Reasons for drug shortages are multi-factorial, and patients are greatly injured. So we needed to reduce the frequency and risk of drug shortages in hospitals. At present, the risk of drug shortages in medical institutions rarely used prediction models. To this end, we attempted to proactively predict the risk of drug shortages in hospital drug procurement to make further decisions or implement interventions.The aim of this study is to establish a nomogram to show the risk of drug shortages.We collated data obtained using the centralized procurement platform of Hebei Province and defined independent and dependent variables to be included in the model. The data were divided into a training set and a validation set according to 7:3. Univariate and multivariate logistic regression were used to determine independent risk factors, and discrimination (using the receiver operating characteristic curve), calibration (Hosmer-Lemeshow test), and decision curve analysis were validated.As a result, volume-based procurement, therapeutic class, dosage form, distribution firm, take orders, order date, and unit price were regarded as independent risk factors for drug shortages. In the training (AUC = 0.707) and validation (AUC = 0.688) sets, the nomogram exhibited a sufficient level of discrimination.The model can predict the risk of drug shortages in the hospital drug purchase process. The application of this model will help optimize the management of drug shortages in hospitals. As for drug shortage, one definition given by the FDA is "a shortage occurring when demands exceed supply at any point in the supply chain, ultimately creating a ’stock-out’ at the point of appropriate service delivery to the patient if the cause of shortage cannot be resolved in a timely manner relative to the clinical needs of the patient" . Drug shAt the macro level, each country must take specific measures to manage drug shortages –20, for At present, the prediction related to drug stock-outs mainly uses time series analysis to predict the use of a drug in the future , 23. HowThis study was performed at The Second Hospital of Hebei Medical University and retrospectively obtained drug procurement data from 1 to 31 March 2022. The data of this study were obtained from the centralized procurement platform of Hebei Province, the weekly epidemic situation broadcast on hospital news, and on-site collection.Data meeting the following criteria were included in the study: (a) drugs existing in the procurement platform; (b) complete data; and (c) drugs in the hospital drug catalog. The exclusion criteria were: (a) active pharmaceutical ingredients and (b) narcotic and psychotropic drugs.This study aimed to establish a model to predict the probability of drug shortages. The drug information was divided into a training set and a validation set according to 7:3. The training set (n = 4836) was used to establish the model, and the validation set (n = 2077) was used to test the diagnostic performance of the model. Approval of the ethics committee of the hospital was not required for this study.Information on drug procurement and shortage factors was obtained from the Hebei Province Central Procurement Platform, weekly epidemic broadcasts in the hospital news, and on-site survey at the receiving department. A total of 11 variables were evaluated. These variables included volume-based procurement (yes/no), therapeutic class, drug dosage form, distribution firm, order date, take orders (in time/not in time), unit price, COVID-19 (whether the manufacturer is in the COVID-19 epidemic area), manufacturer (foreign-funded/Chinese funded), controlled drug list , and number of continuous stock-out times. Drug therapeutic classes were divided into antibacterial drugs, drugs of the respiratory system, hormone-electrolyte-vitamin (HEV) drugs, antineoplastic, immunomodulatory drugs, endocrine drugs, drugs of the nervous system, drugs of the digestive system, drugs of the blood system, drugs of the circulatory system, and others. Drug dosage forms were divided into injection, oral, and others. The distribution firms were divided into three echelons according to business volume. The first echelon consisted of Sinopharm holding Hebei Pharmaceutical and Le Ren Tang; the second echelon consisted of China Resources Hebei Medical University, China Resources YiSheng, Hebei LongHai, and Hebei General; and the third echelon was the other distribution companies. The purchasing and ordering time was from Monday to Friday. Taking orders in time was defined as the time of taking orders and the time of submitting orders on the same day. Drug prices entered the regression analyses in the form of quintiles. The information on whether the manufacturer was in the middle- or high-risk area according to the weekly report of the epidemic was collected. The number of continuous stock-outs of drugs was collected at the site where the drugs were stored. According to the data distribution, it was defined as zero time and > = one time. The outcome was defined as follows: it was shortages if the quantity of delivered drugs was lower than the order quantity and not if they were equal.P < 0.05 in the univariate analyses were analyzed in multivariate logistic regression analyses. The final model selection was performed using a backward step-down selection process with the Akaike information criterion (AIC). After that, a nomogram was constructed using the independent risk factors obtained from the multivariable logistic regression analyses. The receiver operating characteristic (ROC) curve was used to discriminate in the training and validation sets. The calibration curve was used to determine whether the predicted shortage probability of the nomogram was consistent with the actual stock-out probability and to analyze it with the Hosmer-Lemeshow test. The decision curve analysis (DCA) was used to estimate the net benefit and clinical utility of the nomogram. All statistical methods were performed using R version 4.1.2 (http://www.rproject.org) with pROC, calibrate, MASS, rms, foreign, and nricens data packages. P < 0.05 was considered statistically significant in all analyses.Categorical variables were expressed as percentages, and continuous variables were presented as medians. Univariate logistic regression analyses were performed in the training set to identify independent risk factors. The variables with A total of 6913 pieces of drug information were included in the research, of which 70% (n = 4836) were randomly assigned to the training set, and the remaining 30% (n = 2077) were assigned to the validation set. The selection of drug purchasing information is presented in P = 0.000), therapeutic class (P = 0.000), dosage form (P = 0.000), controlled drug list (P = 0.000), manufacturer (P = 0.009), distribution firm (P = 0.000), take orders (P = 0.000), order date (P = 0.000), and unit price (P = 0.000) were significant risk factors for drug shortages. Related risk factors with P < 0.05 in univariate analyses were adjusted for the multivariate analysis. After the multivariate analysis, only volume-based procurement (P = 0.000), therapeutic class (P = 0.000), dosage form (P = 0.000), distribution firm (P = 0.000), take orders (P = 0.000), order date (P = 0.000), and unit price (P = 0.000) were still independent risk factors for drug shortages , immunomodulatory drugs , and endocrine drugs  were more likely to be shortages than other types of drugs. Among them, antibiotics and antineoplastics were often in short supply worldwide [P = 0.661). The risk of shortage was the lowest on Tuesday and Thursday, followed by Monday and Friday, and the risk of shortage was the highest on Wednesday. According to the above results, we should try our best to adjust the order time or set up the safety stock to optimize hospital drug management. The unit price of drugs was grouped by quintiles. Compared with the first quintile, the second, fourth, and fifth quintiles were less prone to the risk of shortage, and the OR was 0.68, 0.64,0.41, respectively. In comparison, there was no difference in the third quintile (P = 0.059). This means that the higher the price, the less likely it was to be stock-outs [Among these predictors, drugs without volume-based procurement were more likely to be shortages than those with volume-based procurement (OR = 0.43). This shows the advantages of volume-based procurement, which can effectively reduce the risk of drug stock-outs . In the orldwide –28. Otheorldwide . Therefoorldwide . Compareorldwide . From thock-outs . When thock-outs .Some of the factors included in our study were not independent risk factors for drug shortages. The results showed that the COVID-19 factors were not an independent risk factor for drug shortages. The possible reason was that China’s epidemic prevention and control policy was very effective, and China’s strong economic resilience ensured the smooth distribution of drugs . Also, tIn general, using this model may help identify high-risk drugs and the shortage risk per hospital purchase. This can prepare for the next step of planning or implementation of interventions. For example, when updating the hospital drug supply catalog, it can be used to identify high-risk drugs or plan for drug shortages when purchasing. It should also be attempted to reduce the risk of shortage before drugs enter the hospital or undergo the procurement process. In addition, we not only validated the discrimination of the model but also the calibration as well as the decision curve analyses. The model performed well in these validations. Finally, we obtained a nomogram, which could help us easily get a score for a drug as well as the risk of shortage and allows us to quickly evaluate two drugs with different information on the same name. Thus, our model still has limitations. The included independent variables are still not comprehensive. This is mainly because some of these unincorporated independent variables are difficult to collect or quantify, such as the occurrence of the domino effect . Other iAs we used retrospective data for modeling, we can use cohort data to continuously test and revise the model in the future. We can also use other medical institutions for external validation to modify the prediction model to achieve better discrimination. In the present study, we used data on hospital drug purchase to establish a prediction model with good prediction ability. This model includes a total of seven variables, all of which are related to hospital drug procurement. It contains some factors reported in the literature and factors not noticed before. After verification, the model performs well in discrimination, calibration, and clinical applicability. Using this model, we can estimate the out-of-stock risk of drugs and decide what intervention measures we need to take. This reflects the initiative of out-of-stock management of hospital drugs. Even in the future, we still need to validate, improve, and expand this model constantly, but the potential of using data modeling for drug shortage management is huge.In summary, we have successfully developed and verified a nomogram for predicting the risk of drug shortage based on drug characteristics. The nomogram shows good diagnostic performance, which is very helpful for the hospital to select a drug that is not often out of stock.


Sarcopenia is well known to be associated with mortality, but there is a lack of evidence on the estimates of life expectancy (LE) for sarcopenia in China. This study aims to estimate total life expectancy (TLE) and sarcopenia-specific LE in community-dwelling older Chinese adults with and without sarcopenia.This study included participants aged 60 years and older who enrolled in the cohort in 2011 and 2013 and at least completed one follow-up until 2015 as part of the China Health and Retirement Longitudinal Study (CHARLS). The criteria for defining sarcopenia were based on the guidelines established by the Asian Working Group on Sarcopenia in 2019. TLE and sarcopenia-specific LE were estimated for the total population and subgroups using continuous-time multistate modeling.A total of 6,029 participants (49.2% women) with an average age of 68.4 (SD: 6.56) years were included in the study. The baseline prevalence of sarcopenia and possible sarcopenia was 19.5 and 44.9%, respectively. We observed that sarcopenia stages naturally deteriorated to worse stages  and returned to better stages (17.1%) during a median follow-up of 3.92 years (IQR: 2.00 ~ 4.00). The average TLE at the age of 60 was 20.9 [95% CI: 20.2–21.5] years . Men, former and current smokers, and those living in northwest China had less TLE. Sarcopenic older adults, those with lower education, those who are unmarried, those with agriculture hukou, and those living in rural and northwest China were expected to live fewer years with non-sarcopenia. Sarcopenic older people, men, those with agriculture hukou, and those living in rural and southwest China were expected to live more years with sarcopenia.The results improved our understanding of the relationship between sarcopenia and life expectancy. We suggested that targeted strategies should be considered in high-risk populations and underdeveloped regions to prevent sarcopenia and improve non-sarcopenic life years for the older population. Sarcopenia is defined as a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and/or physical performance, associated with advancing aging  and withA recent review concluded that the worldwide prevalence of sarcopenia varies widely depending on different assessment criteria, ranging from 9.9 to 40.4%. The average prevalence was 12.9%, according to the European Working Group on Sarcopenia in Older People/Asian Working Group on Sarcopenia (EWGSOP/AWGS) , 9, and With the growing awareness of the need for early recognition of musculoskeletal degeneration, primary care physicians and family caregivers have an increasingly important role in the intervention of older adults with possible sarcopenia. Studies showing risk factors related to sarcopenia, such as increasing age, unmarried status, living alone, rural residence, smoking, physical inactivity, malnutrition, and chronic diseases , 16–18, This study aimed to estimate the TLE and sarcopenia-specific LE  among sarcopenic and non-sarcopenic older adults based on a nationwide cohort study from China. We additionally examined LE in older Chinese adults stratified by demographics, lifestyle factors, and regions.This study is based on the China Health and Retirement Longitudinal Study (CHARLS), which is a nationally ongoing representative longitudinal survey to examine health and economic adjustments to the rapid aging of the population in China. A more detailed description was published elsewhere . BecauseAccording to the AWGS 2019 algorithm , the sarHandgrip strength (kg), an indicator of muscle strength, was measured in the dominant hand and the non-dominant hand, with the participant squeezing a YuejianTM WL-1000 dynamometer  as hard as possible . Every p2) was calculated using the ASM divided by the square of the height in meters. According to the AWGS 2019  and drinking (yes or no) on TLE and sarcopenia-specific LE.To examine potential factors related to TLE and sarcopenia-specific LE, we classified the whole population into subpopulations by sex (man and woman), education , marital status (unmarried and married), and hukou status (agriculture and non-agriculture) by self-reported data in the earliest response. Living residences  and regions  were identified according to government office region using msm (multi-state model) package (elect (Estimating Life Expectancies in Continuous Time) package of R , and the chi-squared test was used to evaluate the difference between the prevalence of sarcopenia by subgroups. Continuous-time multistate models were used to estimate the TLE and sarcopenia-specific LE by the following two steps. In the first step, a general multistate Markov model by the  package  of the R package  was usedage of R . In thisMiddleRiemann” and “Simpson” methods for the numerical approximation . The prevalence of sarcopenia was significantly different in sex (p < 0.001), education (p < 0.001), marital status (p < 0.001), smoking (p = 0.006), drinking (p < 0.001), hukou type (p < 0.001), living residence (p < 0.001), and region (p < 0.001).The mean age of the analysis sample was 68.4 years (SD = 6.56), with 49.2% being women. The baseline prevalence of sarcopenia and possible sarcopenia were 19.5 and 44.9%, respectively. As shown in As presented in As shown in The results of sensitive analyses conducted by different methods were almost consistent with the main analysis . There wThe findings of our study suggest that sarcopenia stages can transition into each other naturally. Sarcopenia stages can deteriorate to a worse stage  but can also turn back to a better stage 17.1%). The majority stayed in the same stages, which is consistent with the previous study, even with a longer follow-up  and more7.1%. TheOur study shows significant differences in TLE and sarcopenia-specific LE between sarcopenic and non-sarcopenic older people. In both absolute and relative terms, at age 60 years, sarcopenic older Chinese expected to live more life years with sarcopenia , fewer life years with non-sarcopenia , and fewer total life years (18.72 vs. 22.08 years), compared to non-sarcopenic individuals. Compared to the average level, the findings of a 10.4% reduction in TLE, a double increase in SLE, and an almost two-thirds decrease in NSLE for sarcopenic older adults are amazing but understandable. Sarcopenia has been proven to lead to multiple adverse health outcomes, including falls, frailty, functional decline, poor quality of life, and mortality . The Ethics Committee waived the requirement of written informed consent for participation. This study is a secondary analysis of the publicly available database of CHARLS, and the data have been fully de-identified.BY analyzed and interpreted the data, drafted and revised the manuscript. JG designed the study, interpreted the data, and revised the manuscript. YW, JX, JJ, and SY contributed to the visualization and revised the manuscript. ZB and JC contributed to interpreting the data. All authors contributed to the article and approved the submitted version.This study was supported by the National Key Research and Development Program of China , the National Natural Science Foundation of China , and the Shanghai Clinical Research Center for Aging and Medicine (grant: 19MC1910500).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background and objectives: The combination of depression and sarcopenia, a condition prevalent worldwide, may cause dis-tinct problems that should not be underestimated. However, to the best of our knowledge, no reports have investigated the combined effects of depression and sarcopenia. In this study, we compared physical function, nutritional status, and daily functioning among older adults with only depression (OD), those with only sarcopenia (OS), and those with sarcopenia with depression (SD) to examine the effects of the combination of depression and sarcopenia. Materials and Methods: The participants were 186 communi-ty-dwelling older individuals who required support or care. The participants were classified into four groups based on the presence or absence of sarcopenia and depression: Control, OD, OS, and SD. The following parameters were evaluated in the four groups: grip strength, walking speed, skeletal muscle mass index (SMI), Mini Nutritional Assessment Short-Form (MNA-sf), and long-term care certification level. In addition, univariate and multivariate analyses of the survey results were performed to identify risk factors leading from OS to SD. Results: We found that 31.2% of older participants who needed support or nursing care had SD, which had more pronounced adverse effects on grip strength, walking speed, SMI, MNA-sf, and level of nursing care than OD or OS. Furthermore, multivariate analysis of SD vs. OS showed that decreased grip strength and worsening MNA-sf were independent risk factors. Conclusions: SD is common among older individuals living in the community. Patients with SD require support and care, and the condition has a greater impact on physical function, nutritional status, and decline in life function compared to OD and OS. Therefore, it is desirable to elucidate the process leading to SD and investigate the risk factors and prognosis. It is expected that sarcopenia with depression will be investigated worldwide in the future. Sarcopenia is characterized by the progressive and generalized loss of skeletal muscle mass and strength with age and disease . SarcopeIn recent years, new concepts of sarcopenia have been reported, such as osteosarcopenia, associated with osteoporosis ,12; respTherefore, we focused on the relationship between mental health and sarcopenia. Depression is a condition that interferes with activities of daily life owing to an unpleasant mood . AccordiThe combination of depression and sarcopenia, a condition prevalent worldwide, may cause distinct problems that should not be underestimated. However, to the best of our knowledge, no reports have investigated the combined effects of depression and sarcopenia. Therefore, we defined sarcopenia with depression (SD). We hypothesized that patients with SD may have greater dysfunction in physical function and daily life than those with only depression (OD) or those with only sarcopenia (OS) because of the interaction between the two with similar risk factors and prognoses. This study aimed to investigate the effects of SD on older patients who require support or care.The purpose of this study was to determine the prevalence of SD as defined by us and the characteristics of SD compared to non-depression/non-sarcopenia, OD, and OS. The results of this study are expected to contribute to our understanding of the manifestation and characteristics of depression associated with sarcopenia in older adults.This cross-sectional study was conducted at a single center between September 2019 and September 2022. In accordance with the guidelines of the Helsinki Convention, all participants were fully informed of the purpose and measurements, and written consent was obtained from those who indicated their willingness to participate. This study was conducted after obtaining approval from the institutional ethical review committee of the International University of Health and Welfare .The inclusion criterion was a survey of our facility (252 users) from September 2019 to September 2022. The facility involved day care for older adults undergoing rehabilitation, including pick-up and drop-off services under the long-term care insurance system. Exclusion criteria were as follows: (1) those who are at risk of falling due to stroke or balance dysfunction and have difficulty maintaining a standing position or walking (39 participants), (2) those who had difficulty in answering the questionnaire due to cognitive decline (21 participants), and (3) those with aphasia (6 participants). Excluding the 66 participants who met the exclusion criteria, 186 participants  were included in the study. None of the participants refused to participate in this study. All the study participants were older Japanese adults living in the community in need of care.Sex, age, body mass index (BMI), long-term care certification level, Mini Nutritional Assessment Short-Form (MNA-sf), and comorbidities  were collected from the medical records.MNA-sf was used to assess nutritional status. It consists of six survey items: (ⅰ) food intake, (ⅱ) weight loss, (ⅲ) mobility, (ⅳ) psychological stress and acute disease, (ⅴ) neuropsychological problems, and (ⅵ) calf circumference, making it useful for nutritional screening of aging adults, with higher scores indicating better nutritional status . The MNAThis study used the level of care required by the Japanese long-term care insurance system to assess the severity of daily functioning. The long-term care certification level is classified according to the severity of the disability into Support 1 and 2 (level requiring support in daily living) and Care 1–5 (level requiring assistance in daily living); the higher the number, the more care is required . In this2 for men and < 5.7 kg/m2 for women [The Asian Working Group for sarcopenia 2019 (AWGS 2019) algorithm  was usedor women . Particior women .Grip strength was measured using a digital grip strength meter . The unit of measurement of the grip strength meter used was kg. The maximum value of the two measurements—taken twice on each side in the chair sitting position with both upper limbs hanging down to the body side—was used as the representative value. SMI was calculated by dividing the skeletal muscle mass of the limbs by the square of the participant’s height . The skeThe Geriatric Depression Scale 15 (GDS-15) was used to assess depression. It consists of 15 short, simple questions about mental health, all of which can be answered with a yes/no response. A higher score indicates a tendency toward depression, and a score of 5 or higher indicates a depressive tendency . The GDSIn this study, sarcopenia was determined by the AWGS 2019 flow, depression was determined by a GDS-15 score of 5 or higher, and SD was defined as the co-occurrence of sarcopenia and depression.Participants were classified into four groups: control , OD , OS group , and SD group  .2 test. Next, each survey item was analyzed using Spearman’s rank correlation coefficient to verify the correlation. The median, mean, and number of cases for the four study groups  were calculated, and significant differences were examined using the Kruskal–Wallis test or χMultivariate analysis was performed using the dependent variable as the survey item that showed a significant difference between the groups, with OD, OS, and SD as independent variables. Multiple regression analysis was used for grip strength, walking speed, SMI, and BMI, and binomial logistic regression analysis was used for MNA-sf and long-term care certification levels.p < 0.05. Power analyses were performed using G*Power, version 3.1.In the binomial logistic regression analysis, MNA-sf was classified into two categories: well nourished (MNA-sf score > 11) and undernourished or at risk of undernourishment (MNA-sf score ≤ 11). The long-term care certification level was classified into support and long-term care certification levels. Furthermore, OS and SD findings were validated by univariate and multivariate analyses. All the multivariate analyses were adjusted for age and sex. SPSS Statistics version 22 (IBM) was used for the statistical analysis, and the significance level was set at In the overall analysis (n = 186), 41 (22.0%) patients had CO, 37 (19.9%) had OD, 50 (26.9%) had OS, and 58 (31.2%) had SD. Of the 108 patients with sarcopenia who required support or nursing care, 53.7%  had SD.A comparison of the four groups showed significant differences in BMI, MNA-sf, long-term care certification level, grip strength, walking speed, SMI, and GDS-15. . In terms of correlations among the survey items, significant correlations were found for all MNA-sf items, and significant correlations were found for all items except GDS-15 for the level of care required .In the multivariate analysis (adjusted variables: sex and age), SD was more strongly associated than OD and OS with worsening grip strength, gait speed, SMI, BMI, nutritional status, and long-term care certification level. In analyses regarding sex, similar associations were found . 2 = 0.201), which was calculated from the regression equation  in patients with sarcopenia reported in a previous study of the general older population was 29.8% . TherefoA notable point of this study is that SD showed a greater tendency to decline than OD or OS in terms of the level of care required. The level of care required is an important indicator that comprehensively evaluates the living conditions and care burden of older adults from multiple perspectives. Worsening levels of the care required are associated with life expectancy  and incrPhysical function and nutritional status also tended to be worse in the SD group than in the OS or OD groups. The risk factors for depression and sarcopenia are similar in some respects, such as lack of exercise, increased inflammatory factors, and hormonal disorders of the hypothalamus–pituitary–adrenal system , and theThis study has several limitations. First, this was a single-center survey in Japan, the number of participants was small, and their demographics were limited. Therefore, the results may differ among regions with different diagnostic criteria for sarcopenia. Second, as this was a cross-sectional study, it was not possible to prove a causal relationship between depression and sarcopenia. Third, symptoms of mild dementia and depression overlap in many respects  and cannHowever, the results of this study show that many sarcopenia patients with depressive tendencies are found among older individuals who require support and care in the community and that their physical function, nutritional status, and long-term care certification level are worse than those with only sarcopenia—this is a new finding. Therefore, SD may be a new geriatric giant among the overall older population. Further studies should be conducted to elucidate the risk factors and prognosis in longitudinal studies, in addition to more detailed SD specificities.SD is common among older adults who require nursing care in the community and may have a greater impact on physical function, nutritional status, and lifestyle function compared to only sarcopenia. Future longitudinal studies are needed to elucidate the prognosis and risk factors of SD.


Post-transplant glomerulonephritis (PTGN) has been associated with inferior long-term allograft survival, and its incidence varies widely in the literature.This is a cohort study of 7,623 patients transplanted between 2005 and 2016 at four major transplant UK centres. The diagnosis of glomerulonephritis (GN) in the allograft was extracted from histology reports aided by the use of text-mining software. The incidence of the four most common GN post-transplantation was calculated, and the risk factors for disease and allograft outcomes were analyzed.In total, 214 patients (2.8%) presented with PTGN. IgA nephropathy (IgAN), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative/mesangiocapillary GN (MPGN/MCGN) were the four most common forms of post-transplant GN. Living donation, HLA DR match, mixed race, and other ethnic minority groups were associated with an increased risk of developing a PTGN. Patients with PTGN showed a similar allograft survival to those without in the first 8 years of post-transplantation, but the results suggest that they do less well after that timepoint. IgAN was associated with the best allograft survival and FSGS with the worst allograft survival.PTGN has an important impact on long-term allograft survival. Significant challenges can be encountered when attempting to analyze large-scale data involving unstructured or complex data points, and the use of computational analysis can assist. Glomerulonephritidies are an important cause of end-stage kidney disease (ESKD), and their tendency to affect the younger age groups results in them being the most prevalent cause of ESKD in patients undergoing renal transplantation in the UK and the second most common in the USA , 2.The incidence of recurrent glomerulonephritis (GN) post-transplant varies widely in studies , 4, reflRecurrent GN is an important cause of allograft loss , 7 and aWhen conducting epidemiological studies using large-scale data, care needs to be taken regarding the accuracy of the clinical data points being considered. The use of computational analysis, such as text mining and natural language processing (NLP), allows the extraction of informative features from many types of raw and unstructured data, thus allowing greater accurately and standardisation. Such techniques may lead to more accurate results and conclusions , 11 and This multicenter study is the first in nephrology, utilizing computational analysis to aid in the diagnosis of GN and aiming to accurately estimate the incidence of GN post-transplantation in a United Kingdom cohort, analyse epidemiological factors influencing their emergence in the post-transplant period and comment on allograft outcomes.This is a multicenter cohort study conducted in four UK transplant centres—Guy’s and St. Thomas’ NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Oxford University Hospitals NHS Trust, and Imperial Healthcare NHS Trust.The study was approved by the East Midlands Nottingham 2 Research Ethics Committee, with reference number 15/EM/0449.The inclusion criteria for the patients during the study period were any individual (>16 years old) who has undergone kidney or simultaneous pancreas and kidney transplantation between January 2005 and October 2016 in the participating centres.Only the first transplant episode per patient was considered during the time of study. There were no exclusion criteria.Routinely collected clinical data were extracted from electronic health records (EHRs) at each center, combined with data from NHS Blood & Transplant and aggregated in a data warehouse on a per transplant and personal level.de novo donor-specific antigens or high calculated reaction frequency. In the period of the study, all centers had their immunosuppression protocols unchanged except for center 1 that switched from cyclosporin to tacrolimus in 2010.Centers 1, 2, and 4 used mostly basiliximab as induction agent and the maintenance immunosuppression regimen of tacrolimus, mycophenolate (MMF), and prednisolone. Center 3 used a steroid-sparing protocol. Alemtuzumab was used as an induction agent in combination with tacrolimus monotherapy and a 7-day prednisolone regime. MMF was added in cases of Regarding biopsy practices, center 3 had criteria-driven protocol biopsies at 1 year post-transplant. The other 3 centers only performed biopsies when clinically indicated.Software to extract the diagnoses of various glomerular diseases from unstructured biopsy text reports was developed using the open-source General Architecture for Text Engineering , 15 framFrequencies and percentages were used to present categorical factors and missing data. Means and standard deviations were used for normally distributed continuous data, while medians and interquartile ranges were used if their distribution was skewed. The distribution of continuous data was explored using histograms.For the evaluation of possible risk factors for the diagnosis of GN post-transplantation, recipient-related characteristics were explored.P-value <0.2 from their univariate Cox regression were added in the multiple Cox regression.Univariate Cox regression analysis was used to explore the influence of each factor on time from transplant to the development of GN and time from transplant to graft failure. The category with the highest frequency was used as reference category in each exploratory factor. Factors with P-value of ≤0.05 was considered to indicate statistical significance.Kaplan–Meier plots were used for the survival analysis. For patients not presenting a graft failure, the date when their creatinine value was measured last was considered. A All statistical analyses were performed with Stata/IC version 15.1.During the period of the study, 7,623 patients had their first renal transplant. The population characteristics between centers were similar, except for an expected variation in ethnicity, with two of the four centres serving large multicultural urban areas. Only 45.9% of the patients had information regarding the cause of ESKD. Of these, in 38.1% of cases, the cause of ESKD was unknown, while 11.1% had a diagnosis of a specific GN and 3.2% had a diagnosis of chronic glomerulonephritis of an unspecified nature.The demographics of our population and patients’ transplant characteristics are described in During the period of the study, 277 (3.6%) patients presented with evidence of glomerular disease in their allograft biopsy.The histological findings in the renal allograft were IgA nephropathy (IgAN) in 48.7% of the biopsies, focal segmental glomerulosclerosis (FSGS) in 18.1%, membranous nephropathy (MN) in 7.2%, membranoproliferative GN and mesangiocapillary GN (MPGN/MCGN) in 2.9%, minimal change disease (MCD) in 0.4%, and thrombotic microangiopathy (TMA) in 22.7%.A statistical analysis was carried out using the four most common GNs, namely, IgAN, FSGS, MN, and MPGN/MCGN. TMA represents a heterogeneous group of conditions and often cannot be unequivocally attributed to a single underlying etiology  even aftBetween 24 and 32 patients per 1,000 transplanted patients (95% CI) are estimated to develop a GN post-transplantation Table 2.The median time from transplant to histopathological diagnosis of GN was 701.5 days .P-value: 0.014) and 1.46  increased risk for developing a GN in their allograft, respectively.Younger age groups, 16–30 years old and 31–45 years old, were found to have a 1.7  as well as unrelated donation .Living related donation was identified to increase the risk for the development of a GN , black ethnicity , transplantation period from 2005 to 2010 , and cold ischemia time   Table 3.P-value: 0.013) and living related donation with a risk increase of 1.8 times . Ethnicity, namely, mixed race and other ethnic minority groups, was identified as another risk factor for post-transplant GN . An HLA DR mismatch of 0 was also a risk factor for developing a GN after transplantation, with an associated 1.4 times increase in risk .From the adjusted analysis, living donation was shown to be a risk factor for developing a GN post-transplantation, with living unrelated donation associated with a risk increase of 2.1 times  and year of transplantation between 2005 to 2010 .The protective factors against the development of GN in the allograft were also identified, specifically, black race . Allograft failure was observed in 25% (54 patients) with a median time from the histopathological diagnosis of GN to failure of 224 days (IQR: 17–414). Death occurred in 8.9% (19 patients) at 587 days  following the diagnosis of GN in the allograft.P-value: 0.001) .From the adjusted analysis, the year of transplantation between 2005 and 2010 was shown to be the only risk factor for graft failure, with an increased risk of 1.4 times  Table 4.When comparing the survival estimate in patients who developed any type of GN post-transplantation to patients who did not develop a disease, the former group of patients was shown to have a similar allograft survival until after approximately 7.5–8 years post-transplantation, at which point there is a suggestion that they did less well Figure 1The probability of graft survival for patients who developed a diagnosis of GN after transplantation, regardless of its histopathological pattern, was approximately 95% at 1 year (95% CI: 0.91–0.97) and 83% at 5 years (95% CI: 0.76–0.88).IgAN demonstrated the most favorable outcome showing a small and stable decline in allograft survival until 8 years post-transplant, with an allograft survival of approximately 75% at this time point. In contrast, FSGS experienced the worst outcome with a progressive decline post-transplant, showing an approximate allograft survival of 30% at 8 years post-transplant. MN presented good allograft survival in the first year post-transplant, with an allograft survival of approximately 55–60% at 7 years post-transplant.This is the first large-scale UK study investigating the incidence and effects of post-transplant GN. It is one of the first reports detailing the use of computational techniques to aid in the analysis of renal biopsy reports in a large patient cohort across multiple centers. We found the overall incidence of GN after renal transplantation to be 2.8%. A large study using registry data focused on recurrent disease and found that the recurrence of the four most common GN subtypes was around 10% . HoweverA major limitation of this study was the inability to accurately define the cause of ESRD in a large proportion of patients and prevented us commenting specifically on recurrent disease. As well as a significant amount of missing data (46%), even where data was available, a large proportion of patients with ESKD had no determined cause (41%). This is particularly true in black patients where a biopsy is less likely to occur and ESKD ascribed to hypertension . The higAnother factor why our study has highlighted a low rate of post-transplant GN might relate to biopsy practice and the low frequency of protocol biopsies carried out. Only one center carried out a form of protocol biopsy at 1 year post-transplant based on specific criteria such as low eGFR. However, the practice of early protocol biopsy is likely to have a little effect as most post-transplant GN develops after the first year, at least histologically. The criteria for performing a biopsy in the longer term vary widely not just between centers but also between individual clinicians and has also changed over time, with the understanding that there are multiple causes of long-term allograft loss.In common with other studies, we found IgAN as the most common GN found in post-transplant biopsies , 18. TheLiving donation has been identified as a risk factor for developing a post-transplant GN, however with conflicting results , 21, 22.Black race was identified as a protective variable for the development of post-transplant GN. This finding could be explained by the fact that this group is more greatly affected by other diseases involving the kidneys (hypertension and sickle cell disease) or because some forms of GN related to APOL1 genotype have a very low risk of recurrence . It has With regards to immunosuppression and its role in the development or reduction of GN disease in the renal allograft , 25, we Cold-ischemia time and HLA mismatches have been implied in the development of GN in the allograft , 26. TheIn our study, allograft failure was observed in 25% of the patients who developed a GN, regardless of histopathologic type. This percentage is in line with previous studies .In our cohort, patients with any type of post-transplant GN presented a similar allograft survival to patients who did not develop the disease until after approximately 7.5-8 years post-transplantation, at which point there is a suggestion that they did less well. Allograft survival at 1 year was 95% and at 5 years was 83%. Recipients with allograft GN also presented a lower allograft survival when compared with the allograft survival estimate for all UK centers  since alFrom all the variables studied, year of transplantation between 2005 and 2010 was shown to be the only risk factor for graft failure. Whether this is due to the immunosuppression used in the early era , lower bThe different types of GN, both in native and transplanted kidneys, behave in distinct ways. As in other studies , we founA major strength of our study is the direct analysis of biopsy reports to determine post-transplantation GN rather than relying on registry data, thus reducing potential inaccuracy in data gathering or disease coding.de novo disease post-transplantation. An improved understanding of the factors limiting long-term renal allograft survival is of importance, both in terms of counselling patients and informing further study to improve long-term allograft survival. Our study adds to the body of knowledge to this area. The identification of highly accurate cohorts of patients with specific GNs in their allografts will allow future detailed studies within these groups. As most GNs have an immunological basis, patients with post-transplant GN occurring despite the use of immunosuppression may provide opportunity to study an extreme clinical phenotype to better understand the contribution of genetic components.The increasing use of EHRs provides an opportunity for the automated collection and analysis of large patient cohorts and “big data” which is of particular importance in nephrology, where the incidence of specific diseases is rare. Our study highlights the difficulties in standardization and accurate collection of complex data points, such as the diagnosis of renal disease, which rely on the analysis of unstructured data. We demonstrate that computational analysis has potential for use in this area, with more advanced techniques involving NLP and artificial intelligence offering the potential of fully automated extraction of complex data points, such as the diagnosis of renal disease. Other limitations to our study are the type of study, retrospective, as well as the abovementioned absence of cause of ESKD, which did not allow us to differentiate recurrent from In conclusion, in this large-scale UK study, we found that GN post-renal transplantation has an important impact on long-term allograft survival, and significant challenges can be encountered when attempting to analyze large-scale data. Nonetheless, machine learning can aid in the study of complex data points.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the East Midlands Nottingham 2 Research Ethics Committee with reference number 15/EM/0449. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The research idea and study design were contributed by PC, RA, CB, MC, and RM. EB, BC, FD, LJ, GO, SH, AMu, BG, LM, JD, KV, and KW contributed to the analysis and interpretation of data. JS and BC contributed to the development of the text-mining biopsy software. Statistical analysis was done by EB and CB. AW, FH, and AS contributed to the management of the project. Drafting the article and providing intellectual content were done by RA, PC, EB, CB, CR, NS, CB, and RP. Approval of the submitted version of the manuscript was done by RA, EB, CB, PC, RP, CB, MH-F, CR, NS, AMc, RP, and GL. Supervision and mentorship was provided by PC. All authors contributed to the article and approved the submitted version.This research was funded by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St. Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.MH-F is currently an employee of UCB Celltech, a pharmaceutical company. Her involvement in the conduct of this research was solely in her capacity as academic at King’s College London.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Dermatological consultations represent a great part of the small animal medical clinic routine. Canine atopic dermatitis (CAD) is a common skin disease that affects a significant amount of dogs, making it a relevant consideration in clinical practice. The role of the endocannabinoid system on skin homeostasis has been described and its deregulation contributes to dermatopathies. Its function in specialized skin cells reveals an expressive therapeutic potential. Due to the difficulties and the growing scientific evidence of the therapeutic benefits of cannabis on animals, this work aimed to evaluate the anti-inflammatory effects of cannabis-derived oil in the treatment of CAD.Fourteen canines diagnosed with CAD were divided into two groups: T: full spectrum high cannabidiol (CBD) cannabis oil, 2,5 mg/kg; and C: control group . The effectiveness was evaluated based on the degree of pruritus, dermatological evaluation (CADESI-4) and histopathological evaluation of the skin including mast cell count.Despite the theoretical basis, there were no significant results obtained between the compared treatments.Thus, it can be concluded that although full spectrum high cannabinoids therapy presents a promising approach to immunological diseases, further research is required in order to establish the actual effective cannabinoid ratio within the myriad possible combinations and for multi-target therapy of CAD. Canine atopic dermatitis (DAC) is a disorder resulting in chronic inflammation and pruritus , 2. DAC According to Tóth et al. , the endIn light of the strong relationship between the endocannabinoid system and skin homeostasis, the objective was to evaluate the effectiveness of full-spectrum cannabis oil rich in CBD in dogs with atopic dermatitis through dermatological assessment, using CADESI-4 and pruritus degree, as well as histopathological analysis with mast cell counting in three regions affected by atopic dermatitis.This study was approved by the Ethics Committee for Animal Use and Experimentation of the Federal University of Santa Maria (CEUA/UFSM) (number 8656301121 - ID 003662) and was conducted in accordance with the ethical principles of the National Council for Animal Experimentation Control (CONCEA).Canine subjects with a diagnosis of atopic dermatitis (AD), with prior exclusion of food allergy and flea bite dermatitis, were selected according to the criteria of Favrot.The inclusion criteria were: AD diagnosis; Absence of concurrent diseases; No systemic treatment within the past 30 days; The exclusion criteria were: Lack of regular flea control; Presence of dental calculus; Moderate-to-severe gingivitis; Any other concurrent disease. No maximum or minimum CADESI values were stipulated for selection or exclusion. Additionally, there was no standardization in the use of shampoo for topical treatment or type of diet used, in order to mimic clinical routine.®). The treatment involved administering 2.5 mg/kg, twice a day for 60 days. Assessments were conducted before (T0) and after (T60) the treatment. The frequency of baths, shampoos, and diets already in use, whether therapeutic or not, was maintained. It was also recommended to withhold any type of treat from the animal.The fourteen canines  were divThe animal was assessed by a dermatologist using the CADESI-4 score, and according to the owner, the degree of pruritus was evaluated using the scale adapted. Both the dermatologist and the owner were blinded to the treatment.®, Zoetis). The biopsy was taken from the interdigital, axillary, and inguinal regions with the aid of a scalpel or punch. The tissue samples were preserved in 10% formalin for subsequent histopathological evaluation and mast cell counting using special toluidine blue staining under a 400× objective. Suturing was done using 3-0 Sultan nylon sutures.For skin biopsy, intravenous sedation was performed using 3 μg/kg fentanyl and 4 μg/kg of dexmedetomidine  Orthokeratotic hyperkeratosis, (b) acanthosis, and (c) perivascular and periadnexal lymphoplasmacytic dermal inflammation. These criteria were subsequently classified into four grades  for the interdigital, axillary, and inguinal regions.t-test (independent groups) or paired t-test (dependent groups) were used when the data did not follow a normal distribution. The Mann-Whitney U test (independent groups) or Wilcoxon signed-rank test (dependent groups) were applied in case of non-normality. The Chi-Square test was used for the association between qualitative variables. Statistical Package for Social Sciences (SPSS) version 17.0 software was used for the analyses, and the significance level was set at 5%.Descriptive statistics were performed for qualitative variables, including calculating frequencies (both absolute and relative), and for quantitative variables, measures of central tendency and variability were calculated. The Shapiro-Wilk test was conducted to test the normality of the data. For comparisons between two groups, the Student's p = 0,042), but there was no difference within group T  or between the treatments performed (p = 0.654). The limit values obtained from this evaluation are shown in In the CADESI-4 evaluation , there wp = 0.396), as well as in the pre- and post-treatment within group T (p = 0.186), but there was a significant decrease in group C (p = 0.039)  .In the axillary region , group TIn the interdigital region , group TIn the inguinal region , OrthokeThe mast cell count  did not The onset of clinical signs of canine atopic dermatitis (CAD) is characterized by alesional pruritus, represented by excessive scratching, biting, or licking. The primary lesions are erythema and papules, which may lead to secondary lesions due to self-trauma, resulting in chronic inflammation and secondary infections, represented by excoriations, alopecia, lichenification, hyperpigmentation, crusting, and seborrhea . Luz-VeiIn a treatment with 2 mg/kg of CBD and CBDA for 4 weeks conducted by Loewinger et al.  in atopiA study conducted by de Santiago et al.  revealedThe results obtained according to the responses of the tutors regarding the pruritus grade disagreed with the dermatologist's evaluation. There are a few studies on the placebo effect in dogs, but there are some theories that do not involve a real placebo effect. (A) Placebo effect of the caregiver or by proxy: this means that due to the investment made, the caregiver believes that they will get a return. As a result, the tutor is highly susceptible to this type of control and may perceive improvements even when they do not exist. A study conducted by Conzemius and Evans  reportedGiven the chronicity, difficulty in controlling clinical signs, and the laborious maintenance of canine atopic dermatitis, the placebo effect concerning the tutor's evaluation can be a reasonable justification, even if not well-supported by the literature. There are reports of improvement according to some tutors, but it is not observed in all cases, which can be related to the placebo effect described above. In other words, there may have been a clinical improvement, but without statistical significance. Recalling the discussion in the “dermatological evaluation” section, it was possible to justify an improvement in the control group because it was not treated with an inert substance, thereby approximating the possible differences between the cannabis-treated group and the control group.It is believed that the main limitation regarding the pruritus scale was the lack of prior information about the pruritus grade. As a result, tutors would confirm a certain level of pruritus that was often higher than the confirmed previous grade, subsequently reporting that the pruritus had indeed decreased. This discrepancy in reporting could be attributed to the absence of initial information and may have influenced the perceived improvement in pruritus.The presence of mast cells is directly proportional to the severity of the clinical condition, pruritus pathogenesis, and disease progression . The resThe histopathological lesions of CAD reveal an inflammatory pattern characterized by chronicity, perivascular dermatitis, hyperplasia, and spongiosis . Scott  reportedThe absence of significant findings in the different evaluations conducted in this study can be mainly justified by the fact that the animals had a dermatopathy, and these changes are primarily related to the dose used. In the present study, the body condition of each patient was not taken into consideration, whereas in the literature, there is evidence of phytocannabinoid deposition in adipose tissue due to their liposolubility. Studies that accounted for this factor revealed an increase of 20% in the dose for obese animals to compensate for this characteristic .Limitations of this study include: small number and uniformized animals; short-term therapy; and possible influence of olive oil. However, despite the absence of clinical improvement in this study, cannabinoids are a promising option to ameliorate the pathophysiology of this disease.Despite the absence of significance in the dermatological evaluations for the canine atopic dermatitis, it is worth noting the individuality of each animal concerning the dosage used, as a very positive result was obtained in the cannabis group. This study reveals that the full-spectrum cannabis oil rich in CBD at a dosage of 2.5 mg/kg does not show therapeutic advantage when compared to olive oil. This is mainly due to the complexity of controlling this disease, which demands a multimodal therapy. Further clinical research involving this topic is recommended to either confirm or definitively rule out potential therapeutic means to aid in controlling this dermatopathy that greatly affects the quality of life.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The animal studies were approved by Ethics Committee for Animal Use and Experimentation of the Federal University of Santa Maria (CEUA/UFSM) . The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent was obtained from the owners for the participation of their animals in this study.CM: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing—original draft, Writing—review & editing. ALS: Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Writing—original draft, Writing—review & editing. ÂIS: Data curation, Formal analysis, Writing—review & editing. APS: Writing—review & editing, Formal analysis. MM: Investigation, Methodology, Writing—review & editing. AVS: Writing—review & editing, Methodology, Supervision. EA: Conceptualization, Resources, Writing—review & editing, Funding acquisition. ST: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing—review & editing.


Background and objectives: The goal of this study was to evaluate the levels of organizational justice, emotional regulation, and workload associated with the level of burnout experienced in medical and non-medical staff from public and private medical units. Materials and Methods: A cross-sectional study was conducted on a sample of 230 healthcare professionals, including 139 medical personnel and 91 non-medical staff respondents. The collected socio-demographic and organizational data and psychological tools were the Maslach Burnout Inventory (MBI HSS), the ECO System, and the emotional regulation questionnaire (ERQ). Results: For medical staff, burnout was measured in terms of emotional exhaustion (M = 27.05 ± 12.34), depersonalization (M = 8.26 ± 3.95), and personal accomplishment (M = 47.35 ± 6.78). The scores for non-medical staff were emotional exhaustion (M = 35.84 ± 14.71), depersonalization (M = 11.79 ± 6.30), and personal accomplishment (M = 44 ± 7.37). In terms of workload, higher scores were observed for non-medical staff (M = 25.43 ± 7.87), while medical staff recorded lower values (M = 20.35 ± 7.65). The scores for the cognitive reappraisal dimension were as follows: medical personnel (M = 32.02 ± 5.37) and non-medical staff (M = 31.67 ± 6.19). In terms of the expressive suppression dimension, medical staff registered at M = 17.99 ± 5.61, and non-medical staff registered at M = 17.19 ± 5.53. For organizational justice, higher scores were registered for medical staff (M = 25.87 ± 6.02) and lower scores for non-medical staff (M = 21.34 ± 5.72). Conclusions: Medical staff felt a higher sense of organizational justice than non-medical staff, as is also evidenced by the level of the workload dimension, which registers higher values for non-medical personnel. In the case of burnout, higher levels of emotional exhaustion and depersonalization dimensions were also revealed for non-medical staff and, in the case of the professional fulfillment dimension, higher scores were registered for medical staff. Burnout is a psychological response to prolonged periods of exposure to stress . The conBurnout can make an individual feel ineffective, exhausted, and distant in relation to work, thus limiting their productivity and success . It has Organizational psychosocial factors that can lead to stress, burnout, or other health problems are represented by excessive demands, a lack of control over the demands of a particular job, a lack of support from colleagues and supervisors, poor working relationships and management, and physical or verbal violence . The EurWorkload becomes overload when the demands of the job exceed human limits . This isThe concept of organizational justice was popularized by Adams’ equity theory , and it Medical staff, represented by nurses, doctors, pharmacists, physiotherapists, biologists, and psychologists, are characterized by demands with an increased degree of difficulty, responsibility, and strong commitment. Nurses, analyzed as an indispensable component of the healthcare workforce, spend most of their lives in healthcare facilities and constitute the largest professional group in the hospital ,12. The The administrative personnel of a hospital play the role of providing and processing the various data needed in the hospital’s decision-making process . Human RIn a meta-analysis conducted by Aronsson et al. , focusinShin et al.  investigA systematic review conducted by Bria et al.  among heThe objectives of this study are represented by an evaluation of the differences between the level of burnout, workload, and organizational justice experienced by medical and non-medical staff in Romanian healthcare units, as well as examining the mediating effect of organizational justice in the relationship between workload and burnout level and the moderating effect of emotional regulation in the relationship between workload and burnout. There is no previous research on burnout, organizational justice, workload, and emotional regulation that compares medical and non-medical staff in Romania.The hypotheses formulated for the research were the following:Hypothesis 1 (H1).There are significant differences in emotional exhaustion, personal accomplishment depersonalization, workload, and organizational justice between medical and non-medical staff.Hypothesis 2.1 (H2.1).Organizational justice mediates the relationship between workload and emotional exhaustion, while cognitive reappraisal moderates the relationship between them.As reported in previously published research, workload was found to be a predictor for burnout. In the case of nurses, the lack of organizational justice is identified when procedures and organizational matters become unfair, triggering, under these conditions, emotional exhaustion and depersonalization. As cognitive reappraisal was related to personal accomplishment and low levels of burnout ,32,33,34Hypothesis 2.2 (H2.2).Organizational justice mediates the relationship between workload and depersonalization, while expressive suppression moderates the relationship between them.As was mentioned earlier, expressive suppression was correlated with depersonalization. The results emphasized, in the scientific literature in the field of burnout, that in the case of healthcare personnel, emotional suppression can lead to depersonalization.Hypothesis 3 (H3).Cognitive reappraisal moderates the relationship between workload and depersonalization.Since cognitive reappraisal strategies were correlated with lower levels of burnout ,32,33,34A cross-sectional study using the snowball sampling method was conducted between 15 October and 30 November 2022. An online questionnaire was constructed for this research; it was distributed with the help of the Order of General Nurses, Midwives, and Nurses of Romania, the Association of Legal Advisers in Public Hospitals in Romania, and the Association of Quality Management Officers in Public Hospitals. In addition, the questionnaire was distributed in private and public university hospitals in Iasi, Constanta, Oradea, Cluj, Bucharest, and Timisoara, the main university cities.The inclusion criterion was that participants should be medical and non-medical staff currently employed in hospitals, clinics, and other public or private institutions in Romania. The exclusion criterion was that respondents filled in the questionnaires after the deadline.The questionnaire informed the participants about the purpose of the study and that the collected data would be used only for scientific purposes. Respondents were also informed that they could withdraw from the study at any time, without consequences. No incentives were given for completing the questionnaires. Participation in the current study was voluntary and the participants’ anonymity was assured. If participants agreed to this information, the questionnaire stated that their continued completion of the questionnaire signified their agreement to participate in the study.To calculate the required number of participants, a power analysis was performed using GPower software   for the (a)The first section collected socio-demographic and medical data, along with information about the type of institution, activity, length of experience in the field, and number of years at the current workplace.(b)The second section used psychological instruments to measure the level of burnout, workload, organizational justice, and emotional regulation.The questionnaire was constructed using the Google Forms application . The questionnaire had two sections:Burnout—The 22-item Maslach MBI human services survey (MBI-HSS) measuring instrument [I feel frustrated with my work ; I feel that I influence other people positively through my work ; and I’m not really interested in what is going on with many of my colleagues . High scores for emotional exhaustion and depersonalization dimensions and low scores for personal accomplishment correspond to higher levels of burnout. Burnout severity is classified according to the subscales, with a high score of emotional exhaustion and depersonalization   [strument  was usedensions) ,37,38,39Workload and organizational justice—the ECO system [O system  was usedO system . For theEmotional regulation—The emotion regulation questionnaire [ionnaire  was usedionnaire . On the The dependent variables considered for the present research were emotional exhaustion, depersonalization, and personal accomplishment. The independent variable taken into consideration was workload and organizational justice was considered as the mediating variable. Expressive suppression and cognitive reappraisal were considered moderating variables.All analyses for this research were performed using the IBM Statistical Package for Social Sciences (SPSS) Statistics 229 for Windows, version 29  for hypothesis testing and the statistical analysis of the data, then using the process extension  to perfoThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the Association of Legal Advisors from Public Hospitals in Romania, Research Ethical Agreement No. 54/15, September 2022.The sample consisted of 139 nurses and 91 administrative staff respondents. Most participants were female (94.3%), with an age of about M = 44.67 ± 8.19 for medical staff and M = 44.31 ± 9.30 for non-medical staff.The majority of them (85.7) were in a relationship, and 81.7% declared that they had at least one child. More than a quarter of them (26.5%) reported that they suffered from a chronic disease.Approximately 40% had a bachelor’s degree. Regarding their experience in the field, we identified that 41.7% had completed at least 20 years of employment, 87% of respondents had more than one job, 83.9% were working in a public institution, and 33.5% were working in an emergency unit.Almost one-fifth of the respondents declared that they had a managerial position. Detailed socio-demographic data are presented in p < 0.01). In the case of those working in the medical field, another strong, negative correlation exists, this time between organizational justice and emotional exhaustion , indicating that when the sense of justice in the workplace is higher, emotional exhaustion is lower and vice versa.As expected, significant, strong correlations between overload and emotional exhaustion can be observed across both work domains .There are significant differences in emotional exhaustion, personal accomplishment depersonalization, workload, and organizational justice between medical and non-medical staff.t-test was used. Thus, the results indicate that there are significant differences between the two groups in terms of emotional exhaustion (p < 0.001), personal accomplishment (p < 0.001), depersonalization (p < 0.001), workload (p < 0.001), and organizational justice (p < 0.001). Medical participants are significantly more professionally fulfilled and experience organizational justice significantly more strongly, while administrative staff experience significantly more emotional exhaustion, depersonalization, and workload.To test this hypothesis, an independent samples Hypothesis 2.1 (H2.1).Organizational justice mediates the relationship between workload and emotional exhaustion, while cognitive reappraisal moderates the relationship between them.Thus, a high workload leads to a low sense of organizational justice, and these, together, affect emotional exhaustion. Cognitive reappraisal moderates the relationship by interacting with overload, with the latter changing its effect strength as a function of cognitive reappraisal values. The moderated mediation model—Model 1 see —was applp < 0.001) was found. The effect of organizational justice on emotional exhaustion (path b1) was also significant . The direct effect of workload on emotional exhaustion (pathway c) was insignificant  but, in contrast, the indirect effect through organizational justice (pathway a1b1) was significant , indicating a total mediation.For nurses, a significant direct effect of workload on organizational justice , therefore the former was not a significant moderator. Thus, a sense of justice at work was a significant mediator in the mediation model. These results indicate that a high level of workload corresponds to a low level of justice, and ultimately, emotional exhaustion is felt more strongly. The mediation model explained 63% of emotional exhaustion .Finally, the total effect (pathway c’) was significant . The interaction between cognitive reappraisal and workload was not a significant one . All effects on emotional exhaustion were nonsignificant (p > 0.05), as was the interaction effect between reassessment and overload. Thus, for non-medical staff, the pattern is insignificant.For non-medical staff, workload had a significant direct effect on organizational justice .Organizational justice mediates the relationship between workload and depersonalization, while expressive suppression moderates the relationship between them.p < 0.001) was found, as well as on depersonalization . However, the effect of justice on depersonalization (pathway b) was insignificant , whereas the interaction between workload and expressive suppression was significant , resulting in significant moderation. The moderation model—Model 2 , while the Johnson–Neyman significance values indicated that the effect of workload on depersonalization becomes insignificant at the 60th percentile of emotional suppression scores. Thus, it appears that at low (−1SD) or medium suppression scores, the effect of workload on depersonalization is significant and positive, whereas, at high suppression scores (+1SD), a high workload does not result in high depersonalization, and the effect is insignificant.For medical staff, a significant direct effect of workload on justice , but no significant direct effect on depersonalization . Although the effect of justice on depersonalization (pathway b) was significant , the indirect effect was non-significant , as was that of moderator interaction, resulting in a non-significant moderated mediation model.For non-medical staff, workload had a significant direct effect on organizational justice .Cognitive reappraisal moderates the relationship between workload and depersonalization.p < 0.001) as was the moderator interaction effect . Thus, the moderation effect was significant, resulting in a moderation model explaining 23% of the variance in depersonalization  .p < 0.001), whereas, at medium levels of reappraisals, the effect decreased  but remained significant. In contrast, at high levels of reappraisals (+1SD), the effect became insignificant . Finally, the Johnson–Neyman significance values tell us that at the 63rd percentile of reappraisal scores, the effect of overload on depersonalization became insignificant, and at the 97th percentile, it became significant again but changed valence and became negative.It was observed that at low (−1SD) levels of reappraisals, the effect of workload on depersonalization was significant and positive , indicating that the moderation model was not significant for this subsample.In contrast, among non-medical staff, all effects on depersonalization were insignificant , they are likely to aspire to regain and maintain their emotional balance .The mediation model was also not significant in the case of non-medical staff, although a significant direct effect of workload on organizational justice was found. In the case of non-medical personnel, even if workload  has a significant effect on attitudes to organizational justice, the connection affects the way administrative staff feel about their professional competency, remuneration, or task distribution. Hence, the perception of organizational justice felt by respondents is not enough to prevent feelings of emotional exhaustion. Thus, even if participants feel that they are fairly treated by superiors and that their performance is valued, if they must complete too many duties, work harder than their colleagues, and engage in overtime, they will feel emotional exhaustion. Additionally, the moderating model by means of cognitive reappraisal, regarding the relationship between emotional overload and exhaustion, did not prove significant, either in the case of medical personnel or in the case of non-medical personnel. Facing a problem and having a positive attitude are not enough to prevent feelings of emotional exhaustion from being determined by overload. These results are consistent with those reported in other research, which has not demonstrated a link between the habitual use of reappraisal and levels of burnout . In the In the case of the mediation model between workload, organizational justice, and depersonalization for medical personnel, it was highlighted that a high level of workload can lead to feeling burnout through the depersonalization dimension. Overload has a direct effect on perceptions of organizational justice, as does depersonalization, but the mediating effect is insignificant. Under these conditions, organizational justice did not prove to be a significant mediator in the relationship between overload and depersonalization. Thus, we can say that regardless of the levels of organizational justice experienced by nurses, they can feel depersonalized in their relationship with the patient when they feel overwhelmed by the tasks they must complete. This is congruent with previous studies that correlated depersonalization with nursing insensitivity developed over time, after nurses had accumulated seniority in their specialty and experienced a high level of workload . In the The moderating model, workload–emotional suppression–depersonalization, was significant only in the case of medical personnel. Medical personnel are trained to deal with negative emotions, develop positive relationships with patients, control their emotions, and detach themselves from negative events. This lack of positive or negative emotions could reduce the level of depersonalization only in the case of medical personnel. In the case of non-medical personnel, the need to control emotions is less learned and practiced, and it may not be enough to alleviate feelings of detachment. Therefore, when overwork is significant, emotional regulation is not sufficient to mitigate the levels of depersonalization experienced by administrative staff.Previous studies showed that expressive suppression was associated with depersonalization, while cognitive reappraisal was related to personal accomplishment. These associations occurred in the expected direction; that is, expressive suppression was associated with a high level of burnout, while cognitive reappraisal strategies correlated with lower levels of burnout . EmotionConsidering the Johnson–Neyman values regarding the moderating effect of cognitive reappraisal in the relationship between workload and depersonalization, we can appreciate that for those with an average or below-average level of reappraisal, a high workload leads to high depersonalization; for those with an above-average level of reappraisal, overload becomes a nonsignificant predictor; in those with extremely high reappraisal, high workload leads to low depersonalization, indicating the importance of cognitive reappraisals, which may change the dynamics of the relationship between workload and depersonalization. For example, compensating for organizational inefficiencies by performing unnecessary tests/procedures creates internal conflict. Semmer et al.  demonstrAlthough, in the case of medical personnel, cognitive re-evaluation may matter, in the case of non-medical personnel, this is no longer valid; depersonalization takes place in non-medical personnel, regardless of the recorded cognitive re-evaluations. This contrasts with previous studies that consistently demonstrate a protective impact of cognitive reappraisal on burnout among health workers and other professionals in general ,56. TherThe strength of the present study is first due to its hypothesis, verified with Romanian medical staff; second, it is due to its generalizability, considering the fact that the questionnaire was distributed in the main regions in Romania. The limitations of the research are related to the fact that some of the variables were assessed with few items because the questionnaire already had many items; measuring all of them with whole scales would result in a very long questionnaire, which would certainly discourage participants from responding. However, the internal consistency measures of the dimensions used were very good. A second limitation is related to the samples, as we had a snowball sample. The sample showed good variability in most socio-demographic and occupational variables, which supports its heterogeneity and, therefore, the generalizability of these results to similar samples. Another limitation concerns the fact that all items were self-reported, which could lead to a possible overestimation of correlations between variables.Future studies should continue this research to include other categories of employees in health facilities, such as doctors and auxiliary staff, to check whether the mediation–moderation model has an effect in the case of other categories of health professionals. The results of the present study could help researchers in the future to focus on variables that are strong predictors of burnout and to test models that highlight the most successful outcomes in this regard. According to our results, the underlying variables appear to be organizational justice, workload, and cognitive reappraisal.Given that the results of the study are post-pandemic, we recommend those variables, paying particular attention to their patterns in healthcare services. However, overload should be further analyzed as a predictor of burnout, as well as emotional regulation as a protective factor against burnout. The results of the research showed that there is a need for objective feedback from both medical and non-medical staff. Constant evaluation of occupation stress and burnout, as well as identifying the level of satisfaction with one’s job, can guide and shape management staff intervention. Approaching burnout syndrome must be managed in a rigorous, scientific way, using methods such as assessment, monitoring, intervention, prevention, and paying increasing attention to vulnerable socio-professional categories. Regular consultations with the medical and non-medical staff regarding working conditions, quality of equipment, protocols, decisions, worktime, professional needs, etc., should also be considered.Medical staff feel a higher level of personal accomplishment and organizational justice than non-medical staff. Similarly, non-medical staff experience a higher level of overload, emotional exhaustion, and depersonalization.When mediators and moderators interfere, in the case of nurses, workload has a direct effect on organizational justice, which, in turn, directly affects emotional exhaustion, whereas cognitive reappraisal does not. Organizational justice was found to be a significant mediator in the relationship between workload and emotional exhaustion. Thus, the mediation model is significant, but the one concerning moderation by cognitive reappraisal in the relationship between workload and emotional exhaustion is insignificant. For non-medical staff, a significant direct effect of justice workload and justice on depersonalization was found. All of the effects regarding emotional exhaustion and the interaction between cognitive reappraisal and workload were nonsignificant.Workload directly affects organizational justice and depersonalization in the case of medical staff, but organizational justice does not directly affect depersonalization. Thus, organizational justice did not prove to be a reliable mediator between workload and depersonalization, neither in the case of medical personnel nor in the case of non-medical personnel. It was also found that expressive suppression has a moderating effect on the relationship between overload and depersonalization in the case of medical staff. The model is also not significant in the case of non-medical personnel, although overload directly affects organizational justice, which, in turn, directly affects depersonalization in the case of this category of personnel. Finally, in the case of medical staff, it was found that cognitive reappraisal moderates the relationship between overload and depersonalization; thus, the moderating effect proved significant. It was observed that at low levels of cognitive reappraisal, the effect of overload on depersonalization is significant and positive, while at medium levels of re-evaluation, the effect decreases but remains significant, and at high levels of re-evaluation, the effect becomes insignificant.


Public crises seriously affect social stability and personal health. When individuals are in a public crisis environment, they will have the impulse and intention to share information, which is a behavioral attitude shown in the face of a crisis. Public crisis information sharing intention will be affected by many factors. This study aims to examine how the process of social presence may influence information sharing intentions during a public crisis and the mediating effects of situational pressure, including risk perception of disease infection and consistency of perception of opinion climate.This was a cross-sectional study with 505 youth SNS users. In order to collect as suitable samples as possible, a research website was commissioned to conduct a questionnaire in the early stages of the COVID-19 pandemic in China. This questionnaire was utilized to measure social presence, risk perception of disease infection, consistency of perception of opinion climate and intention to share information about COVID-19. Structural equation modeling was used to examine variable relationships in the research model.B = 0.42, p < 0.001), consistency of perception of opinion climate  and intention to share information about COVID-19 . Risk perception of disease infection  and consistency of perception of opinion climate  positively predicted youth SNS users’ intention to share information about COVID-19. Risk perception of disease infection and consistency of perception of opinion climate mediated the relationship between social presence and intention to share information about COVID-19 .The results showed that social presence was significantly and positively associated with risk perception of disease infection  and perceived stress factors  may influence information sharing intention. From the perspective of communication psychology, this study enriched the assessment of information sharing on social media and contributes to understanding of social presence and situation pressure, and it helps to provide specific references for effectively promoting netizens’ intention to share information about public crises. During the COVID-19 pandemic, people have become increasingly dependent on the internet for access to and the sharing of information , and COVStudies have suggested that information sharing is influenced by both personal and social factors. The former refers to personal attitudes, positions, and intentions, while the latter refers to social factors such as interpersonal relationships, social structures, social networks, and family structures , 9. ConcIn our view, the intention to share information about COVID-19 reflects individual choice considerations, which is more hidden than actual information-sharing behavior and thus requires further study and exploration. Moreover, while not as tangible as the information-sharing behavior, studying the intention to share information has practical implications. Not all people share information, and many remain in an underlying state of consciousness, which we believe is more critical because its hidden and uncertain nature is more challenging for the long-term stability of society and the response to COVID-19. Finally, research into the intention to share information can guide individuals in regard to awareness and psychology and propose measures to improve mental health and the perception of COVID-19. Consequently, it is important to study the intention to share information on COVID-19.Currently, to prevent the adverse impact of COVID-19 on social stability and personal health, areas in China with a relatively higher case rate have adopted strict protective measures, asking residents to work and study from home and restricting travel and gatherings. As a result, people affected by the pandemic have turned to the internet for social and recreational activities that are not available offline. Tu  found thThe S-O-R model, developed from the S-R (Stimulus–Response) theory, is a theoretical model of environmental influence on individual behavior proposed by Mehrabian and Russell , namely In the context of a global pandemic, we believe that the stimulus should be the state in which individuals perceive the “real” presence of others in the Internet environment. Zhu et al.  studyingIn addition, we use social information processing (SIP) theory to support the S-O-R framework, which emphasizes the influence of situational factors on people’s attitudes and behaviors . SituatiFor the research model, using the S-O-R framework , we placThe use of social media as a form of digital media consumption enables audiences to connect, communicate, and share information . Especiavia social media , the data of respondents aged 45 and above were removed. Therefore, participants in this study were 14–44 year olds who used SNS. According to the 50th Statistical Report on China’s Internet Development, there are approximately 737 million netizens aged from 10 to 49 years old in China, accounting for 70.1% of total netizens . The six items for measuring social presence were identified based on the research by Lu, Fan, and Zhou  = 305.73, GFI = 0.935, AGFI = 0.914, RMSEA = 0.052, TLI = 0.951, CFI = 0.935, IFI = 0.959. The measurement model was evaluated using indicators of reliability and validity. Reliability of the constructs was tested with Cronbach’s α and composition reliability (CR) values, which should be above 0.700 . χ2(130) = 336.65, GFI = 0.929, AGFI = 0.907, RMSEA = 0.056, TLI = 0.944, CFI = 0.952, IFI = 0.952.As R2) and the significance of each path coefficient. The data analysis showed that social presence accounted for 13.6% of the variations in risk perception of disease infection and 16.6% of the variations in consistency of perception of opinion climate. Social presence, risk perception of disease infection, and consistency of perception of opinion climate explained 33.6% of the variation in the intention to share information.The structural model was evaluated using the coefficient of determination  and consistency of perception of opinion climate . SNS users with higher perception of social presence seemed to have a higher risk perception of COVID-19 infection and a greater consistency of perception of opinion climate. Thus, H4 and H5was supported. Social presence has a significant impact on SNS users’ intention to share information about COVID-19 , suggesting that when social presence increased, SNS users were more willing to share information about COVID-19. Thus, H3 was supported. Risk perception of disease infection  and consistency of perception of opinion climate  positively predicted SNS users’ intention to share information about COVID-19, implying that the higher the risk perception or the consistency of perception of opinion climate, the greater their intention to share information about COVID-19. Thus, H1 and H2 was supported  and perceived stress factors  may influence information sharing intention. From a communication psychology perspective, this study enriches the assessment of social media information sharing, contributes to the understanding of social presence and situational pressure, and helps to provide specific references for effectively promoting netizens’ intention to share information about public crises.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Academic Board of the School of Journalism and communication, Chongqing University . Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.XG and HJ: conceptualization. HJ: data curation, formal analysis, methodology, and writing – original draft. XG: funding acquisition and project administration. HJ and TQ: investigation. XG, HJ, and TQ: writing – review and editing. All authors contributed to the article and approved the submitted version.This survey was approved by the National Social Science Fund of China (no. 22BXW15) and Fundamental Research Fund for the Central Universities (no. 2020CDJSK07PY23).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.