direct  and indirect  interactions [The STRING 11.0 version  is one of the popular software devices for functional and pathway enrichment analysis [WebGestalt  and saved in PDB format. The solvent molecules and ligands were removed by PyMOL software. AutoDock software was used to add hydrogenation, electron, and root and carry out other operations. And the formats of compounds and target proteins were converted to pdbqt format. During molecular docking, the protein structure was set as a rigid macromolecule, and the algorithm was Genetic Algorithm Parameters. For the group with the lowest binding energy of each protein in the results, PyMOL was used to draw 3D images, and one online tool (https://proteins.plus/) was used to generate 2D graphics.Firstly, the chemical structure formula of RosA was downloaded from the CTD database and saved in mol2 format. Then, the 3D structures of target gene-associated proteins were downloaded from PDB data  , cellular component (CC), and molecular function (MF). BP enrichment mainly contained the following target genes: biological regulation (52/55), response to stimulus (51/55), metabolic process (49/55), multicellular organismal process (47/55), cell communication (43/55), developmental process (43/55), cellular component organization (38/55), localization (38/55), multiorganism process (34/55), and cell proliferation (26/55). CC enrichment was mainly involved in the following target genes: membrane-enclosed lumen (33/55), membrane (32/55), cytosol (32/55), vesicle (28/55), extracellular space (27/55), nucleus (27/55), endomembrane system (27/55), and protein-containing complex (21/55). MF enrichment was mainly engaged in the following target genes: protein binding (49/55) and ion binding (30/55). All the results are shown in At the same time, we carried out KEGG enrichment analysis of these candidate genes by WebGestalt tool. KEGG pathway enrichment analysis displayed that 55 potential target genes were enriched and 120 signal pathways were significantly related with the target genes (FDR ≤ 0.05). In In order to further clearly show the relationship between compound (RosA), targets, and pathway clearly, we constructed a drug-target-pathway network diagram by Cytoscape 3.7.2 version. It is generally believed that the lower the energy of the conformational stability of the ligand and the receptor, the greater the possibility of interaction. At present, there is no unified standard for target screening of active molecules. The active components with binding energy ≤−5.0 kJ/mol were selected as the basis for screening. The results of molecular docking showed that 13 of the selected target proteins had an affinity of less than −5.0 kJ/mol to RosA. The figure shows the best four docking results with the lowest binding energy. The results are shown in At present, the method of network pharmacology has been paid more and more attention during the process of drug development and utilization. This method can, firstly, evaluate, screen, and optimize some important characteristics of drugs, so as to speed up or simplify the process of drug discovery , 12. UsiLipinski's Rule of Five is a rule of thumb. It is mainly used to evaluate whether a compound can be used as a drug or whether a compound with pharmacology or biological activity can become a human oral drug. Lipinski's rule of five mainly includes the following criteria: the molecular weight (MW) ≤500 g/mol; an octanol-water partition coefficient log P (Log P) ≤5; the donor of hydrogen bond (nitrogen or oxygen atoms with one or more hydrogen atoms) ≤5; the number of hydrogen bond receptors (nitrogen or oxygen atoms) ≤10 , 25. TheDL is used to evaluate the “drug-like” degree of expected compounds. This helps to optimize pharmacokinetics and drug properties . The DL level of a compound is ≥0.18, which can be used as one of the screening criteria of the traditional Chinese herbs . The DL −1 as the screening criterion, we found that the binding energy of 13 of the 18 targets was less than −5.0 kJ·mol−1; that is, RosA may interact directly with these targets. So, they may be the key targets for the pharmacological action of RosA.In the process of drug discovery, the search for target genes is a very important link. More and more molecules, compounds, and drugs have been found to have complex relationships with many genes and proteins –40. At tWe did further GO analysis and pathway analysis of these potential genes through WebGestalt. According to the analysis of BP items, RosA is closely related to biological regulation, response to stimulus, metabolic process, multicellular organismal process, cell communication, developmental process, and so on. These results indicate that RosA may be related to anti-infection and antitumor. What is more, 9 of the first 20 enriched KEGG pathways are related to bacterial, viral, and parasite infections, such as pertussis, Chagas disease (American trypanosomiasis), salmonella infection, hepatitis B, amoebiasis, and toxoplasmosis. These results suggested that RosA may have antibacterial, antiviral, and anti-infective effects. Some of these pathways are related to inflammatory diseases and tumor diseases, for example, the AGE-RAGE signaling pathway in diabetic complications, colorectal cancer. Other studies suggested that RosA can inhibit the growth of cancer cells –43. In aOur studies showed that RosA has many pharmacological activities. At the same time, we analyzed the possible mechanism of action of RosA, which can be used to further develop safe and effective anti-inflammatory and anticancer drugs. Our work provides a new idea for the research, development, and clinical application of RosA. However, its shortcomings such as low oral availability and not easy to pass through the BBB also bring new challenges.


Escherichia coli and anti-Staphylococcus aureus activity, with AUC values (the area under the ROC curve) of 77.5 and 80.0%, respectively, were constructed by the Neural Networks (NN) algorithm after Bagged Classification and Regression Tree (Bagged CART) and Linear Discriminant Analysis (LDA) selection. The in vitro experimental results showed the prediction accuracy of these two models was 75 and 60%, respectively. Four TCMs  were proposed for the first time to show antibacterial activity against E. coli and/or S. aureus. The results implied that the prediction model of antibacterial activity of TCMs based on properties and families showed certain prediction ability, which was of great significance to the screening of antibacterial TCMs and can be used to discover novel antibacterial agents.Traditional Chinese medicines (TCMs), as a unique natural medicine resource, were used to prevent and treat bacterial diseases in China with a long history. To provide a prediction model of screening antibacterial TCMs for the design and discovery of novel antibacterial agents, the literature about antibacterial TCMs in the China National Knowledge Infrastructure (CNKI) and Web of Science database was retrieved. The data were extracted and standardized. A total of 28,786 pieces of data from 904 antibacterial TCMs were collected. The data of plant medicine were the most numerous. The result of association rules mining showed a high correlation between antibacterial activity with cold nature, bitter and sour tastes, hemostatic, and purging fire efficacies. Moreover, TCMs with antibacterial activity showed a specific aggregation in the phylogenetic tree; 92% of them came from Tracheophyta, of which 74% were mainly concentrated in rosids, asterids, Liliopsida, and Ranunculales. The prediction models of anti- Bacterial diseases remain the primary cause of morbidity and mortality worldwide. Currently, antibiotics are effective drugs for the treatment of infections. In recent years, the abuse of antibacterial agents has led to the emergence of “superbacteria,” which has become an increasingly severe global public health problem . It is eTraditional Chinese medicines (TCMs), as a unique natural medicine resource in China, have a long history in the prevention and treatment of infectious diseases. Compared with other antibiotics, TCMs have the characteristics of being multi-component and multi-target, and potentially could be used to overcome drug resistance. Studies have shown that many TCMs, such as Coptidis Rhizoma and Lonicerae Japonicae Flos, have broad-spectrum antibacterial activity and different inhibitory degrees on gram-negative and gram-positive bacteria . So, it in vivo experiments, the drug screening method based on machine learning and extensive data mining has become a potentially powerful technology due to its advantages of fast speed, low cost, etc.With the era of big data coming, data mining technology and machine learning algorithms provide an innovative research direction for exploring TCMs. Data mining is a technique to find the rules from a large amount of data by analyzing every piece of data. The machine learning techniques are considered powerful tools to generate predictive models useful in virtual screening campaigns . These mThe theory of medicinal properties is the core of TCMs, which mainly includes four natures, five tastes, meridian tropism, etc. It reflects the nature, performance, and clinical practice law of TCMs, contains clues to pharmacological effects, and has a great value to guide the clinical application of TCMs . Our teaEscherichia coli (E. coli) and Staphylococcus aureus (S. aureus) were constructed by the machine algorithm, and the reliability was tested by antibacterial experiment. Our results provide a theoretical basis and essential data for improving the screening efficiency of antibacterial activity of TCM and the development and clinical practice of innovative antibacterial  and Web of Science in the past 40 years. We mined the distribution law of properties, families, and species space of antibacterial TCMs through frequency analysis, association rules mining, and phylogenetic tree construction. Then, with the experimental information obtained from the antibacterial literature, the prediction models of antibacterial activity of TCMs against acterial .CNKI and Web of Sciences databases were selected as the database in this paper. The former used “ and ” as search formula, and the latter used “TS =  and TS = ” as the search formula. The search time was set from January 1979 to May 2021. Among them, candidate literature’s screening criteria included as follows: (1) Antibacterial or bacteriostatic experimental papers with clear antibacterial or bacteriostatic indicators, such as minimal inhibit concentration or inhibition zone; (2) Papers whose research object was TCM. According to the above criteria, we screened out the literature and the original data finally.Pharmacopeia of the People’s Republic of China  The names of TCMs were standardized based on of China , Chinesea Medica , Grand DMedicine  and NatiMedicine ; (2) TheMedicine ; (4) Streriology , and theThe antibacterial TCMs were counted according to the families and their properties using Excel, and then the data was imported into Rstudio1.3.959 and was further visualized using the ggplot2 package.The information was imported into the R software platform, taking the families, properties, and efficacies of TCMs as the former item and the antibacterial effectiveness as the last item. Programs and the packages such as arules and arulesViz were used to mine and visualize the association rules . The cor1 to generate a text file of the phylogenetic tree. And then, the text file was uploaded to Interactive tree of life (ITOL)2 for visual analysis  Data integrity check: data with incomplete information was deleted. (2) Data encoding: the principle of “1 represents yes, 0 represents no” was used to describe the characteristics of TCMs properties, and the sequence 1,2,3.n was used to record the families’ characteristics. (3) Data type conversion: the dependent variables were transformed into the factor variables suitable for the classification model. (4) Data Splitting: the dataset was randomly split into 80% training data and 20% test data; (5) Data standardization and centralization: the data was standardized and centralized with the preProcess function.This paper uses the recursive feature elimination method for feature selection, which combines the feature selection process with the training process. The model’s predictive ability was used to measure feature selection . Random After feature selection, six machine learning algorithms, namely Random Forest (RF), k-Nearest Neighbor (KNN), Classification and Regression Tree (CART), Support Vector Machine (SVM), Naive Bayes (NB), and Neural Networks (NN), were used to build models for different datasets. The train function implemented this process in the caret package, and five times 10-fold cross-validation was used in each model.The receiver operator characteristic curve (ROC) of the model was established to predict the occurrence probability of the TCMs antibacterial activity, and calculating the area under the curve (AUC), comparing the performance and evaluating the predictive ability of each model .The parameters of the screened model were optimized to improve the performance further. To obtain the optimal model, the parameters combinations of all models were traversed through the combination of grid parameter adjustment method and random parameter adjustment method. Among them, the critical parameter that significantly affects the KNN algorithm was the neighbor number k. The NN algorithm’s parameters needed to adjust were the number of hidden units size and the weight attenuation parameter decay.Seventy five percent ethanol was purchased from Sinopharm Chemical Reagent Co., Ltd. , and Luria-Bertani (LB) Culture was purchased from Shanghai Aladdin Biochemical Technology Co., Ltd. .Dichroae Radix, Cirsii Japonici Herba Carbonisata, Swertiae Herba, Bubali Cornu, Callicarpae Formosanae Folium, Turpiniae Folium, Changii Radix, and Trachelospermi Caulis et Folium were all purchased from Qingdao Tiancheng Chinese Medicine Co., Ltd. . The TCMs were identified by Professor Baoguo Li, Shandong University of Chinese Medicine.Preparation of ethanol extract of TCMs: Firstly, 50 g of TCM samples were crushed and soaked 10 times in 75% ethanol for 1 h, followed by reflux extraction at 100°C for 2 h. Secondly, the extract was collected, and the remaining residue was extracted eight times using 75% ethanol at 80°C for 1 h. Finally, the two sections were mixed and vacuumed filtrated, and the filtrate was concentrated by rotary evaporation at 45°C to obtain 1 g/mL ethanol extract and stored in –20°C refrigerator until use.Preparation of water extract of TCMs: 75% ethanol was replaced with pure water. According to the preparation method of alcohol extract, the water extract with 1 g/mL was obtained.E. coli and S. aureus were certified and provided by the Ocean University of China and were stored at –20°C. Firstly, the bacteria were activated before use, and 15–20 mL LB culture was poured into the sterilized Petri dish to be spread evenly and solidified for use. Secondly, the inoculation loop was used to dip the bacterial solution, and a “Z” line was drawn on the solid medium. Then, after being rotated 90°, a second line was drawn in the same way, and the operated Petri dishes were sealed with sealing strips and incubated at 37°C for 24 h. Finally, the bacteria were picked up by an inoculation loop in sterile water, and the bacterial solution was shaken until even. Compared with the shaken McFarland Turbidity standard tube, the bacterial suspension containing about 1 × 106 ∼ 1 × 107 CFU⋅mL–1 was prepared and placed for reserve.E. coli suspension were absorbed and evenly spread on the Petri dishes containing 15–20 mL LB culture. Four holes were drilled in the agar medium orderly of each dish. Different TCM extracts (100 μL) were added to the holes of each Petri dish. The water extract was added to the up and down spots, and the ethanol extract was added to the left and right holes. Finally, the inoculated plates were sealed with sealing strips, labeled corresponding information, and incubated for 24 h at 37°C in a constant temperature biochemical incubator. The production of a bacteriostatic ring was observed, and the diameter of the bacteriostatic ring (mm) was measured with a vernier caliper. The experiment was repeated three times.A total of 100 μL of the prepared According to the screening criteria, 904 TCMs were included in the analysis from 999 original species. The number of TCMs from plants (835) was the largest, accounting for 92.4% of the total number, followed by animal TCMs and fungi TCMs. According to the average proportion of the number of effective TCMs from different species, the plant TCMs were the highest, followed by fungi TCMs, animal TCMs, and others .The frequency analysis results on the properties of antibacterial TCMs showed that most medicines were cold nature, bitter, pungent and sweet tastes. Most of the meridians tropism were liver, lung, spleen, and stomach. The statistical results of the two kinds of antibacterial TCMs properties are the same .Association rules are an essential technology of data mining to mine the correlation between valuable data from a large amount of data, reflecting the interdependence and correlation between things . The assAccording to statistics, 714 TCMs from 820 original species were effective against gram-negative bacteria, which were distributed in 170 families, 82 orders, 19 classes, and 9 phyla. Among them, the most significant number of species were found in Asteraceae (76), and Fabaceae (50), Rosaceae (41), Lamiaceae (34), and Ranunculaceae (32) with more than 30 species. The most numerous orders were Lamiales (84), followed by Asterales (80), Ranunculales (67), Rosales (57), and Fabales (54). A total of 730 TCMs were effective against gram-positive bacteria, from 832 original species, distributed in 179 families, 86 orders, 20 classes, and 9 phyla. Similar to the statistical results of TCMs against gram-negative bacteria, the top three families with the largest number of species were Asteraceae (76), Fabaceae (47), and Rosaceae (36), and the top three orders with the largest number of species were Lamiales (82), Asterales (77) and Ranunculales (61) .A total of 147 rules for the families of antibacterial TCMs and the activity against Gram-negative bacteria were screened . The results showed that the highest compelling correlation with anti-gram-negative bacteria activity was Ranunculaceae and Rosaceae, with the confidence of about 91%, followed by Polygonaceae with the confidence of about 90%. The rest were Lamiaceae, Oleaceae, and Asteraceae, which had more than 80% confidence. The orders with high effective associations with anti-gram-negative bacteria activity were Ranunculales, Rosales, Lamiales, Sapindales, and Caryophyllales . With thPharmacopoeia of the People’s Republic of China . The rest were scattered in Metazoa, Fungi, and other kingdoms, consistent with the previous results of the mass of the number of plant TCMs .In the phylogenetic tree of the Viridiplantae kingdom, families with more than two species were identified in the figure due to the significant difference in the number of species in antibacterial TCMs families. The results demonstrated a specific aggregation of TCMs, mainly concentrated in the four branches of rosids, asterids, Liliopsida, and Ranunculales. The antibacterial TCMs in these four branches accounted for 74% of all plant antibacterial TCMs .E. coli with 6093, followed by Pseudomonas aeruginosa (2086) and Acinetobacter baumannii (1634). The most significant number of gram-positive bacteria was S. aureus (4790), followed by Bacillus subtilis (641) and Staphylococcus epidermis (343)  . E. coliThe above analysis of the antibacterial TCMs properties and families found that the TCMs with antibacterial activity had certain regularity and characteristics on the distribution of properties and families. Consequently, the natures , tastes , meridians tropism , and families  were taken as the characteristics to construct prediction model of antibacterial activity.E. coli model, 26 features were retained after RF selection, with an accuracy of 85.1% for cross-validation; 15 features were included after NB selection, with an accuracy of 83.8%; and 20 components were retained after LDA selection, with an accuracy of 83.7%. After Bagged CART selection, 18 features were kept, and the accuracy was 85.0%  and the predicted six TCMs, including Dichroae Radix and Cirsii Japonici Herba Carbonisata, were in accordance with the experimental results. Overall the accuracy of prediction was 75%. In the forecast of the anti-S. aureus activity of TCMs, the results of Dichroae Radix and Bubali Cornu were inconsistent with the experiment; however, three TCMs  were in good agreement with the experiment. The prediction accuracy was 60% (After comparing the results between models’ prediction and  was 60% .As a medical resource with unique advantages and core intellectual property rights, TCMs have become a significant research trend in mining antibacterial under the background of widespread bacterial infectious diseases. This study found that plant antibacterial TCMs were the hotspot of current research, and their antibacterial activity and species were different. For example, Ophiopogonis Radix, Platycladi Cacumen, and Artemisiae Argyi Folium are mainly resistant to gram-positive bacteria, while Pulsatillae Radix and Mori Cortex are primarily resistant to gram-negative bacteria . AlthougE. coli in gram-negative bacteria data. E. coli can cause gastrointestinal infection in humans and various animals under certain conditions leading to diarrhea, while sour medicine is mainly used for astringency and diarrhea (By excavating the distribution rules of properties of antibacterial TCMs, TCMs with cold nature and bitter, sweet and pungent taste accounted for the most significant proportion of antibacterial medicines. In association rule analysis, TCMs with cold nature or bitter taste showed a high correlation with anti-gram-negative bacteria and anti-gram-positive bacteria activity. The majority of TCMs with cold nature and bitter taste have the effect of clearing heat and draining fire, according to the medication principle of internal heat syndrome caused by a bacterial infection . Notablydiarrhea . In termdiarrhea . As a rediarrhea . As for diarrhea .According to the TCMs origin species, TCMs in Asteraceae, Fabaceae, and Rosaceae showed antibacterial activity. Fabaceae had a higher effective correlation with anti-gram-positive bacteria activity, and Rosaceae had a higher effective correlation with anti-gram-negative bacteria activity. Ranunculaceae, Polygonaceae, Lamiaceae, and Asteraceae were highly correlated with anti-gram-negative bacteria and anti-gram-positive bacteria activity. For example, Coptidis Rhizoma in Ranunculaceae, with the reputation of “TCM antibiotics,” had better activity against gram-positive bacteria and gram-negative bacteria . PolygonThe phylogenetic tree is a way to describe the relationships between different organisms. Recently, research has shown that phylogenetic ties can be used to find the formation and development trends of a certain biological group and could be used as a prediction tool. Studies pointed out that the predictive function of the phylogenetic tree can be used to discover TCMs with the same biological activity or to analyze TCMs with similar efficacy . In thisE. coli activity and for anti-S. aureus activity reached 77.5 and 80.0%, respectively. The model’s prediction accuracy was 75 and 60%, respectively, compared with the experimental results. It had a certain prediction ability for the antibacterial activity of TCMs, but there was still a gap with the ideal results. This may be because many factors were affecting the antibacterial activity and the current characteristics information was not comprehensive enough. In the future, relevant characteristics such as composition and target can be considered to be added (The above analysis suggested that antibacterial TCMs had a certain law in medication properties and distribution of families. Based on this, we suggest that the characteristic collection can be constructed using TCM properties and families information. We used the algorithms to build a model to predict the antibacterial activity of TCMs. When it was hard to obtain the effective indexes to evaluate the antibacterial activity of TCMs directly, the results of antibacterial activity were reflected by the relevant information affecting its activity, which significantly reduced the trial and error cost compared with the traditional experimental methods . The recbe added .E. coli while Cirsii Japonici Herba Carbonisata, Swertiae Herba and Callicarpae Formosanae Folium were effective to S. aureus. The water extract of Cirsii Japonici Herba Carbonisata showed apparent inhibition on E. coli, and the ethanol extract of Callicarpae Formosanae Folium had the best bacteriostatic effect on S. aureus. Cirsii Japonici Herba Carbonisata is a processed product of Cirsii Japonici Herba. At present, Cirsii Japonici Herba Carbonisata has been reported to contain a large number of organic acids and flavonoids. Quercetin, as a representative component of flavonoids, has been proved to inhibit a variety of bacteria, including E. coli and S. aureus (Platycodon grandiflorum. It contains many chemical components, including polysaccharides, coumarins, sterols, unsaturated fatty acids, and other components. Studies have shown that vanillic acid, β-sitosterol, and stigmasterol in Changii Radix have an apparent inhibitory effect on E. coli (S. aureus, E. coli, Salmonella, and Pseudomonas aeruginosa (S. aureus to a certain extent (In this paper, we firstly proposed that Cirsii Japonici Herba Carbonisata and Changii Radix had inhibitory effects on . aureus . Changii E. coli . The ingruginosa . Callican extent . The cruE. coli and anti-S. aureus activity were constructed with the characteristics of TCMs properties and families information. The prediction accuracy of the models was 75 and 60%, respectively. Using the constructed antibacterial model, we found four new antibacterial TCMs against E. coli and/or S. aureus. These models can predict the antibacterial activity of TCMs, which provides a scientific basis for the clinical application of TCMs antibiotics and the research and development of innovative drugs.This study analyzed the distribution of reported antibacterial TCMs based on frequency analysis and association rules. The results showed that the cold and bitter TCMs had good antibacterial activity. Furthermore, TCMs in rosids, asterids, Liliopsida, and Ranunculales had potential antibacterial TCM screening value. On this basis, the prediction models of anti-The original contributions presented in the study are included in the article/X-JF and XR conceived and designed the experiments, edited, and reviewed the manuscript. J-TL, Y-WW, M-YW, and C-XY performed the experiments. J-TL wrote the original draft. All authors have read, revised, and approved the final manuscript.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.


As emerging countries, China, Russia, and South Africa are establishing and/or improving their trauma systems. China has recently established a trauma system named “the Chinese Regional Trauma Care System” and covered over 200 million populations. It includes paramedic-staffed pre-hospital care, in-hospital care in certified trauma centers, trauma registry, quality assurance, continuous improvement and ongoing coverage of the entire Chinese territory. The Russian trauma system was formed in the first decade of the twenty-first century. Pre-hospital care is region-based, with a regional coordination center that determines which team will go to the scene and the nearest hospital where the victim should be transported. Physician-staffed ambulances are organized according to three levels of trauma severity corresponding to three levels of trauma centers where in-hospital care is managed by a trauma team. No national trauma registry exists in Russia. Improvements to the Russian trauma system have been scheduled. There is no unified trauma system in South Africa, and trauma care is organized by public and private emergency medical service in each province. During the pre-hospital care, paramedics provide basic or advanced life support services and transport the patients to the nearest hospital because of the limited number of trauma centers. In-hospital care is inclusive with a limited number of accredited trauma centers. In-hospital care is managed by emergency medicine with multidisciplinary care by the various specialties. There is no national trauma registry in South Africa. The South African trauma system is facing multiple challenges. An increase in financial support, training for primary emergency trauma care, and coordination of private sector, need to be planned.The online version contains supplementary material available at 10.1186/s13054-021-03681-8. Trauma is a worldwide public health issue with economic implications. Between 1980 and 2017 road injury was the sixth cause of death in 195 countries and territories . A revieThis article describes trauma systems in emerging countries, China, Russia, and South Africa.2  was created under the government’s auspices, and the first step called “100 Counties Project” was implemented  are located in smaller hospitals. In most trauma centers, there is no specialized “trauma surgery”. The in-hospital trauma care leadership can be assumed by orthopedic and general surgeons, emergency physicians, or other specialists. In level I trauma centers, multidisciplinary teams are available for trauma care management. The vast majority of Chinese provinces are now equipped with level I trauma centers and there is a government national plan to cover the whole territory Fig. c, d.In 2016, the CTRTA created a national trauma registry and databank. Level I trauma centers of the CRTCS are required to record clinical data of trauma patients. In 2021, more than 700,000 trauma patients had been registered. The management of the CRTCS is mainly led by the CTRTA and NCTM under the policy and auspices of the government. The CTRTA and NCTM have established standards for trauma care quality, including regular trauma training courses and meetings required for the certification of trauma centers every 3 years. The level I trauma centers are required to establish the quality control committee. The regular trauma meetings are required for reviewing the process of trauma care. The CTRTA will make regular review of trauma data for monitoring and improving the outcomes of trauma care.China has experienced several high-magnitude earthquakes during the twenty-first century such as the 2008 Wenchuan Earthquake and 2010 Yushu Earthquake that were associated with mass casualties. At those times no definitive trauma systems existed  [Russia covers an area of 17,125,191 kmulation) , and theulation) .The modern trauma system was formed in the first decade of the twenty-first century , the ambulance team arrives at the scene in 20 min only in 3.3% of cases, and the “golden hour” included only 74.4% of accidents . There aRussian trauma centers are located in multidisciplinary hospitals and divided into three levels. Patients with severe injuries are transported to level I and II trauma centers equipped to treat severely injured patients. Medical teams 24 h/day on duty consist of a trauma surgeon, a neurosurgeon, an intensive care physician, with the surgeon most commonly as team-leader.The Russian trauma system is directed and managed by the Ministry of Health. There is no national trauma registry. Each region collects information on the number of injuries according to the International Classification of Diseases codes and sends it to the Ministry of Health. Based on these data, decisions about improvement of trauma systems are made on the Russian Federation State level . ImproveIn the first 15 years of the twenty-first century, 879 people were victims of terrorist attacks in Russia, and more than 2300 were injured . The mosAnalysis of the 12,836 articles on terrorism contained in the database of the Russian Science Citation Index revealed that only 1.5% concerned medical aspects. The same analysis of the 18,334 articles on terrorism contained in the Scopus database revealed 22.7% of medical publications. This analysis outlined the weakness of Russian medical publications on terrorism and called for a better coordination between the three ministries [The development of aeromedical care is a prerequisite for the efficiency of the Russian health care system, owing to its specific climatic and demographic conditions. It is important both for remote areas and megacities. In Russia, the existing aeromedical service was initially carried out only by the Ministry for Civil Defence, Emergencies and Elimination of Consequences of Natural Disasters. The recent development of aeromedical services was initiated by the Ministry of Public Health and the Ministry of Industry and Trade under the instructions of the President of the Russian Federation.Joint Stock Company National Air Ambulance Service, an operator designed to provide emergency aeromedical care throughout Russia, was founded in 2017. The project to create the National Air Ambulance Service was initiated by Rostec State Corporation at the end of 2018. In 2019, 49 regions were involved, and in 2020 their number increased to 70. The cost is funded by the Obligate Medical Insurance fund, and additional resources for payment are issued from the budgets of the Russian Federation. Aviation evacuations from the scene to medical facilities represented 30.9% of cases in 2019 and inter-hospital aeromedical transportations accounted for 68.9%. The lack of a single system and organization that coordinates interaction between Ministries, air services and hospitals in each region, explains that existing aeromedical services are often not used or insufficiently used . The newIt is planned to implement new blocks of emergency care with separation in “red” zone for severe patients, “yellow” for patients of moderate severity and “green” for patients with isolated injuries. The fleet of ambulance cars is also being updated, and aeromedical helicopter numbers are increasing. The government has set targets to be achieved by the end of 2020. A reduction in mortality from road traffic injuries to 10 per 100,000 populations, was achieved by 2019. The next targets are bringing 80% of patients with polytrauma to level I and II trauma centers, and reducing the transportation time to less than 1 h.2 and nine provinces. Provincial health reports to a National Department in the public sphere caring for 84% of the population [South Africa has 58 million people spread across 1,221,037 kmpulation , 37. A fpulation . Trauma pulation , 40. TraHealth care is enshrined in the 2003 National Health Act, which requires provincial oversight of the health facilities, services and human resources in the nine provinces. Independently private hospital groups and Emergency Medical Services (EMS) have their own footprint . There iSince 1985 there is a national EMS telephone number (currently the 112) that routes to the nearest provincial EMS control center, allowing for coordinated dispatch of public paramedic-staffed ambulances and rescue services . This doSouth African aeromedical transportation combines private and public services. EMS use field triage which success is limited by major shortage of ALS providers, and patient flow protocols in public sector services . At the There are no trauma-only hospitals. Trauma Centers are accredited by the Trauma Society of South Africa (TSSA) , 46. TraThere is no national governance. Trauma management has a multi-factorial governance supervised by the government with professional buy-in, and both private and public compliance and dual-payor system. There is no national trauma registry, while regional and facility-based registries exist in academic facilities and private groups. The Health Professions Council, Nursing Council, TSSA and College of Surgeons define quality assurance and trauma qualifications , 48.South Africa is no stranger to major incidents and disasters, with earthquakes, floods, and mass casualty incidents commonplace , 50. DurDaily there are mass casualty incidents when minibuses used as taxis with 15–20 passengers, buses or heavy vehicles crash with numerous casualties that overload the pre-hospital and hospital system. Train crashes occur at least one or twice a year, often with 150–200 casualties. Industrial and mining incidents are also noted about 2–3 times annually . With thThe challenge remains that many public hospital emergency departments are staffed by non-doctors, junior doctors and lack senior leadership, especially at district level where the focus is on primary care, disease prevention, and public health. This leads to the need for phased up-referral to regional and tertiary/quaternary facilities, delaying definitive care to the most vulnerable of the population. Lack of beds and access to ICU facilities, competition from other surgical cases, notably Caesarian Section, delay surgical care at most hospitals , 47. TheA vibrant and competitive private sector component has developed within the private health care arena. The challenge here is that the fee-for-service private sector cares for about 15% of the South African population yet uses up to 50% of the healthcare gross domestic product. With the exception of a small number of accredited Private level I and II trauma units, currently found only in Cape Town, Durban, Pietermaritzburg & Johannesburg, where dedicated trauma wards and a trauma ICU have been established, most private hospitals have no specific trauma wards and patients are accommodated in the ward of the specialist caring for them , 47. AccTo date there is no national trauma databank or equivalent registry. There are facility-based registries and one large private hospital emergency registry, with disparate variables collected and different electronic platforms or even paper-based systems at the core . There iResearch on the trauma system in South Africa suggests improved return to work . But it A trauma system consists of call and dispatch centers, pre-hospital care, in-hospital care, regional trauma networks, trauma registry, rehabilitation, and quality assurance . ConsideIn China, due to the vast territory and an existing health-care system consisting of huge hospital resources with multidisciplinary capacities, the trauma system was conceived as regional, each region forming an inner trauma system as a part of the future national trauma system framework. High local population density, good economic conditions, dense ground transportation network, and the existing hospital resources were key determinants to select middle and eastern provinces as the first stage of the primary “CRTCS” Fig. c. Each rIn Russia, the level III/IV pre-hospital trauma system  was formIn South Africa, public and private health-care both contribute to province-based EMS but with no definite coordination protocol. The country has the best transportation network in Africa which contributes to facilitate ground EMS transportation. In-hospital care is inclusive and the number of accredited trauma centers is limited, resulting in most severely injured patients being transported to the nearest hospital. In-hospital care is managed by emergency medicine and multidisciplinary teams. Huge social disparities coming from the Apartheid period with persisting crowded townships in big cities, a vast territory with a relatively low density of population and lack of governmental priority for trauma care, explains why no unified trauma system currently exists in South Africa. An increase in financial support for trauma care, training in primary emergency trauma care, coordination and utilization of private health-care, also need to be planned.The construction of trauma systems in emerging countries is challenging, requires a thorough design and should be implemented according to a national plan. Flexible adjustments are adapted to specific country conditions. Trauma registry, often defective in the primary trauma system, is essential for the future developments and improvements in quality of care. Geographical, demographic and socio-economic conditions as well as communication network and financial input will markedly influence the development of trauma systems in emerging countries.References for this review were identified through searches of PubMed for articles published any date before February, 2021, by use of the terms “trauma system”, “trauma care”, “trauma center”, “pre-hospital care”, “in-hospital care”, “trauma registry”, “Chinese trauma system”, “Russian trauma system”, “South African trauma system”. Articles resulting from these searches and relevant references cited in those articles were reviewed. Articles published in English and Russian were included.Additional file 1. The Chinese trauma system: historical background.Additional file 2. The Russian trauma system: historical background.Additional file 3. The South African trauma system: historical background.


Serum kallistatin concentration was significantly higher in the SG (p < 0.001), while the level of afamin was significantly lower in this group (p < 0.001). In addition, a positive correlation was observed in the SG between the afamin concentration and the waist to hip ratio (WHR), lipid accumulation product (LAP) and the triglyceride glucose index (TyG index). In the CG, the concentration of kallistatin positively correlated with the LAP and TyG index, while the concentration of afamin positively correlated with all the examined parameters: body mass index (BMI), waist circumference (WC), hip circumference (HC), waist to hip ratio (WHtR), visceral adiposity index (VAI), LAP and TyG index. Serum kallistatin and afamin concentrations are associated with the anthropometric parameters related to being overweight and to obesity, especially to those describing the visceral distribution of adipose tissue and metabolic disorders related to excessive fatness.Extensive clinical and epidemiological evidence has linked obesity to a broad spectrum of cardiovascular disease (CVD), including coronary disease, heart failure, hypertension, cerebrovascular disease, atrial fibrillation, ventricular arrhythmias, and sudden death. In addition, increasing knowledge of regulatory peptides has allowed an assessment of their role in various non-communicable diseases, including CVD. The study assessed the concentration of kallistatin and afamin in the blood serum of patients after a myocardial infarction and without a cardiovascular event, and determined the relationship between the concentration of kallistatin and afamin and the anthropometric indicators of being overweight and of obesity in these groups. Serum kallistatin and afamin were quantified by ELISA tests in a cross-sectional study of 160 patients who were divided into two groups: study group (SG) ( Obesity is one of the major risk factors for cardiovascular disease (CVD) and many other chronic diseases, such as type 2 diabetes, dyslipidemia and hypertension . SeveralKallistatin, also known as serpin family A member 4, was first discovered in human serum as a tissue-kallikrein-binding protein and a unique serine proteinase inhibitor. The inhibitory effect of kallistatin on tissue kallikrein is blocked by its interaction with heparin . As a plHuman afamin is a glycoprotein that binds vitamin E (α-tocopherol) in human plasma. Blood afamin levels are associated with many diseases, such as obesity, pregnancy pathologies, polycystic ovary syndrome, type 2 diabetes, hypertension, and dyslipidemia . In addiDespite intensive research, the body of knowledge concerning kallistatin and afamin’s physiological and pathological properties in obese and myocardial infarction patients is still limited. Most studies assessing the relationship of kallistatin and afamin with being overweight and obese have been conducted in people with type 1 or 2 diabetes and animal models. No studies describe this relationship in patients after myocardial infarction hospitalized in the initial phase of a cardiac rehabilitation program, continuing exercise, dietary and pharmacological therapy. Moreover, our knowledge of the importance of regulatory peptides during cardiac convalescence is still insufficient, and their level in blood serum may become an important therapeutic target in the secondary prevention of CVD, especially in overweight or obese people. Therefore, the study aimed to assess the concentration of kallistatin and afamin in the blood serum of patients after myocardial infarction and without a cardiovascular event, and to determine the relationship between the concentration of kallistatin and afamin and the anthropometric indicators of being overweight and obese in these groups.The study was conducted in accordance with the Helsinki Declaration (updated in 2013). The study was approved by the Bioethics Committee of the Medical University of Lublin  (KE-0254/197/2017), and all respondents participating in the study gave their informed consent in writing. This cross-sectional study was conducted from August to December 2017 among 160 adults divided into two groups: the study group (SG) and the control group (CG).The study group (SG) consisted of patients post-myocardial infarction, hospitalized in the early period of cardiac rehabilitation (up to 14 days after discharge from the end of complete revascularization), continuing physical therapy, dietary and pharmacological therapy in two health and spa facilities in eastern Poland. The study included patients who met the inclusion criteria and provided informed consent to participate from subsequent convalescence stay. All patients in this group had had their first myocardial infarction and were treated with primary percutaneous coronary intervention (PCI). The inclusion criteria for the study group included: age 40–65 years, state after myocardial infarction, and consent to participate in the study in writing. Exclusion criteria included renal failure, cancer, history of lung disease or rheumatic disease, age under 40 and over 65. Other exclusion criteria included factors affecting serum kallistatin and afamin levels, such as dietary supplements, vitamin complexes, and alcohol dependence.The control group (CG) consisted of adults without a cardiovascular incident in the past, presenting for control and prophylactic examinations to an occupational medicine physician as part of periodic examinations. The respondents were recruited in an occupational medicine center in eastern Poland. Inclusion criteria for the study included: age between 40 and 65 years, no history of a cardiovascular event, alow 10-year risk of a cardiovascular event (SCORE < 5) , no chroBlood samples were taken from the ulnar vein in the morning on an empty stomach (7:00–9:00) after an overnight rest into a test tube with a clotting activator and a separating agent (granules), and delivered to the laboratory within 1 h. Until the blood was delivered to the laboratory, the samples were stored at 4 °C and protected from daylight. Plasma was separated by centrifugation at 3000 rpm for 10 min. After centrifugation, the sera were transferred to Eppendorftest tubes, immediately frozen, and stored at −80°C until analysis.The serum lipid profile , triglycerides (TG), HDL cholesterol (HDL-C)), glucose (FBG) and creatinine levels were determined using standard laboratory methods. LDL cholesterol was calculated from the Friedewald formula (when the concentration of TG < 400 mg/dL), eGFR (estimated glomerular filtration rate) from the Cockcroft-Gault formula, and non-HDL using the non-HDL = TC [mg/dL] formula—HDL-C [mg/dL] . The qua2)  × (TG × 0.81) × (1.52/HDL) for women and [WC/(39.68 + (1.88 × BMI))] × (TG/1.03) × (1.31/HDL) for men . The BAIThe interviews with the respondents and the physical examination were performed by nurses specially trained for the study purpose. Sociodemographic data  was obtained using standard questionnaires. A smoker was defined as a respondent who smoked at least one cigarette a month .t-test for continuous variables. Pearson correlations were used to investigate the relationships between the level of kallistatin, afamin and anthropometrics’ measurements. Moreover, linear regression was used to consider the influence of age, sex and smoking on the investigated relationships. The analysis of results is presented as a standardized beta coefficient with standard errors (SE). Due to skewed distribution, the logarithm transformation was applied. Statistical analyses were conducted using IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp. Statistical and Statistica 13 PL . A two-sided p < 0.05 was considered significant.Continuous variables were presented as means with standard deviation (SD) if normally distributed, or median with first quartile (Q1) and third quartile (Q3). The Kolmogorov–Smirnov test was used to assess conformity with a normal distribution. Categorical variables were reported as absolute numbers and percentages. Differences between groups were assessed with the chi-square test for categorical variables and the Mann–Whitney U and p > 0.05). Considering the anthropometric parameters describing the occurrence of overweight and obesity, SG was characterized by significantly higher values of BMI, WC, WHR, WHtR, VAI, LAP and TyG index compared to those observed in CG. The results of the biochemical tests are presented in the p < 0.001). At the same time, the level of afamin was significantly lower in this group (p < 0.001) compared to those without a cardiovascular event.r = 0.60), BMI and TyG index (r = 0.54), and LAP (r = 0.46) in the control group.Increasing knowledge regarding regulatory peptides allows for an assessment of their role in various non-communicable diseases, including CVD . This crYao et al.  revealedKallistatin was initially identified as an important factor in inhibiting inflammation, oxidative stress, fibrosis, and angiogenesis . HoweverThere are few studies assessing afamin concentration in the context of CVD. In a pilot study, Ward et al.  assessedSeveral studies showed a positive relationship between afamin concentration and obesity, e.g., in obese children , and chiAn extensive analysis of the literature has shown that few studies are assessing the relationship between kallistatin and afamin and obesity-related anthropometric indices in the group of patients after myocardial infarction. Second, an analysis of the available literature showed that, in the studies described so far, blood samples for the determination of kallistatin and afamin levels in patients with CAD were collected during the chronic phase of the disease or at the time of exacerbation of symptoms prior to PCI. Therefore, we conducted our study among patients during cardiac rehabilitation in the period of the body’s ongoing repair processes related to past MI.Nevertheless, this study has several limitations. First, it is a cross-sectional study and thus shows no cause–effect or time–effect relationship between kallistatin and afamin levels and obesity-related anthropometric parameters. Secondly, only basic sociodemographic and lifestyle data  were included in the models analyzed. Second, we included a relatively small number of patients per center, especially for SG. The third limitation of our study is the use of electrical bioimpedance analysis (BIA), which is an indirect method of assessing body composition; however, comparative studies have shown a significant correlation between data obtained from BIA measurements and body composition measured by densitometry, which is the gold standard for this type of study; however, it is associated with exposure to X-rays . The fouIn conclusion, in this study, higher concentrations of kallistatin and lower levels of afamin were observed in the group of patients after myocardial infarction, after PCI, during cardiac rehabilitation. Moreover, the concentration of kallistatin and afamin positively correlates with obesity-related anthropometric measures, especially those describing the excessive accumulation of abdominal fat (LAP) and obesity-related metabolic disorders (TyG index). Given the significant relationship between kallistatin and afamin levels and obesity-related anthropometric parameters, further studies in a larger group are required to investigate the relationships, taking into account the intermediary variables in these relationships, e.g., medications that the patient is taking. Nevertheless, conclusions from this study suggest that kallistatin and afamin, in combination with anthropometric indicators related to overweight and obesity, may play an important role duringrecovery in MI patients, and that the levels of these two regulatory proteins may become a therapeutic target. Therefore, after MI, overweight or obese patients are postulated to up-regulate kallistatin levels as it may be an important regulator in protecting post-MI injury and cardiac re-modeling. On the other hand, in the case of afamin, it is postulated to down-regulate its level because too high a level may result in excessive weight gain and thus an increase in the components of the metabolic syndrome, which is also associated with an increase in the number of risk factors for CVD, which is important in secondary prevention of CVC.


Background: There is a paucity of research on mediators of change, within compassion training programs. The aim was to investigate the mediators, of an 8-week compassion cultivation training (CCT) program, on the effect of psychological distress on caregivers of people with a mental illness.Method: Longitudinal path models in a randomized controlled trial (RCT). One hundred ninety-two participants were assessed for eligibility, and 161 participants were included into the trial and randomized. The main outcome was psychological distress measured by the Depression, Anxiety and Stress scale at 6 months. Mediators included self-compassion (SC), mindfulness (FM), emotion regulation (ER), emotion suppression (ES), and cognitive reappraisal (CR). Baseline, post, and 3- and 6-month follow-up measurements were collected.Results: The mediated effects for CCT are as follows: depression at 6 months: SC: −1.81 (95% CI: −3.31 to −0.31); FM: −1.98 (95% CI: −3.65 to −0.33); ER: −0.14 (95% CI: −1.31 to 1.02); anxiety at 6 months: SC: −0.71 (95% CI: −1.82 to 0.40); FM: −1.24 (95% CI: −2.39 to −0.09); ER: 0.18 (95% CI: −1.04 to 1.40); stress at 6 months: SC: −1.44 (95% CI: −2.84 to −0.05); FM: −2.17 (95% CI: −3.63 to −0.71); ER: −0.27 (95% CI: −1.51 to 0.98).Conclusion: Mindfulness and self-compassion are important components in reducing psychological distress experienced by informal caregivers of people with a mental illness. Results contribute to the knowledge about the underlying mechanisms of CCT. Poor mental health is on the rise , and theDespite growing evidence, the processes underlying treatment response remain unclear . In factFour RCTs investigated mediators of an 8-week Mindfulness-Based Stress Reduction (MBSR) program on anxiety disorders . ResultsWe recently published a trial showing effect on mental health of a compassion cultivation training (CCT) program in informal caregivers of people with a mental illness . The RCTTherefore, the expected link between intervention activities, mediators, and outcomes can be depicted by use of a logic model , 14. It We therefore hypothesized that training in mindfulness allowed for informal caregivers to become aware of what they were currently experiencing , and traThe current study design is a longitudinal path model in an RCT. This is a secondary mediation analysis of a published RCT  comparinA computer algorithm with predefined concealed random numbers was used for the block randomization with 40 participants in each block all randomized at the same time. To be included in the RCT, participants had to be an informal caregiver  , betweenN = 79 were randomized into the intervention group, and N = 82 were randomized into the waitlist control group [see Hansen et al.  were not blinded to group assignment when analyzing the data.r = 0.97, which is very high between the SCS-26 and the SCS-12 for a total score of self-compassion. The 15-item Five Facet Mindfulness Questionnaire (FFMQ-15) , which measures symptoms of depression, anxiety, and stress . The intFFMQ-15)  is desigFFMQ-15) . Lastly FFMQ-15) . ERQ cogFFMQ-15) . Danish We analyzed the data using autoregressive models, with four time points of measurement and contemporaneous and constant b paths , 27 Fig. The datWe adjusted at baseline for the mediators and outcome values for the following covariates in the models: sex, age, educational level, years as informal caretaker, schizophrenia, and anxiety (diagnosis of loved one). We allowed for correlations between baseline mediator and outcome measurements errors in order to prevent contamination of the b paths and allowed for correlations of the errors of the mediator and outcome measurements over time. In the model with multiple mediators, we allowed for contemporaneous correlations between the errors of the mediator measurements.via all paths from randomization to outcome .In order to estimate the mediated effect of CCT on outcomes at 6 months in the model with single mediators, we first identified all paths that went from randomization to outcome at 6 months through any measure of the mediator and for each type of mediator. We multiplied the coefficients within each of these paths and added the path specific products to obtain the mediated effect. In the model with multiple mediators, there were five types of mediated effects: mediated, only by FM, only by SC, only by ER, by FM and ER, and by SC and ER. For each of these, we identified the relevant path and proceeded as above. The unmediated effect was estimated based on paths from randomization to outcome at 6 months not passing a mediator . The total effect was the combined effect We estimated the 95% CIs of the results of the overall a paths, the mediated, the unmediated, and the total effect, by use of 50 bootstrap replications. The goodness of fit of the models was tested by the chi-squared test, the comparative fit index (CFI), and the root mean squared error of approximation (RMSEA). We used the following criteria to evaluate model fit; a CFI above 0.90 indicates a good model fit. An RMSEA below 0.08 indicates an acceptable model fit, and an RMSEA below 0.05 indicates a good model fit –29.Results of the single mediation model showed that SC, FM, and ER all had a statistically significant overall mediated effect for CCT on depression at the 6-month follow-up . ResultsResults of the multiple-mediator model including SC, FM, and ER  showed tAll the models with symptoms of anxiety as outcome did not show statistically significant total effects . HoweverLastly, the single model with SC, FM, and ER as mediators showed statistically significant mediated effects on symptoms of stress, and the total effects were statistically significant . ResultsResults of the multiple-mediator model including SC, FM, and ER  showed tWe found strong indications for mindfulness and self-compassion as mediators of the effect of CCT on symptoms of depression and stress at the 6-month follow-up in caregivers of people with mental illness. Regarding symptoms of anxiety, we only found indication for mindfulness as the mediator. We found no support for our hypothesis regarding emotion regulation (ER and ES) as mediators, and mediation of emotion regulation through mindfulness or self-compassion was also not found.A systematic review  investigContrary to these findings, our study suggests that cognitive emotion regulation strategies are not mediating effects in decreasing psychological distress and that self-compassion and mindfulness are. Taken together, these results may suggest that self-compassion and mindfulness are not cognitive emotion-regulating strategies but may be thought of as self-regulating or implicit emotion regulating strategies .Vago and Silbersweig  proposedIn the light of the above framework, caregivers are motivated to learn skills to take better care of their own mental health, with an intention to do so by completing an intervention. During the intervention, they practice increasing and regulating attention and emotions toward kindness and compassion. This leads to a shift from external to internal awareness, and experiencing the benefits of mindfulness and compassion training from the inside. The educational component of compassion throughout the course helps caregivers understand that suffering is universal. Acknowledging and holding the suffering in a mindful and self-compassionate atmosphere may lead to the reduced symptoms of stress, anxiety, and depression. Furthermore, while biased cognition often directs a person to isolation, blame, and judgment, being in a group offers an opportunity for kindness and connection toward self and others. Therefore, as emotions are co-regulated through interactions, we suggest that learning in a group may also impact the caregivers' ability to reduce suffering.This is the first study to date that has investigated multiple mediators of the manualized CCT program, on symptoms of depression, anxiety, and stress. We investigated four potential mediators, established a timeline with four time points, and used a theory as an underlying guide. In addition, we analyzed the mediated and unmediated effects simultaneous by use of longitudinal path models in an RCT design inspired by Goldsmith et al. . IncludiWe assumed the relationship between mediator and outcome  to be reasonably consistent over time. Hence, we made the b paths equal as constant b paths should provide a more precise estimation . We chooWe did not find statistically significant total effects on anxiety at 6 months . In our Unfortunately, it was not feasible to adjust for measurement errors of latent variables as suggested by Goldsmith et al. . As theyMindfulness and self-compassion are important components in reducing the psychological distress experienced by caregivers of people with a mental illness. These results contribute to the knowledge about the underlying mechanisms of a CCT program.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Central Denmark Region Committee of Health Research Ethics (De Videnskabsetiske Komitéer for Region Midtjylland) with approval 238/2017. The patients/participants provided their written informed consent to participate in this study.NH, LF, MF, and LJ developed the study concept and study design. Data collection was performed by NH, LJ, and MF performed the data analysis and interpretation. NH drafted the manuscript and LJ and LF provided critical revisions. All authors approved the final version of the manuscript for submission.This work was partially supported by grants from Trygfonden (LJ: ID: 117789) and the Novo Nordisk Foundation (LJ: ID: NNF15OC0018140).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.


Ankle-brachial index (ABI) and toe-brachial index (TBI) are the recommended tests for the diagnosis of lower extremity peripheral artery disease (PAD) and the assessment of its severity, whereas Doppler ultrasound (DUS) is usually used to localize vascular lesions. However, the performance of DUS as an alternative to TBI and ABI measurement is unknown.The goals were (i) to evaluate the correlation between DUS parameters of distal arteries of the lower extremities with TBI in patients with PAD; (ii) to evaluate the correlation between DUS parameters of distal arteries with ABI; and (iii) to assess the diagnostic accuracy of maximal acceleration time of pedal arteries to detect toe pressure ≤30 mmHg.An observational retrospective study was conducted for 1 year on patients with the diagnosis of PAD on DUS. Demographic data, ABI, TBI, and DUS parameters of the dorsal pedis and lateral plantar arteries (DPA and LPA) were recorded.max) was the most correlated to TBI on both univariate  and multivariate analysis (p < 0.0001). DUS parameters had a weaker correlation with ABI. ATmax > 215 ms showed high diagnosis accuracy to a toe pressure of 30 mmHg or less [sensitivity of 86% [0.57–0.98] and negative predictive value of 97% [0.89–1.00]].Seventy-seven patients with 88 limbs were included, aged 69 [interquartile range: 11 years] with 28.6% of diabetic patients. The highest acceleration time of either DPA or LPA (ATmax demonstrates a high correlation with TBI in patients with PAD, and high diagnostic accuracy for detection of critical limb ischemia. Based on these results, ATmax can represent the next step in evaluating PAD severity with DUS, in patients with advanced lower extremity PAD.AT Lower extremity peripheral artery disease (PAD) is a major burden worldwide, with a steady and significant increase in prevalence over the last decades , 2. PAD Ankle-brachial index (ABI) and toe-brachial index (TBI) are both accepted methods for diagnosing and assessing PAD severity, as a reflection of lower extremity perfusion . ABI is Arterial duplex ultrasound (DUS) has shown a good correlation with angiography on iliac and femoral arteries, but remained weak on distal arteries . Hence, Therefore, this study (i) evaluates the correlation between Doppler ultrasound of distal arteries of the lower extremities  with TBI, in patients with occlusive PAD; (ii) evaluates the correlation between DW parameters of distal arteries of the lower extremities with ABI; and (iii) assesses the diagnostic accuracy of the highest acceleration time of pedal arteries to detect toe pressure ≤30 mmHg.A retrospective study was conducted between January 1 and December 31, 2020 in a single university hospital, from consecutive patients, addressed to our vascular medicine unit for diagnosis or follow-up of PAD.Diagnosis of occlusive PAD was the only inclusion criterion. Diagnosis of PAD was based on the Doppler ultrasound criteria and is given below. For patients with occlusive PAD on both lower limbs, each limb was included separately.Proximal occlusive PAD was defined as occlusion of at least one of the following arteries: aorta or common iliac artery, external iliac artery or common femoral artery, femoral superficial artery, or popliteal artery, diagnosed or confirmed by DUS. Patients with occluded iliac or femoral artery bypass were also included in the study. Patients with distal PAD (stenosis and/or occlusion of at least one of below-the-knee arteries) and/or proximal non-occlusive PAD  were not included.Exclusion criteria were: age under 18 years old, toe or more proximal amputation, protected adults, history of arterial revascularization procedures on the included lower limb causing permeability of arterial axis for the aorta to the popliteal artery.2). For this study, patients were considered as a non-smoker if they had never smoked or declared at least 1-year tobacco cessation. Otherwise, they were considered active smokers.The following demographics data were obtained from the patient electronic medical record: age, gender, declared walking distance before pain, tobacco habits, arterial blood pressure, history of hypercholesterolemia, diabetes, and or severe to terminal chronic kidney failure .All measures were performed by vascular physicians .Patients were scanned in decubitus position. Duplex Doppler ultrasound imaging was performed using a GE Vivid E95  or a Siemens Sequoia . A 4–9 MHz linear array transducer was used for popliteal, fibular, anterior, and posterior tibial arteries, and a 5–14 MHz one for the dorsalis pedis artery (DPA) and LPA. Each ultrasound probe was covered with transmitting gel. Pulsed Doppler waveforms were obtained from a longitudinal slice of the studied artery, with a Doppler color box size adjusted to the size of the vessel. The emission sound beam was placed to be parallel to the flow direction of the vessel. The Doppler sample was obtained at 60° or less, with a volume applied to the center of each artery with a spectral Doppler scrolling of 66 mm/s. Peak-systolic velocity (PSV) and end-diastolic velocity (EDV) were measured manually and expressed in cm/s. Resistivity index (RI), without unit, was calculated as lic peak , 10  with the patient in a supine position after at least 10-min of rest. Blood pressure cuffs were adapted to the weight and height of the patient (10-cm or 12-cm cuff).Bilateral systolic blood pressure (SBP) on the dorsalis pedis artery and the posterior tibial artery was measured with an 8-MHz continuous Doppler probe  and a sphygmomanometer . If blood flow was still detected with a pressure cuff inflation of 250 mmHg or more, arteries were considered as “incompressible.” The value of 250 mmHg was considered as relevant as previously described in international recommendations , with hiAnkle-brachial index (ABI) was then calculated by dividing the highest value of the two SBPs of the leg by the highest value of the right and left arm SBPs .Toe blood pressures were measured by a Laser Doppler flowmetry, using an automatic measure device , and TBI was calculated by dividing the toe pressure by the highest value of right and left arm SBPs. Pressure measurement was conducted according to the instructions of the manufacturer and as described in the literature . A pressThe performer of TBI was not blind to the DW measurements but due to automatic measuring of TBI, we consider the ranking bias to be minimal.max, ATmean, and ATmin, respectively).The following DW parameters were studied: PSV, EDV, RI, and AT on both DPA and LPA, the sum of PSV (from DPA and LPA), highest, lowest, and mean value of AT between DPA and LPA  with TBI in patients with occlusive PAD, on both univariate and multivariate analyses. Age and ABI (as known marker/risk factor of PAD) were also compared to TBI.Our second objective was to evaluate the diagnostic accuracy of the most TBI-correlated variable to detect toe pressure ≤30 mmHg.www.R-project.org), using the R studio interface. Because this cohort was not derived from random selection, all statistics are deemed to be descriptive. No imputation was made for missing data. Continuous variables are expressed as means and interquartile range (IQR), defined as the first and third quartiles. Categorical variables are expressed as counts and percentages. To evaluate the concordance of the Doppler measures, the correlation of DW parameters between contiguous arteries  was tested by Pearson's correlation. Pearson's correlation test was used to correlate Doppler waveform measures with TBI for univariate analysis. All quantitative variables had a normal distribution with no outliers, validating Pearson's correlation test. A Pearson's correlation >0.68 is considered a strong/excellent correlation   known risk factors of PAD in literature  (tobaccoctor ≥5) .p < 0.05. No indeterminate results were recorded.Receiver operating characteristics (ROC) curve represented sensitivity vs. 1—specificity  of the highest acceleration time of pedal arteries according to the presence or absence of toe pressure ≤30 mmHg; and was used to optimal cut-off value to detect toe pressure ≤30 mmHg. The area under the ROC curve (AUC) was used to measure the accuracy of the highest acceleration time of pedal arteries to detect toe pressure ≤30 mmHg. Significance was accepted for value of A total of 92 patients were screened. Six were excluded for the absence of toe pressure measurements, and nine were excluded for the absence of recording of either dorsal pedis artery or LPA. Seventy-seven patients were finally included with a total of 88 limbs.Patient characteristics are summarized in r = −0.75 and −0.75, respectively).r = −0.78). The highest correlation to TBI comes about with the highest value of AT between DPA and LPA  (AT 0.0001) .Regarding our second objective, every DW parameter significantly correlated to TBI was also to ABI but correlation coefficients were systematically lower.max) statistically differs according to the presence or absence of toe pressure ≤30 mmHg: 171.4 vs. 259.7 ms, respectively, p < 0.0001). Diagnosis accuracy of ATmax is high with an area under curve of 0.89 [95% CI [0.81–0.98]]   and imaging, such as CT angiogram, magnetic resonance angiogram, and DUS , 15–17. ia (CLI) . ATmax wAcceleration time seems to be more and more described in the literature as associated with PAD. For example, in 2020, Yagyu et al. published that the acceleration time ratio between the popliteal  and the common femoral artery was highly predictive of femoropopliteal artery lesions with an AUC of 0.93 . RecentlIn our study with patients with occlusive PAD, no DW variable showed a high correlation with ABI. This result is understandable considering the low sensibility of ABI in this population , 6, 25. r = −0.75 and −0.75, respectively). This led us to the conclusion that the highest value of acceleration time of either pedal artery (ATmax) allowed us to moderately increase the correlation (r = −0.78) but also to have a satisfying measure for every included patient. Considering PAT or DAT, missing values were recorded in 22.7 and 21.6% of our population, respectively, due to arterial occlusion. These results could perhaps be explained by the fact that our included patients had more severe PAD. When we considered the highest acceleration time, ATmax could be measured in all our patients as none presented concomitant dorsal and plantar arterial occlusion. On multivariable analysis , ATmax remained highly associated with TBI (p < 0.001).Our results are not consistent with those of Sommerset et al.  as, in oTo help categorize PAD severity through DW, recent studies have studied the benefit and reproducibility of a 13-category arterial Doppler waveform classification, called the “Saint Bonnet classification” , 27.mean) and lowest (ATmin) acceleration time on pedal arteries show strong correlations with TBI. These results need to be replicated on the wider population to confirm the superiority of ATmax compared to ATmean and ATmin.Even if the highest value of acceleration time on pedal arteries showed the best correlation to TBI, mean . However, this study was a proof of concept study and this preliminary result should be validated by a prospective study including a larger number of patients. Second, the prognosis value of ATmax was not evaluated in this work since no patient follow-up was performed. This was not the aim of the study but further studies are required. Third, all ABI and TBI measures were performed by three vascular physicians and intraindividual variability was not evaluated. However, these measures were performed by highly trained and experienced vascular physicians. Moreover, TBI reproducibility could be considered satisfactory due to automatic measuring.Several limitations in this study should be addressed. First, the study was retrospective which cannot provide exhaustive bias control. The number of included patients is modest  is highly correlated to TBI in patients with occlusive PAD. ATmax with a cut-off value of 215 ms could represent a step forward for the diagnosis of toe pressure ≤30 mmHg, one of the criteria of critical limb ischemia. This measure might be of great interest to clinicians who do not have access to TBI.This study suggests that the highest acceleration time of either DPA or LPA (ATMore studies are needed to confirm if the highest acceleration time of pedal arteries is more predictive of PAD severity than plantar acceleration time alone; and confirm the optimal cut-off value for detecting critical limb ischemia.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.J-ET, GM, MC, CT, VC, JG, and DL: conception and design, revising, approval for publication, and agree to be accountable for all aspects of the work. J-ET, GM, JG, DL, and CT: data analysis. J-ET, GM, DL, and MC: drafting. All authors contributed to the article and approved the submitted version.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.