BACKGROUND: : Despite the important biological effects of jabuticaba, its actions on the cardiovascular system have not been clarified. OBJECTIVES: : To determine the effects of jabuticaba hydroalcoholic extract (JHE) on vascular smooth muscle (VSM) of isolated arteries. METHODS: : Endothelium-denuded aortic rings of rats were mounted in isolated organ bath to record isometric tension. The relaxant effect of JHE and the influence of K+ channels and Ca2+ intra- and extracellular sources on JHE-stimulated response were assessed. RESULTS: : Arteries pre-contracted with phenylephrine showed concentration-dependent relaxation (0.380 to 1.92 mg/mL). Treatment with K+ channel blockers (tetraethyl-ammonium, glibenclamide, 4-aminopyridine) hindered relaxation due to JHE. In addition, phenylephrine-stimulated contraction was hindered by previous treatment with JHE. Inhibition of sarcoplasmic reticulum Ca2+ ATPase did not change relaxation due to JHE. In addition, JHE inhibited the contraction caused by Ca2+ influx stimulated by phenylephrine and KCl (75 mM). CONCLUSION: : JHE induces endothelium-independent vasodilation. Activation of K+ channels and inhibition of Ca2+ influx through the membrane are involved in the JHE relaxant effect. FUNDAMENTOS:: Embora a jabuticaba apresente importantes efeitos biológicos, suas ações sobre o sistema cardiovascular ainda não foram esclarecidas. OBJETIVOS:: Determinar os efeitos do extrato de jabuticaba (EHJ) sobre o músculo liso vascular (MLV) em artérias isoladas. MÉTODOS:: Aortas (sem endotélio) de ratos foram montadas em banho de órgãos isolados para registro de tensão isométrica. Foram verificados o efeito relaxante, a influência dos canais de K+ e das fontes de Ca2+ intra- e extracelular sob a resposta estimulada pelo EHJ. RESULTADOS:: Artérias pré-contraídas com fenilefrina apresentaram relaxamento concentração-dependente (0,380 a 1,92 mg/mL). O tratamento com bloqueadores de canais de K+ (tetraetilamônio, glibenclamida, 4-aminopiridina) prejudicaram o relaxamento pelo EHJ. A contração estimulada com fenilefrina também foi prejudicada pelo tratamento prévio com EHJ. A inibição da Ca2+ATPase do reticulo sarcoplasmático não alterou o relaxamento pelo EHJ. Além disso, o EHJ inibiu a contração causada pelo influxo de Ca2+ estimulado por fenilefrina e KCl (75 mM). CONCLUSÃO:: O EHJ induz vasodilatação independente do endotélio. Ativação dos canais de K+ e inibição do influxo de Ca2+ através da membrana estão envolvidas no efeito relaxante do EHJ.
BACKGROUND: : Despite the important biological effects of jabuticaba, its actions on the cardiovascular system have not been clarified. OBJECTIVES: : To determine the effects of jabuticaba hydroalcoholic extract (JHE) on vascular smooth muscle (VSM) of isolated arteries. METHODS: : Endothelium-denuded aortic rings of rats were mounted in isolated organ bath to record isometric tension. The relaxant effect of JHE and the influence of K+ channels and Ca2+ intra- and extracellular sources on JHE-stimulated response were assessed. RESULTS: : Arteries pre-contracted with phenylephrine showed concentration-dependent relaxation (0.380 to 1.92 mg/mL). Treatment with K+ channel blockers (tetraethyl-ammonium, glibenclamide, 4-aminopyridine) hindered relaxation due to JHE. In addition, phenylephrine-stimulated contraction was hindered by previous treatment with JHE. Inhibition of sarcoplasmic reticulum Ca2+ ATPase did not change relaxation due to JHE. In addition, JHE inhibited the contraction caused by Ca2+ influx stimulated by phenylephrine and KCl (75 mM). CONCLUSION: : JHE induces endothelium-independent vasodilation. Activation of K+ channels and inhibition of Ca2+ influx through the membrane are involved in the JHE relaxant effect. FUNDAMENTOS:: Embora a jabuticaba apresente importantes efeitos biológicos, suas ações sobre o sistema cardiovascular ainda não foram esclarecidas. OBJETIVOS:: Determinar os efeitos do extrato de jabuticaba (EHJ) sobre o músculo liso vascular (MLV) em artérias isoladas. MÉTODOS:: Aortas (sem endotélio) de ratos foram montadas em banho de órgãos isolados para registro de tensão isométrica. Foram verificados o efeito relaxante, a influência dos canais de K+ e das fontes de Ca2+ intra- e extracelular sob a resposta estimulada pelo EHJ. RESULTADOS:: Artérias pré-contraídas com fenilefrina apresentaram relaxamento concentração-dependente (0,380 a 1,92 mg/mL). O tratamento com bloqueadores de canais de K+ (tetraetilamônio, glibenclamida, 4-aminopiridina) prejudicaram o relaxamento pelo EHJ. A contração estimulada com fenilefrina também foi prejudicada pelo tratamento prévio com EHJ. A inibição da Ca2+ATPase do reticulo sarcoplasmático não alterou o relaxamento pelo EHJ. Além disso, o EHJ inibiu a contração causada pelo influxo de Ca2+ estimulado por fenilefrina e KCl (75 mM). CONCLUSÃO:: O EHJ induz vasodilatação independente do endotélio. Ativação dos canais de K+ e inibição do influxo de Ca2+ através da membrana estão envolvidas no efeito relaxante do EHJ.
Cardiovascular diseases are a major cause of death worldwide, among which
hypertension accounts for 9.4 million deaths per year.[1] Around 1 billion adults in the world have
hypertension, and that figure will have increased by 25% in 10 years.[2]Vascular tonus regulation is fundamental to appropriate blood pressure control. Blood
vessel contraction and dilation in response to physiological demands are controlled
by changes in the intracellular concentration of Ca2+ in vascular smooth
muscle (VSM) cells. The increase in intracellular concentration of Ca2+
occurs via both Ca2+ influx through the plasma membrane and
Ca2+ release from inner sources, such as the sarcoplasmic
reticulum.[3,4] Effective drugs to blood pressure control, such as
nifedipine, verapamil and diltiazem, which act as Ca2+ channel blockers,
induce vasodilation and reduce blood pressure.[5]The use of natural products as an alternative treatment for hypertension has been
extensively studied, being known to induce hypotension with minimum side
effects.[6,7]
Jabuticaba (Myrciaria cauliflora), also known as Brazilian grape,
is a hard-skinned berry of the Myrtaceae family, largely
distributed in Brazil. It can be consumed fresh or in the form of liqueurs, wines,
jams and sweets, and its consumption has increased in Brazil and
worldwide.[8,9] In addition to the use of
jabuticaba as food and beverage, in folk medicine, that fruit
is used to treat some diseases, such as asthma, inflammations, and gastrointestinal
and cardiovascular disorders.[10]
Recent findings have shown that jabuticaba can decrease oxidative
process,[11] hyperglycemia
associated with insulin resistance[12] and dyslipidemia.[13] In addition, that species has a proven endothelium-dependent
hypotensive and vasodilating effect, mediated by nitric oxide pathway.[14]Considering that jabuticaba has important biological effects and
that its action on the cardiovascular system has been little studied, this study was
aimed at assessing the possible effect of the jabuticaba extract
directly on the VSM, mainly its effect on Ca2+ influx through the plasma
membrane and activation of K+ channels.
Methods
Preparation of jabuticaba extract
For this study, the plant specimens were donated by the "Jabuticabal" wine house
in the city of Hidrolândia, Goiás state, Brazil. A sample of the
plant specimen was stored at the herbarium of the department of botany of the
Federal University of Goiás (UFG), Goiânia, Goiás state,
Brazil (n. 21140). Seedless fruits were dried in a greenhouse with air
circulation, powdered in a pulverizer mill and passed through a 60-mesh sieve at
the Laboratory of Research on Natural Products, Pharmacy School/UFG. The powder
obtained was stored at -20°C. To prepare the extract, the dried material was
exhaustively percolated into an ethanol:water solution (55:45 v/v), and the
material obtained was filtered and submitted to rotary evaporation under reduced
pressure at 40°C, resulting in the ethanol-free jabuticaba
hydroalcoholic extract (JHE). After that process, the JHE was maintained in a
freezer (-20°C) protected from light. On the days of experiment, the JHE was
solubilized in distilled water at the concentration of 120 mg/mL.The phytochemical characterization and pattern of the JHE showed 17.89% of
phenolic compounds, quantified by using the Hagerman and Butler method, adapted
by Mole and Watermen.[15] The
JHE showed ellagic acid (phytochemical marker, determined by HPLC-PDA) at 0.222%
concentration.[14]
According to Abe et at.,[9] the
total ellagic acid content in M. cauliflora fruits ranges from
0.021% to 0.311%. Thus, that phytochemical marker concentration in JHE is in
accordance with the fruit content.
Animals and preparation of isolated arteries
Wistar male rats (200-230 g) from the central vivarium of the UFG were used in
this study. All experimental protocols abided by the UFG Animal Research Ethics
Committee (protocol: 015/2014). This study is in accordance with the European
Union Guide to the Care and Use of Experimental Animals (2010/63/UE).The rats were sacrificed by use of cervical dislocation under inhalation
anesthesia. Thoracic aorta was isolated, cleared of connective and adipose
tissues, and sliced into rings (± 4 mm), which were mounted between two
metal hooks, one of which was connected to a power transducer to record
isometric tension (DATAQ Instruments, Akron, OH, USA) and the other was fixed to
a cube for the isolated organ. The rings were placed into chambers for isolated
organs, containing modified Krebs solution [composition in mM: NaCl, 130.0; KCl,
4.7; KH2PO4, 1.2; CaCl2,1.6; MgSO4,
1.2; NaHCO3, 14.9; glucose, 5.5], at pH of 7.4, under gasification
with carbogen mixture (95% O2 + 5% CO2) at 37°C, and
maintained at baseline tension of 1 g (ideal resting tension, previously
standardized at our laboratory). To prevent the influence of
vascular-endothelium-derived factors, endothelial cells were mechanically
removed by rubbing the vessel lumen with a thin metal rod, the effectiveness of
the removal being evidenced by lack of relaxation due to acetylcholine (1
µM) in aortic rings pre-contracted with
EC50 of phenylephrine (0.1 µM).
Experimental protocols
After 60 minutes of stabilization at baseline tension (1 g), the arteries were
pre-contracted with phenylephrine (0.1 µM), and
cumulative relaxation-concentration-effect curves were built for JHE (0 to 1.92
mg/mL) and for verapamil, used as inner control (10 nM to 100
µM).To assess the cellular pathways responsible for the relaxant effect of JHE,
aortic rings were pre-contracted with phenylephrine (0.1
µM) for 20 minutes after incubation with the
following agents: 1) Ca2+ ATPase of the sarcoplasmic reticulum,
cyclopiazonic acid (CPA, 10 µM); 2) non-selective
K+ channel blocker, tetraethyl-ammonium (TEA, 1 mM); 3) selective
voltage-gated K+ channel (Kv) blocker, 4-aminopyridine
(4-AP, 1 mM); 4) selective ATP-sensitive K+ channel (KATP)
blocker, glibenclamide (3 µM); 5)
Ca2+-dependent K+ channel (KCa) blocker,
clotrimazole (5 µM).To assess the influence of JHE on the contraction induced by adrenergic
contractile agonist, concentration-effect curves were built for phenylephrine
(selective α1-adrenergic agonist, 0.1 nM to 10
µM) in the presence (20 minutes) or absence of JHE at
inhibitory concentration 50% (IC50, 0.5 mg/mL) or 100%
(IC100, 1.92 mg/mL). In addition, the inhibitory effect of the
Ca2+ channel blocker verapamil (IC50, 0.3
µM) was assessed as inner control.In another series of experiments, JHE action on Ca2+ influx stimulated
by two different agents was analyzed. The preparations were initially contracted
with a KCl solution (75 mM) to cause maximum contraction of each preparation
(100% contraction), being then rinsed with Ca2+-free Krebs solution
until total relaxation. To exhaust the intracellular storage of Ca2+,
the preparations were stimulated to contract with phenylephrine in
Ca2+-free Krebs solution until any contractile response
disappeared (approximately 5 or 6 times, for 30-50 minutes). Then the
preparations were rinsed several times with Ca2+-free Krebs solution,
and then incubated for 20 minutes with JHE at inhibitory concentration 50%
(IC50, 0.51 mg/mL) or 100% (IC100, 1.92 mg/mL). In
addition, the inhibitory effect of the Ca2+ channel blocker verapamil
(IC50, 0.3 µM) was assessed as inner
control. After incubation, the contractile stimulus was applied (phenylephrine,
0.1 µM, or KCL, 75 mM), and concentration-effect curves
were built for CaCl2 (0 to 3.0 mM).
Statistical analysis
The results of isometric tension were expressed as mean ± standard error
of the mean (SEM) of at least five experiments (n = 5-8) obtained from different
animals. The graphs were built and analyzed by use of the GraphPad Prism
software (GraphPad Software Corporation, 5.0 version) with ANOVA and Bonferroni
post-test. The 5% significance level (p < 0.05) was adopted for the
differences.
Results
Relaxant effect of JHE on isolated arteries
The JHE caused relaxation in preparations of endothelium-denuded arteries on a
concentration-dependent way, relaxation initiating at the concentration of 0.38
mg/mL, and achieving the maximum effect (Emax) of 98.3% ± 0.4%
(n = 6) at the concentration of 1.92 mg/mL (IC100) (Figure 1A). The JHE concentration that
induced 50% relaxation (IC50) was 0.51 mg/mL. Similarly, verapamil
(used as positive control) induced concentration-dependent relaxation with
Emax of 99.8% ± 1.8% (n = 5) and IC50 of 0.3
µM.
Figure 1
Cumulative concentration-response curves of jabuticaba hydroalcoholic
extract (JHE) (A) and verapamil (B) in isolated endothelium-denuded
arteries. The points represent mean ± SEM of the relaxant
effect expressed as % relaxation.
Cumulative concentration-response curves of jabuticaba hydroalcoholic
extract (JHE) (A) and verapamil (B) in isolated endothelium-denuded
arteries. The points represent mean ± SEM of the relaxant
effect expressed as % relaxation.
Effect of JHE on the phenylephrine-induced contraction
The Emax value for phenylephrine (142.1% ± 7.1%, n = 6) was
significantly (p < 0.001) reduced to 88.7% ± 6.2% (n = 5), 66.1%
± 5.1% (n = 6) and 79.9% ± 5.5% (n = 5) after incubation with
IC50 and IC100 of JHE or verapamil, respectively. The
addition of IC50 and IC100 of JHE or verapamil
significantly increased phenylephrine pD2 values (-log
EC50) from 6.24 ± 0.09 to 5.35 ± 0.04, 5.14
± 0.09 and 5.68 ± 0.07, respectively (Figure 2).
Figure 2
Effect of jabuticaba hydroalcoholic extract (JHE) and verapamil on
the phenylephrine-induced contraction in isolated
endothelium-denuded arteries. Cumulative concentration-response
curves were built in control conditions and after incubation (20
min) with JHE (IC50: 0.51 or IC100: 1.92
mg/mL) or verapamil (IC50: 0.3 µM). The points
represent mean ± SEM of the contractile effect expressed as %
contraction in relation to total KCl-induced contraction (75 mM).
Significant difference: *** p<0.001 vs. Control
Effect of jabuticaba hydroalcoholic extract (JHE) and verapamil on
the phenylephrine-induced contraction in isolated
endothelium-denuded arteries. Cumulative concentration-response
curves were built in control conditions and after incubation (20
min) with JHE (IC50: 0.51 or IC100: 1.92
mg/mL) or verapamil (IC50: 0.3 µM). The points
represent mean ± SEM of the contractile effect expressed as %
contraction in relation to total KCl-induced contraction (75 mM).
Significant difference: *** p<0.001 vs. Control
Effect of JHE on Ca2+-influx-induced contraction in preparations
stimulated with phenylephrine or KCl
Regarding the Ca2+-influx-induced contraction stimulated by
phenylephrine, pre-incubation with JHE (IC50 or IC100)
significantly reduced (p < 0.001) the Emax values from 106.8%
± 7.5% (n = 5) to 58.8% ± 4.9% (n = 6) and 34.5% ± 3.2% (n
= 6), respectively. In addition, treatment with verapamil significantly reduced
(p < 0.001) the contraction to 7.1% ± 1.1% (n = 5) (Figure 3A).
Figure 3
Effect of jabuticaba hydroalcoholic extract (JHE) and verapamil on
the contractile response in isolated endothelium-denuded arteries.
Cumulative concentration-response curves for CaCl2 were
stimulated with phenylephrine (0.1µM) (A) or KCl 75 mM (B) in
control conditions and after incubation (20 min) with JHE
(IC50: 0.51 or IC100: 1.92 mg/mL) or
verapamil (IC50: 0.3 µM). The points represent
mean ± SEM of the contractile effect expressed as %
contraction in relation to total KCl-induced contraction (75 mM).
Significant difference: *** p<0.001 vs. Control.
Effect of jabuticaba hydroalcoholic extract (JHE) and verapamil on
the contractile response in isolated endothelium-denuded arteries.
Cumulative concentration-response curves for CaCl2 were
stimulated with phenylephrine (0.1µM) (A) or KCl 75 mM (B) in
control conditions and after incubation (20 min) with JHE
(IC50: 0.51 or IC100: 1.92 mg/mL) or
verapamil (IC50: 0.3 µM). The points represent
mean ± SEM of the contractile effect expressed as %
contraction in relation to total KCl-induced contraction (75 mM).
Significant difference: *** p<0.001 vs. Control.Regarding the Ca2+-influx-induced contraction stimulated by KCl (75
mM), pre-incubation with JHE (IC50 or IC100) significantly
reduced (p < 0.001) the Emax values from 108.8% ± 4.3% (n =
5) to 63.8% ± 6.1% (n = 6) and 14.6% ± 1.9% (n=6), respectively.
In addition, treatment with verapamil significantly reduced (p < 0.001) the
contraction to 15.5% ± 1.1% (n=6) (Figure
3B).
Effect of reticular Ca2+ ATPase inhibitor, CPA, and
K+-channel blockers on JHE- induced relaxation
Treatment with CPA did not change the JHE-induced relaxation (93.8% ±
4.6%, n = 6) in isolated arteries (Figure
4). Thus, JHE did not change the inner Ca2+ uptake by the
sarcoplasmic reticulum to induce vascular relaxation.
Figure 4
Maximum relaxant effect induced by jabuticaba hydroalcoholic extract
(JHE) in isolated arteries pre-contracted with phenylephrine (0.1
µM) in the absence or presence (20 min) of the reticular
Ca2+ ATPase inhibitor, cyclopiazonic acid (CPA, 10
µM). The bars represent mean ± SEM of the maximum
relaxant effect expressed as % relaxation.
Maximum relaxant effect induced by jabuticaba hydroalcoholic extract
(JHE) in isolated arteries pre-contracted with phenylephrine (0.1
µM) in the absence or presence (20 min) of the reticular
Ca2+ ATPase inhibitor, cyclopiazonic acid (CPA, 10
µM). The bars represent mean ± SEM of the maximum
relaxant effect expressed as % relaxation.As shown in figure 5, except for
clotrimazole (94.1% ± 4.5%, n = 5), K+-channel blockers
changed the JHE-stimulated relaxation. The JHE-induced relaxation
(Emax: 98.3% ± 0.4%, n = 6) was significantly (p <
0.05) reduced by TEA (Emax: 87.6% ± 5.7%, n=5), glibenclamide
(Emax: 61.6% ± 5.8%, n = 6) and 4-AP (Emax:
81.6% ± 5.9%, n = 5). The results showed that JHE-induced relaxation
depends on K+ efflux through the membrane.
Figure 5
Effects of K+ channel blockers on the relaxation induced by
jabuticaba hydroalcoholic extract (JHE) in isolated arteries
pre-contracted with phenylephrine (0.1 µM) in the absence or
presence (20 min) of the blockers tetraethyl-ammonium (TEA, 1 mM),
glibenclamide (Glib, 3 µM), clotrimazole (5 µM) and
4-aminopyridine (4-AP, 1 mM). The points represent mean ± SEM
of the relaxant effect expressed as % relaxation. Significant
difference: *p < 0.05; *** p < 0.001 vs. Control
Effects of K+ channel blockers on the relaxation induced by
jabuticaba hydroalcoholic extract (JHE) in isolated arteries
pre-contracted with phenylephrine (0.1 µM) in the absence or
presence (20 min) of the blockers tetraethyl-ammonium (TEA, 1 mM),
glibenclamide (Glib, 3 µM), clotrimazole (5 µM) and
4-aminopyridine (4-AP, 1 mM). The points represent mean ± SEM
of the relaxant effect expressed as % relaxation. Significant
difference: *p < 0.05; *** p < 0.001 vs. Control
Discussion
The major finding of this study is that JHE, in addition to having a hypotensive
effect and inducing vascular relaxation through endothelial nitric oxide pathway, as
shown by our team,[14] acts directly
on VSM and leads to endothelium-independent relaxation. Therefore,
jabuticaba clearly has cardiovascular effects through multiple
endothelium-dependent and independent pathways. It is worth noting that the JHE
concentration capable of inducing 100% vascular relaxation through the endothelial
pathway is approximately 16 times lower (0.12 mg/mL)[14] than the JHE concentration necessary to induce
100% relaxation acting directly on VSM (1.92 mg/mL).Blood vessel contraction and relaxation in response to physiological demands are
controlled by changes in intracellular Ca2+ concentration of VSM. The
Ca2+ used for contraction includes intracellular or extracellular
sources, or both. Sarcoplasmic reticulum is the major source of intracellular
Ca2+.[16] Our
experiments showed that JHE does not change Ca2+ uptake by the
sarcoplasmic reticulum, because its selective inhibitor, CPA, did not change the
relaxation profile.Voltage-gated Ca2+ channels (VGCC), also known as L-type Ca2+
channels, and receptor-operated Ca2+ channels (ROCC) located on the
plasma membrane of VSM cells play a fundamental role in controlling Ca2+
influx.[17,18] Phenylephrine-induced contraction is mediated by
Ca2+ influx increase via VGCC and ROCC.[19,20] However,
contraction induced by membrane depolarization, such as in high KCl concentrations,
activates preferentially VGCC.[21]
The results of the present study show that treating arteries with JHE inhibits the
vascular contraction induced by the adrenergic stimulus with phenylephrine,
suggesting that JHE blocks Ca2+ influx by interfering with VGCC and/or
ROCC.In an attempt to clarify the cell mechanism through which JHE induces vascular
relaxation, experiments were performed in a Ca2+-free solution. Two
different stimuli, phenylephrine and KCl (75 mM), were used to induce
Ca2+ influx. The JHE, as well as verapamil, used as a positive
control, inhibited the Ca2+-influx-induced contraction mediated by both
stimuli. Because membrane depolarization with high concentrations of K+
activates specifically VGCC, we suggest that JHE acts directly or indirectly by
blocking Ca2+ influx through the plasma membrane, acting preferentially
on VGCC.Natural products have constantly shown the involvement of K+ channels in
their vasodilating mechanism.[22]
Several types of K+ channels, such as ATP-sensitive K+
channels (KATP), Ca2+-dependent K+ channels
(Kca) and voltage-gated K+ channels (Kv), are
present in VSM.[23,24] Those channels can be blocked by glibenclamide,
clotrimazole and 4-AP, respectively.[24,25]
Tetraethyl-ammonium is a non-selective blocker of those channels. When activated,
those channels allow K+ efflux, hyperpolarizing the VSM plasma membrane.
This reduces Ca2+ influx through the VGCC and induces
vasodilation.[26,27] The present study shows that
JHE-induced relaxation in endothelium-denuded arteries is hindered after
K+ channel blockade. Except for clotrimazole, the other blockers
hindered vascular relaxation, allowing relating its activation to the JHE
effect.Our results point to a new biological effect of jabuticaba, a
Brazilian native specimen that has important biological effects on the
cardiovascular system, such as glucose-lowering,[12] lipid-lowering[13] and hypotensive effects.[14] Thus, the biological
jabuticaba-induced effects demonstrated in this study will
contribute to increase the knowledge about jabuticaba-derived
compounds and their use as medicinal plant or functional food to prevent
cardiovascular problems.
Conclusion
This study shows that JHE induces endothelium-independent vasodilation. The major
cellular pathways used by JHE to cause vascular relaxation are inhibition of the
Ca2+-influx through plasma membrane, in addition to K+
channel activation in VSM cells.
Authors: Patricia M Kearney; Megan Whelton; Kristi Reynolds; Paul Muntner; Paul K Whelton; Jiang He Journal: Lancet Date: 2005 Jan 15-21 Impact factor: 79.321
Authors: S Y Yeon; S W Seto; G H H Chan; M Low; H Kiat; N Wang; J Liu; D Chang Journal: Evid Based Complement Alternat Med Date: 2020-09-22 Impact factor: 2.629