A combination of clinical study and Network Pharmacology approach to explore the efficacy and mechanism of Buxue Yimu Pills on gynecological anemia

A combination of clinical study and Network Pharmacology approach to explore the efficacy and mechanism of Buxue Yimu Pills on gynecological anemia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research A combination of clinical study and Network Pharmacology approach to explore the efficacy and mechanism of Buxue Yimu Pills on gynecological anemia Yanfang Wang, Yan Deng, Ruilin Ma, Dong Liu, Bin Luo, Xue Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-38583/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Iron supplement is the first-line treatment for gynecological anemia (GA). However, its performance is limited by common gastrointestinal reactions and some inadequate responses. Traditional Chinese medicine (TCM) has a long history in the treatment of gynecological conditions but has been restricted by limited high-quality research, unknown bioactive ingredients, and mechanisms. Objectives These studies aim to compare the clinical efficacy of Buxue Yimu Pills (BYP),ferrous sulfate, and the addition of BYP to ferrous sulfate on GA through oral administration, and to investigate the mechanisms of BYP using network pharmacology approach. Design: Prospective, open-label, comparative, randomized, multicenter clinical trial. Setting: Gynecology departments in three public hospitals. Patients: 170 patients with hemoglobin of 70–110 g/L were recruited and randomized into three groups: BYP group, oral iron group, and combined BYP & oral iron group. After a four-week treatment, the complete blood count (CBC) along with the markers for iron metabolism were determined for 138 patients. Furthermore, network pharmacology was performed to identify the active ingredients and potential mechanisms of BYP. Results While iron-treated groups showed elevated hemoglobin in accompany with significant changes in iron metabolism biomarkers, the BYP group exhibited hemoglobin improvement without apparent changes in iron metabolism markers. The network pharmacology identified 27 bioactive compounds and 145 targets of BYP on GA. A number of biological processes and pathways were identified, including regulation of inflammation, regulation of steroid hormone, angiogenesis and hemostasis, response to decreased oxygen levels, effects on myeloma cell, and response to metal ions. Conclusions BYP contributes to the practical improvement of gynecological anemia potentially through multi-target mechanisms independent from increasing hemopoietic raw material-iron. Clinical Pharmacology Obstetrics & Gynecology Traditional Chinese medicine Buxue Yimu Pills gynecological anemia network pharmacology multi-target mechanism Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Anemia, one of the major public health issues worldwide, affects about one-quarter of the world’s population, especially among preschool children and young women 1 . There are many common gynecologic diseases associated with anemia 2 , such as uterine fibroids, adenomyosis, endometrial polyps, ovulation disorders, ectopic pregnancy, and abortion, affecting especially young women 3 . Besides, cancer-related anemia and therapy-induced anemia are common in patients with gynecological malignancies 4 – 6 . Oral or intravenous iron supplements is the major therapeutic approach, while its common gastrointestinal side effects, including nausea, constipation, and diarrhea, can lower patient compliance. Over 40% of reproductive age women were reported to fail to adhere to medication 7 . Moreover, patients with gynecological anemia (GA) have been observed to be associated with inflammatory states 8 , causing limited iron absorption and utilization 9 , 10 . Therefore, the exploration of alternative treatment options is encouraged. Traditional Chinese medicine (TCM) has been utilized to treat gynecological diseases and anemia for a long time, showing high safety, tolerability, and compliance even among the patients with malignancy, chronic kidney disease as well as the elderly 11 . Due to the lack of high-quality randomized controlled trial (RCT) evidence and intensive study, the efficacy and therapeutic mechanisms of TCMs have yet to be well understood or appreciated. Buxue Yimu Pills (BYP), a TCM with primary efficacy of Qi-reinforcing and nourishing blood, consists of Angelicae Sinensis Radix (Danggui) , Hedysarum Multijugum Maxim (Huangqi) , Colla Corii Asini (Ejiao) , Leonuri Herba (Yimucao) , and Citrus Reticulata (Chenpi) according to Pharmacopoeia of the People’s Republic of China. Previous studies have shown that Yimucao promoted uterine contractions, thus reducing vaginal bleeding; Ejiao , Danggui , Huangqi , and Chenpi could benefit Qi, activate blood circulation and promote hematopoiesis 12 ; Huangqi and Danggui exerted anti-inflammatory effects 13 , 14 . Therefore, we hypothesized that BYP could treat GA through a variety of mechanisms. To comprehensively assess its clinical effect and herbal pharmacological mechanisms, we performed a randomized clinical trial at three centers, followed by a network pharmacology research. Materials And Methods Clinical study Experimental design and setting. To compare the effects of Buxue Yimu Pills (BYP), ferrous sulfate, and a combination of both treatments on GA, a prospective, randomized controlled trial was conducted between 2017 and 2019 at Gynecology departments of three public hospitals, including Peking Union Medical College Hospital (PUMCH), West China Hospital of Sichuan University, and Hangzhou Maternity and Child Health Care Hospital. This study was approved by the Ethics Committee of PUMCH (No. ZS-1254) at January 2017, and registered at the United States National Institutes of Health (registration number NCT03232554, www.clinicaltrials.gov). Patients Adult females aged 18–50 years with hemoglobin of 70-110 g/L associated with gynecological disorders were enrolled following the informed consent. Exclusion criteria were: (1) patients with uncontrolled gastrointestinal inflammation or bleeding or urological bleeding; (2) patients presented with other diseases leading to iron deficiency; (3) pregnant women; (4) patients complicated with mental abnormalities or other severe diseases; (5) patients with a history of malignancy, chemotherapy or radiotherapy; (6) patients treated with iron supplements, blood transfusion or participating in any other clinical trial within the past month. Eligible participants were randomized into three groups: BYP group received Buxue Yimu Pills (24 g/day); oral iron group received ferrous sulfate tablets (0.9 g/day), and BYP & oral iron group received both drugs above simultaneously. All drugs were provided by ZhuZhou QianJin Pharmaceutical Co., Ltd. The total treatment periods were four weeks. Assessments Assessments were scheduled pre-and post-treatment. A basic physical examination including vital signs, weight, height, body mass index (BMI), blood pressure was performed. Venous blood samples were collected to detect complete blood count, including hemoglobin (Hb), mean cellular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red blood cells (RBC), hematocrit (HCT), reticulocyte (RET) count. Iron indexes of serum iron (SI), serum ferritin (SF), and total iron-binding capacity (TIBC) were analyzed. Moreover, the safety assessment, including liver function, renal function, and a blood coagulation index, were also evaluated (data not shown). Statistical analysis Statistical analysis was carried out using SPSS version 20.0 (IBM). Data from normally distributed parameters are presented as means plus or minus standard deviation (SD); paired t-tests were used to compare the intragroup difference pre- and post-treatment, and one-way analysis of variance (ANOVA) was applied for intergroup comparisons. Variables not normally distributed are expressed as median plus 25-75 interquartile range (IQR); intragroup and intergroup comparisons were evaluated with Wilcoxon matched-pairs signed-rank tests and Kruskal-Wallis tests. A p -value of less than 0.05 (p < 0.05) was considered significant in all statistical analyses. Network pharmacology analysis Bioactive compounds and compound targets of Buxue Yimu Pills Composite compounds were searched manually with the major ingredients of BYP “ Angelicae Sinensis Radix ”, “ Hedysarum Multijugum Maxim ”, “ Colla Corii Asini ”, “ Leonuri Herba ” and “ Citrus Reticulata ”, in Traditional Chinese Medicine System Pharmacology Database and Analysis Platform (TcmSP, http://lsp.nwu.edu.cn/tcmsp.php ) 3 , and Database of Traditional Chinese Medicine and chemical composition from Shanghai Institute of Organic Chemistry ( http://www.organchem.csdb.cn/scdb/main/tcm_introduce.asp ). Next, a combination of oral bioavailability ≥ 30% along with drug-likeness ≥0.18 was applied to explore the bioactive compounds. Potential treatment targets of those bioactive compounds were subsequently obtained from TcmSP; and converted to target genes with official symbols using Uniprot Knowledgebase ( http://www.uniprot.org/ ). Target genes of GA GA-associated targets were retrieved from the Online Mendelian Inheritance in Man (OMIM) database ( https://www.omim.org/ ) and GeneCard Database ( https://www.genecards.org/ ), using “gynecological anemia ”as the keyword. Data were extracted and summarized without duplication. Network construction Potential therapeutic targets are the intersections between the compound targets of BYP and GA-associated targets, which were generated with the VennDiagram R package. After importing the main ingredients, bioactive compounds, and potential therapeutic targets, the compound-target-disease network was built and visualized by Cytoscape software (version 3.6.1, http://cytoscape.org/ ). Functional analysis Based on the obtained potential therapeutic targets, enrichment analysis was performed using the online tool Metascape ( https://metascape.org ) 15 , including Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. A protein-protein interaction (PPI) network was constructed via STRING (Version 11.0, https://string-db.org/ ) with a minimum required interaction score of 0.400. We subsequently used the Molecular Complex Detection tool (MCODE) plugin to identify significant clusters in this PPI network. Results Baseline characteristics Out of 170 enrolled patients with GA,138 patients (81.2%) completed the four-week treatment and were included in the data analysis: BYP group (n=58), oral iron group (n=37), and the combination group (n=43). The baseline characteristics of all three groups showed no statistical difference (Table 1). Laboratory parameters Table 2 shows the values of laboratory parameters before and after treatment. After four weeks of treatment, patients in three groups exhibited a significant increase in Hb, RBC, and HCT (p<0.01), but no significant differences in RET. The changes of Hb (g/L) are listed in the following: BYP group (16.44±14.12), oral iron group (30.84±15.46), and the combination group (37.82±16.9). Pairwise comparison show there are statistically significant differences between BYP group and oral iron group (p<0.01) or BYP group and the combination group (p<0.01), while differences between the two iron-containing groups were not remarkable (p=0.062) (Figure 1). According to the iron indexes, it is expected that there were significant increases in SI and SF accompanied by a substantial decrease in TIBC in the oral iron group (p0.05). However, unexpectedly, the combination group, whose Hb was improved most significantly after treatment, showed noticeable increases in SI and SF but no apparent change in TIBC. Compound-target-disease network Thirty-two molecules, the bioactive compounds, with oral bioavailability ≥ 30% and drug-likeness ≥0.18 were identified through network pharmacology analysis (Table 3), which belongs to the ingredients of Huangqi (20), Yimucao (8), Chenpi (5), and Danggui (2), respectively. Kaempferol (MOL000422, a unique given ID from TcmSP), quercetin (MOL000098), and isorhamnetin (MOL000354) are the three components common in Huangqi and Yimucao . ZINC14758732 (MOL000438), Jaranol (MOL000239), isoflavanone (MOL000398), isomucronulatol-7,2'-di-O-glucosiole (MOL000439), and 5'-hydroxyiso-muronulatol-2',5'-di-O-glucoside (MOL000374) in Huangqi were not included in this network. 1657 potential treatment targets of BYP with official symbols and 270 target genes of GA were identified, among which a number of 145 genes intersected (Figure 2(a)). The compound-target-disease network was constructed with 818 nodes and 1436 connecting edges and shown in Figure 2(b). After analyzing the network with the NetworkAnalyzer plugin in Cytoscape, quercetin (MOL000098, mol17), which is shared by Huangqi and Yimucao , was identified as the most important compound with the overwhelmingly highest degree of 107. Evidence from previous studies has shown that quercetin can improve inflammation and chemotherapy-related anemia through reducing oxidative stress, ameliorating the iron status and protecting red blood cells 16-18 . Functional analysis Figure 3 shows the results of functional enrichment analysis: KEGG pathway, Gene Ontology Biological Process (GOBP), Gene Ontology Cellular Component (GOCC), and Gene Ontology Molecular Function (GOMF), which were mostly associated with cancer, inflammation, steroid hormone regulation, oxidative stress, metabolic syndrome, nervous system diseases, and infectious diseases. Many of these terms are too general for annotation, so we took a deeper insight into their child function clusters and further summarized the biological processes into several underlying functional modules: regulation of inflammation, regulation of steroid hormone, angiogenesis and hemostasis, response to decreased oxygen levels, effects on myeloma cell and response to metal ion (Supplementary Table1). The biological processes with the highest enrichment score in each module were selected to build a compound-target-underlying biological process network (Figure 4), with 139 nodes, 483 edges. Protein-protein interaction (PPI) network of intersecting targets was constructed with STRING, including 145 nodes and 3196 edges (Figure 5 (a)). According to the selection criteria of MCODE scores ≥ 5, degree cutoff = 2, node score cutoff = 0.2, K- core = 2, and max depth = 100, a total of 6 significant clusters were identified (Figure 5(b), Supplementary Table 2). Discussion Consistent with previous studies, after four-week treatment, patients taking ferrous sulfate or ferrous sulfate &BYP showed an elevation of Hb in accompany with significant changes in iron metabolism markers, typically with elevated SI, Fer, and decreased TIBC (oral iron group). One unexpected finding was that we did not find a significant decline of TIBC in the combination group, even though it did show a most significant increase in Hb. BYP group also exhibited hemoglobin improvement without obvious changes in iron metabolism markers. This result may be explained by the fact that patients with GA are commonly found to have several closely related features: abnormal uterine bleeding (AUB), iron deficiency anemia (IDA), chronic inflammatory state 19 . On the one hand, an inflammatory state can upregulate the level of hepcidin, a liver-specific peptide, increasing the degradation of ferroportin (FPN) at enterocytes, hepatocytes, and macrophages, leading to iron overload in nonhematopoietic cells but the iron deficiency in erythroid precursors 20 . In addition, chronic inflammation can cause unbalanced blood production of hematopoietic stem cells (HSCs), impaired HSC self-renewal as well as impaired erythroid production 21 – 23 . The previous study has found a negative correlation between Hb concentration and inflammatory markers, especially interleukin 6 (IL-6) 9 . As mentioned before, Buxue Yimu Pills can reinforce qi and nourish the blood, whose main components have previously been observed to have different efficacies of promoting hematopoiesis and anti-inflammatory effects 12 – 14 . After treatment, with decreased inflammation and increased hematopoiesis, iron in nonhematopoietic cells can be transported to erythroid precursors more efficiently; subsequently, levels of circulating iron decrease. As a consequence, we did observe a slight upward trend of TIBC in the BYP group and an offsetting decline of TIBC in the combination group, while Hb in both groups elevated. We also used network pharmacology technology to investigate the mechanisms of Buxue Yimu Pills further. From the compound-target-disease network, 27 bioactive compounds in Buxue Yimu Pills were identified, among which quercetin, a common component of Huangqi and Yimucao , may play a critical role. One hundred forty-five potential therapeutic targets of these compounds were confirmed. Biological process and pathway enrichment analysis demonstrated that multiple mechanisms including regulation of inflammation, regulation of steroid hormone, angiogenesis and hemostasis, response to decreased oxygen levels, effects on myeloma cell as well as response to metal ions, may contribute to improving GA. Previous studies have demonstrated that reduction of inflammation and oxidative stress can alleviate the absorption and utilization of iron, increase the production of erythropoietin (EPO) and improve hematopoietic function 24 , 25 . Metal ion transmembrane transport contributed to iron uptake and maintenance of iron homeostasis 26 , 27 . In addition, ovulation disorders and coagulation dysfunction have been the main nonstructural etiologies of AUB 28 , 29 . Therefore, the regulation of steroid hormone and hemostasis can have significant implications for this condiction. Since Buxue Yimu Pills may improve anemia through multiple targets, it could have potential applications in diseases needing to deal with oxidative stress damage, such as thalassemia and inflammatory anemia. But on the other hand, one crucial point that needs to be raised is that reduction of oxidative stress might reduce the therapeutic efficacy of anti-neoplastic drugs acting through mechanisms of reactive oxygen species (ROS)-induced injury 30 , which was also indicated in KEGG enrichment (hsa01524, platinum drug resistance). Therefore, Buxue Yimu Pills may not be recommended to patients undergoing cancer treatment. Conclusion A combination of clinical study and network pharmacology approaches not only demonstrates that Buxue Yimu Pills contributes to the effective improvement of GA through multiple mechanisms but also provides us more comprehensive insights into integrated multidimensional relationships between drugs and diseases. Finally, some limitations need to be acknowledged. The sample size and the follow-up duration may have been insufficient to reveal apparent differences between cohorts, and inflammatory indicators were not monitored. Accordingly, based on the results of our study, continued efforts are needed to further verification through larger-scale, more prolonged follow-up cohort research with targeted designs, as well as molecular mechanism studies. Abbreviations ANOVA:one-way analysis of variance; AUB: abnormal uterine bleeding; BYP: Buxue Yimu Pills; CBC: complete blood count; EPO: erythropoietin; FPN: ferroportin; GA: gynecological anemia; GO: Gene Ontology; GOBP: Gene Ontology biological process; GOCC: Gene Ontology Cellular Component GOMF Gene Ontology molecular function; Hb: hemoglobin; HCT: hematocrit; HSC: hematopoietic stem cell; IBM: International Business Machines Corporation; IDA: iron deficiency anemia; IL: interleukin; IQR: interquartile range; KEGG: Kyoto Encyclopedia of Genes and Genomes; MCH: mean corpuscular hemoglobin; MCHC: mean corpuscular hemoglobin concentration; MCODE: Molecular Complex Detection tool; MCV: mean cellular volume; OMIM: Online Mendelian Inheritance in Man; RBC: red blood cells; RET: reticulocyte; ROS: reactive oxygen species; SD: standard deviation; SF: serum ferritin; SI: Iron indexes of serum iron; TCM: Traditional Chinese medicine; TcmSP: Traditional Chinese Medicine System Pharmacology Database and Analysis Platform; TIBC: total iron-binding capacity Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Peking Union Medical College Hospital (No. ZS-1254) at January 2017, and registered at the United States National Institutes of Health (registration number NCT03232554, www.clinicaltrials.gov) . A written informed consent was signed by all participants. Consent to publish Not applicable. Availability of data and materials All relevant data and materials are within the paper and its additional files. Competing interests The authors declare that they have no competing interests. Funding This study was financially supported by ZhuZhou QianJin Pharmaceutical Co., Ltd. Authors' Contributions WYF implemented the research plan and was responsible for data curation, data mining，formal analysis, conceptualization and writing of the manuscript. DY, MRL, LD, LB, WX, DM participated in the enrollment of the patients and data collection. SAJ provided a critical contribution to the organization and cooperation of this multi-center task. Acknowledgements The authors thank ZhuZhou QianJin Pharmaceutical Co., Ltd. for funding and research support for this study. The authors declare that there are no conflicts of interest. Author details 1 Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing100730, China. 2 West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan University, Chengdu 610041, Sichuan, China. 3 Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou 310008, China. * Correspondence: [email protected] . References McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005. Public Health Nutr. 2009;12(4):444-54. Hisa K, Haruna M, Hikita N, Sasagawa E, Yonezawa K, Suto M, et al. Prevalence of and factors related to anemia among Japanese adult women: Secondary data analysis using health check-up database. Sci Rep. 2019;9(1):17048. NJ K, R J, M N, SK W, N J, R L, et al. 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Identification of Guanosine 5'-diphosphate as Potential Iron Mobilizer: Preventing the Hepcidin-Ferroportin Interaction and Modulating the Interleukin-6/Stat-3 Pathway. Sci Rep. 2017;7:40097. Thompson K, Molina RM, Brain JD, Wessling-Resnick M. Belgrade rats display liver iron loading. J Nutr. 2006;136(12):3010-4. Gulec S, Collins JF. Investigation of iron metabolism in mice expressing a mutant Menke's copper transporting ATPase (Atp7a) protein with diminished activity (Brindled; Mo (Br) (/y) ). PLoS One. 2013;8(6):e66010. Marnach ML, Laughlin-Tommaso SK. Evaluation and Management of Abnormal Uterine Bleeding. Mayo Clin Proc. 2019;94(2):326-35. Shankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. von Willebrand disease in women with menorrhagia: a systematic review. BJOG. 2004;111(7):734-40. N L, C S, B Z, H X, D M, G C, et al. Low concentration of quercetin antagonizes the cytotoxic effects of anti-neoplastic drugs in ovarian cancer. 2014;9(7):e100314. Tables Table 1. Comparison of patient characteristics and laboratory data at baseline. BYP (n=58) Iron (n=37) BYP & Iron (n=43) P value Age (y) 40.68±7.43 40.62±7.03 39.17±7.37 0.579 BMI (kg/m 2 ) 23.26±3.22 21.94±2.63 23.05±3.52 0.076 Pulse(bpm) 81.96±9.27 82.33±10.75 79.59±8.69 0.385 SBP (mmHg) 116.15±13.64 116.88±14.27 116.66±16.05 0.969 DBP (mmHg) 71.79±9.23 73.18±9.62 72.68±8.67 0.906 Hb (g/L) 93.56±10.05 93.97±9.75 91.13±11.14 0.538 MCV (fl) 79.28±9.07 80.19±7.77 77.38±9.19 0.231 MCH (pg) 25.17±3.59 25.24±3.63 24.05±4.08 0.469 MCHC (g/L) 307.1±47.3 309.14±16.25 308.42±19.75 0.958 RBC (*109/L) 3.78±0.53 3.71±0.49 3.86±0.54 0.553 HCT (%) 29.85±2.78 30.49±2.58 29.36±2.85 0.28 RET 77.9(55.5,99.4) 70.1(35.3,97.9) 81.1(57.5,109.4) 0.091 SI (umol/L) 15.20(7.78,33.25) 20.00(10.35,26.50) 13.10(8.1,22.55) 0.129 Fer (ug/L) 9.7(4.1,22.6) 8.0(4.0,14.2) 9.9(4.0,33.5) 0.417 TIBC (g/L) 361.0(57.6,415.0) 344.5(58.9,406.5) 321.0(57.7,411.5) 0.898 Table2: The comparison of blood indices and iron metabolism markers between three groups before and after the 4-week treatment. BYP Iron BYP & Iron Pre 4 weeks P-value Pre 4 weeks P-value Pre 4 weeks P-value Hb (g/L) 93.56±10.05 110±13.87* <0.01* 93.97±9.75 124.81±13.87* <0.01* 91.13±11.14 128.95±12.88* <0.01* MCV (fl) 79.28±9.07 78.5±8.73 0.322 80.19±7.77 84.97±7.42* <0.01* 77.38±9.19 83.37±7.16* <0.01* MCH (pg) 25.17±3.59 24.78±3.33 0.23 25.24±3.63 27.53±3.00* <0.01* 24.05±4.08 27.01±2.64* <0.01* MCHC (g/L) 307.1±47.3 314.32±11.48 0.347 309.14±16.25 324.59±13.5* <0.01* 308.42±19.75 323.18±10.56* <0.01* RBC (*109/L) 3.78±0.53 4.46±0.42* <0.01* 3.71±0.49 4.57±0.60* <0.01* 3.86±0.54 4.8±0.47* <0.01* HCT (%) 29.85±2.78 34.72±3.45* <0.01* 30.49±2.58 38.27±4.10* <0.01 29.36±2.85 39.74±4.00* <0.01 RET 77.9(55.5,99.4) 77.7(59.1,91.1) 0.826 70.1(35.3,97.9) 59.8(42.0,78.5) 0.788 81.1(57.5,109.4) 72.4(53.6,91.5) 0.517 SI (umol/L) 15.20(7.78,33.25) 19.80(8.78,32.1) 0.871 20.00(10.35,26.50) 38.80(12.23,59.30) * <0.01** 13.10(8.1,22.55) 26.10(13.90,59.90) * <0.01** Fer (ug/L) 9.7(4.1,22.6) 8.0(5.0,18.5) 0.258 8.0(4.0,14.2) 26.5(14.5,31.8) * <0.01** 9.9(4.0,33.5) 30.0(16.0,42.6) * 0.022** TIBC (g/L) 361.0(57.6,415.0) 380.0(69.8,430.0) 0.12 344.5(58.9,406.5) 274.0(61.8,367.8) * <0.01** 321.0(57.7,411.5) 310.0(67.2,343.0) 0.081 Note: Significant difference with Paired T test (*) or Wilcoxon test (**) Table3: Main ingredients of Buxue Yimu Pills and their bioactive compounds. Ingredients (Chinese Pinyin name) English name Latin name Mol ID Molecule Name OB (%) DL Chenpi Dried Tangerine peel Citrus Reticulata MOL004328 naringenin 59.29 0.21 MOL005100 (Rac)-Hesperetin 47.74 0.27 MOL005815 Citromitin 86.9 0.51 MOL005828 nobiletin 61.67 0.52 MOL000359 sitosterol 36.91 0.75 Danggui Angelica Angelicae Sinensis Radix MOL000358 beta-sitosterol 36.91 0.75 MOL000449 Stigmasterol 43.83 0.76 Huangqi Astragalus Hedysarum Multijugum Maxim. MOL000392 formononetin 69.67 0.21 MOL000422 kaempferol 41.88 0.24 MOL000417 Calycosin 47.75 0.24 MOL000438 # ZINC14758732 67.67 0.26 MOL000098 quercetin 46.43 0.28 MOL000239 # Jaranol 50.83 0.29 MOL000398 # isoflavanone 109.99 0.3 MOL000378 7-O-methy-lisomucronulatol 74.69 0.3 MOL000354 isorhamnetin 49.6 0.31 MOL000380 Astrapterocarpan 64.26 0.42 MOL000371 3,9-di-O-methylnissolin 53.74 0.48 MOL000442 1,7-Dihydroxy-3,9-dimethoxy pterocarpene 39.05 0.48 MOL000439 # isomucronulatol-7,2'-di-O-glucosiole 49.28 0.62 MOL000387 Bifendate 31.1 0.67 MOL000374 # 5'-hydroxyiso-muronulatol-2',5'-di-O-glucoside 41.72 0.69 MOL000433 FA 68.96 0.71 MOL000296 hederagenin 36.91 0.75 MOL000211 Mairin 55.38 0.78 MOL000033 (24S)-24-Propylcholesta-5-ene-3beta-ol 36.23 0.78 MOL000379 9,10-dimethoxypterocarpan-3-O-β-D-glucoside 36.74 0.92 Yimucao Motherwort Leonuri Herba MOL001439 arachidonic acid 45.57 0.2 MOL000422 kaempferol 41.88 0.24 MOL000098 quercetin 46.43 0.28 MOL000354 isorhamnetin 49.6 0.31 MOL001422 iso-preleoheterin 66.29 0.33 MOL001421 preleoheterin 85.97 0.33 MOL001418 galeopsin 61.02 0.38 MOL001420 beta-Sitosterone 38 0.76 Note: # indicates the component not involved in the following network. Supplementary Files Additionalfile1.pdf Supplementary tables. Supplementary Table 1: Underlying functional modules of biological processes of 145 core targets. Supplementary Table 2: Informations about 6 clusters of the PPI network identified using MCODE. Additionalfile2.pdf Graphic abstract. Additionalfile3.pdf Hightlights Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-38583","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":897563,"identity":"2f9cb062-68b2-42cc-b3c7-6690813657b0","order_by":0,"name":"Yanfang Wang","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yanfang","middleName":"","lastName":"Wang","suffix":""},{"id":897564,"identity":"5757ac7a-7d29-48ed-8dee-4957c51724b8","order_by":1,"name":"Yan Deng","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Deng","suffix":""},{"id":897565,"identity":"9946d15d-70e7-44f0-92a3-de43b98202b6","order_by":2,"name":"Ruilin Ma","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ruilin","middleName":"","lastName":"Ma","suffix":""},{"id":897566,"identity":"67b87245-b7a5-4392-9114-da64b4666ede","order_by":3,"name":"Dong Liu","email":"","orcid":"","institution":"West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dong","middleName":"","lastName":"Liu","suffix":""},{"id":897567,"identity":"7f0c91e1-d5e5-4e30-8555-2e78729aee56","order_by":4,"name":"Bin Luo","email":"","orcid":"","institution":"West China Second Hospital, Key laboratory of Birth Defects and Related Diseases of Women and Children","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Luo","suffix":""},{"id":897568,"identity":"1cc30d6c-3676-4799-9fc2-b4c23021c327","order_by":5,"name":"Xue Wang","email":"","orcid":"","institution":"Hangzhou Women's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xue","middleName":"","lastName":"Wang","suffix":""},{"id":897569,"identity":"59f27de6-81c4-4485-9c1c-17230ac3041c","order_by":6,"name":"Miao Deng","email":"","orcid":"","institution":"Hangzhou Women's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Miao","middleName":"","lastName":"Deng","suffix":""},{"id":897570,"identity":"d86e48a8-02e7-4489-87ad-d57ace4b9f86","order_by":7,"name":"Aijun Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYHCCBDBpwN7AcIBELTwHiNcCAQYSCUSqlG8/8IC5sG2bvLnk84eHC2oY5PnFCFhmcCYhgXlm223DnbNzDA7POMZgOHM2AesMGIBaeNtuJxjczmE4zMPGAGQQ0CLf/wCq5ebxB4d5/hGhheEGzJYbDAaHeduI0GJwA2jLjHO3DTecAfqFt0+CsF/k+3MSmAvKbssbHD/++DPPNxt5fmlCDmPgSf+NxJMgpBwE2A8wE6NsFIyCUTAKRjAAABw5RRXKmWI1AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-0049-0906","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital of Skin Diseases and Institute of Dermatology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Aijun","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2020-06-29 08:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-38583/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-38583/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1653077,"identity":"6c94ecb3-7115-4a97-99a8-a67a1eac3a5d","added_by":"auto","created_at":"2020-07-22 18:38:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20183,"visible":true,"origin":"","legend":"Changes in hemoglobin after 4-week treatment in three groups.","description":"","filename":"1.PNG","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/1.PNG"},{"id":1653078,"identity":"86ed7914-d459-43f4-9f06-ddb2cd5f200d","added_by":"auto","created_at":"2020-07-22 18:38:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":203659,"visible":true,"origin":"","legend":"The pharmacology network generated for BYP. (a) Intersection of drug-target and disease-target. (b) Compound-target-disease network with 176 nodes, 409 edges. Red oblong nodes represent target genes; green square nodes represent bioactive compounds; polygon nodes of different colors represent main ingredients of Buxue Yimu Pills. The node size is proportional to degree. Notes: YMC, Yimucao; HQ, Huangqi; CP, Chenpi, DG, Danggui.","description":"","filename":"2.PNG","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/2.PNG"},{"id":1653079,"identity":"299baabc-3041-4e6b-b860-7b209d07b891","added_by":"auto","created_at":"2020-07-22 18:38:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":132260,"visible":true,"origin":"","legend":"Results of functional enrichment analysis: KEGG pathway, GOBP, GOCC and GOMF.","description":"","filename":"3.PNG","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/3.PNG"},{"id":1653080,"identity":"afcb30df-b011-4f4f-80cb-7ca57a65a9e1","added_by":"auto","created_at":"2020-07-22 18:38:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":329246,"visible":true,"origin":"","legend":"Compound-target-underlying biological process network with 139 nodes, 483 edges. Red oblong nodes represent target genes; green square nodes represent bioactive compounds; Blue polygon nodes represent main underlying biological processes. Edges between biological processes and targets are shown in red; edges between bioactive compounds and targets are shown in grey.","description":"","filename":"4.PNG","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/4.PNG"},{"id":1653081,"identity":"1a731fdf-9bd9-4228-a25e-31a3f6dcccd3","added_by":"auto","created_at":"2020-07-22 18:38:15","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":243098,"visible":true,"origin":"","legend":"PPI network (145 nodes, 3196 edges) and 6 clusters were identified using MCODE. Seed target proteins are represented in yellow.","description":"","filename":"5.PNG","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/5.PNG"},{"id":13555925,"identity":"27af33c3-f57a-455a-9fc5-993607bf2415","added_by":"auto","created_at":"2021-09-17 02:46:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1171756,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/a7c508a2-bd7c-44da-a296-f9685b4f5118.pdf"},{"id":1653083,"identity":"7d72e64d-f6be-4347-9994-07819cac7cd6","added_by":"auto","created_at":"2020-07-22 18:38:16","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":123519,"visible":true,"origin":"","legend":"Supplementary tables.\nSupplementary Table 1: Underlying functional modules of biological processes of 145 core targets.\nSupplementary Table 2: Informations about 6 clusters of the PPI network identified using MCODE.\n","description":"","filename":"Additionalfile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/Additionalfile1.pdf"},{"id":1653084,"identity":"403e4a8e-1a58-4aaf-afb8-4873cb81a8c5","added_by":"auto","created_at":"2020-07-22 18:38:16","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":312274,"visible":true,"origin":"","legend":"Graphic abstract.","description":"","filename":"Additionalfile2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/Additionalfile2.pdf"},{"id":1653085,"identity":"67a07a4c-3537-4972-91c5-5e60c7e96257","added_by":"auto","created_at":"2020-07-22 18:38:17","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":23272,"visible":true,"origin":"","legend":"Hightlights","description":"","filename":"Additionalfile3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-38583/v1/Additionalfile3.pdf"}],"financialInterests":"","formattedTitle":"A combination of clinical study and Network Pharmacology approach to explore the efficacy and mechanism of Buxue Yimu Pills on gynecological anemia","fulltext":[{"header":"Background","content":" \u003cp\u003eAnemia, one of the major public health issues worldwide, affects about one-quarter of the world\u0026rsquo;s population, especially among preschool children and young women \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. There are many common gynecologic diseases associated with anemia \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, such as uterine fibroids, adenomyosis, endometrial polyps, ovulation disorders, ectopic pregnancy, and abortion, affecting especially young women\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Besides, cancer-related anemia and therapy-induced anemia are common in patients with gynecological malignancies \u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Oral or intravenous iron supplements is the major therapeutic approach, while its common gastrointestinal side effects, including nausea, constipation, and diarrhea, can lower patient compliance. Over 40% of reproductive age women were reported to fail to adhere to medication \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Moreover, patients with gynecological anemia (GA) have been observed to be associated with inflammatory states \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, causing limited iron absorption and utilization \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Therefore, the exploration of alternative treatment options is encouraged. Traditional Chinese medicine (TCM) has been utilized to treat gynecological diseases and anemia for a long time, showing high safety, tolerability, and compliance even among the patients with malignancy, chronic kidney disease as well as the elderly \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Due to the lack of high-quality randomized controlled trial (RCT) evidence and intensive study, the efficacy and therapeutic mechanisms of TCMs have yet to be well understood or appreciated.\u003c/p\u003e \u003cp\u003eBuxue Yimu Pills (BYP), a TCM with primary efficacy of Qi-reinforcing and nourishing blood, consists of \u003cem\u003eAngelicae Sinensis Radix (Danggui)\u003c/em\u003e, \u003cem\u003eHedysarum Multijugum Maxim (Huangqi)\u003c/em\u003e, \u003cem\u003eColla Corii Asini (Ejiao)\u003c/em\u003e, \u003cem\u003eLeonuri Herba (Yimucao)\u003c/em\u003e, and \u003cem\u003eCitrus Reticulata (Chenpi)\u003c/em\u003e according to Pharmacopoeia of the People\u0026rsquo;s Republic of China. Previous studies have shown that \u003cem\u003eYimucao\u003c/em\u003e promoted uterine contractions, thus reducing vaginal bleeding; \u003cem\u003eEjiao\u003c/em\u003e, \u003cem\u003eDanggui\u003c/em\u003e, \u003cem\u003eHuangqi\u003c/em\u003e, and \u003cem\u003eChenpi\u003c/em\u003e could benefit Qi, activate blood circulation and promote hematopoiesis \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e; \u003cem\u003eHuangqi\u003c/em\u003e and \u003cem\u003eDanggui\u003c/em\u003e exerted anti-inflammatory effects \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Therefore, we hypothesized that BYP could treat GA through a variety of mechanisms.\u003c/p\u003e \u003cp\u003eTo comprehensively assess its clinical effect and herbal pharmacological mechanisms, we performed a randomized clinical trial at three centers, followed by a network pharmacology research.\u003c/p\u003e "},{"header":"Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003eClinical study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExperimental design and setting.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo compare the effects of Buxue Yimu Pills (BYP), ferrous sulfate, and a combination of both treatments on GA, a prospective, randomized controlled trial was conducted between 2017 and 2019 at Gynecology departments of three public hospitals, including Peking Union Medical College Hospital (PUMCH), West China Hospital of Sichuan University, and Hangzhou Maternity and Child Health Care Hospital. This\u0026nbsp;study\u0026nbsp;was\u0026nbsp;approved\u0026nbsp;by\u0026nbsp;the\u0026nbsp;Ethics\u0026nbsp;Committee\u0026nbsp;of PUMCH\u0026nbsp;(No.\u0026nbsp;ZS-1254) at January 2017,\u0026nbsp;and registered at the United States National Institutes of Health (registration number NCT03232554, www.clinicaltrials.gov).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdult females aged 18\u0026ndash;50 years with hemoglobin of 70-110 g/L associated with gynecological disorders were enrolled following the informed consent. Exclusion criteria were: (1) patients with uncontrolled gastrointestinal inflammation or bleeding or urological bleeding; (2) patients presented with other diseases leading to iron deficiency; (3) pregnant women; (4) patients complicated with mental abnormalities or other severe diseases; (5) patients with a history of malignancy, chemotherapy or radiotherapy; (6) patients treated with iron supplements, blood transfusion or participating in any other clinical trial within the past month. Eligible participants were randomized into three groups: BYP group received Buxue Yimu Pills (24 g/day); oral iron group received ferrous sulfate tablets (0.9 g/day), and BYP \u0026amp; oral iron group received both drugs above simultaneously. All drugs were provided by ZhuZhou QianJin Pharmaceutical Co., Ltd. The total treatment periods were four weeks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAssessments were scheduled pre-and post-treatment. A basic physical examination including vital signs, weight, height, body mass index (BMI), blood pressure was performed. Venous blood samples were collected to detect complete blood count, including hemoglobin (Hb), mean cellular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red blood cells (RBC), hematocrit (HCT), reticulocyte (RET) count. Iron indexes of serum iron (SI), serum ferritin (SF), and total iron-binding capacity (TIBC) were analyzed. Moreover, the safety assessment, including liver function, renal function, and a blood coagulation index, were also evaluated (data not shown).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was carried out using SPSS version 20.0 (IBM). Data from normally distributed parameters are presented as means plus or minus standard deviation (SD); paired t-tests were used to compare the intragroup difference pre- and post-treatment, and one-way analysis of variance (ANOVA) was applied for intergroup comparisons. Variables not normally distributed are expressed as median plus 25-75 interquartile range (IQR); intragroup and intergroup comparisons were evaluated with Wilcoxon matched-pairs signed-rank tests and Kruskal-Wallis tests. A\u003cem\u003e p\u003c/em\u003e-value of less than 0.05 (p\u0026nbsp;\u0026lt;\u0026nbsp;0.05) was considered significant in all statistical analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNetwork pharmacology analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBioactive \u003c/strong\u003e\u003cstrong\u003ecompounds and compound targets of Buxue Yimu Pills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComposite compounds were searched manually with the major ingredients of BYP \u0026ldquo;\u003cem\u003eAngelicae Sinensis Radix\u003c/em\u003e\u0026rdquo;, \u0026ldquo;\u003cem\u003eHedysarum Multijugum Maxim\u003c/em\u003e\u0026rdquo;, \u0026ldquo;\u003cem\u003eColla Corii Asini\u003c/em\u003e\u0026rdquo;, \u0026ldquo;\u003cem\u003eLeonuri Herba\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eCitrus Reticulata\u003c/em\u003e\u0026rdquo;, in Traditional Chinese Medicine System Pharmacology Database and Analysis Platform (TcmSP, \u003ca href=\"http://lsp.nwu.edu.cn/tcmsp.php\"\u003ehttp://lsp.nwu.edu.cn/tcmsp.php\u003c/a\u003e) \u003csup\u003e3\u003c/sup\u003e, and Database of Traditional Chinese Medicine and chemical composition from Shanghai Institute of Organic Chemistry (\u003ca href=\"http://www.organchem.csdb.cn/scdb/main/tcm_introduce.asp\"\u003ehttp://www.organchem.csdb.cn/scdb/main/tcm_introduce.asp\u003c/a\u003e). Next, a combination of oral bioavailability \u0026ge;\u0026thinsp;30% along with drug-likeness \u0026ge;0.18 was applied to explore the bioactive compounds. Potential treatment targets of those bioactive compounds were subsequently obtained from TcmSP; and converted to target genes with official symbols using Uniprot Knowledgebase (\u003ca href=\"http://www.uniprot.org/\"\u003ehttp://www.uniprot.org/\u003c/a\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTarget genes of GA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGA-associated targets were retrieved from the Online Mendelian Inheritance in Man (OMIM) database (\u003ca href=\"https://www.omim.org/\"\u003ehttps://www.omim.org/\u003c/a\u003e) and GeneCard Database (\u003ca href=\"https://www.genecards.org/\"\u003ehttps://www.genecards.org/\u003c/a\u003e), using \u0026ldquo;gynecological anemia \u0026rdquo;as the keyword. Data were extracted and summarized without duplication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNetwork construction \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePotential therapeutic targets are the intersections between the compound targets of BYP and GA-associated targets, which were generated with the VennDiagram R package. After importing the main ingredients, bioactive compounds, and potential therapeutic targets, the compound-target-disease network was built and visualized by Cytoscape software (version 3.6.1, \u003ca href=\"http://cytoscape.org/\"\u003ehttp://cytoscape.org/\u003c/a\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the obtained potential therapeutic targets, enrichment analysis was performed using the online tool Metascape (\u003ca href=\"https://metascape.org/gp/index.html#/main/step1\"\u003ehttps://metascape.org\u003c/a\u003e) \u003csup\u003e15\u003c/sup\u003e, including Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis.\u003c/p\u003e\n\u003cp\u003eA protein-protein interaction (PPI) network was constructed via STRING (Version 11.0, \u003ca href=\"https://string-db.org/\"\u003ehttps://string-db.org/\u003c/a\u003e) with a minimum required interaction score of 0.400. We subsequently used the Molecular Complex Detection tool (MCODE) plugin to identify significant clusters in this PPI network.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 170 enrolled patients with GA,138 patients (81.2%) completed the four-week treatment and were included in the data analysis: BYP group (n=58), oral iron group (n=37), and the combination group (n=43). The baseline characteristics of all three groups showed no statistical difference (Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLaboratory parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 shows the values of laboratory parameters before and after treatment. After four weeks of treatment, patients in three groups exhibited a significant increase in Hb, RBC, and HCT (p\u0026lt;0.01), but no significant differences in RET. The changes of Hb (g/L) are listed in the following: BYP group (16.44\u0026plusmn;14.12), oral iron group (30.84\u0026plusmn;15.46), and the combination group (37.82\u0026plusmn;16.9). Pairwise comparison show there are statistically significant differences between BYP group and oral iron group (p\u0026lt;0.01) or BYP group and the combination group (p\u0026lt;0.01), while differences between the two iron-containing groups were not remarkable (p=0.062) (Figure 1).\u003c/p\u003e\n\u003cp\u003eAccording to the iron indexes, it is expected that there were significant increases in SI and SF accompanied by a substantial decrease in TIBC in the oral iron group (p\u0026lt;0.01), but no differences were detected in BYP group (p\u0026gt;0.05). However, unexpectedly, the combination group, whose Hb was improved most significantly after treatment, showed noticeable increases in SI and SF but no apparent change in TIBC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompound-target-disease network \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty-two molecules, the bioactive compounds, with oral bioavailability\u0026thinsp;\u0026ge;\u0026thinsp;30% and drug-likeness \u0026ge;0.18 were identified through network pharmacology analysis (Table 3), which belongs to the ingredients of \u003cem\u003eHuangqi\u003c/em\u003e (20), \u003cem\u003eYimucao\u003c/em\u003e (8), \u003cem\u003eChenpi\u003c/em\u003e (5), and \u003cem\u003eDanggui\u003c/em\u003e (2), respectively. Kaempferol (MOL000422, a unique given ID from TcmSP), quercetin (MOL000098), and isorhamnetin (MOL000354) are the three components common in \u003cem\u003eHuangqi\u003c/em\u003e and \u003cem\u003eYimucao\u003c/em\u003e. ZINC14758732 (MOL000438), Jaranol (MOL000239), isoflavanone (MOL000398), isomucronulatol-7,2'-di-O-glucosiole (MOL000439), and 5'-hydroxyiso-muronulatol-2',5'-di-O-glucoside (MOL000374) in \u003cem\u003eHuangqi\u003c/em\u003e were not included in this network. 1657 potential treatment targets of BYP with official symbols and 270 target genes of GA were identified, among which a number of 145 genes intersected (Figure 2(a)). The compound-target-disease network was constructed with 818 nodes and 1436 connecting edges and shown in Figure 2(b). After analyzing the network with the NetworkAnalyzer plugin in Cytoscape, quercetin (MOL000098, mol17), which is shared by \u003cem\u003eHuangqi\u003c/em\u003e and \u003cem\u003eYimucao\u003c/em\u003e, was identified as the most important compound with the overwhelmingly highest degree of 107. Evidence from previous studies has shown that quercetin can improve inflammation and chemotherapy-related anemia through reducing oxidative stress, ameliorating the iron status and protecting red blood cells\u003csup\u003e16-18\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3 shows the results of functional enrichment analysis: KEGG pathway, Gene Ontology Biological Process (GOBP), Gene Ontology Cellular Component (GOCC), and Gene Ontology Molecular Function (GOMF), which were mostly associated with cancer, inflammation, steroid hormone regulation, oxidative stress, metabolic syndrome, nervous system diseases, and infectious diseases. Many of these terms are too general for annotation, so we took a deeper insight into their child function clusters and further summarized the biological processes into several underlying functional modules: regulation of inflammation, regulation of steroid hormone, angiogenesis and hemostasis, response to decreased oxygen levels, effects on myeloma cell and response to metal ion (Supplementary Table1). The biological processes with the highest enrichment score in each module were selected to build a compound-target-underlying biological process network (Figure 4), with 139 nodes, 483 edges.\u003c/p\u003e\n\u003cp\u003eProtein-protein interaction (PPI) network of intersecting targets was constructed with STRING, including 145 nodes and 3196 edges (Figure 5 (a)). According to the selection criteria of MCODE scores \u0026ge; 5, degree cutoff = 2, node score cutoff = 0.2, K- core = 2, and max depth = 100, a total of 6 significant clusters were identified (Figure 5(b), Supplementary Table 2).\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eConsistent with previous studies, after four-week treatment, patients taking ferrous sulfate or ferrous sulfate \u0026amp;BYP showed an elevation of Hb in accompany with significant changes in iron metabolism markers, typically with elevated SI, Fer, and decreased TIBC (oral iron group). One unexpected finding was that we did not find a significant decline of TIBC in the combination group, even though it did show a most significant increase in Hb. BYP group also exhibited hemoglobin improvement without obvious changes in iron metabolism markers. This result may be explained by the fact that patients with GA are commonly found to have several closely related features: abnormal uterine bleeding (AUB), iron deficiency anemia (IDA), chronic inflammatory state \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. On the one hand, an inflammatory state can upregulate the level of hepcidin, a liver-specific peptide, increasing the degradation of ferroportin (FPN) at enterocytes, hepatocytes, and macrophages, leading to iron overload in nonhematopoietic cells but the iron deficiency in erythroid precursors\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. In addition, chronic inflammation can cause unbalanced blood production of hematopoietic stem cells (HSCs), impaired HSC self-renewal as well as impaired erythroid production\u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The previous study has found a negative correlation between Hb concentration and inflammatory markers, especially interleukin 6 (IL-6)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. As mentioned before, Buxue Yimu Pills can reinforce qi and nourish the blood, whose main components have previously been observed to have different efficacies of promoting hematopoiesis and anti-inflammatory effects\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. After treatment, with decreased inflammation and increased hematopoiesis, iron in nonhematopoietic cells can be transported to erythroid precursors more efficiently; subsequently, levels of circulating iron decrease. As a consequence, we did observe a slight upward trend of TIBC in the BYP group and an offsetting decline of TIBC in the combination group, while Hb in both groups elevated.\u003c/p\u003e \u003cp\u003eWe also used network pharmacology technology to investigate the mechanisms of Buxue Yimu Pills further. From the compound-target-disease network, 27 bioactive compounds in Buxue Yimu Pills were identified, among which quercetin, a common component of \u003cem\u003eHuangqi\u003c/em\u003e and \u003cem\u003eYimucao\u003c/em\u003e, may play a critical role. One hundred forty-five potential therapeutic targets of these compounds were confirmed. Biological process and pathway enrichment analysis demonstrated that multiple mechanisms including regulation of inflammation, regulation of steroid hormone, angiogenesis and hemostasis, response to decreased oxygen levels, effects on myeloma cell as well as response to metal ions, may contribute to improving GA. Previous studies have demonstrated that reduction of inflammation and oxidative stress can alleviate the absorption and utilization of iron, increase the production of erythropoietin (EPO) and improve hematopoietic function\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Metal ion transmembrane transport contributed to iron uptake and maintenance of iron homeostasis\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. In addition, ovulation disorders and coagulation dysfunction have been the main nonstructural etiologies of AUB\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Therefore, the regulation of steroid hormone and hemostasis can have significant implications for this condiction.\u003c/p\u003e \u003cp\u003eSince Buxue Yimu Pills may improve anemia through multiple targets, it could have potential applications in diseases needing to deal with oxidative stress damage, such as thalassemia and inflammatory anemia. But on the other hand, one crucial point that needs to be raised is that reduction of oxidative stress might reduce the therapeutic efficacy of anti-neoplastic drugs acting through mechanisms of reactive oxygen species (ROS)-induced injury \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e, which was also indicated in KEGG enrichment (hsa01524, platinum drug resistance). Therefore, Buxue Yimu Pills may not be recommended to patients undergoing cancer treatment.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eA combination of clinical study and network pharmacology approaches not only demonstrates that Buxue Yimu Pills contributes to the effective improvement of GA through multiple mechanisms but also provides us more comprehensive insights into integrated multidimensional relationships between drugs and diseases. Finally, some limitations need to be acknowledged. The sample size and the follow-up duration may have been insufficient to reveal apparent differences between cohorts, and inflammatory indicators were not monitored. Accordingly, based on the results of our study, continued efforts are needed to further verification through larger-scale, more prolonged follow-up cohort research with targeted designs, as well as molecular mechanism studies.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eANOVA:one-way analysis of variance; AUB: abnormal uterine bleeding; BYP: Buxue Yimu Pills; CBC: complete blood count; EPO: erythropoietin; FPN: ferroportin; GA: gynecological anemia; GO: Gene Ontology; GOBP: Gene Ontology biological process; GOCC: Gene Ontology Cellular Component\u003c/p\u003e\n\u003cp\u003eGOMF Gene Ontology molecular function; Hb: hemoglobin; HCT: hematocrit; HSC: hematopoietic stem cell; IBM: International Business Machines Corporation; IDA: iron deficiency anemia; IL: interleukin; IQR: interquartile range; KEGG: Kyoto Encyclopedia of Genes and Genomes; MCH: mean corpuscular hemoglobin; MCHC: mean corpuscular hemoglobin concentration; MCODE: Molecular Complex Detection tool; MCV: mean cellular volume; OMIM: Online Mendelian Inheritance in Man; RBC: red blood cells; RET: reticulocyte; ROS: reactive oxygen species; SD: standard deviation; SF: serum ferritin; SI: Iron indexes of serum iron; TCM: Traditional Chinese medicine; TcmSP: Traditional Chinese Medicine System Pharmacology Database and Analysis Platform; TIBC: total iron-binding capacity\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;study\u0026nbsp;was\u0026nbsp;approved\u0026nbsp;by\u0026nbsp;the\u0026nbsp;Ethics\u0026nbsp;Committee\u0026nbsp;of Peking Union Medical College Hospital\u0026nbsp;(No.\u0026nbsp;ZS-1254) at January 2017,\u0026nbsp;and registered at the United States National Institutes of Health (registration number NCT03232554, \u003ca href=\"http://www.clinicaltrials.gov)\"\u003ewww.clinicaltrials.gov)\u003c/a\u003e. A written informed consent was signed by all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data and materials are within the paper and its additional files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was financially supported by ZhuZhou QianJin Pharmaceutical Co., Ltd.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWYF implemented the research plan and was responsible for data curation, data mining，formal analysis, conceptualization and writing of the manuscript. DY, MRL, LD, LB, WX, DM participated in the enrollment of the patients and data collection. SAJ provided a critical contribution to the organization and cooperation of this multi-center task.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank ZhuZhou QianJin Pharmaceutical Co., Ltd. for funding and research support for this study. The authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing100730, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan University, Chengdu 610041, Sichuan, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou 310008, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e Correspondence: [email protected].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. 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Front Physiol. 2019;10:976.\u003c/li\u003e\n\u003cli\u003eBerbic M, Ng CH, Fraser IS. Inflammation and endometrial bleeding. Climacteric. 2014;17 Suppl 2:47-53.\u003c/li\u003e\n\u003cli\u003eCamaschella C. Iron-deficiency anemia. N Engl J Med. 2015;372(19):1832-43.\u003c/li\u003e\n\u003cli\u003ePietras EM. Inflammation: a key regulator of hematopoietic stem cell fate in health and disease. Blood. 2017;130(15):1693-8.\u003c/li\u003e\n\u003cli\u003eKovtonyuk LV, Fritsch K, Feng X, Manz MG, Takizawa H. Inflamm-Aging of Hematopoiesis, Hematopoietic Stem Cells, and the Bone Marrow Microenvironment. Front Immunol. 2016;7:502.\u003c/li\u003e\n\u003cli\u003eKing KY, Goodell MA. Inflammatory modulation of HSCs: viewing the HSC as a foundation for the immune response. Nat Rev Immunol. 2011;11(10):685-92.\u003c/li\u003e\n\u003cli\u003eXiao H, Xiong L, Song X, Jin P, Chen L, Chen X, et al. Angelica sinensis Polysaccharides Ameliorate Stress-Induced Premature Senescence of Hematopoietic Cell via Protecting Bone Marrow Stromal Cells from Oxidative Injuries Caused by 5-Fluorouracil. Int J Mol Sci. 2017;18(11).\u003c/li\u003e\n\u003cli\u003eAngmo S, Tripathi N, Abbat S, Sharma S, Singh SS, Halder A, et al. Identification of Guanosine 5'-diphosphate as Potential Iron Mobilizer: Preventing the Hepcidin-Ferroportin Interaction and Modulating the Interleukin-6/Stat-3 Pathway. Sci Rep. 2017;7:40097.\u003c/li\u003e\n\u003cli\u003eThompson K, Molina RM, Brain JD, Wessling-Resnick M. Belgrade rats display liver iron loading. J Nutr. 2006;136(12):3010-4.\u003c/li\u003e\n\u003cli\u003eGulec S, Collins JF. Investigation of iron metabolism in mice expressing a mutant Menke's copper transporting ATPase (Atp7a) protein with diminished activity (Brindled; Mo (Br) (/y) ). PLoS One. 2013;8(6):e66010.\u003c/li\u003e\n\u003cli\u003eMarnach ML, Laughlin-Tommaso SK. Evaluation and Management of Abnormal Uterine Bleeding. Mayo Clin Proc. 2019;94(2):326-35.\u003c/li\u003e\n\u003cli\u003eShankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. von Willebrand disease in women with menorrhagia: a systematic review. BJOG. 2004;111(7):734-40.\u003c/li\u003e\n\u003cli\u003eN L, C S, B Z, H X, D M, G C, et al. Low concentration of quercetin antagonizes the cytotoxic effects of anti-neoplastic drugs in ovarian cancer. 2014;9(7):e100314.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"text-align: justify; text-justify: inter-ideograph; line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003eTable 1. Comparison of patient characteristics and laboratory data at baseline.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse; border: none;\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: DengXian;\"\u003e \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eBYP (n=58)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eIron (n=37)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eBYP \u0026amp; Iron (n=43)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eP value\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eAge (y)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e40.68\u0026plusmn;7.43\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e40.62\u0026plusmn;7.03\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e39.17\u0026plusmn;7.37\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.579\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e23.26\u0026plusmn;3.22\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e21.94\u0026plusmn;2.63\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e23.05\u0026plusmn;3.52\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.076\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; 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line-height: 200%; font-family: 'Times', serif;\"\u003e79.59\u0026plusmn;8.69\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.385\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eSBP (mmHg)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e116.15\u0026plusmn;13.64\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; 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padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e79.28\u0026plusmn;9.07\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e80.19\u0026plusmn;7.77\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e77.38\u0026plusmn;9.19\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.231\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eMCH (pg)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e25.17\u0026plusmn;3.59\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e25.24\u0026plusmn;3.63\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; 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padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eRBC (*109/L)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e3.78\u0026plusmn;0.53\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e3.71\u0026plusmn;0.49\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e3.86\u0026plusmn;0.54\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.553\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eHCT (%)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e29.85\u0026plusmn;2.78\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; 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line-height: 200%; font-family: 'Times', serif;\"\u003eRET \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e77.9(55.5,99.4)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e70.1(35.3,97.9)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e81.1(57.5,109.4)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.091\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eSI (umol/L)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e15.20(7.78,33.25)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e20.00(10.35,26.50)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e13.10(8.1,22.55)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.129\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eFer (ug/L)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e9.7(4.1,22.6)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e8.0(4.0,14.2)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e9.9(4.0,33.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.417\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 16.95pt;\"\u003e\n\u003ctd style=\"border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eTIBC (g/L)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e361.0(57.6,415.0)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e344.5(58.9,406.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e321.0(57.7,411.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 16.95pt;\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e0.898\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003eTable2:\u003c/span\u003e \u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003eThe comparison of blood indices and iron metabolism markers between three groups before and after the 4-week treatment.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 100.0%; border-collapse: collapse; border: none;\" width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 9.52%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" rowspan=\"2\" width=\"9%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 28.52%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" colspan=\"3\" width=\"28%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eBYP\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 30.78%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" colspan=\"3\" width=\"30%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eIron\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 31.18%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" colspan=\"3\" width=\"31%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eBYP \u0026amp; Iron\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 11.24%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003ePre\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.24%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e4 weeks\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 6.04%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"6%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.88%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003ePre\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.54%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"12%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e4 weeks\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 6.36%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"6%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.26%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003ePre\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.54%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"12%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; 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border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"7%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e\u0026lt;0.01**\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 22.15pt;\"\u003e\n\u003ctd style=\"width: 9.52%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"9%\"\u003e\n\u003cp style=\"line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eFer (ug/L)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.24%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e9.7(4.1,22.6)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.24%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e8.0(5.0,18.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 6.04%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"6%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e0.258\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.88%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e8.0(4.0,14.2)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.54%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"12%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e26.5(14.5,31.8) *\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 6.36%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"6%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e\u0026lt;0.01**\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.26%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e9.9(4.0,33.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.54%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"12%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e30.0(16.0,42.6) *\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 7.38%; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"7%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e0.022**\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 22.15pt;\"\u003e\n\u003ctd style=\"width: 9.52%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"9%\"\u003e\n\u003cp style=\"line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003eTIBC (g/L)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.24%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e361.0(57.6,415.0)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.24%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e380.0(69.8,430.0)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 6.04%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"6%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e0.12\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.88%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e344.5(58.9,406.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.54%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"12%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e274.0(61.8,367.8) *\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 6.36%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"6%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e\u0026lt;0.01**\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.26%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"11%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e321.0(57.7,411.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.54%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"12%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e310.0(67.2,343.0)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 7.38%; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 22.15pt;\" width=\"7%\"\u003e\n\u003cp style=\"text-align: center; line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 9.0pt; line-height: 200%; font-family: 'Times',serif;\"\u003e0.081\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"line-height: 200%; tab-stops: 177.0pt;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eNote: \u003c/span\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003eSignificant difference with Paired T test (*) or Wilcoxon test (**)\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003eTable3:\u003c/span\u003e \u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times',serif;\"\u003eMain ingredients of Buxue Yimu Pills and their bioactive compounds.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 100.0%; background: white; border-collapse: collapse; border: none;\" width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 8.5pt;\"\u003e\n\u003ctd style=\"width: 13.12%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"13%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eIngredients\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003e(Chinese \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003ePinyin name)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16.0%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"16%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eEnglish name\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.84%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"11%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eLatin \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003ename\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.32%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"11%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eMol\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eID\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 32.66%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"32%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eMolecule\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eName\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 7.56%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"7%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eOB (%)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 7.52%; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"7%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eDL\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 8.5pt;\"\u003e\n\u003ctd style=\"width: 13.12%; border: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" rowspan=\"5\" width=\"13%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eChenpi\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16.0%; border: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" rowspan=\"5\" width=\"16%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eDried Tangerine peel\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.84%; border: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" rowspan=\"5\" width=\"11%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cem\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eCitrus \u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cem\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eReticulata\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 11.32%; border: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"11%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003eMOL004328\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 32.66%; border: none; background: transparent; padding: 0in 5.4pt 0in 5.4pt; height: 8.5pt;\" width=\"32%\"\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 10.5pt; line-height: 200%; font-family: 'Times', serif;\"\u003enaringenin\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 7.56%; 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line-height: 200%; font-family: 'Times',serif;\"\u003eNote: # indicates the component not involved in the following network.\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Traditional Chinese medicine, Buxue Yimu Pills, gynecological anemia, network pharmacology, multi-target mechanism","lastPublishedDoi":"10.21203/rs.3.rs-38583/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-38583/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIron supplement is the first-line treatment for gynecological anemia (GA). However, its performance is limited by common gastrointestinal reactions and some inadequate responses. Traditional Chinese medicine (TCM) has a long history in the treatment of gynecological conditions but has been restricted by limited high-quality research, unknown bioactive ingredients, and mechanisms.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThese studies aim to compare the clinical efficacy of Buxue Yimu Pills (BYP),ferrous sulfate, and the addition of BYP to ferrous sulfate on GA through oral administration, and to investigate the mechanisms of BYP using network pharmacology approach.\u003c/p\u003e\u003ch2\u003eDesign:\u003c/h2\u003e \u003cp\u003eProspective, open-label, comparative, randomized, multicenter clinical trial.\u003c/p\u003e\u003ch2\u003eSetting:\u003c/h2\u003e \u003cp\u003eGynecology departments in three public hospitals.\u003c/p\u003e\u003ch2\u003ePatients:\u003c/h2\u003e \u003cp\u003e170 patients with hemoglobin of 70\u0026ndash;110\u0026nbsp;g/L were recruited and randomized into three groups: BYP group, oral iron group, and combined BYP \u0026amp; oral iron group. After a four-week treatment, the complete blood count (CBC) along with the markers for iron metabolism were determined for 138 patients. Furthermore, network pharmacology was performed to identify the active ingredients and potential mechanisms of BYP.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWhile iron-treated groups showed elevated hemoglobin in accompany with significant changes in iron metabolism biomarkers, the BYP group exhibited hemoglobin improvement without apparent changes in iron metabolism markers. The network pharmacology identified 27 bioactive compounds and 145 targets of BYP on GA. A number of biological processes and pathways were identified, including regulation of inflammation, regulation of steroid hormone, angiogenesis and hemostasis, response to decreased oxygen levels, effects on myeloma cell, and response to metal ions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBYP contributes to the practical improvement of gynecological anemia potentially through multi-target mechanisms independent from increasing hemopoietic raw material-iron.\u003c/p\u003e","manuscriptTitle":"A combination of clinical study and Network Pharmacology approach to explore the efficacy and mechanism of Buxue Yimu Pills on gynecological anemia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-07-22 18:38:14","doi":"10.21203/rs.3.rs-38583/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb930364-ac90-4de0-9f60-060918ac10af","owner":[],"postedDate":"July 22nd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":190893,"name":"Clinical Pharmacology"},{"id":190894,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2020-07-25T15:36:31+00:00","versionOfRecord":[],"versionCreatedAt":"2020-07-22 18:38:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-38583","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-38583","identity":"rs-38583","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}