Background: Chronic urticaria is a bothersome skin disease, and Chinese herbal medicine (CHM) is commonly used as adjuvant therapy. This study aimed to evaluate the effectiveness and safety of the mixture of two CHM formula, Xiao-Feng-San (XFS) and Qing-Shang-Fang-Feng-Tang (QSFFT), in treating urticaria through a randomized, double-blind, placebo-controlled clinical trial.Methods: 78 participants entered the screening phase between November 2012 and August 2015. Participants were randomly and equally allocated in either CHM group  or control group . Symptom improvement was set as the primary outcome, and the influence on sleep quality and changes in serum markers were used as secondary outcomes. Per protocol design was applied to the final analysis.Results: A total of 56 participants entered the final analysis stage. Participants in the CHM group had more prominent symptom relief on day 56 . In the CHM group, participants' symptom severity reduced progressively  while the decreasing trend was less favored in the control group . The life quality improved gradually in both groups, while the differences between CHM and control groups were statistically insignificant. For urticaria-related cytokines, interferon-γ seemed to decrease positively in the CHM group . For safety issue, the CHM prescription was well-tolerated with no noticeable long-term side effects when compared to the control group. At 6-month follow-up of symptom changes after the end of the trial, the CHM group participants reported positive results in no recurrence or ≥50% improvement .Conclusions: The combination of XFS and QSFFT tended to be feasible and tolerable adjuvant therapy for urticaria in addition to standard therapy. However, larger study population with longer follow-up duration may be still needed.Trial registration: NCT01715740 . Urticaria is one of the most prevalent dermatological diseases, which is diagnosed with clinical manifestations of severe itching and recurrent wheals with central pallor  becomes a possible option in addition to commonly used Western medication therapies. In the US, about 37% patients referred to the dermatology department of a tertiary care center have used at least one kind of herb supplement for their dermatologic problems  in Taiwan Figure . The subTo closely resemble the clinical setting in the real world, in which combining CHM and Western medicine therapy is favored, we try to examine the benefit of add-on CHM therapy for urticaria. After screening for symptom severity and completeness of informed consent, all enrolled participants were given levocetirizine 5 mg once daily with either CHM or placebo medication for the first 4 weeks and then levocetirizine 5 mg alone once daily for the following 4 weeks. The first 4 weeks were referred to as the treatment phase (for short-term effect), while the following 4 weeks were the follow-up phase (for long-term effect). Levocetirizine was chosen as the comparative and baseline therapy in this study because of the recommendation from the dermatologist and rheumatologist in our research team. A total of three in-person visits was arranged for each participant for 8 weeks with the following schedule: day 0 (baseline), day 28 (end of CHM/control medication), and day 56 . Two dates were also set to record symptom severity (days 7 and 35). Satisfaction surveillance through telephone contact was done for all participants 6 months after the trial finished. Outcome assessments were recorded using a self-assessed questionnaire, while blood samplings were done three times  for urticaria-related cytokine assessment, differential blood count, and biochemical profiles of the renal and liver functions. Any adverse events, medication compliances, and concomitant other medications, including Western medicine, folk medicine, and herbal medicine, were recorded routinely by project staff. Baseline characteristic data, such as gender, birthday, comorbidities, food/drug allergy, and history of urticaria, were acquired at the first visit (day 0).Randomization was done by a trial administrator who was not involved in the clinical intervention or evaluation using a computer-generated random sequence before medications were administered. The random sequences evenly distributed all participants to two study arms. Medication bottles with opaque and identical appearance were filled by the medication manufacturer and were then labeled according to the generated random sequences. The pharmacy of CGMH was then provided with these medication bottles in consecutive number randomized as active and placebo. The enrolled participants were then given their interventions with the sequential number on the medication bottles. The randomization and allocation processes were adequately concealed and stored in a security box. All doctors, pharmacists, project managers, statisticians, and participants in this research were blinded to the allocation sequence throughout the entire trial phase.The CHM used in this study was a mixture of two well-known classical formulas, XFS and QSFFT, and each formula was produced at the same time by the Chuang Song Zong Pharmaceutical Company, which is a licensed good manufactured practice pharmaceutical factory in Kaohsiung, Taiwan. On the TCM's viewpoint, XFS is regarded as the important CHM formula to dispel exterior wind and heat, and this makes XFS become one of the most commonly used CHM for allergic skin diseases  and the Dermatology Life Quality Index (DLQI), on every visit . Both questionnaires were commonly used for symptom assessment by clinicians and had been well-validated , and the statistic tests were processed using SPSS  with a per-protocol analysis. Any events that did not conform to the requirements of this trial design, such as missing data, poor medication compliance, and trial withdrawals, were reported in detail. In the case of missing values, the last value would be used. P < 0.05 or less than the p-value modified by the Bonferroni's method for multiple comparisons were thought to be statistically significant.Counts and percentage were used to present categorical data, while mean with standard deviation to describe numerical data. To compare the initial status and outcomes between the CHM and control groups, χA total of 78 volunteer candidates underwent screening between November 2012 and August 2015, and four were excluded because they did not sign the informed consent and did not want to participate in the trial even after a detailed explanation. In August 2015, this trial was terminated because of fund shortage even though the preset goal of 100 participants was not achieved. Subsequently, a total of 74 patients underwent randomization and were allocated to either the CHM group or control group. Figure The baseline characteristics of the CHM and control groups are summarized in Table p < 0.001) than in the control group (p = 0.056). An effective symptom relief could be found both in the CHM and control groups, and the symptom severity tended to be lower in the CHM group. The mean UAS7 in the CHM group was 22.80 at baseline and decreased to 13.2 at 28 days and 9.9 at 56 days. On the other hand, the mean score in the control group decreased from 22.1 at baseline to 14.7 at 28 days, and it slightly increased to 15.6 on 56 days. However, the differences in symptom severity between the CHM and control groups only achieved borderline significance when corrected by the Bonferroni's method (p = 0.038).Figure p < 0.001 for trend analysis). On day 28, about 50% improvement can be observed in both groups, while the improvement became slightly better in the CHM group . Besides, the downward trend of serum IFN-γ could be seen in the CHM group, and the differences between days 0 and 56 were larger in the CHM group  than in the control group .The changes in serum cytokines are summarized in Table p = 0.252). Although the incidence seemed higher in the CHM group (21.4%), the causal relations were not definite. No deaths, anaphylactic shock episodes, or other major imbalances in any system organ affected by adverse events were reported during the study period. Adverse events reported included sweating, constipation, chest tightness, dizziness, herpes zoster, common cold, and sneeze. Additionally, the evaluations on the liver and kidney function profiles were all within the normal range before and after the trials (data not shown).All adverse events during the study period were reported and well-followed-up Table . No signp = 0.054; Table As a subjective outcome, the 6-month follow-up satisfaction was also assessed by phone contact with 42 available participants: 22 in the CHM group and 20 in the control group. The higher 6-month response rate was found in the CHM group (36.4% vs. 20%) with “no recurrence” or “improvement ≥50%.” However, the difference between both groups had no statistical significance , which was calculated by effect size 0.57 (from the differences on day 56) with an α error of 0.0125 (corrected for four comparisons) and β error of 0.8 in 1:1 treatment-control design. Second, the CHM used in this study was premade concentrated powder, and we used only four important compounds to examine the composition of CHM instead of authenticating all its herbal ingredients. Although we did not have detailed data for each herbal ingredient, the four compounds were good enough to determine the composition of a CHM formula according to the regulation for producing CHM in Taiwan. Also, since these two formulas were premade and were the same as those used in clinical practice, the repeatability of the study results could be retained. Third, since this trial was conducted in a single medical center in Taiwan, the pathogenesis or management of chronic urticaria may be different from Western countries. Therefore, the generalizability of using XFS and QSFFT for chronic urticaria may be limited in the Chinese population, and an examination of the external validity is still needed.In clinical settings, CHM is one of the most commonly used adjuvant therapies to Western medicine in Taiwan, and this trial provides the proof that CHM therapy with XFS and QSFFT could be a potential adjuvant therapy to levocetirizine to control urticaria in a longer and better manner. Besides, the safety of CHM was also proven to be similar to levocetirizine alone and is well-tolerated. This work warrants further larger-scale clinical trials and also bench studies on XFS and QSFFT as the core and effective CHM treatments for managing urticaria.S-HY is the principal investigator of this project, and Y-HL cooperate with S-HY for study design, supervision on trial progress, and manuscript writing. J-RL and H-YC are both responsible for study design and statistics calculation. SH, Y-HaY, Y-HsY, Y-SY, and Y-FF are collaborators with this work for expert opinions and subject enrollment. All authors have read and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A gradually increasing prevalence of mild cognitive impairment (MCI) is recognized in the super-aging society that Japan faces, and early detection and intervention in community-dwellers with MCI are critical issues to prevent dementia. Although many previous studies have revealed MCI/non-MCI differences in older individuals, information on the prevalence and characteristics of MCI in rural older adults is limited. The aim of this study was to investigate differential characteristics between older adults with and without MCI. The investigation was conducted over one year from 2018 to 2019. Participants were recruited from Akita in northern Japan. Neuropsychological assessments were applied to classify MCI, including the National Center for Geriatrics and Gerontology Functional Assessment Tool (NCGG-FAT) and the Touch panel-type Dementia Assessment Scale (TDAS) based on the Alzheimer’s disease assessment scale. Our samples consisted of 103 older adults divided into 54 non-MCI and 49 MCI. The MCI group had lower scores of all cognitive items. Our results showed that individuals with MCI had significantly slower walking speed (WS) and worse geriatric depression scale (GDS) compared to non-MCI. In addition, WS was significantly associated with some cognitive items in non-MCI, but not in MCI. Finally, we showed that predictive variables of MCI were WS and GDS. Our study provides important information about MCI in rural community-dwellers. We suggest that older adults living in a super-aging society should receive lower limb training, and avoiding depression in older adults through interaction of community-dwellers may contribute to preventing the onset of MCI. Mild cognitive impairment (MCI) is a transitional state of cognition between normal ageing and dementia that may progress to dementia. MCI is defined by subjective or objective evidence of cognitive decline greater than expected for the individual’s age and education level but that does not interfere notably with activities of daily life, and the early detection and prevention of MCI are a challenge to prevent dementia in older adults . Within To clarify the dementia risk associated with MCI or early stage dementia, a nationwide clinical registry called the Organized Registration for the Assessment of dementia on Nationwide General consortium toward Effective treatment (ORANGE) is ongoing in Japan . The rect test [The participants were recruited in a rural area in Akita with a small population  with a super-aged rate of 38.7% according to public information, from 2018 to 2019. The inclusion criteria were age 65 years and over, having walking ability without personal assistance, and living at home. The exclusion criteria were dementia, major depression, severe hearing or visual impairment, stroke, Parkinson’s disease, other neurological disease, intellectual disability, need for support or care as certified by the Japanese public long-term care insurance system due to disability, and inability to complete cognitive tests at the baseline assessment. The study was approved by the ethics committee of the Faculty of Medicine, Akita University  and was performed in accordance with the Declaration of Helsinki II. Informed consent was obtained from all participants. According to sample size calculations using G*Power for unpaired t test , we estiAfter obtaining informed consent from each participant, demographics  and health variables (body mass index (BMI), medical history of hypertension and diabetes, frail phenotype, medication and Geriatric Depression Scale-15 (GDS)) were collected according to the ORANGE protocol. A questionnaire sent in advance by mail was self-described by each participant, including age, gender, educational duration, presence of hypertension and diabetes , amount of medications, and GDS . Height and weight to calculate BMI were measured by public health nurses. Five components of the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes (NCGG-SGS)  based on2 on the display. For this study, a trained operator supported each participant by setting up the tablet PC and running each test. Participants completed the NCGG-FAT subtests as follows.The computerized multidimensional neurocognitive test was performed on an iPad  with a 9.7-inch touch display. The task instructions were presented with a letter size of at least 1.0 × 1.0 cmThis test is comprised of two computerized tasks of immediate recognition and delayed recall. In the first task of immediate recognition, participants were instructed to memorize 10 words, each of which was displayed for 2 s on the tablet PC. After that, a total of 30 words including 10 target and 20 distracter words were shown to participants, and they were required to select the 10 target words immediately. This task was repeated for three trials. The average number of correct answers was recorded as a score ranging from 0 to 10. In another task, participants were asked to correctly recall the 10 target words after 20 min. The number of correctly recalled target words was scored ranging from 0 to 10. Finally, we calculated the sum score of the two tasks of immediate recognition and delayed recall.In the Trail Making Test Version A (TMT-A) task, participants were instructed to touch the target numbers in a sequence as rapidly as possible. Target numbers from 1 to 15 were randomly displayed on the tablet panel. In addition, the Trail Making Test Version B (TMT-B) instructions required participants to touch target numbers  and letters in turn. The required time (seconds) to complete each task was recorded, within a maximum time of 90 s.In the Symbol Digit Substitution Task (SDST), nine pairs of numbers and symbols were shown in the upper part of the tablet display. A target symbol was shown in the center of the tablet panel, and selectable numbers were displayed at the bottom. Participants were asked to touch the number corresponding to the target symbol shown in the central part of the tablet display as rapidly as possible. The number of correct numbers within 90 s was recorded.The TDAS test was presented on a 14-inch touch panel display. The TDAS subtests consisted of seven of the ADAS-cog test items (11 test items) and two other tasks. Participants were instructed verbally or visually by the computer to complete the TDAS subtests as follows.The WR test was a computerized test based on the WR task of ADAS-cog. At the start of instructions for this task, 12 target words were individually presented on the display for 3 s each at 2 s intervals. After demonstrating the target words, the computer randomly displayed 24 words consisting of 12 target words and 12 non-target words. Participants were then instructed to respond by touching the displayed button of ‘yes’, ‘no’, or ‘unknown’ in response to the question regarding whether the word had been shown previously. Participants completed the trial three times. The total number of incorrect responses for three trials was recorded, with a maximum score of 72.This task was modified from the command task of ADAS-cog. The computer presented 10 selectable icons labelled from 0 to 9 and then required participants to touch the number specified. The number of incorrect responses in two trials was scored with a maximum score of 2.This task was based on the orientation task of ADAS-cog. The computer displayed four screens in sequence. On each screen, participants were asked to touch selectable icons and answer what year, month, day, and weekday it is. The number of incorrect responses was scored with a maximum score of 4.This task was modified from the constructional praxis task of ADAS-cog to evaluate visual-spatial perception. ADAS-cog requires subjects to copy the geometric forms presented. The computer first presented four screens displaying a target geometric form  for 5 s each. Participants were then required to correctly select the target form in response to a question task including the target form and four non-target forms. The number of incorrect responses was scored with a maximum score of 4.This test assessed whether participants can name the fingers correctly, using the protocol of ADAS-cog. Participants were asked to correctly respond to a picture question of a hand marked with a red circle, by touching an icon labelled with the five finger names. An incorrect response was scored as one point, with a maximum score of 5.This task was based on the naming objects task of ADAS-cog. Participants were instructed to touch the correct usage icon  of five selectable icons labelled with the purpose of usage. Three trials were completed, and an incorrect response was scored as one point (maximum score = 3).This task was modified from the ideational praxis of ADAS-cog. The computer displayed seven icons labelled randomly with seven actions. Participants were asked to correctly touch the icons in order. The number of incorrect responses was recorded, with a maximum score of 5.This task assessed the money calculation ability of each participant. Participants needed to combine coins equal to an amount of money from various denominations of coins displayed on the screen. Three trials were completed, and an incorrect response was scored as one point (maximum score = 3).This task included three kinds of question regarding clock time recognition. Participants were instructed to correctly state the time shown on a clock displayed on the screen. The number of incorrect responses was recorded, with a maximum score of 3.According to Petersen’s report  in whicht test. Gender , Hypertension (% Yes), Diabetes (% Yes), Weight loss (% Yes), Poor energy (% Yes), and Low physical activity level (% Yes) were analyzed by chi-squared test for 2 × 2 contingency, except for Pearson’s chi-square test for Frail phenotype  for 2 × 3 contingency. Mann–Whitney test was applied for GS (kg), WS (m/s), Amount of medications (n), Education (years), GDS-15 (score), and cognitive measurements of NCGG-FAT and TDAS , Age, Height, Weight, and BMI were used by the unpaired and TDAS .As the variables of WS, GS, subtests of NCGG-FAT, TDAS, and GDS-15 total score were not statistically normalized from the Kolmogorov–Smirnov test, Spearman correlation analysis for interval scales was applied to analyze the relationship among Age, GS, WS, subtests of NCGG-FAT, TDAS, and GDS total score for each group .pin = 0.2 and pout = 0.25 were set up to select independent variables from p = 0.05.The values of p < 0.0001) (p = 0.03), whereas GS was not different (p = 0.25). Moreover, the MCI group showed a worse score of GDS (p = 0.046 < 0.05). Next, we examined correlations between physical performance, cognitive and mental function in each group (p < 0.01), but these were not significant in the MCI group except for correlations between cognitive items and Age or Education. Finally, we performed an analysis to determine explanatory variables for MCI with reference to non-MCI by binomial logistic regression analysis (p = 0.89), presence of Hypertension  and Diabetes , Weight loss , Poor energy , Low physical activity level  were not significantly associated with MCI classification, and they were not included into predictors for the regression model. Three regression models were estimated according to the predictors of Age, GS, WS, Amount of medications, Education, WR, TMT-A, B, SDST, TDAS, and GDS-15 total score. Model I that included them demonstrated that the classification of MCI had a significant association with Age, TMT-B, SDST, and TDAS. Next, Model II except for T-DAS score from Model I was applied to estimate a specific cognitive profile in MCI. Model II demonstrated that the classification of MCI had a significant association with Age, WR, TMT A, B, and GDS-15 total score. Finally, considering the self-explanatory effect of cognitive items, Model III except for all cognitive variables from Model II was applied to clarify the classification of MCI. As shown in Model III, WS and GDS-15 total score were extracted as explanatory variables of MCI (p = 0.12) in Model I, 84.5% (p = 0.84) in Model II, and 59.2% (p = 0.02) in Model III.Our samples consisted of 103 older participants divided into 54 non-MCI people and 49 MCI people. We confirmed that the MCI group had significantly lower scores or longer required times of all cognitive items including WR test, TMT-A, B, SDST and TDAS scores than the non-MCI group ( 0.0001) . Demograch group . Accordianalysis . Accordis of MCI . In the In this study, we found characteristics of MCI in northern Japanese community-dwellers of super-aging society had slower WS and tendency to depression. Aging continues in the subjects of our survey area, and the population ratio 65 years or older reached 38.7% . Actually, the prevalence of MCI in this study was higher (47.6%) compared with other rural areas which were previously reported to be about 10%–30% ,33. Addip = 0.25), suggesting that reinforcement of lower, but not upper, limb muscular strength may be a critical target in rehabilitation. Likewise, recent studies have indicated that lower extremity motor dysfunction may be a feature of MCI [Interestingly, in Model III excluding all cognitive domains, WS and GDS were selected as explanatory variables although the percentage of correct classifications was not so good in the Hosmer–Lameshow test. These findings indicate that the variables WS and GDS can potentially distinguish the presence or absence of MCI; therefore, they provide suggestive information on the presence of MCI. Recently, some studies have focused on both cognition and locomotor performance as predictors of adverse outcomes in community-dwellers with MCI ,45. In pe of MCI , but lite of MCI ,53. MCI e of MCI . In thise of MCI . Additioe of MCI . Thus, gn = 103) did not reach the calculated required sample size (n = 128) due to difficulty sampling and recruiting in a depopulated, small rural area. Third, considering younger age was associated with MCI, we could not take the association into consideration. Fourth, although focusing this study on frailty concept was important, we guessed it was difficult to analyze frail status in detail due to bias of frail samples between the groups . Further examination concerning frailty is warranted in future research. Finally, we hypothesize that cognitive domains, gait performance, and tendency to depression might be associated with MCI status. For the three regression models in this study, WS and GDS were selected as explanatory variables in Model III. However, further research with sufficient adaptability should be carried out with a large sample size in multiple rural districts. These limitations need to be considered when interpreting this study’s findings.The limitations of our research need to be considered in developing our future research. First, the NCGG-FAT and TDAS used to classify individuals with MCI in this study were a tablet PC version of cognitive measurement tools based on the MCI criteria reported by Petersen , and evaIn conclusion, WS and GDS were shown to be potential predictive variables of MCI in our study, and we consider they provide important information about characteristics of MCI in rural community-dwellers. It is suggested that older individuals living in a super-aging society should work on training lower limb muscular strength, and avoiding depression in older adults by interaction of community-dwellers may contribute to prevention of the onset of MCI.


Background and objectives: Burnout is a syndrome typically occurring in work environments with continuous and chronic stress. Physicians are at increased risk for burnout, as a result of 24-h work, delayed work–life balance gratification, and the challenges associated with patient care. The aim of the present study was to evaluate the psychological parameters of burnout symptoms in relation to biomarkers of stress among physicians with different medical specialties. Materials and methods: A total of 303 physicians were contacted as potential participants. A comparison group of 111 individuals working outside medicine was used as a control to verify the results. The physicians were specialists in internal medicine, general surgery, pathology, and primary care. Serum cortisol, salivary cortisol, adrenocorticotropic hormone (ACTH), insulin (IRI), and prolactin levels were analyzed by chemiluminescence enzyme immunoassay . Fasting glucose in serum and glycated hemoglobin (HbA1C) in whole blood were measured using the automatic analyzer AU 480 Beckman Coulter system. Symptoms of burnout were measured with the Maslach Burnout Inventory (MBI). Results: The group with burnout presented significantly higher levels of serum and saliva cortisol, ACTH, prolactin, fasting glucose, and HbA1C compared with the control group. The correlation analysis between biomarkers showed a positive correlation with moderate strength between serum and saliva cortisol ,as well as serum and saliva cortisol with ACTH  and HbA1C . A weak positive correlation was found between serum and saliva cortisol with prolactin  and glucose . In the multiple logistic regression model, saliva cortisol, HbA1C, and age were significantly associated with burnout . Conclusion: Our findings demonstrated the interest of exploring biomarkers of stress related to burnout in health professionals. Burnout is a state of physical and emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment caused by work-related stress. It is an outcome of chronic depletion of the individual’s coping resources resulting from prolonged exposure to stress, particularly work-related stress . A proloDue to inconsistent findings from literary searches on potential stress biomarkers in occupational burnout, different types of biomarkers were selected for this study to investigate their association with burnout. The aim of the present study was to investigate the relationship between serum levels of cortisol, adrenocorticotropic hormone (ACTH), prolactin, insulin (IRI), glucose, salivary cortisol, glycated hemoglobin (HbA1C) in whole blood, and burnout syndrome in physicians with different medical specialties. The main study hypothesis was that burnout in physicians is associated with significantly higher values of the stress biomarkers investigated.n = 112) or declined to participate (n = 74). Four hundred and fourteen people agreed to participate, and all their data were analyzed. A total of 303 physicians employed at the University Hospital St. George  were surveyed. They were selected personally and in a consecutive manner by a researcher after contact with all of the professionals working on the units. The physicians were specialists in internal medicine, general surgery, pathology, and primary care. A comparison group of 111 individuals working outside medicine was used as a control to verify the results. The control group participants were randomly selected when they were interviewed during routine laboratory investigations and met the criteria for inclusion in the survey after completing key demographic questionnaires. We invited 600 people to participate in the study, 186 of whom were excluded because they did not meet inclusion criteria ; inflammatory or immune diseases, cardiovascular disease, diabetes, rheumatic, peripheral blood disease, cancer, stroke, or metabolic or endocrinological abnormalities; BMI > 30 kg/mAll participants were given a document about the objectives and procedures of the study. The study was completely anonymous, and participants gave written informed consent. The study was conducted according to the principles of the Declaration of Helsinki, as revised in 2013,and was reviewed and approved by the Ethical Commission of the University of Plovdiv (P-244-1/22/02/2018).Symptoms of burnout were measured with the Maslach Burnout Inventory (MBI). This instrument is currently the most commonly used for evaluating burnout in healthcare professionals. The MBI consists of 22 elements, with scores based on the frequency of feelings related to the construction of exhaustion . The MBI’s three subscales were analyzed separately: Emotional exhaustion, depersonalization, and personal accomplishment. Mean values were calculated and subscales were categorized into “low,” “moderate,” and “high” degrees of burnout using the cut-off values suggested by Maslach [Serum cortisol levels, salivary cortisol, plasma ACTH, IRI, and prolactin levels were analyzed by the chemiluminescence enzyme immunoassay method. Measurements were taken with an automatic device . Fasting glucose in serum and HbA1C in whole blood were measured by hexokinase assay and turbidimetric immunoinhibition methods, respectively, using the automatic analyzer AU 480 (Beckman Coulter system).® with instructions on how to collect saliva and conserve samples correctly by chewing a cotton swab for 60 s and placing it in the Salivette®. Venous blood and salivary samples were taken in the morning between 6 and 8 a.m., following the basic rules of specimen collection, and stored at −20 °C until the time of the analysis, but for no longer than two months according to the manufacturer’s instructions.All participants were invited to the study on a voluntary basis. First, before the survey, the purpose of the research was clarified. The participants were instructed on how to fill in the questionnaires and informed that the survey was anonymous and would not have any influence on their work or personal life. Second, sociodemographic information was obtained by a researcher in order to determine whether they met the inclusion criteria. Third, participants signed the written informed consent form and completed the self-administered evaluation and all the abovementioned questionnaires. Fourth, participants were given Salivettep < 0.05. Quantitative variables were presented as mean and standard deviation (SD). Means were compared using a two-tailed t-test. Qualitative variables were presented as occurrence (n) and percentage (%). Column proportions were compared using a two-tailed z-tests. All tests were adjusted for all comparisons within a row of each innermost sub-table using the Bonferroni correction. Dependences between quantitative variables were checked using a Pearson correlation test. A multiple logistic regression model was made to identify predictive factors (independent variables) of burnout (dependent variables). A value of p < 0.05 for the Wald criterion was considered to denote regression coefficients significantly different from zero. The results are shown as odds ratios (Exp.) with 95% confidence intervals (95% CI) for EXP (B). The fit of the models was judged by the likelihood ratio test statistic.Statistical calculations were carried out using IBM SPSS Statistics (v.25.0) and significance was fixed at n = 143) of the physicians worked nightshifts under emergency conditions. The control group used (n = 111) was matched to the physicians by age, sex, and work experience.A description of the study population is detailed in n = 119) and all of the controls (n = 111) did not show symptoms of burnout. In the EE subscale, 28.4% of the physicians (n = 86) without burnout showed a high score, and 15.2% of physicians (n = 46) indicated a higher degree of burnout in the three subscales—high levels of emotional exhaustion and depersonalization with a low level of personal accomplishment. The distribution of physicians by specialties in terms of diagnosis of burnout is shown in a A diagnosis of burnout (yes/no) was assigned if respondents presented high levels in at least two subscales  or in three subscales based on the following scores: EE >27, DP >10, and PA <33. According to this, 39.3% of the physicians  and GPs (61.8%). Regarding depersonalization, 26.4% of the group reported a high score, with the highest percentage again among surgeons. As for personal accomplishment, the results were high in 76.9%, with the largest share among pathologists .p = 0.000). Participants aged over 45 years also showed significantly higher emotional exhaustion compared with those under 45 years of age. Gender affected only emotional exhaustion. More often, men (67.7%) were associated with high values of this symptom than women (53.1%). In multivariate analyses, however, inpatient work was associated with higher emotional exhaustion (93.4%) and depersonalization (43.7%) compared with outpatient-based physicians. Lower personal accomplishment was found among primary care physicians  and depersonalization (38.5%) compared with those working full time (ysicians .n = 86) who did not have burnout, but showed a high score on the subscale of emotional exhaustion, also demonstrated significantly higher values for most of these biomarkers compared with the control group  and burnout physicians. The burnout group presented significantly higher levels for serum and saliva cortisol, ACTH, prolactin, fasting glucose, and HbA1C. We found that some of the physicians , serum and saliva cortisol with ACTH and HbA1C, and fasting glucose levels and HbA1C. A weak positive correlation was found between serum and saliva cortisol with glucose and prolactin levels  and IRI due to the lack of statistically significant difference between the values of this biomarker in the control and the doctors with burnout  (p = 0.002). The model explained 91.0% (Nagelkerke R2) of the variance in exhaustion and classified correctly 98.1% of the cases. With the increase of age, salivary cortisol, and HbA1C, the probability of exhaustion increased.Multivariate logistic regression analysis was performed to identify predictive factors (independent variables) of burnout (dependent variable). From all possible predictive factors—biomarkers and demographics —in the logistic regression model, we excluded work experience due to the high correlation with age (= 0.823) . The logThe present study about burnout and its relationship with stress biomarkers among physicians with different medical specialties is the first large-scale survey in the country and the region. In the present data, 39% of the physicians did not show a high degree of burnout on any of the subscales, which was comparable to that among hospital physicians in Hamburg and Germany, as well as among European family doctors ,29. The In the present study, a higher percentage of physicians  exhibited high scores of EE and DP. In our opinion, the obtained results were connected with the place of employment and the nature of the job: 24-h work, nightshifts, emergency conditions, and inpatient-based physicians. Similar results were shown in a study among physiotherapists in Poland, where they observed the strongest emotional exhaustion and depersonalization among physical therapists employed in hospital unlike physiotherapists employed in health centers . Sex difWe considered that the higher levels of personal achievement among physicians in our study were due to the fact that the study was conducted in university hospitals, where the component “intellectual stimulation at work” is a determinant for personal accomplishment—opportunities for continuous qualification, training of students, and research. Consistently, in a study of Swiss physicians, lower exposure to continuing education was associated with a lower degree of personal accomplishment and a higher risk for depersonalization . In accordance with the purpose of the study, several biomarkers were tested for association with burnout. Our results showed that blood concentration of serum and saliva cortisol, ACTH, prolactin levels, fasting glucose, and HbA1C were significantly higher in burnout physicians compared with healthy controls. Literature searches show a lack of unequivocal conclusions about the association of occupational burnout with stress biomarkers. In a systematic review of 31 studies on 38 biomarkers and meta-analyses, the authors concluded that there are no potential biomarkers in burnout due largely to the incompatibility of the studies stemming from the differences in the methods used to characterize patients and controls to assess biomarkers and to control for confounders . FurtherThe present data in our study on the significant positive correlation between ACTH, cortisol levels, IRI, HbA1C, and glucose support the idea of generally hyperactive HPA axis regulation after stressor response. However, studies focused on the relationship between burnout syndrome and the hyper/hypoactivation reaction process of the HPA axis showed inconsistent results ,22,38,39Our results from regression the model to identify predictive factors of burnout showed that age, saliva cortisol, and blood concentration of HbA1C are significantly associated with burnout in physicians, and the predictive value of these biomarkers had the highest statistical significance in the scale of emotional exhaustion among burnout dimensions. Thus, our data confirmed the significant predictiveness of HbA1C in burnout found in the study by Metlaine et al. . Today, In conclusion, our results indicate that blood concentration of serum and saliva cortisol, ACTH, prolactin levels, fasting glucose, and HbA1C are significantly higher in burnout physicians compared with healthy controls, which corroborates this study’s hypothesis. The significant positive correlation between ACTH, cortisol levels, IRI, HbA1C, and glucose support the relationship between burnout and HPA axis activation. Our results focus on the predictive role of biomarkers, in particular, saliva cortisol and HbA1C, in burnout syndrome. The present data confirm that there are some psychological and physiological aspects related to stress in the medical profession. Indeed, they may be relevant for further research in order to implement prevention programs aimed at reducing the negative aspects of professional distress.


M: +2107 g; p < 0.05). M alone lowered albumin levels . This data on albumin was confirmed by within-group analysis . M and eAA seemed to lower the percentage of gynoid fat (p < 0.05) and android fat (p < 0.01). No significant changes in inflammation or strength were reported. A 4-week intervention with eAA plus M together may be effective in enhancing fat-free-mass compared to M and P but not versus eAA. M alone demonstrates a negative effect on albumin level.This study evaluated the effectiveness of a 4-week intervention of melatonin and essential aminoacid supplementation on body composition, protein metabolism, strength and inflammation in 159 elderly sarcopenic patients , assigned to four groups: isocaloric placebo , melatonin , essential amino acids  or eAA plus melatonin . Data from body composition ), strength (handgrip test) and biochemical parameters for the assessment of protein metabolism  and inflammation (CRP) were collected at baseline and after the 4-week intervention. Compared with P and M, supplementation with eAA plus M increased total fat-free mass (vs. P: +2190 g;  Sarcopenia is a progressive, insidious process characterized by the reduction of lean muscle mass , and is 2+-dependent and -independent contraction, mitochondrial polarity, neuromuscular function and oxidative stress  and post-[T2] measurement) for each group.The descriptive characteristics of the study population at baseline are shown in p < 0.01; vs. M: +2107 g p < 0.05 for EAAM and vs. P: +2618 g p < 0.05; vs. M: +2536 g p < 0.01 for eAA). M alone lowered albumin levels . In addition, the analysis showed lower gynoid fat in the eAA group vs. P . The between-group analysis (groups × treatment × time) revealed a p < 0.05 for albumin and for total fat-free mass (p < 0.01).As showed by the between-group analysis in p < 0.05) and in android fat in eAA . No significant changes in inflammation markers or muscle strength were reported.The intra-group analysis showed a reduction in gynoid fat in M . There was also an increase in fat-free mass in eAA , greater than in eAAM , while for strength and inflammation by PCR no significant changes were reported, even if eAA showed a major effect on strength compared with other treatments.Intra-group analysis for albumin levels confirmed the results obtained by within-group analysis  can worsen protein metabolism. The within-group analysis demonstrated that the intake of melatonin alone significantly lowered albumin levels.Moreover, another significant result of this study is that the presumed detrimental effect of melatonin on protein metabolism can be counteracted by supplementation with eAA.As demonstrated by the between-group analysis, compared with the placebo and with melatonin alone, supplementation with eAA plus M increased fat-free mass both versus P: +2190 g and versus M: +2107 g. In line with numerous recent studies ,29,30, wIt is important to emphasize that during the month of supplementation these subjects ate an adequate amount of protein  and that they probably did not eat adequate protein before admission to hospital because all patients lived at home. In addition, during hospitalization these subjects performed moderate physical activity that they did not do at home. Both aerobic and resistance-type exercise training have been shown to improve the rate of decline in muscle mass and strength with age . ProgresOur results are seemingly in contrast with the current literature, which considers melatonin supplementation, in addition to its well-known beneficial effects on sleep and jet lag ,39,40, tHowever, it has been demonstrated that melatonin exerts an inhibitory ,21 effecTherefore, if melatonin exerts an inhibitory ,21 effecWe consider this a very interesting hypothesis, although the main limitation of our study is that we did not assess insulin in sarcopenic patients, even if the free fat mass analyzed in our study, with the combination of M and eAA, was decreased, compared with eAA alone.Moreover, it is important to note that we decided to administer 1 gram of melatonin, the dosage permitted by Italian laws, which consider melatonin a supplement, and may therefore be an insufficient dosage to cause anti-inflammatory activity.Another limitation was the short time frame of the intervention.In addition, in this study we did not assay blood melatonin concentrations or first-morning-urine 6-sulfatoxymelatonin (aMT6s) levels at baseline or after the intervention, and we did not evaluate any antioxidant blood biomarkers nor any genetic analysis regarding the melatonin receptor 1B gene (MTNR1B).This study observed a higher level of dropout mainly in the fourth group. This is a major weakness of this study because we cannot perform a final analysis. Regardless, this data is important in the clinical setting because it demonstrates that the combination of melatonin and aminoacids can cause possible side effects.Finally, another limitation of our study is the use of routine parameters such as plasma albumin levels and muscle strength evaluated with handgrip, instead of using the gold standard for the evaluation of protein metabolism and muscle strength, such as labelled amino acid uptake or isokinetic muscle force. However, the reduction of circulating plasma albumin observed over time in the placebo group or in melatonin-treated patients is likely to be attributed to reduced liver synthesis and not to accelerated distribution from the intravascular space or increased degradation. The studied patients were in clinical and metabolic stability and performed physical activity according to a rehabilitation protocol. Moreover, the systemic inflammation level was marginal and was similar between all groups, with albumin reduction in the aAA group, which had a significant increase in baseline albuminemia. As for the redistribution of albumin between the various compartments of body fluids, patients had no sign of water retention (edema), being clinically and hemodynamically stable. Handgrip was chosen because of its easy use, even in elderly sarcopenic patients, and because it provides an indication of an individual’s overall strength. It also indicates nutritional status, physical function, and health status and it is predictive of mortality, hospital length of stay, and physical function .Finally, a possible explanation of the decrease seen in free fat mass with the combination of M and eAA, compared with eAA, is that exogenous melatonin produces pharmacological effects on pre- and postprandial intestinal motility and then increases satiety, as already demonstrated in rats .The action of melatonin corresponds to an inhibition of ISA and a reinforcement of the cyclic MMC pattern. One strong point is that we were able to assess the effects of melatonin supplementation separately from essential aminoacid supplementation.In conclusion, this preliminary study demonstrates that the intake of melatonin alone in sarcopenic elderly patients tends to worsen protein metabolism. However, this supposed detrimental effect of melatonin on protein metabolism can be counteracted by supplementation with eAAs. In fact, the association of melatonin with eAAs increased fat-free mass.Given the high number of elderly people who take melatonin for sleep/wake rhythm disorders, if these subjects are sarcopenic, we recommend caution in the intake of melatonin and advise supplementation with essential amino acids.New randomized trials in sarcopenic elderly subjects are needed to confirm the results of our study, and also evaluate the hormonal status , the genetic analysis regarding the melatonin receptor 1B gene (MTNR1B) and the gold standard evaluation of protein metabolism and muscle strength, such as labelled amino acid uptake or isokinetic muscle force of these subjects.


Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive disorders of steroid biosynthesis, in 95% of cases due to 21-hydroxylase deficiency. The resulting hormonal imbalances lead to increased 17-hydroxyprogesterone and androgens levels, at the expense of decreased concentrations of glucocorticoids and, in some cases, of mineralocorticoids. A variety of clinical presentations accompany a range of severities, which are described as different forms of CAH, and are the result of these hormonal imbalances. The incidence of CAH worldwide is approximately 1 in 15,000 live births, and is population-dependent; thus, its inclusion in neonatal screening tests is widely discussed. Diagnosis of CAH is based on the quantification of 17-hydroxyprogesterone, usually by immunoassay, which has low specificity and high false-positive rates, resulting in a relatively high demand for a second-tier confirmation test. We report a case of a newborn recognized as female at birth, but showing ambiguous genitalia and other CAH clinical features, including hypernatremia, in the first days of life. In addition to the classical assays, liquid chromatography–tandem mass spectrometry was used to determine the serum steroid profile, allowing for the accurate and simultaneous quantification of seven steroids in the same analysis. Such an application immediately revealed an alteration in the levels of specific steroids related to CAH, leading to an early intervention by hormone replacement therapy. Subsequently, the diagnosis of classic CAH due to 21-hydroxylase deficiency was further confirmed by molecular testing. Congenital adrenal hyperplasia (CAH), the most common adrenal gland disorder in newborns and children, is a group of autosomal recessive disorders characterized by inherited defects in steroid biosynthesis . The cauWe report the case of a newborn with ambiguous genitalia, who was transferred to the Neonatology Department in Chieti Hospital, Italy. Upon clinical examination, the patient had a small penis/hypertrophic clitoris, two small swellings as bifid scrotum/hypertrophy of the labia majora, a hypospadic urethra with pink mucosa, the absence of palpable testicles as well as vaginal orifice. The child was born from an unrelated marriage, at term, and from spontaneous delivery. The mother had never been exposed to any drugs or hormonal therapy during pregnancy, and had no signs of androgen excess. No family history of infertility, ambiguous genitalia, or unexplained neonatal death was reported. In the first days of life, because of the finding of hypernatremia in the course of physiological weight loss, an infusion of a 5% glucose solution was undertaken, until normalization of the sodium values. Serial electrolyte checks were carried out during the stay, but sodium has been shown to lower the normal limit in a single determination. Upon pelvic and abdominal ultrasound examination, the bladder and uterus were normal-sized for the age; the child reported two masses to the iliac region as ovarian draft, and even in the scrotum/labia, there seemed to be an appreciable gonad for a hemiscrotum (about 6 × 4 mm); no formations referable to testes were adequately assessable in the abdominal regions, and the adrenal lodges were not viewable.2/day (1.5 mg/day). Following this, a molecular test confirmed the suspicion of CAH, highlighting a genetic arrangement fully compatible with classic 21-hydroxylase deficiency. After a week of starting hydrocortisone therapy, thanks to the confirmation of a disease normally associated with a loss of salts, we were also able to start a mineralocorticoid replacement therapy .According to the endocrinologist and the pediatric surgeons, in-depth diagnostic investigations were performed as a result of the strong suspicion of classic CAH. The first laboratory tests showed an increase in adrenocorticotropic hormone (ACTH) levels of 250 ng/dL (n.v. 8.0–65.0), and a huge increase in the total testosterone levels of 22.2 ng/mL, 17-OHP levels >20 ng/mL (n.v. <2 ng/mL), renin levels (500 U/mL), and aldosterone levels of 96.4 ng/dL. Moreover, a progressive reduction in cortisol levels from 12.4 to 4.8 μg/dL on the first and eighteenth day of life, respectively, was observed. Given the urgent situation and considering the 17-OHP borderline values, pending the sex determination and the molecular diagnosis, we performed a serum steroid profile by LC–MS/MS. The typical serum steroid pattern, obtained by LC–MS/MS analysis, allowed us to start a replacement treatment with hydrocortisone on the twelfth day of life, at a dose of 10 mg/mContextually, a molecular investigation was also performed for sex determination.First, 100 µL of serum sample was extracted for steroid quantification by LC–MS/MS analysis, using the in vitro diagnostic reagent kit, CHS™ MSMS Steroids Kit . Details of the sample preparation and LC–MS/MS analysis are fully reported in the 2 > 0.992) for each steroid, as reported in Steroid quantification from the serum patient sample was performed using the calibrators and internal standards provided with the kit. In particular, the calibrators and the quality controls (QCs) consisted of charcoal stripped human serum spiked with seven increasing levels of each steroid analyte. The calibrators were prepared using the same procedure as the patient sample, including the addition of internal standards, as fully described in Genomic DNA was isolated from a buccal swab, using a BioRobot EZ1 instrument, according to the manufacturer’s protocol. A molecular analysis of 11 common mutations in the CYP21A2 gene  was carried out by a reverse-hybridization test strip-based assay , according to the manufacturer’s protocol . The anaThe chromosomal analysis of the patient showed a normal female karyotype . A molecular investigation was also performed for sex determination, showing the amplification of the ZFXY marker on both the X chromosomes and the lack of amplification of the SRY gene and the other Y markers. In this way, we excluded the XX male syndrome.As highlighted in the present case, a newborn with ambiguous genitalia is a clinical emergency, and requires appropriate investigations to be conducted quickly, as a correct diagnosis followed by early treatment is crucial in this inborn error of steroid biosynthesis . It is wIn summary, we describe a case of a newborn having ambiguous genitalia and other CAH clinical features, including hypernatremia, in the first days of life. Given the urgent situation, pending the sex determination, a first rapid confirmation of 21-OHD was possible through a biochemical approach by serum steroid profiling in LC–MS/MS. The typical steroid pattern highlighted was crucial for starting early hormone replacement treatment on just the twelfth day of life, and it was also informative for the final confirmation by molecular genetic testing. We believe that the LC–MS/MS method, requiring only a small serum volume and minimal sample preparation, is well suited to become a second-tier test for CAH suspicion. Furthermore, to become a routinely clinical practice, staff highly specialized in MS is strongly recommended. Interestingly, the described approach would avoid expensive and numerous investigations, sparing a patient’s family the anxiety associated with the long wait for diagnostic confirmation.


This study aimed to investigate whether people scoring higher (compared to lower) on sensory-processing sensitivity respond differently to the work environment. Specifically, based on the literature on sensory-processing sensitivity and the Job Demands-Resources model, we predicted that the three components of sensory-processing sensitivity  amplify the relationship between job demands  and emotional exhaustion as well as the relationship between job resources  and helping behaviour. Survey data from 1019 Belgian employees were analysed using structural equation modelling analysis. The results showed that ease of excitation and low sensory threshold amplified the relationship between job demands and emotional exhaustion. Low sensory threshold also strengthened the job resources–helping behaviour relationship. This study offered first evidence on the greater susceptibility among highly sensitive persons to the work environment and demonstrated that the moderating role might differ for the three components of sensory-processing sensitivity. Additionally, it adds sensory-processing sensitivity to the Job Demands-Resources model and highlights the idea that personal factors may act both as a personal vulnerability factor and a personal resource, depending on the nature of the perceived work environment. Sensory-processing sensitivity (SPS)—a trait characterised by being more sensitive to the environment—has been identified in more than 100 species ), as welSPS has been linked to the phenomenon of differential susceptibility , 11: peodemands  and emotional exhaustion (i.e. moderator of the energetic process). In addition, we hypothesise that SPS acts as a personal resource that strengthens the relationship between job resources  and proactive work behaviours such as helping one’s colleagues.To study this, we turn to the Job Demands-Resources model  offThe current study contributes to the literature in several ways. First, this study goes beyond the evidence on the main effects of SPS presented by Evers, Rasche  and Lombsensory-processing sensitivity (SPS) and presented the Highly Sensitive Person Scale enabling scholars to scientifically measure SPS. Since then, this trait has attracted renewed interest. SPS is characterised by “involving deeper processing of stimuli across a very wide variety of situations, supported by a great response to both positive and negative stimuli that motivates learning and thus leads to more successful responses in future similar situations”  refers to becoming mentally overwhelmed by external  and internal demands . The second dimension, aesthetic sensitivity (AES), is characterised by an elevated awareness of aesthetic things such as art and music, subtleties and having a rich, complex inner life. Finally, low sensory threshold (LST) refers to an unpleasant sensory arousal to external stimuli; that is, being more easily overwhelmed by intense stimuli such as bright lights, strong smells, coarse fabrics or loud noises. Previous studies have identified specific patterns of associations for these components of SPS: while especially EOE and LST seem to relate to health complaints, AES is particularly related to outcomes that may be beneficial in social interactions and enhancing one’s complex inner life [Whereas Aron and Aron  presentener life . For insner life  found thner life  found thdifferential susceptibility [People with different levels of SPS may thus differ in the way they respond to both stressful and beneficial work environments in terms of health and well-being. In this respect, scholars have referred to the phenomenon of tibility , 11. Peotibility . Belsky tibility  particultibility . Aron, Atibility , for instibility  found thIn the specific context of work stress, SPS may offer an explanation as to why certain employees react more strongly to both negative and positive work environments. It is therefore rather surprising that so little research has focused on the role of SPS in employees’ work experience. We are aware of only two studies on SPS in the work context , 8, bothThe JD-R model , 13 divienergetic or health impairment process, job demands may consume employees’ mental and physical resources, leading to energy depletion or burnout  and satisfy the basic psychological needs of autonomy, belongingness and competence  . This mt . Second) e.g., , 22). Th. Thenerg) —also labelled as personal demands—into the JD-R model has been presented as a path for further research [When integrating personal factors into the JD-R model, scholars have mainly focused on positive factors or personal resources, overlooking the role of negative personal factors. research , 27. Perresearch ). They mresearch ).We want to draw on these theoretical principles of the JD-R model to formulate predictions on the interaction between SPS and the work environment in predicting employee reactions , ratherIn this study, we aim to investigate the assumption that people with higher and lower SPS develop a differential susceptibility for the work environment characterised by job demands and resources. By integrating the literature on SPS , 10 and Although we are not aware of previous studies investigating the amplifying role of SPS in the relationships of the JD-R model, indirect evidence comes from a study on another person-related factor both acting as a vulnerability factor and a personal resource. Lu, Lin  found thHypothesis 1: SPS moderates the relationship between job demands and emotional exhaustion, so that this relationship is stronger among employees scoring higher on SPS.Hypothesis 2: SPS moderates the relationship between job resources and helping behaviour, so that this relationship is stronger among employees scoring higher on SPS.To assess whether each SPS component  can account for the amplifying role of SPS in the relationships of the JD-R model, we investigate the hypotheses for each component separately .Data were collected between January 2014 and March 2015 among 2495 employees of nine organisations in Belgium. They were invited by IDEWE  to participate in an assessment of psychosocial risks at their workplace. In total, 1411 employees filled out the questionnaire (response of 56.6%). We deleted all respondents with missing values on at least one of the study variables (see further under Measures), which resulted in a final sample of 1019 employees.SD = 12.36). Next, the majority of the respondents (71.6%) had obtained a higher degree (Bachelor or Master), and 15.1% had a supervisory position (based on information from 1005 respondents). Furthermore, 70.3% of the respondents worked on a full-time basis (information about full-time versus part-time employment was available for 916 employees). Finally, seven of the nine organisations, comprising 766 respondents (75.2%), were private (rather than public) organisations. Three organisations were active in industry ; two in the service sector ; two in healthcare ; one in education ; and one was active in both healthcare and education .In this final sample, 67.6% were female and 59.7% were younger than 45 years old . The average tenure in the current position was 18.46 years  OG117 and was carried out according to the Belgian and international privacy and ethical legislation, allowing posthoc analyses of anonymised data obtained during occupational health surveillance and risk analysis. never) to 5  always). Cronbach’s alpha coefficients were .86, .87, .76 and .78 for workload, emotional demands, task autonomy and social support, respectively.Workload, emotional demands and social support were measured using scales from the Short Inventory to Monitor Psychosocial Hazards (SIMPH) of Notelaers, De Witte . The fornever) to 7 (daily). This scale had a Cronbach’s alpha coefficient of .90. Helping behaviour was measured by the seven-item subscale by Podsakoff [ never) to 5  always). After deleting one item (based on the results of the CFAs: see below), the Cronbach’s alpha coefficient was .78.Emotional exhaustion was measured with the five-item subscale of the Utrecht Burnout Scale (UBOS-A) by Schaufeli and Van Dierendonck . An itemodsakoff  (e.g. “HSensory-processing sensitivity (SPS) was measured with 23 items from the Highly Sensitive Person Scale by Aron and Aron [entirely disagree) to 5 (entirely agree). Cronbach’s alpha coefficients for the final EOE, AES and LST scales were .80, .69 and .66, respectively (after deleting certain items based on the CFAs: see below).and Aron . The seland Aron . Again, and Aron , namely st to 6th grade, 2 = first level of secondary education; 7th to 9th grade, 3 = second level of secondary education; starting from 10th grade, 4 = Bachelor degree, 5 = Master degree) and sector  were used as covariates. Hypotheses were tested with and without controlling for these covariates. As both types of analyses led to the same conclusions, but including covariates came at the cost of the parsimoniousness and the fit of the model, we will only describe the results from the analyses without covariates.Gender , occupational tenure (years), education  by means of MPlus 7.11 . First, Second, several structural models were tested and compared. In a first step, we tested a main effect model with structural paths from job demands and the three dimensions of SPS to emotional exhaustion, and from job resources and the three dimensions of SPS to helping behaviour. In this model, we also controlled for the cross-paths from job demands to helping behaviour and from job resources to emotional exhaustion. The latent factors job demands and job resources were allowed to co-vary, as were the three dimensions of SPS. In a second step, we added one of each of the interactions  to the main effect model. The interactions were tested in separate models, as we estimated interactions between latent factors (a highly intensive estimation procedure).Chi2 or the −2LL difference test.Model fit was evaluated based on the Comparative Fit Index (CFI), the Non-Normed Fit Index (NNFI), the Root Mean Square Error of Approximation (RMSEA) and the Standardised Root Mean square Residual (SRMR). Values of CFI and NNFI equal to or larger than .90, and values of RMSEA and SRMR from .08 and .10, respectively, indicate a good fit. Nested models were compared using the Before testing the hypotheses, we carefully inspected our measurement model based on a series of CFAs, as summarised in Chi2(6) = 182.48, p < .001), (2) a six-factor model in which the items of the emotional exhaustion and helping behaviour scales loaded on a general outcome factor (ΔChi2(6) = 1298.88, p < .001), (3) a five-factor model with a general SPS factor (ΔChi2(11) = 750.78, p < .001), and (4) a one-factor model (ΔChi2(21) = 4177.09, p < .001). These results thus demonstrate the expected dimensionality of the study variables.Furthermore, the final reduced hypothesised measurement model was compared and showed a better fit than four alternative measurement models . Second, a similar result was found for LST: LST amplified the relationship between job demands and emotional exhaustion, meaning that job demands were more strongly related to emotional exhaustion among persons scoring higher on LST  .In addition, we added single interaction terms to the main effect model (see lower part of  < .001) . FinallyThe aim of this study was to investigate the principle of differential susceptibility to cues in the work environment , 11 of pnegative external cues (e.g. job demands), which might explain why we only found evidence for an amplifying effect of the job demands–emotional exhaustion relationship for these components and not for AES. Although we offered initial evidence in the work context, our results align with previous findings [We found support for three out of six moderation effects. First, the amplifying effect of EOE and LST in the positive relationship between job demands and emotional exhaustion demonstrates that these components of SPS can be considered as personal vulnerability factors. In work situations with greater job demands , employees scoring higher on EOE and LST experienced more emotional exhaustion, compared to employees scoring lower on EOE and LST. The idea that SPS can be considered as a strain-enhancing factor is not new and dominates the majority of previous studies on this topic . Highlyfindings . Aron, Afindings , for insawareness of environmental subtleties and this might explain why we found LST to amplify the relationship between job resources and helping behaviour. Only a few previous studies have focused on the moderating effect of SPS on the relationship between positive environmental stimuli and prosocial behaviour , employees scoring higher (in comparison with lower) on LST expressed more helping behaviour. Under optimal conditions (e.g. work situations with many job resources), highly sensitive persons may not be as preoccupied with processing sensory information and may fully respond to these supporting and enriching experiences, to which they are more susceptible . Their gr . Futureand a personal resource, we proceed with a highly innovative, but more nuanced avenue in the research on the JD-R model .r < .50; [r = .85; [Although not the focus of this study, we also examined direct relationships between the SPS components and emotional exhaustion and helping behaviour when calculating bivariate correlations and when testing our SEM models. The results of both types of analyses differed, however. The correlations showed that all three SPS components related positively to emotional exhaustion, and that AES and LST were positively associated with helping behaviour see . Followir < .50; ), demonsr = .85; ) might nAs in any other study, our present study yields several limitations and leads for the future that need to be addressed. First, we relied on self-reports for all study variables. Consequently, our findings could have been influenced by common method bias. However, as common method variance rather deflates than inflates interaction effects, we do not expect our conclusions regarding the hypotheses to be significantly impacted by this method bias . FurtherSecond, our study showed a rather low internal consistency for AES and LST and required that many items were omitted from the SPS subscales to improve model fit. In all, this indicates that the psychometric properties of the three subscales of the Highly Sensitive Person Scale are questionable. Notably, whereas our study was conducted among adults, most studies on the psychometric properties of the Highly Sensitive Person Scale were performed in adolescents and young adults . More reThird, we relied on cross-sectional data and any conclusion regarding causality should be handled with care. As such, building our study around the well-established JD-R model—which has been extensively tested and validated with longitudinal designs—contains a particular strength of the current study. Future studies could, however, investigate our hypothesis using multiple waves, allowing for a growing insight into the exact role of SPS in the work context, also over time.Our research further substantiated the results from an abundance of studies on the JD-R model , 13 demoAdditionally, our findings underscore that, while stress prevention and well-being promotion is beneficial for all employees, this may be particularly so for employees scoring high on SPS. Specifically, we found that EOE and LST amplified the positive relationship between job demands and emotional exhaustion. Consequently, especially for high SPS employees, a decrease in job demands will be associated with lower levels of exhaustion and thus higher well-being. Alternatively, we found that LST amplified the positive job resources–helping behaviour relationship. This suggests that higher levels of job resources relate to higher levels of helping behaviour at work, particularly for employees scoring high on SPS. As such, a well thought-out prevention programme following the JD-R model’s premises on job resources raises the added value of having high SPS employees in the organisation as these employees in particular will contribute to positive well-being and to desired helping behaviour.Overall, the results of this study suggest that—depending on the nature of the work environment in terms of job demands–resources—SPS can be conceived as a personal vulnerability factor and a personal resource that boosts the energetic and motivational process, as outlined in the JD-R model. While EOE and LST were found to amplify the relationship between job demands  and emotional exhaustion, only LST amplified the relationship between job resources  and helping behaviour. This study expands our knowledge by providing evidence of the phenomenon of differential susceptibility of highly sensitive persons to their work environment, and contributes to the JD-R model by adding SPS as a new moderating trait or person-related variable to the model.S1 DataData set, including raw data on the study measures, that was used to conduct the Confirmatory Factor Analyses and the Structural Equation Modelling analyses.(CSV)Click here for additional data file.


Suaeda salsa, the number of flowers and seeds, seed size, anther development, ion content, and flower transcript profiles, as well as the relative expression levels of genes involved in ion transport, were analyzed in S. salsa plants treated with 0 or 200 mM NaCl. The seed size, flower number, seed number per leaf axil, and anther fertility were all significantly increased by 200 mM NaCl treatment. The Na+ and Cl− contents in the leaves, stems, and pollen of NaCl-treated plants were all markedly higher, and the K+ content in the leaves and stems was significantly lower, than those in untreated control plants. By contrast, the K+ content in pollen grains did not decrease, but rather increased, upon NaCl treatment. Genes related to Na+, K+ and, Cl− transport, such as SOS1, KEA, AKT1, NHX1, and CHX, showed increased expression in the flowers of NaCl-treated plants. These results suggest that ionic homeostasis in reproductive organs, especially in pollen grains under salt-treated conditions, involves increased expression of ion transport-related genes.Halophytes are adapted to saline environments and demonstrate optimal reproductive growth under high salinity. To gain insight into the salt tolerance mechanism and effects of salinity in the halophyte  In rice (Oryza sativa), however, the seed yield decreases under salinity have been found to be caused by the reduction of pollen fertility, and to be directly attributable to toxic ion accumulation in plants (Vitis vinifera), salinity negatively affects fruit set and is associated with poor pollen tube growth in the style (Triticum aestivum)   and reduestivum) . Howevered seeds . In the itiation .Suaeda salsa is an annual herbaceous euhalophyte that grows in saline soil environments  family of proteins in vacuolar membranes plays an important role in sequestering Na+ or K+ into the vacuoles in plant cells under salt treatment   . The hignt cells . For exan tomato . There an tomato . HoweverS. salsa. For this purpose, we subjected S. salsa plants to either control or optimum concentrations of NaCl  in the sand medium from the time of sowing, and then monitored the plants throughout their growth period. We investigated reproductive parameters such as flower number, seed size, anther development, and ion content in leaves, stems, and pollen. We also analyzed the transcriptomes of S. salsa flowers from control and NaCl-treated plants using high-throughput Illumina RNA sequencing (RNA-seq). We then annotated the S. salsa reads against five protein and protein function databases and identified differentially expressed genes (DEGs) between the control and NaCl-treated groups. Next, we quantified the relative expression levels of genes involved in ionic homeostasis in flowers from control and NaCl-treated S. salsa plants using quantitative real-time PCR (qPCR). Our findings provide insight into the relationship between salt-tolerance traits and the reproductive development processes of halophytes, and thus may help to identify key factors specific to halophytes that are responsible for the changes in reproductive growth and seed set under saline conditions.The overall aim of this study was to identify which reproductive stages are markedly affected by NaCl and which genes are involved in reproductive processes in Suaeda salsa seeds were collected from the Yellow River Delta  in Shandong, a central-eastern province of China, in 2016. The location is the same as that described by Salt solutions were applied to the sand in which the seeds were sown, until seed maturity, as described by Vegetative growth and the beginning of flowering were observed and recorded. At the end of vegetative growth [100 days after sowing (DAS)], the plant height and number of primary branches in each pot were measured. The aboveground parts of the plants (one seedling in each pot) were harvested from each of six replicate pots and washed with distilled water. Immediately after a quick drying using filter paper, the fresh weight (FW) of plant material was determined. Then the fresh material was dried in an oven  and the dry weight (DW) was measured.S. salsa. During the flowering period, the flowers on the branchlets and leaf axils at the same position  from plants in the two treatment groups were counted, and the inflorescence diameter and flower diameter in each leaf axil were determined. Additionally, the seeds were hand-harvested for each individual plant at maturity and the seed size assessed.There is one inflorescence in each leaf axil in S. salsa from the control and 200 mM NaCl treatment groups, flowers beginning to open were selected randomly, and the development of anthers before flower opening was observed under a stereoscope  and photographed until anther dehiscence. The total percentage of anther abortion was calculated as follows: [(number of aborted anthers)/total number of observed anthers] × 100%.To assess the anther development of S. salsa treatment groups were collected for subsequent ion analysis. The collected materials were oven-dried as described previously and then used for ion determination. Twenty milligrams of oven-dried samples were cut into small pieces and extracted in a boiling water bath with 5 mL ultrapure water  for 10 h; subsequently, the solution was filtered and the final volume adjusted to 10 mL with more ultrapure water, and used for ion determination. The concentrations of Na+, K+, and Cl− in dilutions of the extracts  were determined by ion chromatography, using a DIONEXICS-1100 instrument .At 95 DAS, the young leaves and corresponding stems of branches at the same position of plants from the two S. salsa treatment groups were collected from 9:00 to 11:00 AM, and dried as described above. After the weight of samples measured, 0.1 g for each replicate was extracted in a boiling water bath with 5 mL ultrapure water  for 10 h. Subsequently, the solution was filtered and the final volume adjusted to 10 mL with more ultrapure water, and used for ion determination. The concentrations of Na+, K+, and Cl− extracts (using a dilution factor of 3) were determined by ion chromatography .At 145 DAS (at the full-blossom period), pollen grains from the two S. salsa plants, numbered from the bottom, raised under four different conditions—0 mM NaCl (control), 200 mM NaCl, and two groups whose treatment was switched from 0 to 200 mM NaCl or vice versa at 104 DAS—were collected and then the flowers and seeds were observed and counted under a stereoscope . The data included the flower number and seed number in each leaf axil from control and NaCl-treated plants, and the plants of the treatment conversion groups.To determine the effect of NaCl on the development of inflorescences from the leaf axils, we analyzed the flower and seed numbers in each leaf axil. The branches at the same position of S. salsa flowers using a Total Plant RNA Extraction Kit  according to the manufacturer’s protocols, and the RNA integrity was assessed using the RNA Nano 6000 Assay Kit with the 2100 Agilent Bioanalyzer system . Total RNA and mRNA concentration were measured with a Qubit 2.0 Fluorometer  using a Qubit RNA Assay Kit.Flowers at an early developmental stage (before meiosis during anther development) were collected from control and NaCl-treated plants and were used for sequencing analysis. Three biological replicates of both the control and treated plants were used for RNA-seq. Total RNA was extracted from TM RNA Library Prep Kit for Illumina  following the manufacturer’s recommendations and index codes were added to attribute sequences to each sample. Briefly, mRNA was purified from total RNA using poly-T oligo-attached magnetic beads. Fragmentation was carried out using divalent cations under elevated temperature in NEBNext First Strand Synthesis Reaction Buffer (5×). First-strand cDNA was synthesized using random hexamer primer and M-MuLV Reverse Transcriptase (RNase H−). Second-strand cDNA synthesis was subsequently performed using DNA Polymerase I and RNase H.Sequencing libraries were generated using the NEBNext UltraSequencing was performed on a cBot Cluster Generation System using a TruSeq PE Cluster Kit v3-cBot-HS (Illumina) according to the manufacturer’s instructions. After cluster generation, the library preparations were sequenced on an Illumina Hiseq platform and paired-end reads were generated.De novo transcriptome assembly was performed using paired end reads that had passed the quality control test using Trinity  database | > 2 was set as the threshold to judge the significance of gene expression differences.Genes showing significantly different expression (DEGs) between the flowers of −ΔΔCT method  was performed. Primers for qPCR of these genes were designed using Beacon Designer software (version 7.0) according to the cloned sequences . The actT method . Three bThe vegetative and reproductive growth assessments were performed randomly with six replicate plants, and the RNA-seq and qPCR analyses were performed with three replicates; the results are presented as means ± standard deviation (SD). The values were analyzed using SPSS (version 17) and one-way ANOVA statistical software packages. Different letters indicate significant differences among the means at the level of 0.05 according to Duncan’s test.S. salsa cultured with 0 mM (control) and 200 mM NaCl. We found that the 200 mM NaCl treatment did not inhibit S. salsa growth; on the contrary, this treatment significantly increased the FW, dry weight, plant height, and primary branch number of S. salsa, by 67.6, 40.7, 13.3, and 12.3%, respectively, compared with the control plants (At the end of vegetative growth (100 DAS), we determined the growth parameters of l plants .S. salsa seeds of the control and NaCl-treated plants, we hand-harvested the seeds from the individual plants at maturity and assessed their size. As reported in a previous study  on each plant, and the latter germinates faster and has more salt resistance than the former . That is, the original control plants were switched to NaCl treatment , and the plants originally treated with 200 mM NaCl were switched to the control treatment .To evaluate which stages of the reproductive process of S. salsa, but not in the absence or removal of NaCl.We then analyzed the flower and seed numbers of leaf axils from the branches at the same position of plants from the four different treatment groups. Compared with the controls, the plants that received the 200 mM NaCl treatment throughout showed a significant increase in leaf axil flower number and seed number: 138.9 and 224.4% those of the control, respectively. The leaf axil flower number was 109.2 and 122.6% of the control in the 200→0 and 0→200 groups, respectively—higher than for the control but lower than for the 200 mM NaCl treatment group . These rS. salsa seeds, we determined the numbers of black and brown seeds in flowers growing in the leaf axils  decrease in K+ content in leaves (20.52% reduction) and a smaller reduction in the stems (8.10%) was observed at the end of the vegetative growth stage of S. salsa treated with NaCl (+ content in the pollen was observably higher (1.48-fold) than that in the control , as well as ion transporters in the membrane. S. salsa flowers encoding proteins involved in ion transport, which include cation/H+ exchangers, chloride transporters, potassium transporters, H+-ATPases, and H+-pyrophosphatases. Genes encoding cation/H+ exchangers were significantly upregulated in S. salsa flowers when the plants were treated with NaCl. Five cation/H+ exchanger genes as well as a gene encoding an Na+/H+ antiporter in the plasma membrane (SOS1) were expressed threefold or more in the flowers of S. salsa treated with NaCl. Furthermore, the expression of genes encoding Cl− channels and carriers, such as ICln and CLC, was also increased by NaCl treatment. On the other hand, the expression of the genes encoding proteins involved in K+ uptake, such as KEA and AKT, was also increased many-fold by NaCl treatment. Furthermore, genes encoding H+-transporting ATPases (in the plasma membrane and tonoplast) and H+-pyrophosphatases (in the tonoplast), which provide energy for ion transport, were all significantly upregulated in the flowers of S. salsa plants treated with NaCl.Ion homeostasis and pH homeostasis of plants is considered to be critical for plant growth and survival in a saline environment. These processes require the proton-motive force (PMF) , PM-H+-ATPase (AHA4), and V-H+-PPase (AVP1) showed very high relative expression levels in the flowers of NaCl-treated plants   and Cl− channels (SsICln and SsCLC) were also significantly upregulated in flowers subjected to NaCl treatment, with expression levels 8.7, 8.9, 9.7, 4.9, and 3.6 times those in control plants, respectively  . Genes eectively .S. salsa is positively affected by salt treatment, as this plant displayed enhanced growth in the presence of 200 mM NaCl , and control switched to NaCl (0→200 group). The number of flowers in leaf axils in the 0→200 group was significantly increased compared with control and 200→0  of S. salsa requires a certain concentration of external NaCl. By contrast, the reproductive growth of non-halophytes is greatly limited by NaCl  and a lower number of ORF representations  were obtained in the transcriptome of S. salsa. Perhaps, the high number of duplicated BUSCO coverage (50.1%) suggested the possibility of that S. salsa is a polyploidy, just like in quinoa, which is in the same Caryophyllales , for example, K+ deficiency results in a lower efficiency of seed set due to reduced carbohydrate and ATP contents in the K-deficient pistils , which is preferentially expressed in flowers and participates in ion homeostasis in the flowers  is essential for nutrition, stress resistance, and ion homeostasis, and the results of the present study are consistent with data from Arabidopsis indicating that CLC is required for anion homeostasis and pH adjustment  and tonoplast (V-ATPases), as well as H+-pyrophosphatases such as AVP1 (+ pumping creates a transient hyperpolarization (−250 mV) and tends to depolarize the membrane potential to −155 mV, thus forming the PMF and providing electrical energy for ion transport  from the halophyte Lobularia maritima  in Arabidopsis, types I and II, and the type II enzymes (AtVHP2s) are abundant in flowers (+-ATPase (in the plasma membrane and tonoplast) and H+-pyrophosphatase genes revealed a significant increase in their relative expression levels in flowers from NaCl-treated versus control plants , that in the reproductive organs was lower, but still higher than that in the control plants. The NaCl treatment did not decrease the K+ content in the pistils significantly, and it increased the K+ content in pollen grains. The higher K+ content in the reproductive cells may have resulted from specific higher expression of K+ transporter genes  in the flowers of NaCl-treated plants. The ionic homeostasis and the high K+/Na+ ratio in the reproductive organs and pollen of S. salsa treated with NaCl comprise a specific mechanism that enables S. salsa to maintain better growth conditions for reproduction than it could without the extra NaCl. Ion homeostasis could have been achieved by the increased expression in the flowers of genes, such as SsSOS1, SsAKT1, SsKEA3, SsCLC, SsNHX1, SsCHX13, and SsCHX14, as well as the proton pump genes, such as SsAHA4, SsVHA, and SsAVP1. We propose a possible pathway whereby the reproductive organs of S. salsa distribute Na+ and Cl− between leaves, stems, and flowers (A 200 mM NaCl treatment significantly increased the Na flowers . In saliJG and BW conceived the original project, designed the experiments, and wrote the article. JG and XD performed most of the experiments. XD and GH performed the statistical analysis. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Few studies have reported the clinical characteristics and outcomes of young adult patients diagnosed with hepatocellular carcinoma (HCC). This study aimed to formulate a nomogram to predict the prognosis of young adult HCC patients.Young adult patients diagnosed with HCC from 2004 to 2015 were screened from the Surveillance, Epidemiology, and End Results (SEER) database. Based on the multivariate analysis results, a nomogram was constructed. The concordance index (c-index) and calibration were used to assess the predictive performance of the nomogram. The clinical benefit was measured by using decision curve analysis (DCA).The mean follow-up time of the patients was 25.0±34.0 months. Gender, race, AFP level, Edmondson–Steiner classification, treatment and TNM stage were selected as independent prognostic factors and integrated into the nomogram. The c-indexes of the two sets were 0.786 and 0.775, respectively. The calibration curves showed good agreement between the nomogram-predicted probability and the actual observations. Furthermore, the DCA indicated that the nomogram had positive net benefits compared with the conventional staging system.The nomogram could accurately predict the prognosis of young adult HCC patients. Hepatocellular carcinoma (HCC) is the most common primary liver malignancy worldwide and continues to have a high incidence . GeneralTo date, few studies have addressed the clinical characteristics and outcomes of HCC in patients younger than 40 years of age. Furthermore, due to the low HCC incidence, the number of cases in such studies was limited. For instance, Niederle et al . reporteThe Surveillance, Epidemiology, and End Results (SEER) Program is an authoritative source of information on cancer in the United States, covering approximately 34.6% of the U.S. population . The nomThis study was performed using SEER*Sat software (Version 8.3.5). The SEER 18 Regs Research Data (1973–2015) was used to search for patients. We searched patients between 2004 and 2015 by using the site code C22.0 and a histological diagnosis of HCC  from the SEER database. The primary selective criteria were patients age ≥18 and ≤40, and a total of 1050 patients were screened. Afterwards, patients who did not have a clear TNM stage or who were diagnosed at autopsy or on the death certificate only were excluded. We also excluded patients who had zero days of survival or follow-up. Finally, a cohort including 808 patients was used for further analysis. This project was approved by the Ethical Committee and Institutional Review Board of West China Hospital of Sichuan University.Clinical traits including age at diagnosis, race/ethnicity, gender, Edmondson–Steiner classification, alpha fetoprotein (AFP), marital status at diagnosis, treatment, TNM stage (6th and 7th edition), months of survival and vital status were extracted for each patient. To conduct further analysis, the screened patients were randomly grouped into a primary set (n = 404) and a validation set (n = 404).The chi-squared test or Fisher’s exact test was used to compare the categorical variables between the primary set and validation set, and the continuous variables were compared by using the Mann-Whitney U-test. Survival distributions were estimated by the Kaplan-Meier method and log-rank test. Univariate and multivariate survival analyses were performed using the Cox proportional hazard model to identify factors associated with survival, and the hazard ratios (HR) and their 95% confidence intervals (95% CI) were recorded.https://www.r-project.org/). The methods of nomogram construction and internal validation were described in previous studies [According to the results of multivariate survival analysis, a nomogram was constructed using R software  and R software (Version 3.5.1). All tests were two-sided, and p<0.05 was considered statistically significant.From the SEER database, a total of 808 young adult patients (aged ≥18 and ≤40 years old) who were diagnosed with HCC between 2004 and 2015 and had relatively complete follow-up details were identified by screening and included in further analysis. The clinical details of the patients are shown in The mean follow-up time in the primary set was 27.9±36.5 months. As shown in Since gender was always regarded as a predictive factor associated with HCC prognosis, this factor was integrated into the nomogram, 18. In The c-index for the constructed prognostic nomogram was 0.786 , and the calibration curves for 2-, 3- and 4-year OS indicated good agreement between the nomogram-predicted probability and the actual observations. For the validation set, the mean follow-up time was 28.3±35.3 months. The nomogram exhibited a high accuracy of prognosis prediction  and displayed good calibration curves for the prediction of 2-, 3- and 4-year OS .As shown in This study collected clinical characteristics of young adult HCC patients diagnosed between 2004 and 2015 from the SEER database. After screening, 808 HCC patients were finally included in the analysis and randomly separated into two groups . Subsequently, we constructed a nomogram that contained the risk factors associated with the prognosis of HCC to predict the OS of young adult HCC patients. The calibration cures for 2-, 3- and 4-year OS closely matched the ideal 45-degree line, and the c-index of the nomogram was 0.786, which was significantly higher than that of the conventional staging systems–AJCC (6th) and AJCC (7th). Furthermore, the DCA analysis also indicated that compared with the conventional staging system, our nomogram had a superior net benefit with a wider scale of threshold probabilities in the primary set and validation set.Although HCC is one of the most common malignancies in the world and accounts for numerous cancer-related deaths, few studies have thoroughly discussed the clinical characteristics and prognosis of young adult HCC patients , 6, 19. On the basis of the multivariate analysis results and taking into account the results of previous studies, gender, race, AFP level, Edmondson–Steiner classification, treatment, and TNM stage were regarded as risk factors associated with the prognosis of young adult HCC patients and were integrated into the nomogram. Among them, the TNM stage, AFP level and treatment were the variables most strongly related to the OS of young adult HCC patients. The serum AFP level was the most common laboratory value for HCC diagnosis and was used for decades . The AFPIt is not surprising that young adult HCC patients who received surgical treatment had a better OS, especially in our study. First, according to the description in the SEER database, the reasons that patients did not receive surgery were that it was contraindicated or not recommended, which indicated that these patients usually had a later stage of cancer or a worse physical condition. Consequently, these patients undoubtedly had a dismal prognosis. In contrast, Mao et al  demonstrAnother important finding was the relatively low transplantation rate in young adult HCC patients. In this study, only 7.2% of patients received liver transplantation. Furthermore, using data obtained from the United Network of Organ Sharing (UNOS) and Organ Procurement and Transplantation Network (OPTN) databases, a recent population-based study discovered that only 464 young adult HCC patients received liver transplantation between 1987 and 2012 . We specThis study represented one of the largest cohorts focusing on the prognosis of young adult HCC patients. The data were collected from multiple centers, and heterogeneity in various centers could be successfully resolved. However, limitations still exist. First, this work was a retrospective study. Second, due to the limitations of the SEER database, several prognostic factors, such as microvascular invasion (MVI), hepatic virus infection, liver function and Eastern Cooperative Oncology Group performance status (ECOG-PS), were not available in this study. The presence of MVI was proven to be associated with early recurrence and poor OS; it reflects the invasiveness of HCC and is integrated into several staging systems to predict prognosis and guideline treatment , 38. In In conclusion, we demonstrated that gender, race, Edmondson–Steiner classification, AFP level, treatment and TNM stage were independent prognostic factors for the prognosis of young adult HCC patients. Afterwards, a reliable nomogram was constructed that could predict the prognosis of these patients. Further exploration involving more patients and more independent prognostic factors should be performed, and a nomogram with higher accuracy and specificity than ours might be constructed in the future.S1 FileThis file provided all of the information of young adult patients diagnosed with hepatocellular carcinoma in this study.(XLSX)Click here for additional data file.