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Background: Patients with sepsis with low albumin levels and high red blood cell distribution width levels have poor prognoses. Red blood cell distribution width to albumin ratio (RAR) has recently attracted attention as an innovative inflammation biomarker. We aimed to explore the association between RAR and the prognosis of patients with sepsis. Methods: This retrospective observational study included 402 patients meeting the sepsis-3 standards admitted to Yantai Yuhuangding Hospital's intensive care units (ICUs) between January 2020 and December 2022. The relationship between RAR and mortality in patients with sepsis was examined using regression analysis, Kaplan–Meier analyses, and a receiver operating characteristic curve. Subgroup and sensitivity analyses were conducted to assess the results' robustness. Results: RAR, when considered as a continuous variable, was a significant independent in-hospital mortality risk factor (adjusted odds ratio [OR]: 1.383; 95% confidence interval [CI]: 1.164–1.645; P < 0.001). When considering RAR as a categorical variable, the ORs (95% CIs) of hospital mortality for quartile 2 (Q2), Q3, and Q4 compared with Q1 were 1.027 (0.413–2.551), 3.632 (1.579–8.354), and 4.175 (1.625–10.729), respectively, P < 0.001. Similar outcomes were observed for 28- and 90-day mortalities. Conclusions: RAR may indicate clinical prognosis for patients with sepsis in the ICU, potentially providing a low-cost, easily repeatable, and accessible biomarker for risk categorization for these patients. [ABSTRACT FROM AUTHOR]

Background: High-dose cytarabine (HDAC) is commonly used for consolidation therapy in young acute myeloid leukemia (AML) patients, but the dosage of cytarabine is still controversial in the clinic due to its obvious post-chemotherapy adverse effects. The aim of this study was to contrast the efficacy in different dose groups of cytarabine after consolidation therapy in Chinese AML patients. Methods: AML patients treated with cytarabine consolidation at Qilu Hospital, Shandong University from January 2010 to September 2022 were retrospectively analyzed, from which 346 AML patients with relatively complete follow-up data were selected for this study. We compared the patients' overall survival (OS) rate, relapse-free survival (RFS) rate, and hematologic adverse events in terms of their general characteristics, cytarabine consolidation therapy dose, consolidation course, 2022 European Leukemia Net (ELN) risk stratification, and transplantation. Results: In AML patients under 60 years of age, the 5-year RFS rate with high-dose cytarabine consolidation therapy was superior to that of small-dose cytarabine (P = 0.024), while the 5-year RFS rate was comparable in the high-dose and intermediate-dose groups, and there was no obvious difference among the three groups in the 5-year OS rate (P > 0.05). OS and RFS of those given more than 3 courses of cytarabine consolidation therapy were better than those in the 1–2 courses group (P = 0.060, P = 0.040). OS and RFS were better in patients with cumulative dose of cytarabine ≥ 36g than in patients with cumulative dose < 36g (P < 0.05), but cumulative dose ≥ 54g was comparable in OS and RFS with ≥ 36–< 54g group (P > 0.05). There was no significant difference in hematologic adverse effects among the three treatment groups. In the latest ELN risk stratification favorable-risk group, the cumulative dose of cytarabine ≥ 36g had a better 5-year RFS rate than the < 36g group (P = 0.038), and in the intermediate-risk group the 5-year OS rate and RFS rate were better in the ≥ 36g group than the < 36g group (P = 0.012, 0.025). In addition, the prognosis of transplanted patients was better than that of non-transplanted patients, whereas in non-transplanted patients, consolidation therapy with ≥ 36g cytarabine can effectively improve outcomes. Multivariate analysis indicated that age, fibrinogen (FIB) and the cumulative dose of cytarabine of ≥ 36–< 54g were predictors of OS, while age, white blood cell (WBC) and HDAC were predictors of RFS. Conclusion: The results of the study showed that consolidation therapy with cytarabine up to a cumulative dose of ≥ 36–< 54g in AML patients who did not undergo transplantation significantly improved patient prognosis. In the latest ELN risk stratification, cumulative doses of cytarabine ≥ 36g had a better prognosis in favorable and intermediate-risk patients. [ABSTRACT FROM AUTHOR]

Affective empathy is generally considered an important inhibitor of aggression. However, the meta-analysis studies on the relationship between affective empathy and aggression have challenged this common-sense view and found no substantial correlation between the two variables. We proposed a double-edged sword model to explain this counterintuitive phenomenon and tested this model by establishing an inconsistent mediation model. A total of 663 college students in China (59.1% female; Mage = 20.69 years) completed questionnaires measuring affective empathy, sympathy, personal distress, anger proneness, and physical aggression. The results showed that on the one hand, affective empathy can indirectly inhibit physical aggression by increasing sympathy; on the other hand, affective empathy can indirectly promote physical aggression through the serial mediation of personal distress and anger proneness. Such two pathways offset each other, leading to an insignificant relation observation between affective empathy and physical aggression. The findings revealed the complexity of the relationship between affective empathy and aggression, which suggested that more efforts to reduce aggression should be made to develop individuals' sympathy, while affective empathy training should be moderate to avoid excessive empathic emotional arousal. [ABSTRACT FROM AUTHOR]

Simple Summary: Palbociclib is one of the preferred treatments for hormone-receptor-positive, HER2-negative metastatic breast cancer in women; its effectiveness and safety in the Chinese real-world population require further investigation. Our study aimed to identify the clinical outcomes of patients who received palbociclib in combination with endocrine therapy (ET) in China. The effectiveness of palbociclib plus ET in treating metastatic breast cancer was confirmed in 397 Chinese patients across eight clinical sites. The regimens were well tolerated by both the general and elderly groups. However, some factors were identified as potential hindrances to the therapy's benefits, including higher Ki-67 expression, primary resistance to ETs, liver metastases, more metastatic sites, later line of therapy, and the use of fulvestrant instead of aromatase inhibitors. Palbociclib is useful for treatment of metastasis breast cancer, and our study may provide a basis for further research. Background: Palbociclib has been approved for marketing in China. However, its effectiveness, safety, and latent variables in the Chinese population require further investigation. Methods: Information was retrieved from 397 patients with metastatic breast cancer (mBC) who received at least two cycles of palbociclib plus endocrine therapy (PAL plus ET) at eight clinical sites in China. The patients' demographic characteristics, treatment patterns, and adverse events (AEs) were analyzed. Results: The objective response rate (ORR) and clinical benefit rate (CBR) for PAL plus ET were 28.97% and 66.25%, respectively. The median PFS was 14.2 months in the whole population. In addition to protein Ki-67 status and sensitivity to ETs, no liver metastases, fewer metastatic sites, an earlier line of therapy, and treatment combined with AI instead of FUL were also considered as independent prognostic factors for PAL treatment. Administration of PAL was generally well tolerated in patients with hormone-receptor-positive and human-epidermal-growth-factor-receptor-2-negative (HR+/HER2−) advanced breast cancer (ABC). The therapy was safe in the elderly population, which is consistent with the outcomes of the whole population and previous reports. Conclusions: In this most widely distributed study in China to date, palbociclib combined with ET proved its effectiveness for HR+/HER2− ABC treatment, and adverse events were manageable. Here, we identified some independent prognosis factors, but the mechanism by which these factors influence effectiveness requires further verification. [ABSTRACT FROM AUTHOR]

Objectives Mortality of dermatomyositis patients positive with anti-melanoma differentiation-related gene 5 antibody (anti-MDA5-DM) is alarming, especially during the first several months. Infection is an important cause of early death. As there are no reports regarding the effect of prophylactic use of compounded sulfamethoxazole (coSMZ; each tablet contains 400 mg of sulfamethoxazole and 80 mg of trimethoprim) in anti-MDA5-DM patients, we conducted this study to evaluate the efficacy of coSMZ in reducing the incidence of Pneumocystis jirovecii pneumonia (PJP). Methods Consecutive patients with new-onset anti-MDA5-DM from June 2018 to October 2021 in our centre were retrospectively reviewed for >12 months. They were divided into two groups—coSMZ and non-coSMZ—based on the initial use of prophylactic coSMZ. Mortality and the incidence of severe infection within 12 months were compared between two groups. Results Compared with the non-coSMZ group (n  = 93), the coSMZ group (n  = 121) had lower mortality (18.8% vs 51.1%; P   <  0.001) and a lower incidence of PJP (6.8% vs 15.2%; P  = 0.040) and fatal infection (16.1% vs 3.3%; P  = 0.001) during the first 12 months from diagnosis. After adjusting for age, gender, disease duration, peripheral blood lymphocyte count, anti-MDA5 antibody titres, ground-glass opacity scores and treatments, an inverse association was revealed between the prophylactic use of coSMZ and incidence of PJP [adjusted odds ratio 0.299 (95% CI 0.102–0.878), P  = 0.028]. Conclusion Prophylactic use of coSMZ is an effective and safe way to improve the prognosis of anti-MDA5-DM patients by preventing the incidence of PJP. [ABSTRACT FROM AUTHOR]

Background: Denosumab entered the Chinese market for the first time in 2020. Since it is a short period of time, there is a lack of data on its effectiveness and safety in Chinese people. The objective of this study was to evaluate the effectiveness and safety of denosumab in delaying skeletal-related events (SREs) in patients with breast cancer metastatic to bone. Methods: The study retrospectively analyzed data from breast cancer patients with bone metastases (BM) who were treated with denosumab in the First Affiliated Hospital of Nanjing Medical University from September 2020 to January 2022. The primary endpoint was SRE incidence at 1 year after receiving denosumab treatment. The secondary endpoints included time to first on-study SRE and safety. Descriptive analysis was utilized to display clinicopathological features. The Kaplan-Meier method was used to estimate the median time to first on-study SRE in total population and subgroups. Logistic regression analysis and χ2 test were employed to determine the potential factors influencing the occurrence of SREs. Results: Fifty breast cancer patients with BM were enrolled in our study, and 54.0% of the patients had 5 or more metastatic bone lesions. After a median follow-up of 17.00 months, 24% of the patients developed SREs at 1 year after receiving denosumab treatment, and the median time to first on-study SREs was not reached. Five or more metastatic bone lesions were an independent risk factor for SRE occurrence (odds ratio = 6.06, 95% CI: 1.09-33.54, P =.039). The adverse events (AEs) associated with denosumab mainly included hypocalcemia (68.0%), periodontitis (28.0%), and myalgia (14.0%). Only 3 cases of grade III/IV AEs were reported, and no serious AEs occurred. Conclusion: Denosumab was effective and well tolerated in Chinese breast cancer patients with BM. [ABSTRACT FROM AUTHOR]

To determine whether late percutaneous coronary intervention (PCI) of an infarct-related artery >12 h after ST-segment elevation myocardial infarction onset is beneficial, patients were included from the prospective, nationwide, multicenter China Acute Myocardial Infarction registry. The number of patients who underwent PCI or received drug therapy alone was 4791 and 1149, respectively. Hazard ratio (HR) and associated 95% confidence interval (CI) were calculated. Compared with drug therapy, PCI was associated with lower incidences of 2-year major adverse cardiac and cerebrovascular events (MACCE; 6.43 vs 20.19%; HR,.27; 95% CI,.23-.32; P <.001), all-cause death (4.13 vs 15.74%; HR,.24; 95% CI,.20-.30; P <.001), myocardial infarction (1.73 vs 3.31%; HR,.49; 95% CI,.33-.72; P =.0003), stroke (1.02 vs 2.00%; HR,.47; 95% CI,.28-.77; P =.0026), and revascularization (10.96 vs 27.56%; HR,.32; 95% CI,.26-.39; P <.001). Subgroup analysis consistently indicated that PCI was superior to drug therapy. Moreover, the left ventricular ejection fraction in the PCI group was increased after 2-year follow-up, whereas there was no significant increase in the drug therapy group. In conclusion, late PCI is common in Chinese clinical practice, and it is associated with significant improvements in cardiac function and survival compared with drug therapy alone. [ABSTRACT FROM AUTHOR]

Objective Our aim was to investigate the association between gene polymorphisms in catalase (CAT), a well-known oxidative stress regulator, and susceptibility to idiopathic nephrotic syndrome (INS) or responses to steroid therapy in a Chinese pediatric population. Methods We analyzed 3 CAT single-nucleotide polymorphisms (SNVs; rs7943316, rs769217, and rs12270780) using multi-polymerase chain reaction combined with next-generation sequencing in 183 INS patients and 100 healthy controls. Results For the allele and genotype frequencies of the CAT SNVs, no significant differences were observed between INS patients and controls. Patients with C allele of CAT rs769217 had a higher risk of developing steroid-dependent nephrotic syndrome than the steroid-sensitive nephrotic syndrome patients (P = 0.018; odds ratio = 1.76). Conclusion Our data suggests that genetic variations in CAT were unlikely to confer susceptibility to INS in Chinese children, whereas the C allele of the CAT rs769217 polymorphism showed a strong association with steroid-dependent responses in Chinese INS children. [ABSTRACT FROM AUTHOR]

Objective To investigate the influencing factors of postoperative meningioma recurrence. Methods A total of 176 patients with meningioma treated in Beijing Tiantan Hospital, Capital Medical University from May 2010 to January 2011 were included. The general information, imaging findings, extent of tumor resection and postoperative pathological results were analyzed. Kaplan - Meier survival curve comparison and Log - rank test were used to compare the related influencing factors of meningioma recurrence. Multifactor Cox's proportional hazards regression model was used for survival analysis. Results The median progression free survival (PFS) of patients with preoperative Karnofsky Performance Status (KPS) < 70 was lower than that with KPS ^ 70 [(8.04 ± 1.98) years vs. (8.08 ± 1.18) years; X2 = 5.370, P = 0.020]. The median PFS of patients with peritumoral edema grade 2-3 was lower than that with peritumoral edema grade 0-1 [(8.05 ± 1.79) years vs. (8.06 ± 1.09) years; x = 9.805, P = 0.002]. The median PFS of patients with dural mater invasion was lower than that without dural mater invasion [(7.97 ± 1.70) years vs. (8.06 ± 1.09) years; x = 12.357, P = 0.000]. The median PFS of patients with WHO grade 23 was lower than that with WHO grade 1 [(5.14 ± 2.07) years vs. (8.12 ± 0.87) years; x = 113.774, P = 0.000]. Multivariate Cox's proportional hazards regression model showed that WHO grade 2-3 could increase the risk of postoperative meningioma recurrence (RR = 15.693, 95%CI: 5.905-41.707; P = 0.000). Conclusions The preoperative KPS score, peritumoral edema, dura mater invasion and WHO grade may affect the recurrence of meningioma, and WHO grade 2-3 can increase the risk of meningioma recurrence. [ABSTRACT FROM AUTHOR]

The publications on elbow pain (EP) in overhead sports are increasing. The results of previous studies mostly focus on the influence of EP in the ball game and throwing sports. Thus, a bibliometric analysis of these publications may show the direction of hot topics and future research trends. The purpose of this study is to identify the research trends on EP in overhead sports. For the methods, the first step is to use the main keywords of 'Elbow pain' and 'Overhead sport' merging auxiliary vocabulary to reach the relevant global publications between 1970 and 2022 in the Web of Science (WoS) database. The literature data set is imported into EndNote literature manager software to remove duplication. Secondly, the duplication-reduced articles are imported to an Excel sheet according to the inclusion and exclusion criteria of this study. In the third step, VOSviewer software is applied as the main analysis tool in extracting data for analysis from the articles. Then, the main research results for three aspects are obtained by VOSviewer software which extracted and analyzed the parameters of author name, article title, publication journal, keywords, organization, publication country/region, and the sum of times cited from 455 qualified papers. The study found that the United States of America made the most outstanding contribution to this theme study. The research on EP in overhead sports in China requires more attention from scholars. EP in swimming is a new research direction worthy of attention. In conclusion, the research results prove the growth trend of EP in overhead sports. The EP problem not only exists in the ball game and throwing sports but also swimming. Sport commercialization and the involvement of related professional sports organizations determine the degree of EP's attention in a specific sport and the development of solutions. The development of a region or country also affects the depth and scope of EP study. Clinical research development and in-depth exploration are one of the bases to solve EP problems. Non-clinical action is beneficial to EP patients, but it still needs to be explored and studied. [ABSTRACT FROM AUTHOR]

Breast cancer is the most common cancer in women in the world. Statistics revealed the number of breast cancer patients less than 40 years of age increased over time. Clinical studies found there is a trend of yearly illness happening in younger patients, whose needs related to the illness are different from older patients. The purpose of this study was to explore the uncertainty and needs of patients in different age groups who were newly diagnosed with breast cancer. A descriptive cross-sectional survey study was adopted to recruit 128 patients. The Mishel's Uncertainty in Illness Scale (MUIS, Chinese version) and the Cancer Needs Questionnaire (short-form, CNQ-SF) were used to collect data. The results revealed that a patient's age and religion negatively correlated with illness uncertainty. A patient's age, educational level, work or not, and children's age correlated with needs for care. Age, illness uncertainty, and educational level were important predictors of the needs of care, with an explanatory power of 29.0%. In Conclusion, patients ≤40 years of age had greater illness uncertainty and needs for care than those who were >40 years of age. For younger patients newly diagnosed with cancer, medical professionals should take the initiative to provide detailed and complete information on breast cancer treatment plans, prognosis, and home self-care, which helps clarify the possible future treatments and results and further enables patients to acquire self-care skills and knowledge. [ABSTRACT FROM AUTHOR]

At present, percutaneous nephrolithotomy has become an option for hospitals increasingly to treat calculus. However, due to the certain risk of percutaneous nephrolithotomy, it may lead to postoperative complications. Analyzing the preoperative factors of septic shock after percutaneous nephrolithotomy can provide guidance for reducing the incidence of septic shock after PCNL. This article establishes a logistic regression model based on preoperative factors, uses statistical methods, and uses the professional statistical software SPSS to create a database and analyze the data. The method of classification data analysis was used to determine various influencing factors including patient factors, stone factor, and preoperative factors and combined B-ultrasound guidance and percutaneous nephrolithotomy to reduce the risk of surgery. The experimental results found that the percutaneous nephroscope laser lithotripsy guided by the smart Internet of Things can effectively perform lithotripsy; in this paper, the preoperative data of different complications are obtained, and the risk of surgery is closely related to the operation time. The operation time exceeds 90 minutes and causes the risk of severe bleeding after PCNL. It is twice the operation time of less than 90 minutes and 5 times the operation time of less than 60 minutes. [ABSTRACT FROM AUTHOR]

Background: Body water measured by bioelectrical impedance analysis (BIA) predicts the outcomes of many diseases. This study aimed to evaluate the relationship between body water and the prognosis of cancer patients with sarcopenia. Methods: This study employed 287 cancer patients with sarcopenia underwent BIA from a prospective multicenter study of patients with cancer in China from 2013 to 2020. The primary outcome of interest was all-cause mortality presented as the longest time to follow-up available. Eight indicators of body water [total body water, extracellular water, intracellular water, free fat mass, active cell mass, extracellular water/intracellular water, extracellular water/total body water (ECW/TBW), and intracellular water/total body water] were included in the research. Neutrophil–lymphocyte ratio (NLR) = neutrophil (× 109)/lymphocyte (× 109). The discriminatory ability and prediction accuracy of each factor were assessed using the C-index. The hazard ratios (HR) and 95% confidence intervals (CI) were calculated using the Cox proportional hazard model. Results: The median age was 65 years old, and 138 (48%) patients were men. During a mean follow-up of 46 months, 140 deaths were recorded, resulting in a rate of 204.6 events per 1000 patient-years. ECW/TBW showed the best predictive accuracy (C-index = 0.619) compared to the other indicators [p = 0.004, adjusted HR (95% CI) 1.70 (1.18,2.44)]. In the middle tertile (0.385–0.405), ECW/TBW had a strong independent negative association with patient survival [adjusted HR (95% CI) 2.88 (1.39–5.97), p = 0.004]. Patients who had a high ECW/TBW (ECW/TBW ≥ 0.395) combined with a high NLR had 3.84-fold risk of mortality (p < 0.001, 95% CI 1.99,7.38). Conclusions: ECW/TBW was better than other indicators in predicting survival of cancer patients with sarcopenia. High ECW/TBW combined with high NLR would further increase the risk of mortality. Trial registration: The Investigation on Nutrition Status and Clinical Outcome of Common Cancers (INSCOC) (Chinese Clinical Trial Registry: ChiCTR1800020329, URL of registration: http://www.chictr.org.cn/showprojen.aspx?proj=31813). [ABSTRACT FROM AUTHOR]

Although growing evidence has shown that ginsenosides from stems and leaves of Panax ginseng (GSLS) exercise a protective impact on the central nervous system, in the model of memory damage induced by scopolamine, it is still rarely reported. Thus, the mechanism of action needs to be further explored. This study was to investigate the effect of GSLS on scopolamine (SCOP)-induced memory damage and the underlying mechanism. Male ICR mice were treated with SCOP (3 mg/kg) for 7 days, with or without GSLS (75 and 150 mg/kg) treatment for 14 days. After GSLS treatment, the memory damage induced by SCOP was significantly ameliorated as shown by the improvement of cholinergic function (AChE and ChAT), brain tissue hippocampus morphology (H&E staining), and oxidative stress (MDA, GSH, and NO). Meanwhile, immunohistochemical assay suggested that GSLS increased the expression of brain-derived neurotrophic factor (BDNF) and Tyrosine Kinase receptor B (TrkB). Further mechanism research indicated that GSLS inhibited the Tau hyperphosphorylation and cell apoptosis by regulating the PI3K/AKT pathway and inhibited neuroinflammation by regulating the NF-κB pathway, thereby exerting a cognitive impairment improvement effect. This work suggested that GSLS could protect against SCOP-induced memory defects possibly through inhibiting oxidative stress, inhibiting neuroinflammation and cell apoptosis. [ABSTRACT FROM AUTHOR]

Background: The local Dong people in Qiandongnan Prefecture, Guizhou Province, China, with rich biocultural diversity, have developed the traditional rice-duckweed-fish-duck agroecosystem (RDFDA) to support biodiversity conservation and to meet food and cultural needs. However, there is still not much research on traditional ecological knowledge (TEK) in this area. In particular, there is a lack of traditional knowledge of edible plants used by the Dong people as flavoring to grill fish (Cyprinus carpio) collected from RDFDA, which is extremely valuable in their traditional culture. The study focused on documenting plant species used in grilling fish and analyzing the status of its TEK. Methods: Twenty-one sampling points of three Dong minority villages in Qiandongnan were selected for the research. The local TEK associated with plant resources for fish-grilling was recorded through free listing and semi-structured interviews. Fidelity level (FL) and ethnoecological importance value (EIV) indicators were designed to determine the socioeconomic influence of TEK. The non-metric multidimensional scaling (NMDS) method was used to evaluate the differentiation of edible plant species distribution in dissimilar accessibility types. Results: A total of 430 people were interviewed about grilled fish, of whom 75% were men and 85% were farmers. Thirty-four edible plants were documented for fish-grilling in three Dong villages. They belong to 16 plant families, such as Apiaceae, and Asteraceae. The life forms included herbaceous (76%), shrubs (18%) and trees (6%). Leaves are the most commonly used part of for grilling fish, followed by aerial parts, and whole plants. Among these edible plants, Allium hookeri, A. macrostemon and Houttuynia cordata with the highest fidelity level (100%) were cited as edible plants for grilling fish by all informants. The NMDS showed different accessibility types of collection sites, with different importance values. Paddy rice field edge (2.03) has the highest value, followed by forest-farming ecotone (1.74), streamsides (1.71) and woodland (0.48). Conclusion: The purpose of this study was to investigate the traditional knowledge of edible plant materials used by the Dong people for grilling fish. The results demonstrate the strong connection between local people, the bio-environment and agroecosystem services. The survey and comparative analysis revealed that plant species with high FL values may be potential sources of natural flavors. [ABSTRACT FROM AUTHOR]

This qualitative study describes the psychological experience of patients hospitalized with COVID-19. These patients went through 3 psychological stages: extremely uncertainties during the initial diagnostic stage, complicated feelings of negativity during the treatment stage, and positive growth in the recovery stage. It is important for nurses to provide holistic care. [ABSTRACT FROM AUTHOR]

To explore the clinical experiences of the intern nursing students who did their internship in the Intensive Care Unit (ICU) at least two months. The key point is to investigate how nursing students achieved self-development in ICUs. Using qualitative study based on the grounded theory, we enrolled 15 intern nursing students from November 2021 to April 2022 in a Grade A hospital in Hunan Province, China. This study developed an explanatory theoretical framework of the interns' experience in ICUs, which was described as a comprehensive growth process for ICU interns. In this process, the intern nursing students often go through three stages: pressure period, adjustment period and growth period. Self-regulation and social interaction play a key role to help them get over the negative experiences they experienced in the stress period and achieve personal development. Clinical nursing educators could make appropriate interventions based on the characteristics of students at different intership stages in ICUs. The target training of intern nursing students should focus on their theoretical knowledge, emotion regulation, communication skills and personality optimization. In addition, clinical tutors should be trained regularly to prepare well for their important roles. [ABSTRACT FROM AUTHOR]