Gastrocolic ligament lymph-node dissection may increase the incidence of delayed gastric emptying after colon cancer surgery with D3 lymphadenectomy.

PURPOSE: Delayed gastric emptying (DGE) is associated with prolonged hospital stay and higher healthcare costs. This study aimed to investigate the risk factors for DGE after D3 radical resection for colon cancer and to build a nomogram for this complication. METHODS: We analyzed, retrospectively, 1160 consecutive patients who underwent surgery with D3 lymphadenectomy for colon cancer between January, 2012 and June, 2018. A multivariate logistic regression analysis was used to identify the risk factors for DGE and to build a DGE nomogram model. RESULTS: There were ten, six and four patients with DGE classified as grades A, B and C, respectively, representing a DGE rate of 1.7%. Multivariate analysis revealed that age (P = 0.001), dissection of the gastrocolic ligament lymph nodes (GCLNs) (P = 0.001), surgical duration (P = 0.017) and preoperative hemoglobin level (P = 0.016) were independent risk factors, and were included to build a predictive model for DGE. The therapeutic index of GCLN dissection was approximately half that of D3 lymphadenectomy (2.9 vs. 5.6). CONCLUSIONS: DGE is more likely to develop in patients aged > 75 years, those with a preoperative hemoglobin < 90 g/L, those with a surgical duration > 210 min, and those who undergo GCLN dissection. The nomogram may facilitate the stratification of patients at risk for DGE following D3 lymphadenectomy for colon cancer. Assessing long-term outcomes will help to evaluate the survival benefit of GCLN dissection in the future, to avoid unnecessary dissection and reduce the incidence of DGE.

Atractylenolide III Ameliorates TNBS-Induced Intestinal Inflammation in Mice by Reducing Oxidative Stress and Regulating Intestinal Flora.

The present study aimed to explore the therapeutic effects of the main active ingredients of Atractylodes macrocephala on the 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced mouse colitis model. TNBS-induced colitis was established in mice, which were treated with 8-ß-Hydroxyasterolide (Atractylenolide III) for 14 days. The body weight of the mice in the middle and high dose groups of Atractylenolide III was increased compared with that of the model group. The disease activity index score was significantly reduced. The activity levels of myeloperoxidase were significantly decreased following increase in the dosage of Atractylenolide III, as determined by histological analysis. Moreover, Atractylenolide III downregulated the expression levels of the inflammatory factors interleukin-1ß and tumor necrosis factor-α, and greatly suppressed the levels of the pro-oxidant markers, reactive oxygen species and malondialdehyde, while enhancing the expression levels of the antioxidant enzymes catalase, superoxide dismutase and glutathione peroxidase. The protein expression levels of formyl peptide receptor 1 (FPR1) and nuclear respiratory factor 2 (Nrf2) were upregulated in the colonic tissues of TNBS-treated mice. This effect was effectively reversed by Atractylenolide III treatment. In vivo studies indicated that TNBS alone induced a decrease in the abundance of lactobacilli and in the biodiversity of the colon. In conclusion, the present study suggested that Atractylenolide III attenuated TNBS-induced acute colitis by regulating oxidative stress via the FPR1 and Nrf2 pathways and by affecting the development of intestinal flora.

A nomogram for predicting rectovaginal fistula after low anterior resection for rectal cancer.

PURPOSE: Rectovaginal fistula (RVF) is a complicated and troublesome complication of low anterior resection (LAR) for rectal cancer. We aimed to investigate the risk factors for post-LAR RVF and develop a predictive nomogram. METHODS: We performed a retrospective analysis of 821 female patients with rectal cancer who underwent LAR between October 2010 and October 2018. Logistic regression was performed to identify risk factors. A nomogram was developed to predict RVF. RESULTS: The incidence of post-LAR RVF was 3.4% (28/821). A multivariate analysis showed that the preoperative serum hemoglobin level (OR 2.449, 95% CI 1.144-5.239), the distance between the tumor and anal verge (OR 4.158, 95% CI 1.392-12.418), surgical procedure (OR 2.369, 95% CI 1.117-5.027), hysterectomy (OR 2.996, 95% CI 1.106-8.833), and bilateral oophorectomy (OR 5.823, 95% CI 1.639-20.689) were significantly associated with the development of RVF. A nomogram was developed, which showed a C-index of 0.824 (95% CI 0.730-0.918) and an adjusted C-index of 0.790. CONCLUSION: This study identified the preoperative serum hemoglobin level, the distance between the tumor and the anal verge, the type of surgical procedure, hysterectomy, and bilateral oophorectomy as predictors of post-LAR RVF. A nomogram was successfully developed. It could aid in the prediction of RVF in patients undergoing LAR.

Genus Periploca (Apocynaceae): A Review of Its Classification, Phytochemistry, Biological Activities and Toxicology.

The genus Periploca belongs to the family Apocynaceae, which is composed of approximately ten species of plants according to incomplete statistics. Most of these plants serve as folk medicines with a long history, especially Periploca sepium and Periploca forrestii. The botanical classifications, chemical constituents, biological activities and toxicities of the genus Periploca were summarized in the literature from 1897 to early 2019. Though the botanical classification of this genus is controversial, these species are well-known to be rich sources of diverse and complex natural products-above all, cardiac steroids and C21 pregnane steroids with special structures and obvious pharmacological activities. The various crude extracts and 314 isolated metabolites from this genus have attracted much attention in intensive biological studies, indicating that they are equipped with cardiotonic, anti-inflammatory, immunosuppressive, antitumor, antimicrobial, antioxidant, insecticidal and other properties. It is noteworthy that some cardiac glycosides showed hepatotoxicity and cardiotoxicity at certain doses. Therefore, in view of the medical and agricultural value of the genus Periploca, in-depth investigations of the pharmacology in vivo, the mechanisms of biological actions, and the pharmacokinetics of the active ingredients should be carried out in the future. Moreover, in order to ensure the safety of clinical medication, the potential toxicities of cardiac glycosides or other compounds should also be paid attention. This systematic review provides an important reference base for applied research on pharmaceuticals and pesticides from this genus.

High rates of depression anxiety and suicidal ideation among inpatients in general hospital in China.

Objective: To investigate the prevalence rates of depression anxiety and suicidal ideation among Chinese general hospital inpatients and to identify the potential associations with sociodemographics. Method: A cross-sectional survey was applied in a Chinese general hospital. A questionnaire set, including sociodemographic variables, Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder Scale-7 (GAD-7), was completed by the participants. Clinically significant depression (CSD) and clinically significant anxiety (CSA) were defined as a score above 10 on the two scales. CSD and CSA are proxy measures but not specific diagnoses of mental disorders. Results: Data from 1329 patients were included in the final analysis. 422 (31.8%) reported clinically significant depressive symptoms, 83 (6.3%) reported frequent suicidal ideation, and 204 (15.3%) reported clinically significant anxiety. Household income was negatively associated with CSD. Inpatients with lower household incomes and educational levels had higher rates of CSA. Middle-aged inpatients were more prone to suicidal ideation, and stable marital status was related to less suicidal ideation. Conclusion: Depression, anxiety, and suicidal ideation were determined to be common psychological problems in Chinese inpatients. Chinese medical personnel must pay attention to the mental health conditions of inpatients, particularly inpatients with lower income, educational levels, and poor marital status. Key Points This is one of the first studies focusing on the prevalence of depression and anxiety in Chinese hospitalized inpatients in non-psychiatric departments of a general hospital. The PHQ-9 and GAD-7 were determined to be potential screening tools to aid Chinese medical workers in recognizing depression and anxiety in nonpsychiatric departments. The prevalence of depression, anxiety and suicidal ideation was observed to be relatively high in inpatients, which requires more attention from Chinese clinicians.

The development and validation of Huaxi emotional-distress index (HEI): A Chinese questionnaire for screening depression and anxiety in non-psychiatric clinical settings.

BACKGROUND: Depression and anxiety among general hospital patients are common and under-recognized in China. This study aimed toward developing a short questionnaire for screening depression and anxiety in non-psychiatric clinical settings, and to test its reliability and validity. METHODS: The item pool which included 35 questions about emotional distress was drafted through a comprehensive literature review. An expert panel review and the first clinical test with 288 general hospital patients were conducted for the primary item selection. The second clinical test was performed to select the final item in 637 non-psychiatric patients. The reliability and validity of the final questionnaire were tested in 763 non-psychiatric patients, in which 211 subjects were interviewed by psychiatrists using Mini International Neuropsychiatric Interview (MINI). Multiple data analysis methods including principal components analysis (PCA), item response theory (IRT), and receiver operating characteristic (ROC) curve were used to select items and validate the final questionnaire. RESULTS: The series selection of items resulted in a 9-item questionnaire, namely Huaxi Emotional-distress Index (HEI). The Cronbach's α coefficient of HEI was 0.90. The PCA results showed a unidimensional construct. The area under the ROC curve (AUC) was 0.88 when compared with MINI interview. Using the optimal cut-off score of HEI (≥11), the sensitivity and specificity were 0.880 and 0.766, respectively. CONCLUSIONS: The HEI is considered as a reliable and valid instrument for screening depression and anxiety, which may have substantial clinical value to detect patients' emotional disturbances especially in the busy non-psychiatric clinical settings in China.

Validation of the Chinese version of the PHQ-15 in a tertiary hospital.

BACKGROUND: This study aimed to investigate the reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-15) in a tertiary hospital. METHODS: Using a cross-sectional study design, the Chinese version of the PHQ-15 was administered to a total of 1329 inpatients. To examine the discriminant validity of this questionnaire, we investigated the correlation of the PHQ-15 score with sociodemographic data and the PHQ-9 and GAD-7 scale scores. Exploratory factor analysis was performed to assess the internal consistency of the PHQ-15. To evaluate the consistency of this questionnaire with item response theory (IRT), IRT analysis was performed. RESULTS: The Chinese version of the PHQ-15 showed good reliability (Cronbach's alpha = 0.83). The correlations of the PHQ-15 scores with the PHQ-9 depression scale scores (r = 0.565) and the GAD-7 anxiety scale scores (r = 0.512) were moderate; these results suggested that the PHQ-15 had discriminant validity. We identified three factors, referred to as "cardiopulmonary," "gastrointestinal," and "pain/neurological," which explained 56 % of the total variance. A second-order factor analysis including these three factors produced an acceptable model. Several items (4, 8 and 11) displayed extreme floor effects. Additionally, item 4 displayed a very small variance of 0.35 and showed very small differences in its thresholds based on IRT analysis. CONCLUSIONS: The PHQ-15 scale had good reliability and high validity to detect patients with high somatic symptom severity in a Chinese tertiary hospital. Several of the current findings were consistent with previous research on the PHQ-15 in Western countries and in China. To improve the diagnostic quality of this questionnaire, items 4, 8 and 11 can be omitted.

Impacts of semi-transparent window on reflectance from metallic gratings at oblique incidence.

This work both numerically and experimentally investigates the reflectance from the smooth side of a semi-transparent 508-µm-thick window with metallic gratings attached on the other side. The incident light is oblique and linearly polarized, and its wavelength ranges from 2.5 to 25 µm. Three gratings with various levels of profile complexity and periods are investigated. Influences from the intrinsic material absorption, light refraction, total internal reflection, interference, and diffraction on both the specular and hemispherical reflectance are studied. Moreover, the applicability of effective medium theory to our samples is verified.

[Content of mineral elements of Gastrodia elata by principal components analysis].

OBJECTIVE: To study the content of mineral elements and the principal components in Gastrodia elata. METHOD: Mineral elements were determined by ICP and the data was analyzed by SPSS. RESULT: K element has the highest content-and the average content was 15.31 g x kg(-1). The average content of N element was 8.99 g x kg(-1), followed by K element. The coefficient of variation of K and N was small, but the Mn was the biggest with 51.39%. The highly significant positive correlation was found among N, P and K . Three principal components were selected by principal components analysis to evaluate the quality of G. elata. P, B, N, K, Cu, Mn, Fe and Mg were the characteristic elements of G. elata. CONCLUSION: The content of K and N elements was higher and relatively stable. The variation of Mn content was biggest. The quality of G. elata in Guizhou and Yunnan was better from the perspective of mineral elements.

[Study on sustainable development of industy of ethnic medicine in minority area].

Ethnic medicine industry is facing many problems such as narrow market, exhaustion of resource, decline of ethnic medicine and no qualified successors. Sustainable development theory was utilized to analyse the elements and problems of ethnic medicine industry, and the counter measures were put forward to get rid of the predicament and to realize the sustainable development which depends on the ethnic medicine resources, national medicine, industrial policy, personnel training and modern technology. The development issues of ethnic medicine industry can be solved by the coordination of enterprise, government and public. Finally the ethnic medicine can provide better services for society.

[Research on life history and phenological period of wild-stimulated cultivated Gastrodia elata f. elata in Guizhou].

In order to get to know the imitation of wild Gastrodia elata in life history and phenology period, by G. elata f. elata forest wild simulated cultivation in Dafang county, Guizhou province, observing and recording its morphological characteristics of each growth and development stage. This experiment summarized the law of its life history over 24 months, amplified the characteristics of each 5 phenology periods over the sexual and asexual reproduction of wild simulated cultivated G. elata f. elata in Guizhou. Which the results could clear the process of wild simulated cultivated G. elata f. elata in Guizhou, and provide a theoretical support for the standard technical of the simulated wild G. elata.

HPLC-based metabolomics of Dendrobium officinale revealing its antioxidant ability.

Dendrobium officinale is an orchid with medicinal and nutritional properties that has received increasing attention because of its health benefits; however, there is limited information about the metabolic basis of these properties. In this report, secondary metabolites and the antioxidant activity of D. officinale stem samples from three provenances were analyzed, using a UHPLC-QqQ-MS/MS-based metabolomics approach. In total, 411 metabolites were identified including 8 categories such as flavonoids and phenolic acids, 136 of which were differential metabolites. These differentially accumulated metabolites (DAMs) were mainly enriched in secondary metabolic pathways such as flavone, flavonol, tropane, piperidine, pyridine, isoquinoline alkaloid biosynthesis and tyrosine metabolism. The metabolomic profiling suggested that the quantity and content of flavonoid compounds accounted for the highest proportion of total metabolites. Hierarchical cluster analysis (HCA) showed that the marker metabolites of D. officinale from the three provenances were mainly flavonoids, alkaloids and phenolic acids. Correlation analysis identified that 48 differential metabolites showed a significant positive correlation with antioxidant capacity (r ³ 0.8 and p < 0.0092), and flavonoids were the main factors affecting the different antioxidant activities. It is worth noting that quercetin-3-O-sophoroside-7-O-rhamnoside and dihydropinosylvin methyl ether might be the main compounds causing the differences in antioxidant capacity of Yunnan provenance (YN), Zhejiang provenance (ZJ), and Guizhou provenance (GZ). These finding provides valuable information for screening varieties, quality control and product development of D. officinale.

Identification of the NAC Transcription Factor Family during Early Seed Development in Akebia trifoliata (Thunb.) Koidz.

This study aimed to gain an understanding of the possible function of NACs by examining their physicochemical properties, structure, chromosomal location, and expression. Being a family of plant-specific transcription factors, NAC (petunia no apical meristem and Arabidopsis thaliana ATAF1, ATAF2, and CUC2) is involved in plant growth and development. None of the NAC genes has been reported in Akebia trifoliata (Thunb.) Koidz (A. trifoliata). In this study, we identified 101 NAC proteins (AktNACs) in the A. trifoliata genome by bioinformatic analysis. One hundred one AktNACs were classified into the following twelve categories based on the phylogenetic analysis of NAC protein: NAC-a, NAC-b, NAC-c, NAC-d, NAC-e, NAC-f, NAC-g, NAC-h, NAC-i, NAC-j, NAC-k, and NAC-l. The accuracy of the clustering results was demonstrated based on the gene structure and conserved motif analysis of AktNACs. In addition, we identified 44 pairs of duplication genes, confirming the importance of purifying selection in the evolution of AktNACs. The morphology and microstructure of early A. trifoliata seed development showed that it mainly underwent rapid cell division, seed enlargement, embryo formation and endosperm development. We constructed AktNACs co-expression network and metabolite correlation network based on transcriptomic and metabolomic data of A. trifoliata seeds. The results of the co-expression network showed that 25 AtNAC genes were co-expressed with 233 transcription factors. Metabolite correlation analysis showed that 23 AktNACs were highly correlated with 28 upregulated metabolites. Additionally, 25 AktNACs and 235 transcription factors formed co-expression networks with 141 metabolites, based on correlation analysis involving AktNACs, transcription factors, and metabolites. Notably, AktNAC095 participates in the synthesis of 35 distinct metabolites. Eight of these metabolites, strongly correlated with AktNAC095, were upregulated during early seed development. These studies may provide insight into the evolution, possible function, and expression of AktNACs genes.

[Study on germination characteristics of Disporum cantoniense].

OBJECTIVE: To study the seed germination characteristic and optimal germination condition of wild Disporum cantoniense. METHODS: Used wild Disporum cantoniense seed as the test materials, the rate of water absorption of the seed was determined. The germination rates under different conditions, along a temperature gradient (15, 20, 25 and 30 degres C), in light or dark, on top or between wet filter papers, and keeping or removing the seed coat, were determined respectively using petri dish method. At the same time germination trends were observed. RESULTS: The thousand seed weight was 33.24 g, and the seed water-absorbing reached saturation pot after soaking for 30 h. Higher germination rates were respectively recorded at 25 degrees C, between filter papers, and in dark after 24 h soaking in the pretreatment solution. CONCLUSION: The optimal condition for the germination of the seed of wild Disporum cantoniense is as follow: keeping testa, seed soaking for 24 h in seed germination agent and being incubated between wet filter papers in dark at 25 degrees C.

Atractylenolide III inhibits epithelial­mesenchymal transition in small intestine epithelial cells by activating the AMPK signaling pathway.

Compared with the available drugs for the treatment of fibrosis in other organs, the development of intestinal anti­fibrosis drugs is limited. Therefore, it is of practical significance to examine novel drugs to delay or block the development of intestinal fibrosis. The present study aimed to investigate the effect of atractylenolide III (ATL­III) on intestinal fibrosis. An MTT assay was used to detect the effect of ATL­III on the activity of IEC­6 cells. The migration and invasion of fibrotic cells stimulated with TGF­ß were determined via wound healing and Transwell assays. An immunofluorescence assay and western blotting were conducted to assess the expression levels of protein associated with epithelial­mesenchymal transition (EMT). The role of the AMP­activated protein kinase (AMPK) pathway was verified using compound C (an AMPK inhibitor) treatment. The results of the present study indicated that ATL­III had no effect on the cells at a dose of 1­20 µmol/l. Moreover, ATL­III can inhibit the invasion and migration of cells induced by TGF­ß1, as well as block the EMT process. It was found that ATL­III could also activate the AMPK pathway. Furthermore, compound C reduced the inhibitory effect of ATL­III on stimulated cells, which indicated that the AMPK pathway plays a role in the inhibition process. In conclusion, ATL­III may inhibit the EMT of IEC­6 cells stimulated with TGF­ß1 by activating the AMPK signaling pathway.

Surgical Treatment of SplenicFlexure Colon Cancer: Analysisof Short-Term and Long-Term Outcomes of Three DifferentSurgical Procedures.

Background: The aim of this study was to compare the short- and long-term outcomes of splenic flexure colectomy (SFC), left hemicolectomy (LHC) and extended left hemicolectomy (ELHC) for splenic flexure colon cancer. Methods: Between January 2011 and December 2018, 117 patients with splenic flexure cancer were enrolled in the study. We retrospectively compared the postoperative, pathological and long-term outcomes of patients with splenic flexure cancer. Results: Of the 117 patients, 73 (62.4%) underwent SFC, 22 (18.8%) underwent LHC, and 22 (18.8%) underwent ELHC. No statistically significant differences were found among the groups regarding postoperative complications, pathological data or recurrence. No metastatic lymph nodes at the root of the inferior mesenteric artery (IMA) were observed; lymph node metastasis appeared at the root of the middle colic artery (MCA), but in a low proportion of cases (4.4%). Looking at long-term prognosis, no differences were observed among the three groups regarding both 5-year overall survival (94.0% vs 90.2% vs 94.1%) and disease-free survival (88.2% vs 90.2% vs 83.0%). Conclusion: Our retrospective review suggests that splenic flexure colectomy in minimally invasive surgery is a safe and effective treatment option for splenic flexure colon cancer. The rate of metastatic lymph nodes at the root of the central artery and gastroepiploic arcade node was relatively low.

Stereochemical insights into neuroprotective alkaloids from the aerial parts of Emilia sonchifolia.

A new alkaloid featured with a dibenz[c,e]azepin-5-one scaffold, namely emililactam A (3), together with a known pyrrolidine alkaloid (emilisonchine, 1) and a known flavonoid alkaloid [8-(2″-pyrrolidinone-5″-yl)-quercetin, 2] were isolated from the aerial parts of Emilia sonchifolia. Compounds 1 and 2 were isolated as racemic forms which were further separated, for the first time, to their corresponding enantiomers [(+)-1/(-)-1 and (+)-2/(-)-2], respectively, by using chiral-phase HPLC. The structure of new compound 3 was elucidated by extensive spectroscopic analysis. In addition, the absolute configurations of optically pure (+)-1/(-)-1 and (+)-2/(-)-2 were determined by the time-dependent density functional theory electronic circular dichroism (TDDFT-ECD) calculations. In an in vitro bioassay, compounds (+)-1, (-)-1, (±)-1, and 3 exhibited moderate neuroprotective effects against corticosterone-induced injuries of PC12 cells.

Collagen score in the tumor microenvironment predicts the prognosis of rectal cancer patients after neoadjuvant chemoradiotherapy.

BACKGROUND AND PURPOSE: Little is known about the relationship between collagen and the prognosis of patients with locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (nCRT). This study aimed to quantitatively analyze collagen alterations, establish a collagen score (CS) in the tumor microenvironment, and evaluate and validate the relationship of the CS with prognosis in these patients. MATERIALS AND METHODS: A total of 365 primary patients diagnosed with LARC after nCRT between 2011 and 2018 were retrospectively reviewed (training cohort: 210; independent validation cohort: 155). Multiple collagen features of two fields in the tumor microenvironment, the core of the tumor (CT) and the invasive margin (IM), were derived from multiphoton imaging, and the CSIM-CT was generated using least absolute shrinkage and selection operator (LASSO) Cox regression analysis. RESULTS: The CSIM-CT was created based on 3 features: collagen area, number of collagen fibers and a Gabor textural feature. In the training cohort, the CSIM-CT predicted 3-year disease-free survival (DFS) with an area under the receiver operating characteristic curve (AUROC) of 0.765 (0.675-0.854) and an overall survival (OS) with AUROC of 0.822 (0.734-0.909). Additionally, the CSIM-CT was significantly associated with DFS and OS in the two cohorts. A nomogram with the CSIM-CT was developed and showed good prognostic value predicting a 3-year DFS with an AUROC of 0.826 (0.748-0.905) and an OS with AUROC of 0.882 (0.803-0.960). CONCLUSIONS: The CSIM-CT is an effective prognostic marker in patients with LARC after nCRT, and the nomogram with the CSIM-CT can be used to accurately predict the individual prognosis of these patients.

Workplace factors can predict the stress levels of healthcare workers during the COVID-19 pandemic: First interim results of a multicenter follow-up study.

Background: Research is lacking on the long-term influence of workplace factors on the mental health of health care workers during the COVID-19 pandemic. Methods: We distributed two online surveys to health care workers between May and October 2020 (T1) and between February and April 2021 (T2). Perceived stress, coronavirus-related risks, and workplace factors were measured via self-report questionnaires at both time points. We conducted hierarchical linear regression to investigate the predictive factors for high stress. Results: A total of 2,110 participants from seven countries and 4,240 participants from nine countries were enrolled at T1 and T2, respectively. Among them, 612 participated in both surveys. We called this cohort T1 + T2. High stress was reported in 53.8 and 61.6% of participants at T1 and T2, respectively. In cohort T1 + T2, compared with the baseline, the level of stress rose significantly (6.0 ± 2.9 vs. 6.4 ± 3.1), as did health/safety in the workplace (3.9 ± 0.8 vs. 4.2 ± 0.7). Unfortunately, we did not detect any significant difference concerning support in the workplace. Among all factors at baseline, being older than 35 [ß (95% CI) = -0.92 (-1.45, -0.40)], support [-0.80 (-1.29, -0.32)], and health/safety in the workplace [-0.33 (-0.65, -0.01)] were independent protective factors, while a positive history of mental disorders [0.81 (0.26, 1.37)] and rejection in private life [0.86 (0.48, 1.25)] were risk factors for high stress at T2. Conclusion: To relieve the high stress of health care workers, organizational-level approaches should be implemented, especially measures designed to enhance support, health/safety in the workplace, and to reduce the rejection of the public.