The purpose of this study was to explore the relationship between quantitative epicardial adipose tissue (EAT) based on coronary computed tomography angiography (CCTA) and coronary slow flow (CSF).A total of 85 patients with < 40% coronary stenosis on diagnostic coronary angiography were included in this retrospective study between January 2020 and December 2021. A semi-automatic method was developed for EAT quantification on CCTA images. According to the thrombolysis in myocardial infarction flow grade, the patients were divided into CSF group (n = 39) and normal coronary flow group (n = 46). Multivariate logistic regression was used to explore the relationship between EAT and CSF. Receiver operating characteristic (ROC) curve was plotted to evaluate the diagnostic value of EAT in CSF.EAT volume in the CSF group was significantly higher than that of the normal coronary flow group . There was no significant difference in epicardial fat attenuation index between the two groups (P > 0.05). Multivariate logistic regression analysis showed that EAT volume was independently related to CSF . The area under ROC curve for EAT volume in identifying CSF was 0.86 (95% CI: 0.77–0.95). The optimal cutoff value of 118.46 mL yielded a sensitivity of 0.80 and a specificity of 0.94.Increased EAT volume based on CCTA is strongly associated with CSF. This preliminary finding paves the way for future and larger studies aimed to definitively recognize the diagnostic value of EAT in CSF.The online version contains supplementary material available at 10.1186/s12872-023-03541-z. Contrast agent flow in coronary angiography acts like coronary blood flow, and the distal vessel opacification may be delayed despite the absence of obstructive coronary artery disease. This phenomenon of coronary angiography is commonly referred to as primary coronary slow flow (CSF) phenomenon. It has been considered a specific disease entity, however, whether it should be considered a specific coronary syndrome or a stage in the development of coronary microvascular dysfunction remains undefined , 2. CSF Epicardial adipose tissue (EAT) is a visceral fat deposit between the myocardium and the visceral pericardium. EAT has paracrine effects. Released cytokines such as interleukin (IL)-6, IL-1β and tumour necrosis factor (TNF)-α diffusing and accumulating in the epicardial vascular wall may induce local inflammatory reactions that potentially result in endothelial dysfunction . The latAll coronary angiography records  at the Department of Cardiology in General Hospital of Northern Theater Command between January 2020 and December 2021 were retrospectively collected. All patients underwent diagnostic coronary angiography for suspected coronary artery disease. Patients with percutaneous coronary intervention , percutaneous transluminal coronary angioplasty  or coronary artery bypass grafting (n = 59), coronary artery stenosis ≥ 40% , myocardial infarction, heart valve disease, cardiomyopathy, arrhythmia, myocardial bridge, heart failure and malignant tumor (n = 622) were excluded. According to TIMI coronary flow grade, all patients were divided into two groups: CSF group (n = 152) with TIMI 1–2 flow and normal coronary flow group  with TIMI 3 flow. Both groups excluded patients who had not undergone CCTA or CCTA time distance coronary angiography more than 1 month  and had incomplete clinical information . We finally enrolled 39 subjects in CSF group and 46 subjects in NCF group , previous history and laboratory test results within 3 days before coronary angiography. In addition, left ventricular (LV) function assessed by transthoracic echocardiography within 24 h before coronary angiography was obtained from hospital records, including LV end-diastolic diameter, LV ejection fraction (LVEF), and the ratio of diastolic mitral inflow velocity E peak and A peak (E/A).CCTA was performed on a 256-slice CT scanner . Prospective ECG-gated scan was performed and all images were reconstructed using iterative reconstruction method. About 60–70 mL of iodine contrast agent was intravenously injected through the cubital vein at a rate of 4.5–5.5 mL/s using a high-pressure injector, followed by 20–30 mL of saline flushing at the same flow rate. A bolus tracking technique was used with a trigger threshold of 100 Hounsfeld units (HU) at the descending aorta. The scan parameters were set as follows: tube voltage 120 kV, tube current modulation technique, detector collimation 128 × 0.625 mm, pitch 0.16, slice thickness 0.9 mm, section increment 0.45 mm, rotation time 0.27 s, field of view 180 × 180 mm, matrix 512 × 512.EAT was quantitatively measured on axial CCTA images at 75% of the R-R interval. Pericardium was semi-automatically segmented and EAT was measured with a software tool as reported previously  from ourEAT was defined as all voxels with attenuation between − 190 HU and − 30 HU, and epicardial FAI was defined as the average CT attenuation of the adipose tissue within the pre-specified attenuation window of -190 HU to -30 HU. Our software was used to identify EAT and quantify its parameters Fig. .P < 0.05 was considered to be statistically significant.Continuous variables were presented as mean ± standard deviation (SD) or median [interquartile range (IQR)]. Categorical variables were presented as absolute values and percentages. Continuous variables were compared by independent t-test or Mann-Whitney U test, and categorical variables were compared by chi-square test. The variables with significant differences in the univariate analysis were included in the multivariate logistic regression to determine the independent factors. Receiver operating characteristic (ROC) curve was plotted, and the area under the ROC curve (AUC) was calculated to evaluate the diagnostic value. The optimal cutoff value was determined by the maximum Youden index. Statistical analysis was performed with SPSS Statistics v.26 software . Two-sided tests were used and P > 0.05, Table There were no statistically significant differences in age, gender, BMI, history of hypertension and smoking between CSF group and NCF group , left circumflex (LCx), and right coronary artery (RCA) with delayed distal vessel contrast opacification. TIMI 2 was present in 12 of the 20 patients, and TIMI 1–2 was present in 8 patients. In 19 of 39 CSF patients, coronary angiography revealed single vessel with delayed distal vessel contrast opacification, including LAD affected in 15 patients , LCx affected in 1 patient (TIMI 2), and RCA affected in 3 patients .Z = -6.83, P < 0.001), whereas there was no significant difference in epicardial FAI between the two groups (P > 0.05) , whereas other laboratory indicators and echocardiographic parameters showed no significant differences   (Table Univariate and multivariate logistic regression analysis showed that EATV was independently related to CSF (The ROC curve of EATV for identifying CSF was shown in Fig. This study revealed the relationship between EAT and CSF. EATV in CSF group was greater than that in NCF group with statistical significance and multivariate logistic regression analysis showed that EATV was independently related to CSF. To the best of our knowledge, this is the first study to explore the relationship between EAT based on CCTA and CSF. There are several previous studies on the relationship between EAT thickness based on two-dimensional echocardiography and CSF –18. ErdoSeveral studies have found that EAT was correlated with the occurrence and severity of coronary artery disease , 24. It In addition, this study found that the level of homocysteine in CSF group was higher than that in NCF group with statistical significance. Homocysteine is a sulfur-containing amino acid. Studies showed that elevated homocysteine level can lead to vascular endothelial injury, resulting in CSF , 32. DemThere were certain limitations in this study. First, this was a single-center retrospective study with a relatively small sample size. The single-center nature of the study limited the ability to generalize findings to a broader population. The retrospective nature of the study limited the establishment of causality. Since the study was cross-sectional, it couldn’t establish a temporal relationship between EAT and the onset of CSF. Secondly, the medication of patients was not taken into account. Statins have been reported to be associated with a reduction in epicardial fat accumulation, especially when given in high doses . HoweverEATV based on CCTA is strongly associated with CSF, and further studies are necessary to determine the role of EAT in the genesis and development of CSF.Below is the link to the electronic supplementary material.Supplementary Material 1


Oral midazolam and nitrous oxide inhalation were commonly used sedative and analgesic techniques during tooth extraction. It is still controversial whether oral midazolam can replace the nitrous oxide inhalation for sedative and analgesic treatment of tooth extraction. Therefore, we conducted this study in order to provide a reference for doctors to choose effective sedative and analgesic treatment in tooth extraction.We searched the Chinese and English databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Wanfang and VIP information databases.Through this meta-analysis, we found that the success rate of sedation and analgesia treatment with oral midazolam during tooth extraction was 75.67% and the incidence of adverse reactions was 21.74%. The success rate of sedation and analgesia treatment using nitrous oxide inhalation during tooth extraction was 93.6% and the incidence of adverse reactions was 3.95%.The use of nitrous oxide inhalation for sedation and analgesia during tooth extraction is very effective, and oral midazolam can be used as an alternative to nitrous oxide inhalation. Patients will experience pain or fear during tooth extraction treatment. Studies have proved that nearly 50% of dental patients have fear disorder . EspeciaNitrous oxide inhalation is a commonly sedative and analgesic technique during tooth extraction. Nitrous oxide was developed successfully in 1722. And in 1844, the American dentist Wells first used it for tooth extraction analgesia. Nitrous oxide is one of the earliest clinical application of sedative and anesthetic drugs. Nitrous oxide can stimulate neurons to release endogenous opioid peptides and activate opioid receptors and -aminobutyric acid and noradrenergic transmitter pathways to achieve analgesic effect. Through the benzodiazepine binding site to activate the beta-aminobutyric acid receptor to achieve the anxiolytic effect [Midazolam is a commonly drug for pharmacological analgesia and sedation. Midazolam is a benzodiazepine with anti-anxiety, sedative, hypnotic, central muscle relaxation and anterograde amnesia effects. It acts as a receptor for benzodiazepine stimulation of the inhibitory transmitter GABA of the ascending reticular activating system, exerting a calming effect by enhancing the inhibition and blockade of arousal in the cortex and limbic system . MidazolWe searched the Chinese and English databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Wanfang and VIP information databases. The retrieval time was set to the database building until November 2022. The search keywords were "Dental Extraction", "Midazolam", "Nitrous Oxide". No language and the types of studies restrictions were set for this retrieval.The study population was the patients undergoing dental extraction therapy. Inhalation of nitrous oxide and/or oral midazolam for sedation and analgesia were used in the studies. The success rate of sedative and analgesic treatment with nitrous oxide inhalation and/or oral midazolam and the incidence of adverse reactions were among the evaluation criteria. We have no restrictions on the types of studies.Repeated published articles. Inhalation of nitrous oxide and/or oral midazolam were not used for sedation and analgesia. The evaluation indexes of the study do not include the evaluation indexes that need to be extracted, such as the success rate, the incidence of adverse reactions, etc.Two researchers independently extracted relevant data from the included literature, Including the first author of the article, the year of publication, the country, sample size, evaluation indicators, etc. The Newcastle–Ottawa Scale (NOS) and the Cochrane Risk of Bias Tool were used to assess the quality of the included literature. The NOS was mainly used to evaluate non-randomized controlled trials. The NOS was used to evaluate the quality of the study from three aspects: selection, comparability and exposure . CochranIn this study, according to the common evaluation indicators in the included literature, we set the success rate of sedation and analgesia with nitrous oxide inhalation or oral midazolam during tooth extraction as the primary outcome indicator. The secondary outcome indicator was the incidence of adverse reactions of sedation and analgesia with nitrous oxide inhalation or oral midazolam during tooth extraction.P = (sin(tp/2))2) to get the final conclusions. In the process of meta-analysis, we used the random-effect models to analyze the data. Egger’s test was used to detect publication bias of the included literature. If P > 0.05, it was considered that there was no publication bias. Otherwise, there was publication bias.Stata 16.0 software was used for statistical analysis of the data. According to the standard single arm meta-analysis method introduced by Jan J Barendregt et al. , originaA total of 508 articles were retrieved. After screening, 8 articles were finally included in this meta-analysis –17. The P = (sin(tp/2))2) was used to restore this result, and the final result was 0.7567. Therefore, the success rate of sedation and analgesia treatment with oral midazolam during tooth extraction was 75.67%. Secondly, we analyzed the incidence of adverse reactions of oral midazolam for sedation and analgesia during tooth extraction. We performed meta-analysis using the data transformed by double arcsine method, and the result was 0.97 )2) was used to restore this result, and the final result was 0.2174. Therefore, the incidence of adverse reactions of oral midazolam for sedation and analgesia during tooth extraction was 21.74%. Thirdly, we analyzed the success rate of sedation and analgesia treatment using nitrous oxide inhalation during tooth extraction. We performed meta-analysis using the data transformed by double arcsine method, and the result was 2.63 )2) was used to restore this result, and the final result was 0.9360. Therefore, the success rate of sedation and analgesia treatment using nitrous oxide inhalation during tooth extraction was 93.6%. Finally, we analyzed the incidence of adverse reactions in sedation and analgesia treatment with nitrous oxide inhalation during tooth extraction. We performed meta-analysis using the data transformed by double arcsine method, and the result was 0.40 )2) was used to restore this result, and the final result was 0.0395. Therefore, the incidence of adverse reactions in sedation and analgesia treatment with nitrous oxide inhalation during tooth extraction was 3.95%. Detailed meta-analysis results are shown in Table P > 0.05)  (Fig. 3 (Fig. PIn this study, we used a single arm meta-analysis method to analyze the therapeutic effect of oral midazolam or nitrous oxide inhalation for sedation and analgesia during tooth extraction. Through meta-analysis, we found that the success rate of sedative and analgesic treatment with oral midazolam during tooth extraction was 75.67%, and the incidence rate of adverse effects was 21.74%. In the process of tooth extraction, the success rate of sedation and analgesia treatment using nitrous oxide inhalation was 93.6%, and the incidence of adverse reactions was 3.95%. From these data, we can know that the success rate of sedation and analgesia treatment using nitrous oxide inhalation during tooth extraction is higher than that of oral midazolam, and the incidence of adverse reactions of nitrous oxide inhalation is much lower than that of oral midazolam.Nitrous oxide as an auxiliary anxiety control is widely used in European and American countries, and 90% of pediatric dentists have used nitrous oxide inhalation for sedation and analgesia treatment in clinical work . StudiesOral midazolam is considered as an alternative to nitrous oxide inhalation. Oral midazolam is administered at doses of 0.50–0.75 mg / kg, and a single dose of 15 mg is safe and effective. Midazolam has little effect on respiration and circulation, and can improve the tolerance threshold of adverse stimuli in children . This stA total of 8 studies were included in this meta-analysis, which systematically evaluated the sedative and analgesic effects of oral midazolam or nitrous oxide inhalation in 337 patients during tooth extraction. To date, this is the first meta-analysis comparing the efficacy of oral midazolam and nitrous oxide inhalation for sedation and analgesia during tooth extraction. This study has obtained reliable conclusions through scientific and rigorous meta-analysis. However, this meta-analysis also has some limitations: The method of the single arm meta-analysis was used in this study, the data were analyzed with high heterogeneity because of the lacking of control groups. Among the 8 studies included in this meta-analysis, 5 were from China and 3 were from the United Kingdom. Chinese patients accounted for 68.84%, and whether the research conclusions are applicable to patients in other countries still needs further verification.In conclusion, the use of nitrous oxide inhalation for sedation and analgesia during tooth extraction is very effective, and oral midazolam can be used as an alternative to nitrous oxide inhalation.


Transmediastinal radical esophagectomy (TME) is a new minimally invasive approach without thoracotomy. However, the transcervical dissection of subcarinal lymph nodes (SCLN) is challenging. The shape or narrowness of the mediastinal space, particularly around the aortic arch to the tracheal bifurcation, may increase the difficulty of this procedure. The present study aimed to clarify predictors of the difficulty of transcervical SCLN dissection.n = 126). Four indicators, the cervical angle, carina distance, aorta distance, and sternum distance, were defined as indicators of mediastinal narrowness by 3D-CT. The relationships between the difficulty of transcervical SCLN dissection and clinicopathological features, including the above indicators, were investigated.Patients who underwent TME between 2016 and 2019 were included (p = 0.023), aorta distance (p = 0.002), and middle thoracic tumor (p = 0.040) correlated with difficulty. The median cervical angle and aorta distance were 15° and 33 mm in difficult cases and 19° and 43 mm in easy cases, respectively. In a multivariate analysis, the short aorta distance  and middle thoracic tumor  were independent predictive factors.In a univariate analysis, the cervical angle (The cervical angle, aorta distance, and middle thoracic tumor may predict the difficulty of transcervical SCLN dissection. In difficult cases, a transhiatal approach should be combined for complete SCLN dissection. Esophageal cancer (EC) is the seventh most common cancer worldwide and the sixth leading cause of cancer-related death worldwide . EsophagThe transmediastinal approach provides an excellent view and handling along the esophagus for lymphadenectomy. In comparison with the transthoracic approach, the lymph nodes along the left recurrent laryngeal nerve or thoracic aorta, which are located behind the esophagus in the transthoracic approach, are dissected more easily with the transcervical approach using single-port mediastinoscopy , 6 or thThe aim of this study was to identify predictive factors for the difficulty of transcervical SCLN dissection. Several angles and distances derived from the mediastinal shape were calculated by preoperative 3D computed tomography (3D-CT) and defined as indicators of mediastinal narrowness, and the relationships between the difficulty of transcervical SCLN dissection and clinicopathological features, including the above indicators, were investigated.A total of 126 patients who underwent TME and preoperative 3D-CT for EC at Kyoto Prefectural University of Medicine Hospital between 2016 and 2019 were retrospectively analyzed. TME was used as a primary option for curative resection. Patients on whom R2 resection was performed or SCLN dissection was skipped were excluded. 3D-CT was performed preoperatively for all patients undergoing TME to understand the transmediastinal surgical anatomy, particularly the mediastinal courses of the bronchial arteries . Tumor sTME was performed according to previously reported procedures . In brieSCLN were basically dissected with the left cervical procedure. After esophageal dissection from the trachea, SCLN and the bilateral main bronchi were exposed on the dorsal plane or membranous portions, respectively. Then, SCLN were separated from the tracheal bifurcation. In case where it was difficult to separate SCLN from the tracheal bifurcation due to unsuitable device angle for dissection or peritumoral adhesion, SCLN were dissected safely and completely with the following transhiatal procedure as SCLN and bilateral main bronchi were already exposed transcervically.All cases were operated by a dedicated team consisting of three expert surgeons, and the transcervical procedures were performed by the two surgeons who were certified as a specialist in esophageal surgery by the Japan esophageal society.Four evaluation indicators were defined as follows using preoperative 3D-CT images of a sagittal section through the carina Fig. . (1) CerPatients in whom SCLN dissection was completed using the transcervical approach alone were selected as easy cases. Those in whom SCLN dissection was judged to be difficult due to unsuitable device angle for dissection or peritumoral adhesion, and completed with the following transhiatal approach were defined as difficult cases.p value < 0.05 was considered to be significant. All statistical analyses were performed using JMP 10 software .Proportions or distributions of variables were compared using the chi-squared test. A multivariate analysis of predictive factors for difficulty was performed using a logistic regression analysis and odds ratio (OR), and the 95% confidence interval was subsequently calculated. Forward stepwise regression method was used for selecting independent and significant variables. All statistical tests were two sided, and a n = 53; 42%), followed by lower thoracic tumors . All patients had squamous cell carcinoma. Sixty-four patients (51%) received neoadjuvant chemotherapy. The median cervical angle, carina distance, aorta distance, and sternum distance were 18°, 13 mm, 41.5 mm, and 96 mm, respectively. Fifteen cases (12%) were defined as difficult cases for transcervical SCLN dissection.The clinicopathological features of all patients are shown in Table Representative 3D-CT images and surgical views in easy and difficult cases of transcervical SCLN dissection are shown in Fig. p = 0.040), cervical angle (p = 0.023), and aorta distance (p = 0.002) were identified as significant predictive factors, while BMI was also associated with the difficulty (p = 0.057). No significant differences in blood loss and mediastinal surgical time were observed between easy and difficult cases. In the multivariate analysis, short aorta distance ≤ 30 mm , and middle thoracic tumor  were independent predictive factors for the difficulty of transcervical SCLN dissection. In addition, chronological distribution of difficult cases was investigated in relation to the aorta distance (Fig. The results of univariate and multivariate analyses of predictive factors for the difficulty of transcervical SCLN dissection are shown in Table  p = 0.02, and aorWe recently reported that SCLN were dissected equally between TME and TTE . HoweverThe mediastinum is a narrow space surrounded by the bilateral mediastinal pleura, sternum, thoracic spine, thoracic inlet, and diaphragm . We empiTo the best of our knowledge, this is the first study to assess the technical difficulty of TME with a focus on transcervical SCLN dissection. Two previous studies have examined the factors influencing technical difficulty in esophagectomy , 20. FujThere are some limitations. This was a retrospective study with small sample size in a single institute. although SCLN dissection was performed safely for all the study patients by a fixed team, judgements on whether to complete SCLN dissection with the transcervical approach may depend on the subjectivity or learning curve of the surgeon. In this regard, chronological distribution of difficult cases in relation to the aorta distance was investigated Fig. . ConsequIn conclusion, we defined new indicators using preoperative 3D-CT images to assess the difficulty of transcervical SCLN dissection, and the aorta distance and middle thoracic tumor were identified as independent predictive factors. SCLN dissection needs to be performed in combination with the transhiatal approach if difficulty is predicted, particularly for surgeons who introduce TME.


A considerable variety of donor–acceptor (D–A) combinations offers the potential for realizing highly efficient thermally activated delayed fluorescence (TADF) materials. Multiple D–A type compounds are one of the promising families of TADF materials in terms of stability as well as efficiencies. However, those emitters are always composed of carbazole-based donors despite a wide choice of moieties used in linearly linked single D–A molecules. Herein, we developed a multiple D–A type TADF compound with two distinct donor units of 9,10-dihydro-9,9-dimethylacridine (DMAC) and carbazole as the hetero-donor design. The new emitter exhibits high photoluminescence quantum yield (PLQY) in various conditions including polar media blend and high concentrations. Organic light-emitting diodes (OLEDs) showed a reasonably high external quantum efficiency (EQE). In addition, we revealed that the multiple-D–A type molecules showed better photostability than the single D–A type molecules, while the operational stability in OLEDs involves dominant other factors. This phenomenon occurs at room temperature because of a small single-triplet energy gap (ΔEST) between the lowest excited singlet and triplet states (S1 and T1), which can be realized by spatially separating the highest occupied molecular orbital (HOMO) and the lowest unoccupied molecular orbital (LUMO). Thus, the unique molecular design of TADF emitters is based on various types of donor (D) and acceptor (A) units5. Recent interest in the research area of TADF is related to the control of rate constants, for example, maximizing the RISC rate (kRISC)14. The fast kRISC can reduce long-lived triplet excitons, which would contribute to decreasing exciton losses and efficiency rolloff16. Since fluorescent emitters generally exhibit better stability than phosphorescence and TADF emitters with high energy triplet excitons, another expected benefit of the fast kRISC is the improvement of the device durability, which has been a long-standing and serious problem in the applications of TADF20. However, the relationships among device durability, kRISC, and molecular structures have not been understood comprehensively. For example, a series of compounds with carbazole donors and benzonitrile acceptors represented by 4CzIPN achieved satisfactory high stabilities despite moderately fast kRISC (~ 106 s−1)21. From the viewpoint of the chemical structure, the multiple donor units allow not only variation of D–A interactions and charge transfer (CT) strength but also the intramolecular π–π interactions and delocalization effect, which may be associated with the high stability22. In addition, the hetero-donor strategy introducing second donor units might improve stabilities further in addition to photophysical properties24. However, the multiple and hetero-donor designs are always based on carbazole-based donors such as parent carbazole and 3,6-disubstituted-carbazole29. Therefore, it is desired to verify multiple and hetero-donor strategies by incorporating a different type of donor and compared to linearly linked single D–A molecules.Thermally activated delayed fluorescence (TADF) has emerged as the third-generation emitter in organic light-emitting diodes (OLEDs), which facilitates harvesting both singlet and triplet excitons through reverse intersystem crossing (RISC), resulting in 100% internal quantum efficiency (IQE)EST prove efficient TADF properties for 2Cz2DMAC2BN. Thus, the stabilities of some different types of excellent TADF materials with similar photophysical properties were accordingly compared. The analysis of the photophysical parameters and stabilities of these compounds would provide a better understanding of the structure–property relationship in multiple and hetero-donor designs.In this paper, we developed a new multiple and hetero-donor type molecule, named 2Cz2DMAC2BN Fig. , inset, NAr reaction  of 3.8 µs were also achieved  character. The triplet LE (3LE) of Cz and DMAC are relatively high at > 3.0 eV31. Although the 3LE of BN-Ph-BN was reported to be 2.9 eV29, the highly twisted DMAC might offer the space to planarize BN-Ph-BN rings, resulting in the decrease of 3LE. Interestingly, 2Cz2DMAC2BN showed constantly high PLQY even in polar solvents such as acetone, which is a clear difference from 4CzIPN -1,1′-biphenyl) kept near-unity PLQY in 6–50 wt% doping concentrations  and in PPT -dibenzothiophene) are also excellent although the polarity of PPT is relatively higher than mCBP /HAT-CN (10 nm)/Tris-PCz (30 nm)/electron blocking layer (EBL) (5 nm)/x-wt%-2Cz2DMAC2BN:host (30 nm)/hole blocking layer (HBL) (10 nm)/BPy-TP2 (40 nm)/Liq (2 nm)/Al (100 nm), where HAT-CN is dipyrazinoquinoxaline-2,3,6,7,10,11-hexacarbonitrile, Tris-PCz is 9,9′,9″-triphenyl-9H,9′H,9″H-3,3′:6′,3″-tercarbazole, BPy-TP2 is 2,7-bistriphenylene, and Liq is 8-hydroxyquinolinolato-lithium -voltage (V) and rolloff characteristics were improved with the increase of the doping concentrations since the recombination zone shifted to the center by enhancing the electron transport in the EML as observed in the devices of 4CzIPN21. Although the PLQY values were nearly the same for 6–50 wt% doped mCBP films, the maximum EQE values were slightly decreased because of some quenching processes. The J–V characteristics of the devices using CCP hosts are independent of the doping concentrations  is slightly shallower owing to substituents of diphenyl amines at 3,6-positions of carbazole. The photophysical properties of these materials in the neat films were summarized in Supplementary Fig. 1 energies. In addition, these materials also have similar τd values of 1–2 µs and kRISC values of 8–10 × 105 s−1, which is considered to be an important parameter related to the stability of TADF molecules. However, the excited state stabilities estimated from the PL intensity changes as a function of the irradiation time are largely different for these compounds. The half-life times of the emission intensities are three times longer in 4CzIPN than 2Cz2DMAC2BN and DACT-II, and four times longer compared to ACRXTN. This result cannot be explained by only photophysical parameters such as HOMO–LUMO levels, PLQY, ΔEST, and kRISC of the materials. Thus, we assume that the stability is strongly affected by the chemical structures of the compounds. Here, we classified two distinct features, that is, multiple donor-based D–A molecules (2Cz2DMAC2BN and 4CzIPN) vs. linearly linked single D–A molecules (ACRXTN and DACT-II), and donor structure types of DMAC-based (2Cz2DMAC2BN and ACRXTN) vs. Cz-based (4CzIPN and DACT-II) molecules. For the same class of donor units, the multiple donor-based D–A molecules showed better stabilities compared to the single linear D–A molecules. This is attributed to the crowded substituents with intramolecular π–π stacking. The photodegraded samples of carbazole derivatives showed products via dissociation of the C–N bond, e.g., carbazole and dicarbazole isophthalonitrile from 4CzIPN38. Thus, the delocalization and stabilization of the CT state in the excited state through the donor–donor interactions might suppress the dissociation of the donor units. This may also be related to the results that Cz-based TADF molecules showed better stability than DMAC-based ones. The larger dihedral angles between DMAC and Ph rings should not only weaken the bond strength but also more localize the D–A in the CT. Note that the photostability for the doped films also showed a similar tendency . The TD-DFT calculations were conducted at the B3LYP/6-31+G level for the excited states calculations.−4 Pa. The substrates were cleaned with acetone and isopropanol and then treated with UV/ozone to remove adsorbed organic species before deposition.Organic thin-films for optical measurements were fabricated on clean quartz and silicon substrates by thermal evaporation at a pressure lower than 1 × 10The fabrication and measurement procedures are described in Supplementary Methods http://www.ccdc.cam.ac.uk/data_request/cif].Single crystals suitable for X-ray structural analysis were obtained by vacuum sublimation. X-ray crystallographic information files (CIFs) are available [CCDC 2249866 contains the Supplementary Information 1.Supplementary Information 2.


Beta-amyloid (Abeta) and tau protein in cerebrospinal fluid (CSF) are established diagnostic biomarkers for Alzheimer’s disease (AD). However, these biomarkers may not the only ones existing parameters that reflect Alzheimer’s disease neuropathological change. The use of quantitative metabolomics approach could provide novel insights into dementia progression and identify key metabolic alterations in CSF and serum.In the present study, we quantified a set of 45 metabolites in CSF (71 patients) and 27 in serum (76 patients) in patients with mild cognitive impairment (MCI), AD, and controls using nuclear magnetic resonance (NMR)-based metabolomics.p = 0.0195) and serum  levels of the ketone body acetoacetate in AD and MCI patients. Additionally, we found decreased levels  of the branched-chain amino acid (BCAA) valine in the CSF of AD patients with increased valine degradation pathway metabolites . Moreover, we discovered that CSF 2-hydroxybutyrate is dramatically reduced in the MCI patient group . On the other hand, vitamin C (ascorbate) was significantly raised in CSF of these patients (p = 0.008). We also identified altered CSF protein content, 1,5-anhydrosorbitol and fructose as further metabolic shifts distinguishing AD from MCI. Significantly decreased serum levels of the amino acid ornithine were seen in the AD dementia group when compared to healthy controls . When investigating the effect of sex, we found for AD males the sign of decreased 2-hydroxybutyrate and acetoacetate in CSF while for AD females increased serum creatinine was identified.We found significantly reduced CSF  and individual lifestyle factors . NMR-based metabolomics combined with standardization in sample preparation and analysis allows to phenotype metabolic shifts in CSF and blood. In CSF we monitored a decrease in acetoacetate, a ketone body, in both MCI and AD. We furthermore identified low 2-hydroxybutyrate, which can mark insulin resistance, in MCI. Finally, 1,5-anhydrosorbitol, a metabolite from the polyol pathway is higher exclusively in dementia (AD & MCI) males. In blood serum, we identified lower acetoacetate in the MCI group, lower blood serum ornithine in the AD group, higher glucose in MCI, and an increase of creatine in AD females when compared to AD males. In conclusion, we added a scheme of metabolomic transitions to highlight the close position of valine and valine degradation products to various key metabolites .  Alzheimer’s disease (AD) is the most common cause of dementia globally . AD is cA wide range of analytical techniques and matrices  can be used to generate a metabolomics knowledge base . Hereby,Several publications distinguish MCI and AD groups by CSF metabolic fingerprints . Additioin vitro diagnostics research (IVDr) standard operation procedure (SOP) of CSF and serum aliquots’ sample preparation technique with further profiling of NMR spectra. This standardized approach guarantees the highest reliability and reproducibility  subjects, MCI patients, and AD patients.This study was performed in accordance with the Declaration of Helsinki. All participants gave their written consent and samples were collected by the biofluid biobank at the Hertie Institute for Clinical Brain Research, the Center of Neurology, University of Tübingen, Tübingen, Germany. In total, 71 CSF and 76 serum samples were investigated. The participants were divided into different sub-cohorts as illustrated in Cerebrospinal fluid and serum aliquots were stored at −80°C and transported on dry ice until preparation for NMR analysis. All samples were prepared according to a commercial SOP for CSF and serum . In brief, on the day of preparation, the samples were thawed at room temperature and then directly prepared. Each CSF sample (200 μL) was mixed with a pH neutral (pH = 7.40) CSF preparation buffer , containing 60% deuterium oxide, 0.9 mM potassium monophosphate, 0.06% sodium 3-(trimethylsilyl)-2,2,3,3-tetradeuteropropionate (TSP) and 1.2 mM bacteriostatic sodium azide. Serum samples (350 μL) were mixed with a pH neutral (pH = 7.40) plasma/serum preparation buffer , containing 20% deuterium oxide, 0.075M sodium monophosphate, 4.6 mM sodium 3-(trimethylsilyl)-2,2,3,3-tetradeuteropropionate (TSP) and 0.04% bacteriostatic sodium azide, as published previously .After thoroughly mixing (no vortexing!), a portion of the resulting mixture  was transferred into a 4″  NMR glass tube and then placed into an autosampler . The Bruker SOP instructs to operate with a higher volume of a sample prepared and then transfer a lesser amount into an NMR tube for better analytical reproducibility and allows to hold an additional technical aliquot. Samples for NMR metabolomic analysis were stored at 6°C in the autosampler prior to analysis and kept for 5 min inside the NMR probe head to reach temperature stability.Nuclear magnetic resonance experiments were accomplished on a Bruker Avance III HD 600 MHz NMR spectrometer . Samples were measured with a 5 mm TXI probe, using Bruker TopSpin version 3.6.1 (serum dataset) and 3.6.2 (CSF dataset), including additionally required IVDr experiments and software plug-ins as provided by Bruker BioSpin GmbH, Ettlingen, Germany. Quality control (QC) was performed regularly and was accomplished within the Bruker IVDr guidelines of QC testing of the spectroscopic system.1H NOESY  experiment at a temperature of 300.0 K. 1H NOESY spectra were utilized to generate a prepared dataset for the subsequent manual metabolite annotation and quantification (Chenomx NMR suite 8.5 software). TSP was used as the chemical shift and the shim reference signal as well as the internal standard calibrator. All spectra were manually matched with database entries from the Chenomx and the HMDB  libraries containing up to 1,000 compounds fit for 600 MHz NMR spectral dataset. The use of the HMDB library was necessary for those CSF metabolites that were presenting a better spectral fit (citric acid) or unique presence  in contrast to the other library.Cerebrospinal fluid spectra were recorded using 1H NOESY  experiments at a temperature of 310.0 K. 1H NOESY spectra were utilized to generate a prepared dataset for the subsequent automated metabolite annotation and quantification .Serum spectra were recorded using 1H NOESY spectra, as reported previously  were identified and quantified in all spectra, excluding ethanol, glycerol, and metabolites with less than 1/3 of the total cohort presented concentration values (zeros). Additionally, we calculated ratios of some small molecule metabolites that can provide a comprehensive view of blood metabolomic status in patients: the Fisher’s ratio , Pearson correlation coefficients (used in PatternHunter plots), oPLS-DA , sPLS-DA , AUC (area under the curve) values from the ROC (receiver operating characteristic) analysis and VIP (variable importance in projection) score of metabolites. For combined NMR data and clinical CSF AD biomarkers, we used logarithmic scaling which results in a normal-like distribution of concentrations with subsequent Pearson’s correlation analysis. In order to produce consistent statistical tests , we applied the following set of thresholds: statistical significance threshold for p-values p < 0.05 and VIP scores threshold for significant findings VIP > 1.0; AUC values threshold for significant findings AUC > 0.70. Additionally, GraphPad Prism 9.0.1 software was used for unpaired t-test boxplot and ANOVA boxplot visualization. Several figures in the current work were created with the BioRender.com online-based service.Data from the CSF biomarkers and metadata were normalized via logarithmic scaling in order to monitor changes of multiple magnitude of metabolic data, biomarkers, and metadata. For each comparison, the following set of parameters was determined: A total of 71 CSF and 76 serum patient samples  were exaAdditionally, we have provided table of unnormalized concentration means and standard deviations for metabolites measured in CSF and blood serum , 2. A grp < 0.001), 2-hydroxybutyrate (2-HB), alpha-ketoisovaleric acid, ascorbate, 3-hydroxyisobutyrate (3-HIB), and acetoacetate. Whereas, acetoacetate and 3-HIB were decreasing in both AD and MCI , and creatine . This overview approach was applied to Abeta1–42, h-Tau, and p-Tau correlations retrieved from the CSF cohort .p = 0.01) and ornithine decreased in the AD and MCI groups, while glucose showed an increase in the MCI group, and acetoacetic acid (acetoacetate) depleted in dementia individuals. Significant variables of the ANOVA could be directly compared to the whole dataset of profiled compounds within the averaged heatmap plots of the three patient groups in the serum cohort  in the blood of MCI-dementia patients  in AD. Additionally, we determined a set of metabolic variables significantly altered in the sub-cohort of CSF with the available CSF biomarkers entries , We used Remarkably, there were more substantial dementia-defined alterations from the oPLS-DA score and VIP, the limited size cohort was used, in the CSF analysis . Within Applying a correlational and regression model statistic  that incp-value via ANOVA) contrasting the two different patient groups were brought to the context of the sex-based bias investigation ; serum creatinine and creatine levels were higher in female controls  by analyzing the statistical summary of the current data, which is shown in tigation .After the FDR adjustment, many variables of the cerebrospinal fluid , namely We also looked at the CSF-to-serum ratios of metabolic values for the following 22 metabolites: 3-hydroxybutyrate , acetate (acetic acid), acetoacetate (acetoacetic acid), acetone, alanine, citric acid, creatine, creatinine, dimethyl sulfone, formate (formic acid), glucose, glutamine, histidine, isoleucine, lactate (lactic acid), leucine, lysine, methionine, phenylalanine, threonine, tyrosine, valine. Valine serum-to-CSF ratio was significant  in discrWe discovered distinctive alterations in the established AD CSF biomarkers which were consistent with previous studies . Adding Hypercholesterolemia and hyperglycemia are dangerous AD pre-conditions, potentially aggravating metabolic conditions in the brain . A ketogKetone bodies serve as an alternative energy source in case of glucose deficiency in the dementia brain . We founFrom the standpoint of brain energy supply by ketone bodies, of which acetoacetate (acetoacetic acid) was significantly decreased in both CSF and serum measurements of patient cohorts. Both 3-hydroxybutyrate and acetoacetate potentially have neuroprotective properties due to the reduction of ROS effects . The redTherefore, we propose that dementia is caused by a breakdown of brain energy balance, which leads to specific metabolic alterations in both CSF and serum. Furthermore, we suppose that the imbalance in glucose consumption can also be seen in the AD group, as seen by a slight increase in lactate CSF concentrations, which is to previous findings . AnotherHigher blood BCAAs levels negatively influence tryptophan uptake into the brain at the blood-brain barrier. Therefore, BCAAs could affect serotonin production and signaling and thus, could potentially be linked to Abeta plaque formation . Yet, soAn additional metabolite that can be linked to the described BCAAs metabolism alterations , as wellt-test analysis revealed both ketoisovalerate and 3-HIB to be statistically significant only for the AD-Con comparison. The ketoisovalerate alterations in CSF could also explain changes in 3-hydroxyisobutyrate (3-HIB). 3-HIB is a metabolite that is closely associated with the valine degradation pathway , which was significantly higher in cerebrospinal fluid analytes of dementia patients. Ketoisovalerate is involved in the valine and leucine catabolic pathway, implying a change in the BCAAs levels in CSF of cognitively impaired individuals. It is worth noting that the  pathway .In addition to using the established CSF Abeta and tau biomarkers for the diagnosis of AD, we were also provided with the clinical MMSE score, ApoE4 alleles count, and cholinesterase inhibition therapy positive status. These biomarkers could provide a categorical ranking of a patients’ state of dementia. As a result, identifying the metadata parameters to the main experimental tables in both CSF and serum sub-cohorts has become an important goal.A set of three CSF metabolic parameters  was identified to positively correlate with CSF tau levels. Several studies indicate a potential link between AD and the glycation process of proteins and the formation of advanced end glycation products (AGEs) . The meaInterestingly, higher CSF protein content as measured by NMR was closely associated with tau protein amounts in both AD- and MCI-diagnosed patients. The CSF protein content variable measured via NMR metabolomics presents the total CSF protein content, e.g., albumin content in cerebrospinal fluid aliquots. As a result, we presume that the observed increase in total protein levels may be linked to a slower renewal of cerebrospinal fluid in patients .Higher CSF acetate in dementia patients demonstrates the same trend for the dementia patients described previously . AcetateEarlier on, we described the significance of BCAAs  and 3-hydroxyisobutyrate in cerebrospinal fluid aliquots. Interestingly, these variables had demonstrated negative correlations to tau protein levels and positive – to the CSF Abeta levels. Therefore, we could support that CSF AD and MCI dementia patients have a high significance of BCAA metabolism alongside valine degradation pathway to take place and become a potential target in SOP CSF screening within the future studies of the neuropathology of Alzheimer’s.Correlational PatternHunter plots (serum) narrowed down glutamic acid and glutamine as highly changing in dementia. We were also able to detect that ornithine levels were in lower amounts together with serum glutamic acid, while higher glutamine serum levels were found in both patient groups. Blood glutamine and glutamate level changes were reported in the context of metabolic disruption in AD and MCI patients’ blood analytes . Our resNotably, the ranking variables of CSF lactate in the VIP scores plot were shown to have a significantly greater average concentration in the CSF of female AD and MCI patients than in males of the sample phenotype. In elderly, CSF lactate is reported to be interacted with CSF glucose but not with the sex factor . HoweverWithin the scope of the present investigation, we are able to emphasize the observed creatine levels high in the female part of our serum cohort with a specifically high positive correlation with the sex factor (and we saw some significance between creatine in CSF to the sex factor of the whole cohort of patients) that may indicate the differentiation of sex-based blood creatine differences (higher creatine in women) as reported in Related to the AD-related anomalies, we were able to see some sex-based differentiations in phenotype via the regression model approach applied, i.e., CSF methionine elevation that was highly characterizing the female MCI patients versus their female-AD counterparts (had lowered CSF methionine). It is possible that as of an AD-potential transitionary stage, the higher female-MCI over AD methionine in CSF, where MCI is generally more often occurrence in women , could bWithin the male part of the CSF cohort investigation of existing sex-based bias in AD and MCI against the healthy controls, we were able to detect unique findings of CSF 2-hydroxybutyrate being lowered in male dementia  patients compared to controls. Similarly, CSF and also serum acetoacetate, and a number of other regression model-significant parameters were attributed to the male AD-Con-MCI 3-group comparison. Additionally, 2-hydroxybutyrate has been identified as an early marker for impaired glucose regulation and indicates underlying metabolism of oxidative stress . Moreovep-value) and are similar to lipoprotein panel bias toward the sex factor reported for the same utilized serum patients’ cohort recently . As a result, it is possible that a male-based phenotypic influence was the most prevalent.Overall, our NMR metabolomic data for serum and CSF revealed some noteworthy differences within the studied cohorts. Therefore, we provide a graphical summary of the patient groups’ comparison .t-test analysis. Wherein, lysine and formate in CSF showed significantly lower concentrations in the AD specimen. Valine had an altered CSF-to-serum ratio that had been a single statistically and AUC-significant entry.The 39-patient-based comparison of both biofluids was performed to see whether there were any novel cohort-specific between AD and MCI dementia stages. Only metabolites that were identified in both biofluids were applied for the Within this study, the current finding of valine (serum/CSF) is represented as a well-performing AD-MCI patient cohort discriminator, that could be further tested within the context of future dementia investigations.The implementation of this NMR-based metabolomics approach to human biofluids of dementia patients using a strict SOP has been found to be a major strength of the current study. Primarily, we are able to initially minimize sample preparation inaccuracies and concentration shifts in analytes. Secondly, with the possibility of wider implementation of the same SOP to other blood  and cerebrospinal fluid samples, researchers would obtain an advantage of a direct comparison of summarized data matrixes including meta-cohort analysis. Indeed, the overall number of CSF and serum samples  inside tThe sex-specific analysis, herein, is resulting in a lower statistical significance due to the overall segmentation of a limited cohort size. As this study was based on a retrospective biobank cohort unfortunately no more samples could be obtained. Our results still show sex-specific trends which we hope to be validated in future investigations having access to larger cohorts.Our quantitative NMR-based metabolomics investigation of CSF and serum aliquots from AD and MCI patients and individuals with cognitively normal function identified several metabolite alterations. The results were obtained from both biofluids and were identified to be ketone bodies, branch-chained amino acids, and brain energy metabolites in CSF. On the other hand, glutamic acid, acetoacetic acid (a ketone body), and valine (a branched-chain amino acid) were considerably changed in patients’ serum metabolome. From unsupervised statistical analysis, we believe that ketone bodies-associated differences in CSF between the patient groups could provide significant input for dementia patients’ screening and could provide an additional axis of comparison of dementia progression. Within the regression model analysis, patient MMSE score and CSF tau protein levels were highly correlative in CSF with the elevation of CSF protein content in both patient groups. Wherein, higher CSF fructose and 1,5-anhydrosorbitol levels identified a potential pathological role of the polyol pathway. We also believe that another key to AD screening might be 2-hydroxybutyrate, a potential pre-diabetes condition marker as well as a metabolite demonstrating an influence of oxidative stress. Finally, we believe that the diagnostic combination of small molecule type metabolites and AD clinical biomarkers could be a first step toward establishing an expanded tool for longitudinal monitoring of dementia patients.Mean concentrations with standard deviations for CSF and serum metabolites are provided in the The studies involving human participants were reviewed and approved by the Ethics Committee of the Medical Faculty of Eberhard-Karls-University and University Hospital Tübingen . In the CSF samples study, the protocol was approved by the local institutional review boards and ethical committees of all participating sites of the German Center for Neurodegenerative Diseases (DZNE). The study was conducted in accordance with the Declaration of Helsinki. The patients/participants provided their written informed consent to participate in this study.GB, CL, and CT contributed to the experimental design, data acquisition, and data analysis and interpretation. GB wrote the original draft. All authors approved the final manuscript.


The genomes of present-day non-Africans are composed of 1–3% of Neandertal-derived DNA as a consequence of admixture events between Neandertals and anatomically modern humans about 50–60 thousand years ago. Neandertal-introgressed single nucleotide polymorphisms (aSNPs) have been associated with modern human disease-related traits, which are risk factors for pancreatic ductal adenocarcinoma (PDAC), such as obesity, type 2 diabetes, and inflammation. In this study, we aimed at investigating the role of aSNPs in PDAC in three Eurasian populations.–6), with a P-value close to a threshold that takes into account multiple testing.The high-coverage Vindija Neandertal genome was used to select aSNPs in non-African populations from 1000 Genomes project phase 3 data. Then, the association between aSNPs and PDAC risk was tested independently in Europeans and East Asians, using existing GWAS data on more than 200 000 individuals. We did not find any significant associations between aSNPs and PDAC in samples of European descent, whereas, in East Asians, we observed that the Chr10p12.1-rs117585753-T allele (MAF = 10%) increased the risk to develop PDAC (OR = 1.35, 95%CI 1.19–1.54, P = 3.59 × 10Our results show only a minimal contribution of Neandertal SNPs to PDAC risk.The online version contains supplementary material available at 10.1186/s40659-023-00457-y. By comparing the genome sequences of Neandertal and modern genomes it has been shown that ~ 1–3% of the genomes of present-day non-Africans are of Neandertal ancestry –6. ThrouAlongside a small number of environmental risk factors –24, PDACConsidering that aSNPs are associated with several PDAC risk factors and that the genetic contribution to PDAC etiology still needs to be elucidated, we aimed at investigating the Neandertal legacy of PDAC genetic risk. We analysed PDAC GWAS cohorts from different Eurasian populations for significant associations with aSNPs to study the role of Neandertal admixture and PDAC risk in different ancestry groups. This study is the first attempt to investigate the role of archaic admixture on PDAC development.In this study, 389 144 aSNPs were identified among the non-African populations of the 1000 Genomes project . The ass2 > 0.5). After pruning, 51 independent aSNPs associations spanning across 51 loci were observed . The SNP with the lowest P-value was Chr2p14-rs12998719,  , 1154 independent aSNPs with a P < 0.05 were observed  (Table j = 2.30 × 10–6).In FinnGen, 251 090 aSNPs were found, and after LD-pruning (r–6), whose P-value was very close to the Bonferroni-adjusted threshold (pj = 2.28 × 10–6) . This association was not statistically significant when considering multiple testing. However, it is very close to the Bonferroni corrected threshold (pj = 2.28 × 10–6). The functional implications of this aSNP have not been clarified yet: according to GWAS catalog, it is not associated with any complex human trait.In JaPAN, we found that the T allele of Chr10p12.1-rs117585753 increased the risk to develop PDAC , whereas it is almost absent in the other populations represented in 1000 Genomes project . Since Chr10p12.1-rs117585753 is polymorphic only in Asians, it is possible that the role of this aSNP in complex traits has not been elucidated yet because most of the association studies have been conducted in cohorts with participants of European descent . The lowPRTFDC1 gene, in which, according to the GWAS catalog, there are SNPs associated with blood cell count [PRTFDC1 (Chr10p12.1-rs7905553) is in weak LD  with Chr10p12.1-rs117585753 in EAS, and according to GWAS catalog it is associated with red blood cell distribution width (RDW) [PRTFDC1 genomic region and Chr10p12.1-rs117585753 in PDAC and immunity.Chr10p12.1-rs117585753 lies in an intron of the protein-coding ll count –49. Sevell count , 51. Oneth (RDW) , which iSeveral Neandertal-derived haplotypes involved in immunity have been reported to be under selection after Neandertal-AMH introgression. In fact, the positive selection of aSNPs that lead to adaptation (adaptive introgression) has been observed to be driven by the immune response to pathogens , 54–57.Possible limitations of our approach are represented by the fact that we could have underestimated the role of rare variants (MAF < 1%) because we did not have enough statistical power to detect associations between rare aSNPs and PDAC, although we used the largest PDAC datasets currently available, which included more than 200 000 individuals of three different ancestries. An additional potential limitation of this work is that 93 695 out of 389 144 aSNPs identified in Eurasian genomes could not be found in PanScan + PanC4, FinnGen, and JaPAN. Therefore, the role of these aSNPs in PDAC susceptibility was not explored. In future analyses, larger reference panels for imputation could be used to maximize the investigated Neandertal-derived genetic variability.In conclusion, we observed that the Neandertal introgressed DNA does not influence PDAC susceptibility in populations of European descent. Interestingly, we observed a potential association between Chr10p12.1-rs117585753-T and an increased risk of developing PDAC in populations of Asian descent, although not formally significant after correction for multiple testing. This aSNP is polymorphic only in East Asians and is situated in a genomic region involved in immunity. Further investigations are needed to elucidate the evolutionary processes that lead to these aSNPs in the AMH gene pool and the role of aSNPs in PDAC risk, and more broadly, to explore the Neandertal legacy in the susceptibility to other cancer types.., and Dannemann et al. was used [The method to select aSNPs was previously described . Brieflywas used , 58. Briwas used , 60 wereAll the analyses were based on human genome assembly GRCh37, and only biallelic loci were considered, excluding indels.The association between aSNPs and PDAC risk was tested in three ancestry groups: non-Finnish Europeans, Finns and East Asians. A two-phase association study (discovery and replication) was performed to examine if aSNPs identified in non-Finnish Europeans affected PDAC susceptibility. On the other hand, a validation set was not available for Finns and East Asians, and the association between aSNPs and PDAC was tested by searching for aSNPs in FinnGen and JaPAN datasets, respectively (see below).https://www.ncbi.nlm.nih.gov/gap/). The dbGaP study accession numbers were: phs000206.v5.p3 and phs000648.v1.p1.; the project reference number was #12644. Details about data collection, genotyping methods and analyses are described in the original publications [For non-Finnish European analyses, the discovery set included data of the Pancreatic Cancer Cohort Consortium (PanScan) and the Pancreatic Cancer Case–Control Consortium (PanC4). The data were downloaded from the database of Genotypes and Phenotypes  [−6). After imputation, SNPs with low imputation quality (INFO score r2 < 0.7) were excluded. Finally, the imputed datasets were merged. A total of 7 543 430 SNPs passed the quality controls on the autosomal genome, and 8738 PDAC cases and 7034 controls were used in the analysis   and the ich.edu) . Prior tThe replication of aSNPs with a P-value of association with PDAC risk lower than the Bonferroni-adjusted threshold (see below) was attempted in the Pancreatic Disease Research (PANDoRA) consortium , 65. PANhttps://FinnGen.gitbook.io/documentation/) [Non-Finnish Europeans and Finns were analysed separately because PanScan + PanC4 and PANDoRA mainly include subjects with Central European ancestry. We used the FinnGen Release 8 (R8) data that consists of GWAS summary statistics of 1249 pancreatic cancer cases and 259 583 controls with Finnish ancestry (Table tation/) .http://www.aichi-med-u.ac.jp/JaPAN/current_initiatives-e.html) and include 34 631 individuals of East Asian origin (2039 PDAC cases and 32 592 controls) . Comprehensive information on genotyping and data analysis are given in the original publication . Summary2 > 0.5) with each other were excluded, and in each LD block the aSNP with the lowest association P-value was selected. Then, all aSNPs showing an association lower than the threshold for statistical significance corrected for multiple testing in PanScan, PanC4 and in the combined datasets were selected for replication in PANDoRA.For non-Finnish Europeans, the association between aSNPs and PDAC susceptibility was tested in the PanScan + PanC4 dataset using logistic regression analysis, adjusting for age, sex and the top eight principal components Fig. . To obta® 96 DNA QIcube® HT Kit . The genotyping was done using TaqMan RealTime PCR assays in 384-well plates. Each plate included cases and controls, duplicated samples for quality controls (QCs) and negative controls. The fluorescent signal detection was detected through a QuantStudioTM 5 Real-Time PCR system  and genotypes were called using the QuantStudio™ Design and Analysis Software v1.5.1. Samples with a genotyping call rate lower than 75% were excluded from the analysis. Hardy–Weinberg equilibrium test was performed with the Pearson chi-square test. To test the association between aSNPs and PDAC risk in PANDoRA, a logistic regression adjusted for age, sex, and country of origin was used.The genomic DNA of the PANDoRA samples was extracted from circulating blood using the QIampFor Finns and East Asians, the analyses were carried out in parallel, keeping separated the two ancestry groups. Considering that for FinnGen and JaPAN we used summary statistics, we looked at the P-value for association in these two datasets for the aSNPs selected for the two populations. Since JaPAN is a meta-analysis of three studies, along with P-value, the concordance of the direction of the effect between the three GWASs was considered.r2 < 0.8) aSNPs. The adjusted significance thresholds were: 0.05/19 623 = 2.55 × 10–6 for PanScan + PanC4 and PANDoRA; 0.05/21 780 = 2.30 × 10–6 for FinnGen; 0.05/21 965 = 2.28 × 10–6 for JaPAN.P-value correction for multiple testing was performed using Bonferroni correction and considering the independent  identified in PanScan+PanC4 association studiesDescription of data: Independent (r2<0.5) aSNPs showing an association P<0.05 in PanScan, PanC4, and combined datasets. The displayed summary statistics and MAF are referred to the analyses with the combined datasets. .


According to the 90-90-90 strategy, the focus is on 90% of people living with HIV and/or AIDS knowing their HIV status, initiated on antiretroviral treatment and achieving viral suppression. The challenge is that only 74% of people living with HIV and/or AIDS are on antiretroviral treatment, and HIV mortality still occurs. Literature recommends the incorporation of a Nurse Initiated Management of Antiretroviral Treatment (NIMART) course within the undergraduate nursing programme to capacitate new nurses to manage people living with HIV and/or AIDS immediately after completion of their training. However, the NIMART course is still not incorporated, and there is dearth of information on this topic in North West Province (NWP).To explore and describe nurse educators’ perceptions regarding the incorporation of NIMART course within the undergraduate nursing programme in NWP.The setting of this research study was nursing education institutions of the NWP.Phenomenography qualitative research design was followed. Twelve nurse educators underwent purposive selection and unstructured individual interviews were conducted. The research co-coder verified the findings. There were ethical considerations and trustworthiness maintained throughout the study.Main themes that emerged in this study depicted benefits and challenges associated with NIMART course incorporation within the undergraduate nursing programme as stated in This study concluded that NIMART course incorporation within the undergraduate nursing programme is a good and relevant idea, which requires human and non-human resources.The study contributed new knowledge on how nurse educators perceive the NIMART course incorporation within the undergraduate nursing programme in NWP. Human immunodeficiency virus (HIV) is still the deadliest infection among human beings to date, despite the use of Antiretroviral treatment (ART)  adopted the WHO’s 2008 Task Shifting Strategy and introduced Nurse Initiated Management of ART (NIMART) course to increase ART coverage NDoH :6. The iSince the inception of the NIMART course in South Africa, it is only for Professional Nurses (PN) registered with the South African Nursing Council (SANC) NDoH :9. MngqiSeveral Nursing Education Institutions (NEI) in Africa have been at various stages of planning a nation-wide sustainable curriculum for nursing and midwifery programmes  (university and college) in NWP, SA, which offers nursing education and training. The NEIs referred to in this study have two sub-campuses each. Two campuses are in Ngaka Modiri Molema district and two are in Dr Kenneth Kaunda district. The two NEIs are 179 km apart. One principal and two campus heads manage the two colleges, while the university has school directors in each campus. These NEI’s were selected because that is where NEs are based and also form part in the curriculum development.The population for this study was 43 NEs from NEIs in NWP:This study utilised non-probability sampling, which is a type of sampling that uses human judgement to make some members of the population more likely for selection than are others (Bryman & Bell 2017:380). Twelve NEs were purposively selected at the respective NEIs. The criteria used for inclusion in the study comprised nurse educators with teaching responsibilities in the undergraduate nursing programme, as well as those registered with SANC.Preceptors and clinical accompanists were excluded as they spend less time with students and do not often form part of the undergraduate curriculum committee members within the NEIs.In this study, unstructured individual interviews were conducted using one central open-ended research question and probing questions. Probing was for clarity seeking and for stimulating participants for more information. The interviews were conducted through Microsoft Teams application and thereafter transcribed. According to Menzies, Williams and Zimmermann :125, an What are your perceptions regarding incorporation of Nurse Initiated and Managed Antiretroviral Treatment course in the undergraduate nursing programme in NWP?Thematic data analysis was used to analyse the data. Thematic data analysis involves detecting themes and patterns, which emerge from participants and are central to credible research, because it is a flexible method for data analysis in qualitative research; its application can also be in other kinds of learning  granted ethical approval for this study (ethics number: NWU-00297-21-S1). Respect for persons, beneficence, justice was maintained. Also informed consent was obtained from the participants prior to data collection in line with The results of the study are presented in themes and sub-themes that resulted from the qualitative data collected among 12 participants. All 12 participants had more than 5 years of experience facilitating undergraduate nursing programme curriculum and were permanent employees of their designated NEI. This is the first theme that emerged from this study and it highlighted the importance of incorporating NIMART into the undergraduate nursing programme. The following sub-themes emerged, benefits to the students, community and NEI.In this study, the majority of participants affirmed that incorporation of the NIMART course would allow students to acquire more knowledge, skills and confidence to manage People Living with HIV and/or AIDS (PLWHA). The participants expressed the following:‘The students will be competent in NIMART and when are competent it will increase their confidence in managing people with HIV or those who need NIMART services so competency and confidence of the students.’ (Participant C)Another participant said:‘If you are NIMART trained before you even go to the clinics or before you go to practise I think you will have a better understanding and you will be able to work more sufficiently in practise.’ (Participant E)To further support that the NIMART course benefits students, another participant expressed:‘If somebody is empowered they are confident in what they are doing because they know exactly what they have been taught. They are knowledgeable so if you are knowledgeable you got all the information you got the skill then you are confident and then you can deliver quality care to the patient.’ (Participant J)Students would have clinical competency in managing PLWHA, and this was echoed as follows:‘When they go to practise, they will be able to take the history comprehensively whereby again they will be able to use WHO staging criteria … they will be able to assess aah opportunistic infections aah manage them in time … management of STI’s at an early stage is very important and early diagnosis and management of opportunistic infections is very important. students will be knowledgeable will start initiation of adults and children because … acquire skills necessarily to monitor patients from NIMART including the management of kidney failure, they will acquire skills from counselling and adherence of clients on NIMART again they will be knowledgeable on a pre and post counselling. They will also be knowledgeable on the monitoring of clients including children, monitor for the viral loads and checking the CD4 count.’ (Participant H)‘I think it’s very important if I was a student and it was part of the course, I would have much large understanding of ARV and how it works.’ (Participant E)Other participants mentioned that when undergraduate nursing students complete the NIMART integrated training they will share the information learned with professional nurses already in practice:‘So they will be able to share that knowledge with other nurses after they have been trained on management and treatment of HIV, STI and Tuberculosis.’ (Participant B)Several participants in this study indicated that the community would benefit with the NIMART course incorporated into the undergraduate nursing programme through the supermarket approach, whereby everything is one stop shop, meaning all patients complaints would be treated in one consulting room thus saving time:‘Because when the clients go to the facilities remember with the primary healthcare approach it is that it should be a supermarket approach then it means that when a client enters a consulting room this client will receive everything that needs to be on him and on his way out as he leaves the consulting room everything will be done to this client.’ (Participant I)There would be no need for patients to be referred to other facilities and travel long distances to access HIV services, as transport issues would be solved as people do not have money to be travelling around. This was explained as follows:‘Everything will be one stop shopping you are coming for your hypertension medication then professional nurses trained in NIMART would be able to take care of you for your HIV treatment regime and also it means it will save the society like the community a lot of money, time and what “yeah” all that’ Community will benefit in the sense that whenever the nurse is placed, then we know that the nurse will holistically be able to take care of the patient because we have challenges of patients having to travel long distance to access health care that is still a challenge.’ (Participant L)Another participant explained the benefits to the community as follows:‘There will be no need to refer them to someone else they can be able to help the patients there, … some of the patients are not on treatment because they have so many challenges around that fact you say to the patients okay go to such clinic or come back on such a date so that you can be seen by someone who is been trained for this specific course and then the patients doesn’t pitch up based on so many challenges. One of it being maybe they don’t have transport to come to the clinic for that so if one is a professional nurse trained in NIMART the patient can get that treatment right at that first consultation.’ (Participant G)‘It will mean that now our whole community will receive treatment in time they won’t just go disappear without any type of trace because … they experience challenges one of it being financial challenges maybe the patient have to catch a taxi to go to the clinic now they are there you telling them to come back again they don’t have money for that.’ (Participant G)Community mortality statistics will reduce, as patients will be started on treatment early, thereby reducing Loss to Follow-Up (LTFU) rate exacerbated by patients’ financial challenges to reach the facilities offering NIMART services:‘Obviously the patients will be started early on the treatment by the people who know and just reducing the stats and mortality … of people living with HIV.’ (Participant F)In this study, some participants indicated that the NEIs would benefit from positive feedback from the community regarding the NIMART services rendered by new graduate nurses trained in NIMART:‘Our community, our people, our patients will come back and say we really thank the institution for the people they trained who are well cooked and have relevant qualifications and experience when coming to NIMART … it will benefit a lot of people it will benefit the students, institution, community, patients their families and so on.’ (Participant C)Another benefit was that students who receive NIMART incorporated training would have a market advantage compared to those not trained, thereby putting the NEI on the map:‘If this kind of students comes out with that competency, it means the student themselves will be marketable, it puts our institution into the map again without being really selfish.’ (Participant K)Furthermore, participants expressed their readiness and interest to incorporate the NIMART course should the NEI endorse such an innovation:I am saying when we revise it, like this 3-year Diploma one when we revise it, we are definitely going to do this, it will be good if we incorporated it, we will incorporate it.’ (Participant F)‘I agree 100% that NIMART must be incorporated.’ (Participant C)The participants recommended that NIMART course be a module on its own, and the following sub-themes emerged:In this study, some participants explained there was a need to recognise HIV and AIDS as a killer that is harmful to society. Therefore, when incorporated into the undergraduate programme, the NIMART course should be a module on its own with its own National Qualifications Framework (NQF) level, module notional hours, module credits and not encapsulated within modules such as general nursing science or community nursing:‘I am saying it should be a module on its own its should not be put under other module like let us say general nursing science or community nursing science it must be on its own with its own NQF level.’ (Participant C)‘I am suggesting that it should have 12 credits and we know that 12 credits need at least 120 notional hours so this will be a full module were students will be given theory and in class given assignments, texts, examinations.’ (Participant C)Participants indicated the important need for stakeholder collaboration to take HIV and AIDS management in cognisance and regard it as a speciality as it is a public health concern:‘I say collaboration for an example SANC as a regulatory body can also take into consideration the HIV & AIDS management together the Department of Higher Education and Training (DHET), Department of Health (DoH), South African Nursing Council (SANC) and nursing education institutions. They should come together to recognise NIMART course as a speciality … because it’s a public health crisis.’ (Participant D)In this study, a few challenges were highlighted and were explained in three subthemes.Three sub-themes emerged as follows: knowledge gap regarding NIMART, poor patient management and cost of training nurses on completion of undergraduate programme.Participants in this study explained that it is fruitless for more student nurses to graduate in large numbers from different NEIs without being knowledgeable on NIMART. Often new graduate nurses lack the knowledge to manage PLWHA, and such incompetency contributes towards patient mismanagement:‘Nursing students graduate from different institutions in large numbers and to me it is fruitless for them to graduate without more insight of proper management of patients living with HIV & AIDS.’ (Participant D)‘If you are not NIMART trained you cannot initiate the patient …it means they will have to wait for the doctor just like when it was done previously which will waste patient time.’ (Participant A)‘Books used within the institution of higher learning are old and lack NIMART information. My experience is that ey … NIMART trained nurse’s focus into the current HIV and/or AIDS management.’ (Participant K)Participants indicated that if newly qualified nurses were not NIMART trained, there is a possibility they may lack the skills to manage PLWHA, particularly pregnant women. In addition, the delayed incorporation of the NIMART course has led to mortality among PLWHA.The following participants said:‘Most of professional nurses often manage pregnant HIV positive women poorly because they do not have proper knowledge on how to treat those patients.’ (Participant B)‘Well the study on incorporation of NIMART course into undergraduate programme come late when a lot of people have already died because of not receiving care from people who have relevant experience and qualification but something can still be done we cannot just folds’ hands.’ (Participant C)It is expensive to offer the NIMART course post-undergraduate qualification, as accommodation and meals have to be booked for a week for participants to attend. These nurses have to attend the training during the clinic working time leading to staff shortages and poor service delivery:‘If our students can be trained while they are still doing nursing, kere (am saying) it will be less expensive as compared to when they are trained while they are registered nurses. Number one this training takes a week if I am not mistaken and by that time accommodation and meals have to be booked for those professional nurses.’ (Participant B)‘Okay because we have shortage of staff and when for example 2 professional nurses for that particular week are on NIMART training it means patients will not be attended too … mortality and mobility rates increase due to shortage of staff.’ (Participant B)Participants shared few challenges that might hinder incorporation of NIMART course into undergraduate programme. The sub-themes below give emphasis to this main theme.Some participants in this study stated that the undergraduate nursing programme curriculum was overloaded:‘This new programme, the R171 there is too much content so I don’t know how will they be able to just incorporate it … in first year these students are doing maybe 5 system if I am talking about the biological science within a limited time.’ (Participant A)‘This R171 the new curriculum iyhooo! Is a headache on its own so maybe when we are already settled in terms of this new curriculum maybe yeah we can start introducing something else. The period has been cut off from 4 years to 3 years so accommodating something else I don’t think is going to be easy.’ (Participant G)The following was in support of a loaded curriculum:‘So it is a tedious process and I don’t think it will be something that will be done like tomorrow it will take a while given the fact that we are just starting with a new curriculum.’ (Participant I)Trustworthiness refers to the effort to signal openness, relevance, thoughtfulness in data collection and analysis, epistemology and methodological correspondence, including the researcher’s self-understanding about the findings  at an early stage, manage kidney failure, monitor patients’ viral loads and CD4 count and be able to provide pre- and post-counselling. Ngcobo and Mchunu :1, LekhuParticipants in this study stated the NIMART course incorporation in the undergraduate nursing programme would benefit the community by addressing the challenges they encounter to access HIV and/or AIDS healthcare services. There may be some elimination of communities’ financial problems in that they could access treatment at their nearby facility without the need for them to transfer to facilities where there is someone with NIMART skill. New graduate nurses will offer holistic care by applying the supermarket approach whereby the treating of HIV and AIDS, including other chronic conditions, will be on the same day in one consulting room. This finding is supported by Mngqibisa et al. :153 who Participants reported that NEI might have a market advantage for their student nurses’ post-graduation, because they will be NIMART trained compared to NEIs not offering it. Nursing education institutions will also receive positive feedback from the community for having trained, qualified and experienced nurse graduates who can offer HIV services at their facilities. Moreover, this study’s findings highlighted that many nurse educators within the NEI are interested and willing to study and incorporate the NIMART course within the undergraduate nursing programme. Ngcobo and Mchunu :9 agree Participants in this study accentuated the vital need for HIV and/or AIDS to be firstly recognised as a killer that is destroying our society. Given the adverse impact of HIV, participants indicated a need for the NIMART course to have its own NQF level, module hours and to have the recognition as a module on its own. In this study, participants explained that stakeholder collaboration among Department of Higher Education and Training (DHET), South African Qualification Authority (SAQA), SANC, NDoH and NEI’s is important to recognise HIV and AIDS management as a speciality. Similarly, Mboweni and Makhado :10 recomAccording to findings in this study, the NIMART course offered post-graduation leads to shortages of staff at the facilities; for example, when two professional nurses go for weeks of NIMART training, the facility becomes short staffed. Because of this shortage of staff PLWHA are left vulnerable and some return home without having ART initiated on the same day. This practise conflicts the NDoH’s (2021:20) guideline recommendations on initiating PLWHA same day on ART if there are no clinical contraindications. Another cost that emerged was that the NIMART course, when offered on completion of the undergraduate nursing programme, is more expensive than when in the undergraduate nursing programme, reason being that accommodation and meals have to be booked for weeks during the NIMART training and it is expensive. Jones and Cameroon :842 statFurthermore, the NIMART incorporation study came late, after many people had already died. Human immunodeficiency virus was first diagnosed in the 1980s; it is now 2022, and we are still talking about it, so this study is important. The study of Mboweni and Makhado :6 explaiIn this study, the participants explained that NIMART incorporation at undergraduate nursing programme was not feasible because of the current curriculum overload. According to the findings, the R171 programme already has too much course content. Participants also indicated that incorporating the NIMART course into the undergraduate nursing programme could require lot of time as it is going to be a tedious process and a headache. The other challenge was that with the new curriculum in place, there has been a reduction in the duration to complete the programme in colleges, from 4 to 3 years, which makes the content too much. Additionally, without stakeholder support to capacitate NEI equally, there will be a challenge to incorporate the NIMART course as the university employees are outdated with HIV and/or AIDS information and not invited to HIV conferences for capacitation. Jones and Cameron :841 alsoInitially, the targeted population were from a university with three campuses and a nursing college with two campuses. The limitations of this study were that in one university campus only one participant volunteered to take part in the study. Therefore, the researcher is of the opinion that findings could have been different had the participants from the other NEIs participated. Network challenges and electricity power outages restricted some participants from taking part in the interviews at agreed times. The study’s strength was its ability to conduct interviews remotely, thereby limiting the need to travel to participants for interviews.This study recommends that experts in NIMART should train nurse educators so that they are able to train the undergraduate nursing students for knowledge transfer. Nursing Education Institutions will also need a curriculum committee to plan the incorporation of NIMART into the undergraduate programme, including relevant credits.Apart from training nurse educators, participants also recommended there should be NIMART updated guidelines available on different technological platforms for easy access. The NIMART guideline will keep nurse educators up-to-date with relevant information to teach their students.Another recommendation was for access to medication to show the students during teaching and learning. Access to internet and computer devices such as laptop was recommended in this study for students to be able to search for information regarding the NIMART course. In addition, there is a need for continuous professional development in terms of HIV and/or AIDS training for nurse educators in order for them to remain updated with information and teach updated contemporary information.The SANC, NDoH, SAQA, NEIs and non-governmental research organisations, such as the Aurum Institute need to collaborate and give support to the NEIs on implementation of updated NIMART training and guidelines. This study also recommended that the NIMART course has the recognition as a module on its own by stakeholders.The ideal level for incorporating NIMART should be 2nd or 3rd year depending on whether the students have done anatomy, physiology, pharmacology, ethics and English modules for them to understand the concepts taught in NIMART course.The study recommends the conducting of similar research at different provinces with larger sample size. Also recommended is that quantitative and mixed method research be used to quantify the results in future. Additionally, research funders, such as National Research Foundation (NRF), NDoH and other sponsors, should consider the prioritisation of research studies focusing on NIMART course incorporation within the undergraduate nursing programme.This study concludes that incorporation of the NIMART course into the undergraduate nursing programme is a good idea, which could benefit the student nurses, the communities and the NEIs. Nurse educators endorse the NIMART course incorporation in that it will increase student knowledge and skills to manage PLWHA in healthcare facilities, including those in rural villages, and address patient financial challenges. When the NIMART course is incorporated, new graduate nurses will immediately render HIV management services among PLWHA and curb the shortage crisis of NIMART nurses within healthcare facilities. However, the incorporation of the NIMART course faces anticipated challenges, such as current nursing programme curriculum overload and lack of stakeholder buy-in. In addition, pre-requisites, such as human and non-human resources, are necessary for a successful incorporation.