Human immunodeficiency virus (HIV) related depression has seriously affected the quality of life and treatment outcomes of patients living with HIV (PLWH), which has become a hot topic in recent years. This study aims to discover the main keywords, predict frontier topics, and give meaningful suggestions for researchers by bibliometric analysis.Publications between 1999 and 2022 on depression in HIV/AIDS were searched in the Web of Science core collection. Microsoft Excel 2010 and VOSviewer were utilized to key contributors . VOSviewer and CiteSpace were used to analyze the knowledge evolution, collaborative maps, hot topics, and keywords trends in this field.In total, 8,190 publications were included in the final analysis. From 1999 to 2021, the number of published articles roughly presents a steadily increasing trend. The United States, South Africa, and the United Kingdom were three key contributing countries/regions to this field. University Calif San Francisco (United States), University Calif Los Angeles (United States), and Johns Hopkins University (United States) were three key contributing institutions. Safren, Steven A. was the most productive and highest cited author. AIDS Care was the top prolific journal. Antiretroviral therapy and adherence, men has sex with men, mental health, substance abuse, stigma, and Sub-Saharan Africa were the central topics regarding the depression-related research in HIV/AIDS.This bibliometric analysis reported the publication trend, major contributing countries/regions, institutions, authors, journals and mapped the knowledge network of depression-related research on HIV/AIDS. In this field, topics such as “adherence,” “mental health,” “substance abuse,” “stigma,” “men who have sex with men” and “South Africa” have attracted considerable attention. HIV/AIDS ranks as the top 10 causes of disease-related life loss in adolescents  and adults  in 2019, a significant increase compared to 1999  infection and its’ caused acquired  ~20–40% . Prior s ~20–40% . Further ~20–40% . Depress ~20–40% .Many scholars are devoted to studying the association between HIV and depression. As early as 2001, Ciesla et al. have evaluate the relationship between HIV infection and depression through a meta-analysis . Leah H Bibliometrics is the cross-disciplinary science of quantitative analysis of the keyword clusters and hotspot bursts in a given field by mathematical, bibliographical, and statistical methods . It typiIdentify key contributors  and how they collaborate.Discover main topics and knowledge evolution based on keywords and co-cited references.Overview this field, predict frontier topics, and give meaningful suggestions for researchers.2.2.1.On September 06, 2022, we conducted an advanced search on the Web of Science Core Collection (WoSCC). Search formulas were “TS = (depress* OR depression OR depressed OR depressive disorder OR mood disorder)” AND “TS = (HIV OR HIV AND AIDS OR human-immunodeficiency-virus OR acquired immune deficiency syndrome),” to identify publications primarily focused on HIV in the field of depression. The date ranged from 1999/01/01 to 2022/09/06, language type was set as English, and the document type was limited to articles and reviews. First, two authors (Xiaoyu Du and Qian Zhang) independently searched the WoSCC and then screened the title, abstract, or full manuscript to identify whether these publications met this research topic. Second, the other two senior scholars (Jing Liu and Jia Chen) read and evaluated the discrepancies between the former authors, and discussed with them until a consensus was reached. All publications were exported as the format of “Full Record and Cited References,” and then used for bibliometric parameters extraction.2.2.Firstly, we used VOSviewer  to extract the following bibliometric parameters, mainly including the following elements, e.g., title, keywords, authors, institutions, countries/regions, published journals, publication year, total citations (TC), citations per publication (CPP) and cited references. Then we used Microsoft Excel 2010  to identify the publication trend, the top contributors . And we mapped the collaboration network between authors, institutions, and countries by VOSviewer, to demonstrate their scientific influence in this field. CiteSpace (Version 6.1. R1) were used to map the co-cited references network and identify references with highly citation burst. Co-occurrence of author keywords and keywords with citation burst were used to visualize the knowledge evolution, hot topics and potential research frontiers in this filed. In the map of VOSviewer and CiteSpace, the node size positively related to the number of publications, and the line width positively associated with their link strength.3.3.1.3.2.3.3.3.4.3.5.3.6.n = 683 publications) was the top prolific journal, followed by AIDS Behavior (n = 615 publications) and JAIDS-J Acquired immune deficiency syndromes (n = 224 publications). However, in terms of CPP, AIDS (n = 153 publications) has recorded the highest CPP (n = 46.4 CPP), followed by JAIDS-J Acquired immune deficiency syndromes  and AIDS Patient Care and STDS . Co-cited journals were journals frequently cited in a series of selected publications. Of which, AIDS Behavior , AIDS Care , and AIDS  ranked the first three.3.7.Citation is a quotation from one article to another article. The number of citations to the literature has been used as an indicator of the value, interest and utility of different articles in terms of the advancement of knowledge . Table 23.8.Co-citation is defined as two publications being cited by a third at the same time . The ana3.9.n = 2,703), “depression” , and “mental health” (n = 641). Further, to decipher potential research frontiers in this field, we used the overlay map of keywords occurrence by VOSviewer and keyword citation burst by CiteSpace. Frequently used keywords can be detected during a particular period. Keyword citation burst is an increase in the frequency and number of keyword occurrences within a certain period of time (n = 49.9). In the early stage, “stress,” “quality of life,” “cocaine” received lots of attention. And then keywords like “social support,” “adherence,” “risk behavior” got much attention. In recent years (2010-now), keywords have received more attention , which suggests that these keywords are likely to become frontier hot topics in the future.VOSviewer and CiteSpace were used to conduct keyword co-occurrence analysis to present major hotspots and frontiers in this field. To count the number of keyword occurrences more accurately, we used a thesaurus  to merge of time . Figure 4.4.1.In this study, 8,190 publications were included in the final analysis. We observed from 4.2.Lancet, a very authoritative journal. The top most cited articles, all collaborations between the University Queensland, University Washington, and Harvard University, were published in Lancet. They analyzed the global burden of disease and mortality, which suggested that HIV/AIDS and depression were the top 10 leading diseases for global disease burden in recent decades . We reasoned that this may be attributed to the top prolific author, Safren, SA . He has established a close collaboration with Mayer, KH. and Mimiaga, MJ, and Pence, BW, all of them ranked the top 10 prolific authors in 4.4.Analysis of keywords can help to quickly understand the knowledge network of a field. As shown in In this study, we visualized the knowledge networks and research paradigms of depression-related research among HIV/AIDS. The results showed 83 keywords appeared more than 40 times in 4.4.1.n = 346),” “antiretroviral therapy (ART) (n = 322),” “medication adherence (n = 101),” “highly active antiretroviral therapy (HARRT) (n = 94),” and “cognition (n = 81).” Since the inception of ART, the lifespan of HIV patients has been greatly improved. Adherence to ART plays a significant role in the effectiveness of treatment  in PLWH in Khayelitsha, South Africa ,” “sexual risk behavior (n = 45),” “sexual orientation (n = 61),” “condom use (n = 47)” and “childhood sexual abuse (CSA) (n = 31).” MSM remain the high-risk group for HIV, accounting for 69% of new HIV-positive diagnoses in the United States in 2020 ,” “social support (n = 266),” “discrimination (n = 63),” “China (n = 132),” and “COVID-19 (n = 61).” Stigma and discrimination are one of the biggest issues facing PLWH ,” “alcohol use (n = 149),” “drug use (n = 70),” and “methamphetamine (n = 55).” Approximately 14% of the global burden of disease is caused by neuropsychiatric diseases, of which, depression, alcohol use, and substance use are the top three reasons ,” “quality of life (n = 258),” “stress (n = 141),” and “suicide (n = 68).”There has been substantial evidence that the depression and anxiety experienced by HIV-infected patients are related to neurobiological changes caused by the ongoing attack on the central nervous system by the virus ,” “women (n = 283),” “pregnancy (n = 88),” “adolescents (n = 56),” “uganda (n = 94),” and “Kenya (n = 60).” Under this cluster, they focus on adolescents and women living with HIV. Globally, there are 1.6 million adolescents living with HIV, 70% of whom are living in Eastern and Southern Africa  were not included in this study. Second, the indicators for the quality of an article, an author, or an institution only included the number of publications, TC, and CPP. Other metrics are widely used in other studies, such as H-index, Impact Factor, CiteScore, etc. Third, due to the included criteria of language and publication types, only articles or reviews in English were included in this analysis. However,“English” remains the most common language used in published academic literatures worldwide, future research should integrate multiple non-English language  publications to provide a more comprehensive analysis of this field.5.This bibliometric analysis provides an overview of depression-related research on HIV/AIDS from 1999 to 2022. This study reported the publication trend, major contributing countries/regions, authors, institutions, journals and mapped the knowledge network of depression-related research on HIV/AIDS. In this field, topics such as “adherence,” “mental health,” “substance abuse,” “stigma,” “men who have sex with men” and “south africa” have attracted considerable attention. Further work should emphasize the following initiatives: (1) strengthen the co-operation between authors, institutions, and countries. (2) exploring different interventions to improve adherence. (3) developing more organizations to help PLWH reduce stigma and provide social support, especially in MSM (4) increasing investments to low-resource settings, especially in Sub-Saharan Africa.The original contributions presented in the study are included in the article/XD and QZ conceived of the study, participated in its design, and drafted the manuscript. JL and JH involved in study design, obtained data and contributed to interpretation, and helped to draft the manuscript. JC provided the theoretical frameworks and performed much of the editing of the manuscript and provided the fund support. All authors contributed to the article and approved the submitted version.This study was supported by the Hunan Science and Technology Innovation Platform and Talent Plan (grant: 2017TP1004).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We obtain covariance and Choquet integral representations for some entropies and give upper bounds of those entropies. The coherent properties of those entropies are discussed. Furthermore, we propose tail-based cumulative residual Tsallis entropy of order  ThV with cumulative distribution function (cdf) To estimate and identify risk measure, the law invariance (A) is an essential requirement. When a risk measure Some risk measures have other desirable properties; for example, (B1) Standardization: For V beyond the quantile To capture the variability of the risk Landsman  proposedV. As its extension, Furman et al. )ime (see ).The initial, weighted and dynamic entropy risk measures are closely related, as shown in From a risk measure point of view, the initial entropy risk measures can capture the variability of a financial position as a whole. The dynamic entropy risk measures can depict the variability of a financial position focused on feasible choices of the ranges (upper tail or lower tail).In finance and risk management, Markowitz’s mean-variance portfolio theory plays a vital role in modern portfolio theory. It is known that the initial entropy and simple dynamic entropy risk measures are measures of variability. We can replace variance with the initial entropy and simple dynamic entropy risk measures, respectively. The initial entropy risk measure is used to capture ordinary  risk, and it is favored by investors, such as the firm’s ordinary business and the shareholders’ interests. The dynamic entropy risk measure is used to depict the tails of risks (extreme events), which is to reduce (or avoid) the impact of extreme events and is favored by regulators and decision makers (see ). For exand Chen , we can Let Let Remark 2.Let α=1 in  (or α→1  (α→1 in ); we obtand Chen :where Let Remark 3.Let α=12 in ; we obseLet ent (see ): (26)TERemark 4.Let r=2 in ; we obtawhere We now introduce two risk measures of entropy shortfall, which are linear combinations of Theorem 5.Assume that (1) where(2) (3) The below statements are equivalent: (i) Proof. (1)Using  and 23)23) of ESy obtain  and 28)ESp(X) an(2)From , the pos(3)Noting that a 4.2 of , one obtNext, by Theorem 2.1 of  and 28)28), we kFurthermore, by Corollary 4.65 of , we learRemark 5.Let all see ,39), whi, whiα=2 tfall in .Theorem 6.Assume that (1) where(2) (3) The below statements are equivalent: (i) Proof. Let ing with , we obtaTheorem 7.Assume that Furthermore,Proof. By , we haveNote thating with , we obtaing with . Therefoing with , ending Theorem 8.Assume that Furthermore,Proof. Let ing with , we obtaX exists, its form will be fX(v):=Cumulative generator Landsman and Valdez  proved tt, logistic and Laplace distributions, are given as follows.Now, several important cases, including normal, Student-Example 21. Let and the normalization constants are given byThen,where Without loss of generality [for the convenience of simulation], let quations , 30) an anX∼N1. Let The normalization constants are given bywhere where Let quations , 30) an anX∼St10quations , we can m. When m is small, p, while p instead of increasing when m is larger than a threshold. From p. However, when p is fixed, p. However, when p is fixed, p. Moreover, when p is fixed, From Example 23.(Logistic distribution). Let The normalization constants are given byThen,where Let quations , 30) an anX∼Lo10quations , we can p, p. However, when p is fixed, p. Moreover, when p is fixed, It is seen from Example 24.(Laplace distribution). Let andThe corresponding normalization constants are given byThen,where Let quations , 30) an anX∼La10quations , we can p has almost no impact on p. However, p, p. However, when p is fixed, p. Moreover, when p is fixed, It is seen from Example 25.(Inverse Gaussian distribution) An inverse Gaussian random variable From Example 4.3 of Landsman and Valdez (2005), we can obtainwhere Let quations , 30) an anX∼IG10quations , we can Example 26.(Gamma distribution) A random variable Landsman and Valdez  providedwhere Let quations , 30) an anX∼Γ5,1quations , we can Example 27.(Beta distribution) A random variable We can obtainwhere Let quations , 30) an anX∼B5,2quations , we can This paper has derived covariance and Choquet integral representations of some entropies, and has proposed shortfalls of entropy CRTES and RTDS. In particular, CRTESs of elliptical, inverse Gaussian, gamma and beta distributions are computed. Furthermore, Hou and Wang  generali


Vitamin D supplementation exerts several supporting effects on improving glycemic status, however, results are inconclusive. Thus, in the present study, we aimed to conduct an umbrella of meta-analysis regarding the impact of vitamin D on type 2 diabetes (T2DM) biomarkers.The Scopus, PubMed, Web of Science, Embase, and Google Scholar online databases were searched up to March 2022. All meta-analyses evaluating the impact of vitamin D supplementation on T2DM biomarkers were considered eligible. Overall, 37 meta-analyses were included in this umbrella meta-analysis.Our findings indicated that vitamin D supplementation significantly decreased fasting blood sugar (FBS) , hemoglobin A1c (HbA1c) , insulin concentrations , and homeostatic model assessment for insulin resistance (HOMA-IR) .This umbrella meta-analysis proposed that vitamin D supplementation may improve T2DM biomarkers.The online version contains supplementary material available at 10.1186/s13098-023-01010-3. Impaired glucose metabolism is associated with an increased risk of several chronic diseases, including obesity, Type 2 diabetes (T2DM), metabolic syndrome, and cardiovascular disease . Both geVitamin D, a lipid-soluble vitamin, is well-known for regulating bone metabolism and calcium-phosphorus homeostasis . HoweverThe impact of vitamin D on T2DM biomarkers has been broadly examined through many meta-analyses of randomized controlled trials (RCTs), yet the fact that vitamin D supplementation is an effective strategy for controlling T2DM still remains controversial, which has led to inconsistent conclusions about the role of vitamin D on T2DM biomarkers , 27–29. The current umbrella review of meta-analysis, was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement , and theA comprehensive online search for relevant published records was conducted from inception until March 2022, using Scopus, Web of Science databases, Embase, PubMed, and Google Scholar. Based on MeSH and text keywords, the following pattern of search was applied: "vitamin d" OR "ergocalciferols" OR "supplementation "OR "vitamin d3″ OR "vitamin d2″ OR "intake" AND “blood glucose” OR “Glucose” OR “FBS” OR “HOMA-IR” OR “insulin sensitivity” OR Insulin” OR “HbA1c” OR “insulin resistance” AND "systematic review" OR "meta-analysis". To enhance the sensitivity of the search approach, the wild-card phrase "*" was used. Database searches were done by two authors (VM and MV). Hand searches were also conducted on the reference lists of related articles to ensure that no studies were missed. We included English-language publications.vitro, in vivo, and ex vivo studies, controlled clinical trials, studies with insufficient data, and studies without full texts. The paper selection process was completed by two independent reviewers (ZK and VM), and any disagreements came into a consensus through discussing with a senior author (PD).Meta-analyses investigating the effect of vitamin D supplementation on T2DM biomarkers  providing the effect sizes (ESs) and confidence intervals (CIs) were considered eligible for including in this umbrella meta-analysis of randomized controlled trials (RCTs). Studies with the following criteria were excluded: observational studies, quasi-experimental studies, case reports, conference papers, letters, in Two independent reviewers  extracted the following information from included studies: the first author, publication year, location of the project, study population and sample size, dosage and duration range of Vitamin D, ESs and CIs  regarding study outcomes. The disagreements were consulted by a third reviewer (VM).The methodological quality of eligible articles was assessed by two independent reviewers using the assessment of multiple systematic reviews (AMSTAR2) tool . The AMSTAR2 questionnaire consists of 16 questions, which reviewers are required to answer "Yes," "Partial Yes", "No", or "No Meta-analysis". “High quality”, “Moderate quality”, “Low quality”, and “Critically low quality” were the categories on the AMSTAR2 checklist .2 statistics, in which I2 values greater than 50% or p < 0.1 were considered as significant heterogeneity. A separate analysis was carried out for each type of SMD and WMD in view of their natural differences. In order to explore sources of heterogeneity, we performed subgroup analysis applying the duration of study , gender , mean age , sample size , dose , and health conditions . The sensitivity analysis was conducted to establish how dependent the overall ES was on a specific study (Leave-one-out Method). Egger's and Begg's tests were used to examine the small-study effect. The presence of publication bias was detected using a visual inspection of the funnel plot. If publication bias was identified, the trim and fill method carried out. STATA version 16 software was used for the statistical analyses .Random-effect models, based on the restricted maximum likelihood method (REML), were used to estimate the overall ESs and 95% CI . HeterogThe PRISMA flow chart of the literature search process is depicted in Fig. Regarding study location, fourteen meta-analyses were performed in China , 33–44, Table I2 = 92.0%, p < 0.001). Subgroup analyses indicated that the reductions in FBS levels were more pronounced in patients with a mean age of > 50 years, patients with gestational diabetes mellitus (GDM), a sample size of ≤ 1000, and studies with a duration of intervention ≤ 15 weeks, and dosage of ≤ 4000 IU/day when compared to their counterparts   , with significant inter-study heterogeneity   indicated that vitamin D administration significantly improved HbA1c  with a high degree of study heterogeneity . The intervention duration of ≤ 15 weeks among women with GDM and age ≤ 50 years contributed to a greater decrease in HbA1c  . Vitamin D supplement of ≤ 4000 IU/day in studies with intervention duration of ≤ 15 weeks, subjects younger than 50 years with GDM, sample size of > 500 contributed to a more robust reduction in insulin    . The heterogeneity was considerable between studies . The I2 index showed considerable heterogeneity among meta-analyses  , and HOMA-IR (p < 0.05). Moreover, no evidence of a small study effect was detected after conducting Egger’s and Begg’s tests for insulin levels (p˃0.05). Also, visual checking of the funnel plot . The overall quality of included meta-analyses shown in Table Different parameters such as the latitude, skin pigmentation, duration of sun exposure, and season can affect the production of vitamin D , 65. SevIn our meta-analyses, we observed that vitamin D significantly decreased HbA1c levels, proposing that vitamin D is helpful to delay or decrease the development and occurrence of diabetic problems. In 2007, the UK prospective diabetes study estimated a 1% decrease of HbA1c related to a 14% decrease in risk of cardiovascular events . A revieThe possible mechanisms of action of vitamin D may be through amplification of insulin secretion by the expression of vitamin D (VDR) in the pancreatic β-cells, increasing insulin sensitivity, suppressing the production of pro-inflammatory mediators and cytokines, and regulation of the intracellular and extracellular calcium flux –89. The Overall, the present umbrella meta-analysis showed that vitamin D supplementation has lowering effect on FBS, HOMA-IR, HbA1c, and insulin levels. Vitamin D supplementation might be proposed as a beneficial dietary component in managing hyperglycemia and its complications. Moreover, current findings suggest to supplement with a dosage of > 4000 IU and for a treatment period of < 15 weeks. Overall, vitamin D supplementation as a complementary treatment for diabetes management is supported by the findings of this review.Additional file 1. The results of funnel plot for the effect of the vitamin D on glycemic indices.


Of 543 psychiatrists, 79% reported “patients were not willing to discontinue hypnotic/anxiolytic” whereas a certain number of patients conveyed “psychiatrists did not explain in enough detail about hypnotic/anxiolytic discontinuation such as procedure (18.3%), timing (19.2%), and appropriate condition (14.4%)”. Conclusion: The results suggest that the majority of psychiatric outpatients were taking hypnotic/anxiolytics for a long time against their will. There might be a difference in perceptions toward hypnotic/anxiolytic use and decision making for its discontinuation between psychiatric outpatients and psychiatrists. Further research is necessary to fill this gap.Background: Although long-term use of benzodiazepines and z-drugs (BZDs) is not recommended, little is known about the stakeholders’ perceptions. This study aimed to assess and compare the perceptions of BZD use and decision making regarding its discontinuation between psychiatric outpatients and psychiatrists. Methods: A cross-sectional survey was conducted. Results: Of 104 outpatients, 92% were taking hypnotics and 96% were taking anxiolytics for ≥a year, while 49% were willing to taper hypnotic/anxiolytics within a year of starting. Most psychiatrists felt that “patient and psychiatrist make the decision together on an equal basis” compared to patients ( Benzodiazepines and z-drugs (BZDs) act as positive allosteric modulators of the benzodiazepine binding sites of GABAA receptors, and have hypnotic-based sedation and anti-anxiety effects . These dThe long-term use of BZDs has disadvantages such as dependence, decline in cognitive function, and motor impairment, leading to hip fractures associated with falls ,5,6,7. WThe prescription of BZDs is higher in Japan than in Western countries, according to a 2010 United Nations report . Given tIn recent years, traditional patient–clinician interaction that focused on the “expert” healthcare provider informing the patient on the best course of action for a specific treatment has been replaced with patient-centered approaches, such as shared treatment decision making ,14. In lPatients are willing to be aware of their illness and participate in the decision-making process . This teHowever, patient involvement in treatment decision making in clinical settings is not fully understood. The extent to which patients are involved in prescribing behaviors related to BZD use remains unclear. Considering the long-term and high-dose use of BZDs, patient involvement may not be implemented in psychiatry in Japan.This study aimed to assess the perceptions of BZD use and decision making regarding discontinuation of BZDs between psychiatric outpatients and psychiatrists. Considering the long-term and high-dose use of BZDs, we hypothesized that there might be discrepancies between the outpatients and psychiatrists regarding BZD use and discontinuation.We performed a cross-sectional, anonymous survey.n = 740) on 25 October 2021 via COMHBO email listservs with a link to the as a Google Forms survey. Those who met the following criteria were invited to participate in this survey: aged 20 years or above and currently on hypnotic/anxiolytic regimen or having taken hypnotic/anxiolytic drugs in the past. A reminder email was sent after two weeks, and the survey was closed on 26 November 2021.For psychiatric outpatients, we included members of the Mental Health and Welfare Bonding Organization (COMHBO), which is a nonprofit community organization comprising individuals with mental illnesses, such as schizophrenia and bipolar disorder, their families, and formal/informal caregivers. An invitation was sent to individuals with mental illnesses (n = 1690). An invitation was sent to each psychiatrist on 10 January 2022 via email listservs of the association, which included a link to the as Google Forms survey. We also dispatched each psychiatrist the survey by post to enable them to respond by whichever mode they preferred. The survey was closed on 26 January 2022.We included psychiatrists belonging to the Japanese Association of Neuro-Psychiatric Clinics .2) test was used to compare outpatients’ responses to those of psychiatrists’ regarding the decisions on continuing/tapering hypnotic/anxiolytics. The results were considered statistically significant at p ≤ 0.05.The variables for the questionnaire were developed based on a literature review and discussions within the steering group of this study, including psychiatrists, a psychiatric nurse, and an outpatient with mental illness. The questionnaire consisted of the following components: (1) demographics; (2) current situation related to hypnotic/anxiolytic use, such as experience, duration, and the number of hypnotic/anxiolytic medications taken; (3) perspectives of hypnotic/anxiolytic use (desirable timing of reduction after symptom improvement and permissible situation of its continuation); (4) decision making regarding the continuing/tapering of hypnotic/anxiolytic use; and (5) difficulties when attempting to reduce hypnotic/anxiolytic use in the past. Regarding each variable, anxiolytics were benzodiazepines and hypnotics included both benzodiazepines and z-drugs . We thenIn total, 104 psychiatric outpatients and 543 psychiatrists completed the survey. Overall, 52.9% of outpatient respondents reported that they had taken both hypnotics/anxiolytics, while 30.8% had hypnotics only and 16.4% had anxiolytics only. Regarding the duration of taking hypnotics/anxiolytics, 92.0% of outpatient respondents reported that they had taken hypnotics for over a year, and 95.8% had anxiolytics for more than one year .The most frequent response of the outpatients was “no need to reduce hypnotic/anxiolytic if there are no side effects” (23.1%), followed by “immediately after symptom improvement” (19.2%), and “within 3 months after symptom improvement” (16.4%). On the other hand, 49.16% of outpatients desired to reduce hypnotic/anxiolytic usage within 12 months after symptom improvement, who constitute the participants that selected one of the following four variables: “immediately” (19.2%), “within 3 months” (16.4%), “within 6 months” (3.9%), and “within 12 months(9.6%).”The most desirable reduction timing of hypnotic/anxiolytic use for the psychiatrists after patient’s symptom improvement was “within 3 months after symptom improvement” (38.1%), followed by “within 6 months after symptom improvement” (22.5 %), and “immediately after symptom improvement” (14.2%). Overall, 85.5% of psychiatrists desired to reduce hypnotic/anxiolytic use immediately within 12 months after symptom improvement as a total of four variables: “immediately” (14.2%), “within 3 months” (38.1%), “within 6 months” (22.5%), and “within 12 months” (8.3%).p < 0.001) and “within 6 months” (p < 0.001) compared to outpatients, while more outpatients thought that the reduction should occur “after 12 months passed” (p < 0.001) and “no need to reduce if there are no side effects” (p < 0.001) compared to psychiatrists  am (is) still suffering from symptoms of insomnia or anxiety” , followed by “when my (the patient’s) social functioning is disrupted”  and “when I (the patient) still have (has) physical or mental problem, which led to the start of the medication administration” .p < 0.001) and “physical and mental problems, which led them to start to take the medication” (p < 0.001), and “the number of medications taken” (p < 0.001) compared to the patients  the decision together, on an equal basis” , followed by “the decision is (was) made, considering the psychiatrist’s opinion”  and “the decision is (was) made, considering the patient’s opinion”. In contrast, there was a significant difference between the proportion of outpatient respondents and psychiatrists for each variable. Thus, our hypothesis that there would be a discrepancy between outpatients and psychiatrists was accepted. Most psychiatrists thought that they made decisions on continuing/tapering hypnotic/anxiolytics using shared decision making on an equal basis, while the majority of outpatients believed that they made a decision considering the psychiatrist’s opinion. .The most frequent difficulty of the outpatients was “I could not reduce the medication because withdrawal symptoms appeared when I tried” (24.0%), followed by “I could not reduce the medication because of worsening symptoms” (23.1%) and “I never had any particular problem regarding the medication reduction” (21.2%). Moreover, the outpatients experienced the following difficulties because of insufficient related information: “I did not know how to reduce the medication” (18.3%), “I did not know when I should reduce the medication” (19.2%), and “I did not know the situation or condition where the medication could be reduced” (14.4%). The most frequent answer of the psychiatrists was “I could not reduce the medication because the patient was unwilling to reduce it” (78.8%), followed by “I could not reduce the medication because of worsening symptoms” (61.3%) and “I could not reduce the medication because withdrawal symptoms appeared when I tried” (37.6%).p < 0.001), “when I should reduce the medication” (p < 0.001), and “the situation or condition where the medication can be reduced” (p < 0.001) due to insufficient information compared to the psychiatrists. On the other hand, more psychiatrists felt that they could not reduce the medication because of “worsening symptoms” (p < 0.001) and “withdrawal symptoms appeared when tried” (p < 0.001) compared to the patients  and “within 6 months” (p < 0.001) compared to outpatients. Thus, the stakeholders’ preferences were in line with the recommendations described in several clinical guidelines, which recommend that hypnotics/anxiolytics should not be prescribed for a longer time [In this study, almost half of the psychiatric outpatients 49.1%) and the majority of the psychiatrists 85.5%) desired to reduce hypnotic/anxiolytic use within 12 months of symptom improvement. In particular, psychiatrists were more willing to implement medication reduction if they thought that the reduction should occur “within 3 months” (5.5% desi.1% and tger time . Howeverger time . AccordiThis study found discrepancies between the perspectives of outpatients and psychiatrists. Thus, our hypothesis was accepted. First, more psychiatrists perceived permissible situations for hypnotic/anxiolytic continuation in relation to social functioning and physical or mental problems, which led to the start of the medication, compared to the patients. Second, more psychiatrists found worsening psychiatric and withdrawal symptoms challenging while attempting to reduce medication compared to the patients. These results suggest that patients may not focus on symptoms and function, whereas psychiatrists do. Thus, these discrepancies mean that psychiatrists might fail to understand the patient’s preferences and values, which should be clarified through conversation with the patients in a clinical setting. Third, more psychiatrists felt that they had already implemented shared decision making, while more patients felt that the decision had been made considering the psychiatrists’ opinions. This discrepancy is crucial because SDM may not be as widely implemented as psychiatrists believe. Several studies have reported similar situations. For instance, Matthias et al. observed appointments in psychiatric outpatient services for medication management and found that psychiatrists initiated most of the decisions . VerwijmBased on the results of this study, we propose some solutions for the current situation in Japan, where long-term and high-dose BZD use remains. First, >90% of the patients in this study had used hypnotic/anxiolytic medication for over a year. Other countries have already set limits on the duration of BZD prescriptions at four weeks ,34,35,36This study had several limitations. First, outpatients and psychiatrists were recruited from different organizations. The findings might have been different if the study had been conducted with a combination of the psychiatrist in charge and their patients. Second, outpatients in this study had mental health conditions, such as schizophrenia and bipolar disorder. The results may have differed with patients under primary care because mental illness is considered a risk factor for the long-term use of BZDs ,41,42. TThis study assessed and compared the perceptions on BZD use and decision making regarding its discontinuation between psychiatric outpatients and psychiatrists. The results suggest that the majority of psychiatric outpatients were taking hypnotics/anxiolytics for a long time against their will. There might be a difference in perception toward hypnotic/anxiolytic use and decision making for its discontinuation between psychiatric outpatients and psychiatrists. Further research is required to address this gap.


Background: The tricarboxylic acid cycle (TCA cycle) is an important metabolic pathway and closely related to tumor development. However, its role in the development of esophageal squamous cell carcinoma (ESCC) has not been fully investigated.Methods: The RNA expression profiles of ESCC samples were retrieved from the TCGA database, and the GSE53624 dataset was additionally downloaded from the GEO database as the validation cohort. Furthermore, the single cell sequencing dataset GSE160269 was downloaded. TCA cycle-related genes were obtained from the MSigDB database. A risk score model for ESCC based on the key genes of the TCA cycle was built, and its predictive performance was evaluated. The association of the model with immune infiltration and chemoresistance were analyzed using the TIMER database, the R package “oncoPredict” score, TIDE score and so on. Finally, the role of the key gene CTTN was validated through gene knockdown and functional assays.Results: A total of 38 clusters of 8 cell types were identified using the single-cell sequencing data. The cells were divided into two groups according to the TCA cycle score, and 617 genes were identified that were most likely to influence the TCA cycle. By intersecting 976 key genes of the TCA cycle with the results of WGCNA, 57 genes significantly associated with the TCA cycle were further identified, of which 8 were screened through Cox regression and Lasso regression to construct the risk score model. The risk score was a good predictor of prognosis across subgroups of age, N, M classification and TNM stage. Furthermore, BI-2536, camptothecin and NU7441 were identified as possible drug candidates in the high-risk group. The high-risk score was associated with decreased immune infiltration in ESCC, and the low-risk group had better immunogenicity. In addition, we also evaluated the relationship between risk scores and immunotherapy response rates. Functional assays showed that CTTN may affect the proliferation and invasion of ESCC cells through the EMT pathway.Conclusion: We constructed a predictive model for ESCC based on TCA cycle-associated genes, which achieved good prognostic stratification. The model are likely associated with the regulation of tumor immunity in ESCC. Esophageal cancer is one of the leading causes of cancer-related deaths worldwide. According to the Global Cancer Statistics 2020, esophageal cancer ranks 7th and 6th in terms of incidence and mortality . The 5-yThe tricarboxylic acid cycle (TCA cycle) is a crucial pathway for the metabolism of sugars, lipids, and amino acids , and itsGiven the significance of the TCA cycle and the metabolic dysfunction that occurs during tumor development, we used an innovative bioinformatics approach to screen for the key TCA-related genes involved in ESCC in order to identify potential therapeutic targets. In addition, we established a risk score model based on the prognostically significant TCA cycle-related genes to identify patients with poor prognosis and monitor therapeutic response.The RNA expression profiles of ESCC were obtained from The Cancer Genome Atlas (TCGA) database. The samples were subsequently split into a training and validation cohort at 5:5 ratio. The GEO dataset (GSE53624) was downloaded as an independent validation cohort. All data were in FPKM format and converted to log2 scale. The R package “limma” was used to adjust the batch effects between TCGA and GSE53624. In addition to DNA expression, DNA methylation, IncRNA and mRNA expression data, clinical information  was also extracted from the datasets. The single-cell sequencing dataset GSE160269 that includes 60 samples was obtained from the GEO database. All datasets were required to meet the following analysis criteria: 1) availability of complete information, 2) sample size >50, and 3) all cases underwent surgery without prior radiotherapy or other treatment.The quality control of the scRNA-seq data was performed using the “seurat” R package. The TCA cycle-related genes were extracted from the MSigDB database. To assign a TCA cycle activity score to each cell type, the “AUCell R” package was used to determine the status of gene set activity. The TCA cycle score for each patient in TCGA cohort was determined by Single sample gene set enrichment analysis (ssGSEA). Finally, weighted correlation network analysis (WGCNA) was performed to derive gene clusters that were correlated with TCA cycle scores using transcriptomic data of ESCC.p < 0.05 as the threshold. Lasso regression was then performed on the survival-associated genes to eliminate covariates, and the best gene combination was determined to construct a risk score prediction model. The risk scores for all patients in the training cohort were calculated, and the patients were stratified into the high-and low-risk groups using the median risk score as the threshold value. The survival curves of two groups were plotted using the Kaplan-Meier method, and compared with the log-rank test to assess the predictive effect of the model. The prognostic model was similarly tested on multiple validation cohorts. The predictive performance of the prognostic model was further assessed by plotting ROC curves at different endpoints and calculating the area under the curve (AUC). A nomogram was then constructed by combining the TCA risk score and other clinical parameters, and its predictive performance was evaluated by the Kaplan-Meier method and log-rank test as described. The clinical practicability of the nomogram was assessed by decision curve analysis (DCA). Stratified analyses were also performed for subgroups based on different clinical features.The TCA cycle genes significantly associated with survival in ESCC were first identified through univariate Cox analysis, with The level of immune infiltration in ESCC patients was determined by seven algorisms, including CIBERSORT, CIBERSORT_ABS, EPIC, MCPcounter, quanTIseq, TIMER, xCell. In addition, ssGSEA was performed on genes in the TCA-related model. The “estimate” R package was used to determine the relative abundance of stromal cells, immune cells, and tumor cells, and compare these values across risk categories. The genetic mutations in the high-risk and low-risk patients were also compared by analyzing the mutation profiles of ESCC patients from TCGA using the “maftools” software. The half-maximal inhibitory concentration (IC50) of common chemotherapeutic agents in the two risk groups using the R package “oncoPredict”.2. CTTN was knocked down in both cell lines using two specific siRNAs  that were synthesized by GenePharma . The cells were transfected with the siRNA constructs using JetPRIME  according to the manufacturer’s instructions, and harvested 48 h later for follow-up experiments.Two esophageal cancer cell lines, KYSE150 and TE-1, were procured from the American Type Culture Collection (ATCC) repository. All cell lines were cultured in RPMI medium at 37°C in a humidified incubator containing 5% COTotal RNA was extracted from the cells using TRIzol reagent , and reverse transcribed using PrimeScript RT Master Mix . RT-PCR was performed using TB Green Premix Ex Taq II (Tli RNaseH Plus)  on the ABI 7500 qPCR cycler . The primers were synthesized by Sangon Biotech (Shanghai), and the sequences were as follows: CTTN forward, 5′-GTGGTTTTGGCGGCAAGTATG-3′; CTTN reverse, 5′-CTCTCTGTGACTCGTGCTTCT-3′; GAPDH forward, 5′-CGAGATCCCTCCAAAATCAA-3′, GAPDH reverse, 5′-TTCACACCCATGACGAACAT-3′; E-cadherin forward, 5′-ATTTTTCCCTCGACACCCGAT-3′; E-cadherin reverse, 5′-TCCCAGGCGTAGACCAAGA-3′; Vimentin forward, 5′-AGTCCACTGAGTACCGGAGAC-3′; Vimentin reverse, 5′-CATTTCACGCATCTGGCGTTC-3′; N-cadherin forward, 5′-ATTGGACCATCACTCGGCTTA-3′; N-cadherin reverse 5′-CACACTGGCAAACCTTCACG-3′; Snail forward, 5′-TCGGAAGCCTAACTACAGCGA-3′; Snail reverse, 5′-TCGGAAGCCTAACTACAGCGA-3′. Each reaction was performed in triplicate.4 cells/well, and labelled using the BeyoClick™ EdU-488 Cell Proliferation Assay Kit after 24 h of culture. The fluorescence intensity of the cells was measured, and the ratio of EdU-488+ cells to DAPI+ cells was calculated to determine the proliferative capacity.The cells transfected with si-NC, si-CTTN-1 or si-CTTN-2 were seeded in a 24-well plate at the density of 6 × 10KYSE150 and TE-1 cells were seeded in 6-well plates at the logarithmic growth stage, and the culture medium was replaced every 3 days. Following transfection, the cells were cultured for 12 days. The resulting colonies were fixed with 4% paraformaldehyde, stained with 0.1% crystal violet, and counted.The suitably transfected cells were seeded into the upper chamber of Transwell inserts pre-coated with 1:5 diluted Matrigel in serum-free medium. The lower chambers were filled with complete medium. After culturing for 24 h, the cells remaining on the upper surface were swabbed off, and those that migrated to the lower surface were fixed with 4% paraformaldehyde and stained with 0.1% crystal violet. The number of cells were counted in 5 random fields of view per well to determine migration rate.Proteins isolated from the transfected cells were separated by SDS-PAGE and transferred to PVDF membranes. After blocking with 5% skimmed milk powder for 2 h, the membranes were incubated overnight with primary antibodies specific for GAPDH , E-cadherin , Snail , Vimentin  and N-cadherin  at 4°C. The membranes were washed thrice with TBST for 10 min each time, and then incubated for 1 h with peroxidase-conjugated secondary antibody .Using the UMAP method, we annotated the ESCC single cell samples into 38 clusters  and eighp < 0.001). To further explore the relationship between TCA and prognosis of ESCC patients, we intersected the most relevant genes affecting TCA cycle activity in single cells and the differential genes identified by WGCNA, and identified 57 genes for further analysis , and this result was validated in the GSE53624 cohort  in the age, M classification, N classification, and TNM stage between the two groups. Patients in the high-risk group were younger, and had lower M-stage, higher N-stage and higher TNM stage , a key gene in risk score, for further analysis. The CTTN gene was successfully knocked down in the KYSE150 and TE-1 cell lines using specific siRNA sequences . The EdUESCC is a major public health challenge worldwide. Although the prognosis of ESCC has improved in recent years with development of multimodality approaches, there is still lack of effective treatment approach for ESCC . Conventin vitro. A previous study showed that downregulation of RNF128 induced EMT and stemness in melanoma cells through CD44 and CTTN ubiquitination  and gene expression data, which affect the reliability of the results. Therefore, the present findings will have to be validated further on independent datasets. Secondly, genetic differences among different ethnic groups may have an impact on the results, and should be taken into consideration in future studies. Thirdly, most of the genes in the risk model have not been previously associated with ESCC, and the correlation between these genes and esophageal cancer need to be investigated further. Finally, it remains to be elucidated whether this model can be applied to esophageal adenocarcinoma or even esophageal cancer in general.In conclusion, we constructed a TCA cycle-based risk score to evaluate the prognosis, immune infiltration, immunotherapy response, and chemoresistance of ESCC patients. The risk score achieved good predictive performance in several independent datasets. CTTN, a key gene of the risk score model, affects the proliferation, invasion and EMT of ESCC cells, thus providing new insights into the relationship between metabolic abnormalities and EMT.


Resins have enormous potential in the removal of naphthenic acids (NAs) from transformer oil due to their rich porosity and high mechanical and diversified functionality, whereas their poor adsorption capacity limits application. In this work, the polystyrene–diethylamine resin (PS−DEA−x) was prepared by grafting diethylamine (DEA) onto chloromethylated polystyrene (PS−Cl) resin to efficiently adsorb cyclopentane carboxylic acid from transformer oil for the first time. The characterization analysis results indicated that amine contents were significantly enhanced with the increase in DEA. Particularly, resin with a molar ratio of 1:5 depending on chloromethyl to DEA (PS−DEA−5) exhibited the highest amine contents and efficient adsorption of cyclopentane carboxylic acid (static adsorption capacity up to 110.0 mg/g), which was about 5 times higher than that of the pristine PS−Cl. The thermodynamic and kinetic studies showed that the adsorption behaviors could be well fitted to the Langmuir isotherm equation and pseudo−second−order rate equation. Moreover, it was found that 1 g of the PS−DEA−5 can decontaminate about 760 mL transformer oil to meet reuse standards by a continuous stream, indicating its potential application in industry. Transformer oil is an essential insulating medium for power transmission and transformation equipment in a power system ,2. Howev3O4/SiO2 NH2/C18) magnetic nanoparticles, and they found that Fe3O4/SiO2 NH2/C18 had a 2.7 times higher adsorption capacity compared to the unmodified silica−coated (Fe3O4/SiO2) nanoparticles toward 4−heptylbenzoic acid from octane. For now, most studies concerning NA removal still concentrate on the water phase, while only a few study the extraction of NAs from the oil phase. Additionally, practical applications of these adsorbents are limited because of high cost and synthesis difficulty, and powdered adsorbents are hard to separate from oil [NAs, a kind of weak acid, are a mixture of alicyclic carboxylic acid and saturated aliphatic acid ,14. Morefrom oil . Hence, In recent years, resins have drawn significant attention in the removal of NAs from transformer oil, since they display high specific surface area, strong mechanical strength, tunable porous texture, and easy separation. Debashish et al.  studied Based on the above discussion, we prepared a series of resins with different amine contents using DEA−modified PS−Cl to reinforce NA adsorption in transformer oil. Various characteristic analysis methods were used to verify the successful introduction of DEA in PS−Cl. Particularly, the adsorption process was described by kinetic, thermodynamic, and dynamic adsorption studies. Since the real system is a complex mixture of chemical species, the adopted approach to promote a better comprehension of the phenomenon was to study model systems composed of cyclopentane carboxylic acid with transformer oil.−1 identified as −CH2Cl groups of PS−Cl were significantly weakened after the amination reaction [2Cl in the PS−Cl, leading to the gradual decrease in chloromethyl groups. Meanwhile, all typical peaks of DEA can be observed in the PS−DEA−x. The new peaks at 2975 cm−1 and 1370 cm−1 were found due to the stretching and bending vibration of −CH3 in DEA, while the peak at 1200 cm−1 was ascribed to the stretching vibration of C−N in DEA [The FT−IR spectra of the synthesized resin were investigated to better confirm the chemical structures, as shown in reaction ,26. ThisN in DEA . These r2Cl [The TG of the PS−DEA−x is shown in 2Cl , which w2Cl . These r2 adsorption–desorption analysis to evaluate the textural properties of PS−DEA−x. The N2 adsorption isotherms of PS−Cl and PS−DEA−x were assigned to Type IV, and the hysteresis ring of PS−DEA−x belongs to H3 , implying that monolayer adsorption occurred during CPCA adsorption on PS−DEA−5 [G reflected the spontaneous adsorption of CPCA onto PS−DEA−5. Meanwhile, positive values of ΔS mean that the disorder degree of solid–liquid interface increases when CPCA is adsorbed on the active site of the PS−DEA−5 and also reflect the high affinity of PS−DEA−5 to CPCA [As described in PS−DEA−5 . In addiPS−DEA−5 . Based o to CPCA .2 ≥ 0.99) by the pseudo−second−order rate equation illustrated that chemical adsorption predominated the adsorption process. Noticeably, the correlation coefficient R2 of the pseudo−first−order model was also as high as 0.97, which hinted that the physical adsorption should also give an outstanding contribution to the adsorption process [2 value of PS−DEA−x increased gradually as the amine contents increased, which further reflected that the existence of amine played a predominant role in the adsorption performance of CPCA. This can be explained by the relatively strong interaction between CPCA and amine groups and therefore enhances the adsorption capacity.To illustrate the adsorption behavior of PS−DEA−x towards CPCA, two kinetic models of pseudo−first−order and pseudo−second−order kinetic models were carried out. The fitting curve is shown in  process . Signifi2 was as high as 0.995. This indicates that the limiting step was not caused by external and internal diffusion [Dynamic adsorption is a direct evaluation of an adsorbent’s efficacy during continuous column operation; hence, the breakthrough characteristics of PS−DEA−5 towards CPCA were tested in a fixed−bed experiment. iffusion . AdditioChloromethyl polystyrene resin  was bought from Nankai Chemical University Factory , N, N−dimethyl formamide (DMF), ethyl alcohol, alkali blue 6B, cyclopentane carboxylic acid (CPCA) and diethylamine (DEA) were all supplied by Aladdin Reagent  Co., Ltd. Potassium hydroxide was bought from Sinopharm Chemical Reagent  Co., Ltd. Transformer oil was provided by Moroke  Co., Ltd.The synthesis route of DEA−modified PS−Cl is shown in NAm (g) is the mass of acid used to prepare a certain volume oilV (mL) of a known TAN value solution; oilρ (g/mL) and NAM (g/mol) are the specific mass and the molecular mass of the CPCA, respectively; KOHM (mg/mol) is the molecular mass of the KOH.The total acid number (TAN) is considered the index to predict the corrosiveness ability of the naphthenic acids. TAN (mg KOH/g) values exceeding 0.1 indicate that the oil or any petroleum fractions may cause damage to equipment material. Therefore, the model transformer oils were prepared aiming TAN around 0.15 mg KOH/g, as shown in the following expression:2 adsorption–desorption experiments of all samples were tested on the Micrometrics system . The specific surface area of the samples was calculated through the Brunauer–Emmett–Teller (BET) model and the calculation of t−plot micropore volume, while the pore size distribution and total pore volume were determined by the BJH method to the nitrogen desorption data. Scanning electron microscopy (SEM) images of all samples were acquired using an S−4800N field emission microscope .The organic groups of the resin were determined by Fourier transform infrared spectroscopy . The quantitative analysis of carbon, hydrogen, nitrogen, and other elements was analyzed with an elemental analyzer . The stability test was performed using a thermogravimetric analyzer (Mettler Toledo TGA/DSC 3+). Neq) was computed by the following equation.0C (mg/L) and eC (mg/L) represent the initial concentration and equilibrium concentration, respectively, while V (L) and m (g) represent the volume of the aqueous solution and the mass of adsorbent, respectively.CPCA was dissolved into transformer oil and 0.15 mg KOH/g simulated waste transformer oil was accurately prepared. In all, 10 mg of adsorbent was mixed with 10 g of the simulated waste transformer oil and shaken in a thermostatic oscillating water bath at 328 K with an oscillation frequency of 140 r/min. After 6 h of adsorption, 5 g of the oil was taken for titration with alcoholic potassium hydroxide to determine the acid value. The adsorption capacity (t (min), tq (mg/g), was calculated using Equations (2) and (3).The adsorption kinetics experiments were implemented at 328 K, and the initial acid value of the oil was 0.15 mg KOH/g. For each kinetic experiment, simulated oil and adsorbent were simultaneously weighed into six 500 mL flasks with the same oil/adsorbent mass ratio (1000:1) in each flask. The flasks were shaken at 328 K for 6 h. In this process, a flask was taken every 10 to 30 min to separate the adsorbent from the oil, and the oil sample was taken for titration with alcoholic potassium hydroxide to determine the acid value. The adsorption quantity at time The adsorption kinetics were investigated using the pseudo−first−order kinetic model and pseudo−second−order kinetic model. The expressions for kinetic models are as follows:Pseudo−first−order :(4)lgqe−tq (mg/g), e, exqp (mg/g) are the adsorption capacity at time t (min) and equilibrium, respectively. 1k (1/min), 2k (g/(mg·min)) are rate constants for pseudo−first−order and pseudo−second−order models.Pseudo−second−order :(6)tqt=1t, tq (mg/g), was calculated using Equations (2) and (3).Adsorption isotherm experiments were performed by adding 15 mg resins into a series of flasks containing various initial acid value  of 15 g of simulated oil. After shaking at 308, 318, and 328 K for 6 h the absorbent was separated from the oil. Finally, the adsorption capacity at time The adsorption isotherms were fitted by Langmuir and Freundlich models. The model equations are as follows:Langmuir:eq (mg/g), mq (mg/g) represent the equilibrium adsorption capacity and maximum adsorption capacity, respectively. ec (mg/L) is the equilibrium concentration of CPCA, while Lk (L/mg), Fk ((mg/g)·(L/mg)1/n) are the Langmuir constant and Freundlich adsorption constant, respectively. n is a measure of adsorption intensity.Freundlich:cK is the equilibrium constant and qck (L/g) is the equilibrium adsorption coefficient. eq (mg/g), eC (mg/L) are the reduced mass concentration and equilibrium concentration of the solution after adsorption, respectively. R J/(mol·K) is the universal gas constant, and T (K) represents the solution temperature. ΔG (kJ/mol) is the change in Gibbs free energy; ΔH (kJ/mol) is the enthalpy; ΔS (J/(mol·K)) is the entropy.Adsorption thermodynamics:t (min)is the time at any time; tC (mg/L) is the concentration of outlet liquid at any time; 0C (mg/L) is the concentration of inlet liquid; Q (mL/min) is the volume flow rate of liquid; tq (mg/g) is the dynamic equilibrium adsorption capacity. m (mg) is the mass of adsorbent in the adsorption column.For dynamic resin adsorption, the adsorption column was a glass column (diameter 10 mm) filled with 1 g dry resin. The adsorption column temperature was 328 K, which remained constant during the adsorption process. The simulated oil with an initial acid value of 0.15 mg KOH/g was passed through the resin column at flow rates of 1.0 mL/min, and the acid value of the exported oil was continuously recorded until the initial acid value was reached. Dynamic adsorption capacity was calculated by numerical integration of Equations (2) and (14).In this work, we synthesized a kind of amine−modified resin (PS−DEA−x) to improve the adsorption capacity to NAs. The static adsorption capacity of PS−DEA−5 was 110.0 mg/g, which was about five times higher than that of unmodified PS−Cl. The adsorption isotherms were well consistent with the Langmuir model, and the adsorption kinetics was in good agreement with the pseudo−second−order model. At an initial TAN of 0.15 mg KOH/g and a flow rate of 1.0 mL/min, the breakthrough capacity of CPCA on PS−DEA−5 was 187.5 mg/g, and about 760 mL of transformer oil can meet reuse standards. After adsorption, PS−DEA−x are easy to separate from the transformer oil and will not affect the insulation performance of the transformer oil. Based on the above results, this study indicates that amine resin may be promising in the removal of NAs from transformer oil.


We propose a mechanismfor α-helix folding of polyalaninein aqueous urea that reconciles experimental and simulation studies.Over 15 μs long, all-atom simulations reveal that, upon dehydratingthe protein’s first solvation shell, a delicate balance betweenlocalized urea–residue dipole interactions and hydrogen bondsdictates polypeptide solvation properties and structure. Our workclarifies the experimentally observed tendency of these alanine-richsystems to form secondary structures at low and intermediate ureaconcentrations. Moreover, it is consistent with the commonly acceptedhydrogen-bond-induced helix unfolding, dominant at high urea concentrations.These results establish a structure–property relationship highlightingthe importance of microscopic dipole–dipole orientations/interactionsfor the operational understanding of macroscopic protein solvation. Here, especially, urea is a common osmolyteknown to denature a native structure of a polypeptide sequence ora protein in general. Indeed, urea–peptide interaction is somewhatnontrivial given that many competing interactions govern the macroscopicsolvation behavior.14 In this context, most studies have discussed theimportance of weak van der Waals (vdW) forces, the strength of whichis less than a kBT atroom temperature T = 298 K, and relatively strongerhydrogen bonds (H–bond), the strength of which is between 4–8kBT.16 Here, kB isthe Boltzmann constant. The generally accepted view of the microscopicorigin of protein denaturation in aqueous urea states that the ureamolecules preferentially interact with the protein backbone, impactingthe hydrophobic core and thus the unfolding of a sequence.14 In this context, NMR experiments of alanine-rich polypeptides havesuggested that the driving force for the urea-induced denaturationis due to a high tendency to form urea–residue H-bonds17 that disrupts the residue–residue H-bondnetwork responsible for stabilizing a helical conformation. Consistentwith this common wisdom, circular dichroism (CD) spectroscopy resultshave shown that the α – helix content, quantified interms of mean residue ellipticity, gradually decreases with increasingurea molar concentration cu below 4.0M.18 Ideally, if all residues denaturein aqueous urea mixtures, one should expect a relatively rapid decreasein the α-helix content with cu.However, the observed trends in CD  might indicate that, while some residues tendto denature due to urea, specific residues may even fold under theinfluence of urea molecules. This observation is further supportedby a recent set of experiments where it has been shown that poly-alanineshows an increased degree of stable secondary structure in aqueousurea mixtures.19Understanding(bio)macromolecularsolvation in solvents, especially in binary solvents, is at the onsetof many developments in designing biocompatible materials.18 werewell reproduced by an effective theoretical model. In particular,within the Zimm–Bragg description,20 a polypeptide is approximated as a chain of residues, each in eithera helix or a coil state. By computing the equilibrium constant ofhelix formation, s, it is possible to estimate thetheoretical mean residue ellipticity. The effect of urea can thenbe introduced using the linear extrapolation method (LEM), i.e., theshift in solvation (unfolding) free energy ΔGs is a linear function of cu with a slope m.21 Thisgives s = s0 exp(−mcu/RT), with s0 being the value of s at cu = 0 M and R = 8.314 J mol–1 K–1 is the gas constant. By fitting the experimentalmean residue ellipticity, a value of m = −0.12kJ mol–1 M–1 (or −0.048 kBT M–1) perresidue was obtained.18 Here, we note inpassing that a substantial contribution to the total free energy comesfrom H-bonds. Thus, the m-value estimated above isexpected to be significantly larger, simply because of the largerH-bond strength.16 Indeed, simulations have reported over an order of magnitude larger m-value than the LEM predictions,22 see also the Supporting Information, Section S5 and Figure S11. Therefore, the connection between theseeffective models, experiments, and the microscopic picture of peptidesolvation needs to be adequately clarified.The CD results discussedabove23 For this purpose, we perform over 15 μsmolecular dynamic simulations by taking a model system of polyalaninewith 60 residues (Ala60) in aqueous urea mixtures. In addition tothe role played by the large poly alanine sequences in promoting theself-assembly of intrinsically disordered proteins,24 the choice of Ala60 was motivated by its well-defined secondarystructure.25 See the Supporting Information, Sections S1 and S2 for the simulationdetails.Motivated by theseobservations, we investigated the structure–propertyrelationship in polypeptide solvation to establish a correlation betweenmicroscopic interaction details and macroscopic conformations. Inparticular, we show how a delicate competition among dispersion, H-bonding,and local dipole–dipole interactions (DDI) controls the solvationbehavior of a sequence. Here, it is essential to note that, to thebest of our knowledge, simulations  ignored the highly local DDI-based explanations, which are expectedto play an essential and nontrivial role in the polypeptide solvation.Indeed, recent experimental work has commented on the importance ofdipole orientations within the protein’s first solvation shell(FSS), and its direct correlation with the solvation behavior.cu. Note that, for the clarityof presentation, we also report the urea mole fraction xu. It can be appreciated that the data show a nonmonotonicfunctional dependence with cu. More specifically,different solvation regions are observed: (a) For cu = 0.0 , we observe a rather globularconformation with virtually zero α – helix content. Itis well-known that water is a poor solvent for poly–alanine,with his α – helix being unstable in water at room-temperature.27 Our simulations reproduce these observations. (b) Ala60 expandsupon increasing cu, and starting at cu ≃ 2 M, the α-helix content growsup to 60%, which at cu ≃ 4 M propagatesalmost to the whole Ala60 k-Phe-NH218 may also reveal that, whilealanine residues have the tendency to fold, the other residues competeto denature, thus overall, a structure remains reasonably constant.(c) Within the range 4 M < cu <6 M, we observe an apparent destabilization of the α-helix content,with Ala60 exhibiting relatively large coil regions. Finally, thereis a second α-helix stabilization at around cu = 7 M. Here, we note in passing that, while the α-helixcontent shows a nonmonotonic variation, ΔGs decreases monotonically with cu for polyalanine.22 This difference suggeststhat ΔGs and the conformationalbehavior are somewhat decoupled. A structure–thermodynamicdecoupling was also observed when a polymer28 or an intrinsically disordered polypeptide22 collapses in a mixture of two miscible solvents. However, the microscopicorigin of polymer collapse  is qualitativelydifferent from the trends observed in In cu , indicating the well-accepted concept of preferential bindingof urea with polyalanine. Note also that the generally accepted microscopicorigin of this urea preferential binding to a poly peptide was shownto be dictated by the dispersion forces.14 However, if the dispersion forces were the only driving force inAla60 solvation, ΔGs is expectedto be much weaker than 2–3 kBT in the concentration range 2–8 M . Hence, other strongerinteractions are also expected to be relevant. A closer inspectionof the urea molecules within FSS reveals an interesting moleculararrangement. See Supporting Information, Figure S7).Additionally, we compute the corresponding CDF for Ala60 and water. Theseresults indicate a preferential tendency to form antiparallel alignmentbetween the α-helix and the urea and water dipole moments withinthe FSS. Within this picture, it is expected that the alignment ofthe dipoles corresponds to an energetically stable configuration thatdecreases the binding free energy of the system. Indeed, it has beenrevealed that molecular DDI does play an essential role in determiningprotein properties,31 whose precise role remains elusive.32 Here, a recent experimental effort has aimed to elucidatethe electric dipole network within the FSS.23What causes such a counterintuitivestructure–thermodynamicrelationship? To address this issue, we will now investigate the alanine-(co)solventcoordination within the first solvation shell (FSS). To this aim,we define the cylindrical correlation functions by employing the symmetryaxis indicated in the helix. See the orange arrow in r = 3.95 D and a urea molecule μu = 4.38 D, we find EK ≃ −6.55 kJ mol–1 (or −2.64 kBT)33 for r = 0.6 nm  at T = 298 K. This suggests thatthe urea–residue dipole–dipole interactions are indeedrelevant. We also note in passing that EK considers all possible orientations of the dipoles involved within r = 0.6 nm. In contrast, by taking the dipole moment ofliquid water μw = 2.95 D separated by r = 0.6 nm from the residue , we obtain EK ≃ −2.97 kJ mol–1 (or −1.20 kBT). Since these water–residueDDI energy contributions are screened by thermal fluctuations, weexclude them from the discussion below. Hence, the most dominant contributionsusually come from the dipole orientations between the residues withinan Ala60 (termed Scenario I) and between a residue andthe urea molecules (termed Scenario II). In the following,we characterize different contributions to the total resultant dipole–dipoleinteractions.A simple expression to estimate the energetic contributiondueto DDI is the so-called Keesom energy  with  beScenario I: We first consider anα-helix, asshown by the model representation in 34 We evaluate the DDI energy on a residue i using Ei =∑j∈⟨i,j⟩εi,j,35 wherei, j⟩ represents the nearest neighbors of i,i.e., the residues i ± 4, i ± 3, i ± 2, and i ±1. μi is theelectric dipole of the i-th residue, and the vector r = ri – rj is the separation between dipoles i and j. Ei ≃ −5.29 kJ mol–1 (or −2.13kBT), indicating that the α-helixis stabilized via intramolecular DDI.Scenario II: (a) One possible moleculararrangementis when a urea molecule stacks side-by-side in antiparallel dipolarorientation within FSS of the residue i. Using thesame model above, but now including the urea molecule, we obtain Eu = ∑j∈⟨u,j⟩εu,j ≃−6.99 kJ mol–1 (or −2.81kBT) for r = 0.6 nm separationbetween the geometric centers of the residue and the urea molecule.See Supporting Information, Figure S9. (b) It is apparent from the Supporting Information, Figure S7 that urea molecules also align with a dipole momentparallel to the residue of the dipole. This arrangement is not energeticallyfavorable for urea molecules placed side-by-side with respect to theresidue. Hence, the second possible configuration is when a urea moleculesits between residues i and i +4, for example, with dipole moments aligned in head-to-tail orientation,with the head being the NH2 groups of urea and the tailas carboxyl group of an alanine residue. See Eu ≃ +1.89 kJ mol–1 (or +0.76kBT). Since the latter estimateis smaller than kBT,an by symmetry the antiparallel configuration gives Eu ≃ −1.89 kJ mol–1 , thermal fluctuations are expected to induce flip–flopof a urea dipole moment at this particular position and thus introducelocal configurational fluctuations.Ei ≃−15.95 kJ mol–1 (or −6.34kBT) and Eu ≃ −20.65 kJ mol–1 (or −8.20kBT) for an incoming urea moleculewith a dipole moment aligning head-to-tail with the i-th residue. See Supporting Information, Figure S10. These results indicate that from the DDI point of view,the peptide unfolded state is more favorable than a stable α-helixconformation by ΔEi ≃ −10.66 kJ mol–1 (or −4.24kBT). Hence, a pure dipole-basedenergetic argument can not fully explain the conformational behaviorof an Ala60 in aqueous urea mixtures. In addition to DDI, we underlinethat α-helix structures are further stabilized by H-bond interactionsbetween i and i ± 4 residues.We will return to this point in the last part of the manuscript.Even when the energy valuesdiscussed above suggest that the dipoleinteraction can stabilize an α-helix, it is still importantto emphasize that DDI alone is insufficient to stabilize the secondarystructure. For example, considering a test case of a fully expandedchain shown in 3d, we ficu, which is as follows:cu ≤ 4.0 M (orbelow 10%), i.e., when only a small amount of urea molecules is addedin the aqueous solution, they preferentially arrange in the side-wiseantiparallel configurations next to the Ala60 residues because ofthe favorable minimum energy configuration (Scenario II (a)) and thus dehydrate FSS of Ala60. This scenario stabilizes anα-helix structure by the urea–residue DDI, in additionto H-bond interactions between i and i ± 4 residues.For cu > 4 M, in addition to the side-wisearrangements discussed above, the additional urea molecules can alsosit within the interstitial regions between i and i ± 4 residues (Scenario II (b)). In thisregion, and taking into account the energy considerations above, ureadipoles can flip-flop and thus disturb the intramolecular H-bond network,promoting the formation of intermolecular H-bonds between the NH2 groups of urea and the carboxyl groups of Ala60. These combinedeffects then induce the α-helix unfolding into a dipole-compensatedstructure within the range 4 M ≤ cu ≤ 6 M, see 17 destabilizing the Ala60secondary structure.Upon a further increasein the urea concentration, i.e.,for cu > 6.0 M issomewhat surprising. We do not have a concreteargument for such behavior. However, based on the trajectory inspection,we speculate that the urea molecules within the FSS join hands, makinga H-bonded chain-like configuration that decreases the number of urea–residueH-bonds. Indeed, urea is soluble in water at ∼9 M, thus, weexpect urea molecules to aggregate at cu > 6 M, preventing the formation of urea–residue H-bondsandconstraining the DDI in the FSS. Free of urea’s strong influence,the Cα H-bond network reconnects, stabilizing theα-helix.The apparent secondstability region for We return to the H-bond analysisto further consolidate ourarguments based on the competition between DDI and H-bonds. For thispurpose, we have computed the excess number of hydrogen bonds xuexc = xuH-bond/xu between urea andthe peptide, where Nu-rH-bond and Nw-rH-bond being the average number of H-bondsbetween residueand urea and residue and water, respectively. xuexc > 1 indicatesan excess of H-bonds, as seen in the top panel of 17 Lastly, to unravelthe competition between dipole alignment and H-bond formation with cu, we define and compute excess quantities tobring together our proposed mechanism and simulation results. We focuson the average number of urea  and water molecules in the FSS with antiparalleldipole orientation . We define the antiparallel urea mole fraction as, xuH-bond. To this end, we compute the ratioδH-bondantiparallel = xuantiparallel/xuH-bond in Given the discussion presented above, we can now understand thenonmonotonic variation in α-helicity with cu ≃ 5 M. For cu < 5 M, the antiparallel dipole alignment is more important thanH-bonds, while H-bonds dominate for cu > 5.0 M. This trend agrees with the re-entrant behavior observedin Consistent with the energy-based arguments, 19 Our interpretation highlights that the effective models, such asthe linear extrapolation method,21 mustbe adjusted to explain the polypeptide unfolding as they severelyunderestimate the shift in solvation free energy.22 This work also challenges the common understanding basedsolely on the preferential interaction of urea with protein via vdWforces and shows that several delicate microscopic details, such asthe local dipole–dipole interactions, are responsible for thepolypeptide  solvation in binary mixtures.In a broad sense, our results hint at a direct route to an operationalunderstanding of the polypeptide interactions in binary solutions.Thus, they may provide a new twist on our present understanding ofprotein solvation.In conclusion, we have investigated the structure–thermodynamicsrelationship of polyalanine in aqueous urea mixtures using moleculardynamics simulations of an all-atom model. We emphasize the importanceof a delicate competition between the H-bond and the dipole–dipoleinteractions that govern the macroscopic conformational behavior ofthe polypeptide sequence. We provide a probable microscopic pictureof the observations discussed in the experimental literature.


Electronic databases included the Cochrane Library, PubMed, EMBASE, and Web of Science. Literature was obtained from the establishment of each database until June 2022. The patients included in the study had pretreatment with P2Y12 inhibitors with long-term oral or loading doses, or conventional aspirin treatment (non-pretreatment). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs) during follow-up within 30 days after PCI, which included determining the composite endpoints of cardiac death, myocardial infarction, ischemia-driven revascularization, and stroke. The safety endpoint was a major bleeding event.Electronic databases were searched for studies comparing pretreatment with different types and doses of P2Y12 inhibitors pretreatment . The network meta-analysis results showed that compared to patients without pretreatment, patients receiving clopidogrel pretreatment  and double-loading pretreatment  had a lower incidence of MACCEs. There was no statistically significant difference in the incidence of major bleeding events among the six pretreatments (P > 0.05).A total of 119,014 patients from 21 studies were enrolled, including 13 RCTs and eight observational studies. A total of six types of interventions were included—nonpretreatment (placebo), clopidogrel pretreatment, ticagrelor pretreatment, prasugrel pretreatment, double loading pretreatment  and P2Y12 inhibitors before percutaneous intervention reduced the incidence of recurrent ischemic events without increasing the risk of major bleeding after PCI compared with nonpretreatment. Clopidogrel or double loading dose P2Y12 inhibitors can be considered for the selection of pretreatment drugs.In patients with NSTE-ACS, pretreatment with P2Y Routine pretreatment with a P2Y12 receptor inhibitor is not recommended in patients whose coronary anatomy is unknown, and early invasive management is planned . The effects of pretreatment with P2Y12 inhibitors on bleeding and recurrent ischemic events in patients with NSTE-ACS undergoing PCI remain controversial. Therefore, we performed a network meta-analysis to assess the efficacy and safety of these therapies.In patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), undergoing percutaneous coronary intervention (PCI), platelets are activated during the perioperative period, increasing the risk of stent thrombosis and coronary no-reflow . Early oc events , also rec events , 5. Howereatment , 5. Therreatment , 7. The 12 inhibitor pretreatment (intervention group or control group) in patients with NSTE-ACS following PCI; (2) patients were clearly diagnosed with NSTE-ACS  randomized controlled trials and observational studies that compared P2YNSTE-ACS ; and (3)Studies were excluded for the following reasons: (1) patients had other diseases that affected platelets and blood coagulation, such as severe hematological diseases or immune system diseases; (2) there was a combination of pretreatment and other interventions; and (3) the studies were duplicates.The prognostic indicators synthesized in this study were the results of follow-up 30 days after PCI in patients with NSTE-ACS. The clinical endpoints analyzed included the following: The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE) during follow-up within 30 days after PCI, and these MACCEs included the composite endpoints of cardiac death, myocardial infarction, ischemia-driven revascularization, and stroke. The MACCEs in this study were reported in a single study and were not recalculated. The safety endpoint was a major bleeding event.12 inhibitors before PCI in patients with NSTE-ACS. The databases included the Cochrane Library, PubMed, EMBASE, and Web of Science. Literature retrieval, literature screening, data extraction, and data analysis were performed in accordance with the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Literatures were obtained from the establishment of each database until June 2022.Electronic databases were searched for studies related to pretreatment with P2YThe search strategy was determined after multiple pre-searches using a combination of MeSH terms and free words, and fine adjustments were made based on a specific database. To reduce publication bias, manual queries were performed for relevant conference papers, academic reports, and dissertations to supplement the search results.The search terms were as follows: “coronary artery disease”, “acute coronary syndromes”, “ACS”, “non-ST-elevation”, “NSTEMI”, “NSTE-ACS”, “percutaneous coronary intervention”, “PCI”, “angioplasty”, “balloon”, “coronary revascularization”, “high-dose”, “double-dose”, “loading dose”, “pretreatment”, “intensive”, “reload”, “load”, “preload”, “upstream”, “timing”, “antiplatelet”, “ticagrelor”, “clopidogrel”, “prasugrel”, “cangrelor”, and “elinogrel”.The search strategy was as follows: (“coronary artery disease” OR “acute coronary syndromes” OR “ACS” OR “non-ST-elevation” OR “NSTEMI” OR “NSTE-ACS”) AND  AND (“high-dose” OR “double-dose” OR “loading dose” OR “pretreatment” OR “intensive” OR “reload” OR “load” OR “preload” OR “upstream” OR “timing”) AND (“antiplatelet” OR “ticagrelor” OR “clopidogrel” OR “prasugrel” OR “cangrelor” OR “elinogrel”).Duplicate literatures were removed using the Endnote software. Literatures were excluded by reading the title and abstract, based on the inclusion and exclusion criteria. Finally, related literatures were excluded by reading the full text. The selected studies were independently checked and cross-checked by two researchers. If the opinions of the two researchers were inconsistent, a third researcher negotiated to reach a consensus.12 inhibitors, and outcome indicators. Quality was independently evaluated according to the method recommended in the Cochrane Handbook 5.1.0  and 95% confidence intervals (95% CIs) were calculated for categorical variables. In the presence of a closed loop, the consistency between the direct and indirect comparisons was judged using the node-splitting method. When P < 0.05, the inconsistency was evident. The area under the cumulative ranking (SUCRA) showed the possibility of each intervention being the best.Stata software (version 17.0) was used for the data meta-analysis. Descriptive analyses were used for data that could not be quantitatively synthesized. Relative risks (12 pretreatment. Nonpretreatment refers to patients receiving only aspirin treatment before PCI without P2Y12 inhibitor treatment. Clopidogrel pretreatment refers to patients receiving clopidogrel (300 mg loading dose) treatment before PCI. Ticagrelor pretreatment refers to patients receiving ticagrelor (180 mg loading dose) before PCI. Prasugrel pre-treatment refers to patients receiving prasugrel treatment (30 mg prasugrel loading dose) before PCI. Double-loading pretreatment refers to treatment with a double-loading P2Y12 inhibitor  before PCI. P2Y12 pretreatment refers to patients included in the original study who received P2Y12 inhibitor  treatment before PCI, without distinguishing the types of P2Y12 inhibitors.A total of 5,844 articles were retrieved from the databases. Five related articles were obtained through manual retrieval of conference papers, academic reports, and dissertations. Duplicate articles were eliminated using the EndNote software, and 3,997 articles were obtained. On careful assessment of the titles and abstracts, a total of 3,874 articles which were not related to our topic were eliminated. The remaining number of articles was 123. Studies that did not meet the inclusion or exclusion criteria, or had unclear expressions were further eliminated by reading the full text, and 21 articles were obtained –29, inclTwenty-one studies with 119,014 patients with NSTE-ACS were included in this study , 11–29. I2 = 4.21, P = 0.239); therefore, the consistency model was used for the analysis. The network plots are shown in P > 0.05). The results of the direct meta-analysis are shown in RR = 0.78, 95% CI: 0.66, 0.91, P < 0.05) and double loading pretreatment  had a lower incidence of MACCEs; compared with the patients who received ticagrelor pretreatment, the patients who received double loading pretreatment  had a lower incidence of MACCEs  , 11–29. f MACCEs .12 inhibitor pretreatment (SUCRA = 69.1), clopidogrel pretreatment (SUCRA = 68.5), prasugrel pretreatment (SUCRA = 29.7), placebo (SUCRA = 23.8), and ticagrelor pretreatment (SUCRA = 18.9). The SUCRA curves for the different pretreatment methods are shown in RR = 0.78, 95% CI: 0.66, 0.91, P < 0.05) and double-loading pretreatment  had a lower incidence of MACCEs. Compared to the patients who received ticagrelor pretreatment, those who received double-loading pretreatment  had a lower incidence of MACCEs , P2Yf MACCEs . There w2I = 0.04, P = 0.851); therefore, the consistency model was used for the analysis. The network plots are shown in P > 0.05). The results of the direct meta-analysis are shown in Sixteen studies with major bleeding events were included in the subgroup analysis  –26, 28. 12 inhibitor pretreatment (SUCRA = 72.0), double-loading pretreatment (SUCRA = 63.6), ticagrelor pretreatment (SUCRA = 56.9), placebo (SUCRA = 56.5), clopidogrel pretreatment (SUCRA = 40.4), and prasugrel pretreatment (SUCRA = 10.5). The SUCRA curves for different pretreatment methods are shown in The higher the SUCRA value of the pretreatment method, the fewer major bleeding events occurred in the patients who received the pretreatment method. The SUCRA values of the six pretreatment methods were ranked from highest to lowest as follows: P2YFunnel plots were constructed to test for publication bias ,B. Funne12 inhibitors to analyze the impact of P2Y12 inhibitor pretreatment on the incidence of MACCEs and major bleeding events in patients with NSTE-ACS. The results were as follows: 1) pretreatment with a P2Y12 inhibitor before PCI in patients with NSTE-ACS reduced the incidence of MACCEs without increasing the risk of major bleeding events; 2) clopidogrel or a P2Y12 inhibitor with a double-loading dose could be selected as the pretreatment scheme; and 3) compared with pretreatment with ticagrelor, a P2Y12 inhibitor with a double loading dose could reduce MACCEs.Twenty-one studies involving 119,014 patients with NSTE-ACS were included in this network meta-analysis. We compared different pretreatment strategies for P2Y12 inhibitors orally before PCI , if the methods of P2Y12 inhibitor pretreatment are not differentiated, this may lead to some heterogeneity in the meta-analysis. Another network meta-analysis divided the interventions into six groups: early clopidogrel, delayed clopidogrel, early prasugrel, delayed prasugrel, early ticagrelor, and delayed ticagrelor  and double-loading pretreatment (P < 0.05) had a lower incidence of MACCEs. Compared to patients who received ticagrelor pretreatment, those who received double-loading pretreatment (P < 0.05) had a lower incidence of MACCEs. For major bleeding events, the SUCRA values suggested that the priority of the selected pretreatment scheme was P2Y12 pretreatment, double-loading, ticagretor, placebo, clopidogrel, and prasugrel pretreatment. Therefore, pretreatment with P2Y12 inhibitors significantly reduced the number of recurrent ischemic events without increasing the occurrence of major bleeding events. Clopidogrel or P2Y12 inhibitors  with a double-loading dose should be selected as the pretreatment protocols for patients with NSTE-ACS.We ranked all potential combinations of P2YP < 0.001); however, the number of major bleeding events was significantly higher in patients with NSTE-ACS than in those in the control group  . Also, there were different research results regarding the timing of pretreatment. The onset of clopidogrel administration was relatively slow. Compared with patients who received clopidogrel pretreatment >6 h before PCI, those who received clopidogrel pretreatment <6 h before PCI had significantly fewer primary ischemic events  of clopidogrel, a double-loading dose (600 mg) of clopidogrel did not show an advantage. The pretreatment method included a maintenance dose of 75 mg clopidogrel for 5 days or a loading dose of 300 mg clopidogrel before PCI. An early CURE study showed that the incidence of MACEs in patients with NSTE-ACS in the clopidogrel group was significantly reduced  before PCI] or a double-loading dose of a P2Y12 inhibitor . Additionally, this study found that a double-loading dose of a P2Y12 inhibitor was superior to a single-loading dose (180 mg) of ticagrelor. The above-recommended pretreatment method can reduce the incidence of MACCEs without increasing the risk of major bleeding events.In summary, this study supports the use of pretreatment with P2Y12 inhibitors.Current guidelines do not recommend routine pretreatment before angiography because of the risk of intracranial hemorrhage and delayed CABG. If the patient needs to undergo coronary artery bypass grafting after angiography, ticagrelor should be discontinued for at least 3 days, clopidogrel for at least 5 days, and prasugrel for at least 1 week . Therefo12 inhibitor pretreatment in patients with NSTE-ACS before PCI mainly included clopidogrel pretreatment. Third, for the definition of some endpoints, there were differences between the studies, especially TIMI bleeding, GUSTO bleeding, and MACCEs, which may lead to heterogeneity in this indicator. Fourth, it included open-label randomized controlled trials because it is difficult to use double-blind P2Y12 inhibitor strategies and timing. Finally, the comparison between the use of a P2Y12 inhibitor with a double loading dose and ticagrelor included only three studies, with a confidence interval of 0.36–0.99. Therefore, the results of this study need to be interpreted carefully.However, this study has some limitations. First, the outcome indicators in this study were based on follow-up 30 days after PCI, which lacked laboratory-related indicators (platelet aggregation) and in-hospital bleeding. Future investigations of the perioperative period and related laboratory indicators should be performed. Second, the 21 studies included in our analysis comprised 13 randomized controlled trials and eight observational studies. In addition, the current research on P2Y12 inhibitors before PCI reduced the incidence of recurrent ischemic events without increasing the risk of major bleeding events after PCI compared with nonpretreatment. Clopidogrel or double loading dose P2Y12 inhibitors can be considered for the selection of pretreatment drugs.For patients with NSTE-ACS, pretreatment with P2Y