BACKGROUND:Synthetic polymers,such as polypropylene and polyester,used for the treatment of abdominal wall defects not only lack biodegradability and bioactivity but also fail to meet the demands of complex and irregular wounds.Therefore,finding bioactive materials with low immunogenicity and good histocompatibility has become a hot spot in the repair of abdominal wall defects. OBJECTIVE:To prepare methacryloyl modified dermal extracellular matrix hydrogel and explore its potential application in abdominal wall defect. METHODS:(1)The porcine dermis was acellular with 0.25%trypsin and 1%Triton X-100 in turn to obtain the dermal extracellular matrix.After pepsin digestion and methacrylic anhydride modification,the methacrylated dermal extracellular matrix hydrogel was formed by photocrosslinking.The microscopic morphology of the hydrogel was observed by scanning electron microscope,and its rheological properties,swelling properties and other physical and chemical properties were tested.(2)Mice fibroblasts(L929)were inoculated into methacrylated dermal extracellular matrix hydrogel to detect the cell compatibility.(3)Totally 12 SD rats were randomly divided into two groups(n=6)to create abdominal wall defect model with peritoneum preserved.The defect site of the polypropylene group was filled with polypropylene material,and the hydrogel group was filled with methacrylated dermal extracellular matrix hydrogel.The wound skin of both groups was covered with polypropylene material.The wound healing was observed and histological analysis was carried out. RESULTS AND CONCLUSION:(1)Enzymatic hydrolysis had a good decellularization effect on porcine dermis after decellularization,and the original glycosaminoglycans and collagen were well retained.Scanning electron microscope observation revealed that the dermal extracellular matrix hydrogel presented loose and porous structure.The aperture was between 70 and 120 μm.The swelling ratio was(16.88±3.24)%and the water absorption was(94.24±1.11)%.The rheological property test showed that the methacrylated dermal extracellular matrix hydrogel was stable and had shear thinning characteristics,with injectability.(2)CCK-8 assay and live/dead staining showed that methacrylated dermal extracellular matrix hydrogel had good cell compatibility.(3)The results of animal experiments showed that the skin wound healing rate of the experimental group was higher than that of the control group at 7,10,and 14 days after operation(P<0.05).Hematoxylin-eosin and Masson staining of skin and muscle tissue exhibited that compared with the polypropylene group,the skin wound epithelialization,hair follicle formation,collagen fiber arrangement,and neovascularization were better in the hydrogel group 14 days after surgery.The skin wound new tissue structure was similar to the normal tissue at 28 days after surgery,and scar hyperplasia was less.A small amount of muscle regeneration was observed on day 28 after operation.(4)The results show that the methacrylated dermal extracellular matrix hydrogel can promote wound skin healing and muscle tissue regeneration in rats with abdominal wall defect.

OBJECTIVES: This study aimed to investigate the perception of dental outpatient care quality from multiple perspectives of administrators, physicians, nurses, and patients and propose nursing care quality evaluation indices that are consistent with the clinical reality to provide reference for the construction of a scientific, systematic, and comprehensive dental outpatient care quality evaluation system. METHODS: A total of 39 interviewees, including 7 administrators, 11 doctors, 11 nurses, and 10 patients, were selected for semi-structured in-depth interviews in five regionally representative tertiary-level A stomatological specialty hospitals nationwide during January-April 2024 by using a multistage sampling method. Colaizzi 7-step analysis was used to analyze and summarize the interview data. Themes were extracted on the basis of the Structure-Process-Outcome (SPO) three-dimensional quality assessment model. RESULTS: Five main themes and 15 secondary themes were extracted from three quality dimensions: structure, process, and result. The related topics of structural quality were as follows: disinfection and isolation norms, equipment and consumable management, nursing manpower ratio and nurse education structure, and emergency capability. The related topics of process quality were as follows: pre-diagnosis risk assessment, patient triage and guidance, communication and attitude, health education, humanistic care, continuous care, specialty operation, and four-hand operation. The related topics of result quality were as follows: satisfaction, adverse event management and analysis, effective complaints and disputes. CONCLUSIONS Structure quality is the foundation, process quality is the core, and result quality is the key in the evaluation of the quality of oral outpatient care. The standardization of disinfection and isolation, equipment and consumable management, allocation of reasonable nursing manpower and post capacity, implementation of high-quality nursing services, and improvement of the quality and satisfaction of medical cooperation are necessary guarantees to ensure the quality of oral outpatient care.
Humans ; Quality of Health Care ; Ambulatory Care/standards* ; Dental Care/standards* ; Outpatients

OBJECTIVES: This study aimed to construct an evaluation index system for nursing quality management in outpatient dental clinics based on the structure-process-outcome model and provide an objective standard for the evaluation of nursing quality in outpatient dental clinics. METHODS: Through literature review, multi-subject interviews, and expert meetings, the first draft of the evaluation index for nursing quality management in outpatient dental clinics was formulated. The Delphi method was adopted to select and invite 15 experts in the fields of hospital infection management, nursing management, and specialized oral care from across the country to modify the first draft. RESULTS: The positive coefficients of the experts in the two rounds of consultation were 86.7% and 92.3%, respectively. The total authority coefficients of the experts were 0.791 and 0.717, respectively. The mean scores of the importance and feasibility of the third-level indices in the two rounds of consultation were all ≥4.333; the coefficients of variation were all ≤0.150; and the Kendall's coordination coefficients were 0.308 and 0.184 respectively, with P<0.05 for all. These results indicated that the experts were motivated to participate in this study. They recognized the importance and feasibility of the overall items in this index system, and their opinions were relatively consistent. Finally, an evaluation index system, which included 3 first-level indices, 7 second-level indices, 22 third-level indices, and 69 index connotations, for nursing quality management in outpatient dental clinics was determined. The weights of the three first-level indicators were all 0.333. Patient satisfaction (0.076, outcome dimension), hand hygiene (0.061, outcome dimension), chair care ratio (0.057, structural dimension), and turnover rate (0.057, structural dimension) were the top tertiary indicators in terms of portfolio weight. CONCLUSIONS The construction method of the evaluation index system for nursing quality management in outpatient dental clinics is scientific and reliable. It can provide a reference for the evaluation of the management level of nursing quality in outpatient dental clinics and promote the continuous improvement of nursing quality in outpatient dental clinics.
Humans ; Dental Clinics ; Delphi Technique

Objective:To explore the application strategies and clinical effects of superior gluteal artery perforator tissue flaps in repairing stage Ⅳ pressure ulcers in the sacrococcygeal region.Methods:This study was a retrospective observational study. From July 2019 to April 2024, 89 patients with stage Ⅳ pressure ulcers in the sacrococcygeal region who met the inclusion criteria were admitted to the First Affiliated Hospital of Nanchang University, including 59 males and 30 females, aged 21 to 84 years. There were 89 sacrococcygeal pressure ulcers, with an area of 5.0 cm×4.0 cm-21.0 cm×21.0 cm after debridement. According to the shape, size, and depth of the wounds after debridement, combined with the elasticity and texture of the skin around the wounds, and the principle of minimizing damage to the donor area, the appropriate forms of superior gluteal artery perforator tissue flaps were cut for wound repair in the following three conditions. (1) For wounds with a round shape, an area of 5.0 cm×5.0 cm-21.0 cm×21.0 cm, and a depth of 1.0-3.5 cm, the superior gluteal artery perforator propeller flap or myocutaneous flap, bilobed superior gluteal artery perforator relay flap, and bilateral superior gluteal artery perforator rotational flap were used. (2) For wounds with an oval shape, an area of 5.0 cm×4.0 cm-18.5 cm×10.5 cm, and a depth of 1.0-3.0 cm, the superior gluteal artery perforator propeller flap or myocutaneous flap, unilateral superior gluteal artery perforator propeller flap combined with contralateral superior gluteal artery perforator V-Y advanced flap or keystone flap were used. (3) For wounds with a fusiformis shape, an area of 7.0 cm×4.0 cm-17.5 cm×6.0 cm, and a depth of 1.5-5.0 cm, the unilateral or bilateral superior gluteal artery perforator V-Y advanced flap, superior gluteal artery perforator keystone flap, or superior gluteal artery perforator keystone flap combined with gluteus maximus muscle flap were used. In this group of patients, a total of 40 superior gluteal artery perforator propeller flaps (with an resection area of 11.0 cm×6.0 cm-17.0 cm×11.0 cm), 22 superior gluteal artery perforator propeller myocutaneous flaps (with an resection area of 10.0 cm×5.0 cm-14.0 cm×8.0 cm), 7 bilobed superior gluteal artery perforator relay flaps (with a main flap resection area of 5.5 cm×5.5 cm-18.0 cm×11.5 cm and a side flap resection area of 4.5 cm×3.0 cm-11.0 cm×6.5 cm), 5 bilateral superior gluteal artery perforator rotational flaps (with a total resection area of 20.0 cm×16.0 cm-26.0 cm×21.0 cm on both sides), 14 superior gluteal artery perforator V-Y advanced flaps (with an resection area of 12.0 cm×10.0 cm-18.0 cm×18.0 cm), 13 superior gluteal artery perforator keystone flaps (with an resection area of 13.0 cm×6.5 cm-19.0 cm×18.0 cm), and 3 gluteus maximus muscle flaps (with an resection area of 8.0 cm×3.0 cm-15.0 cm×4.5 cm). The donor area wounds were all directly sutured. The survival of tissue flaps was observed and the incidence rate of delayed wound healing in the reception area was calculated, and wound healing in the donor area was observed. The appearance and texture of tissue flaps and recurrence of pressure ulcers were followed up.Results:After surgery, all bilateral superior gluteal artery perforator rotational flaps, superior gluteal artery perforator V-Y advanced flaps, superior gluteal artery perforator keystone flaps, and gluteus maximus muscle flaps survived well. There were 6 cases of delayed wound healing in the reception area after surgery, with an incidence rate of 6.7% (6/89). Two patients had incision dehiscence in the donor area wounds due to postoperative bleeding, the wounds healed after debridement, vacuum sealing drainage, and dressing change. The wounds in the donor area of the remaining patients healed well. Six patients were lost to follow-up. Eighty-three patients were followed up for 3-48 months, of whom 4 patients died. Among the remaining 79 patients, 3 cases had pressure ulcers recur due to improper nursing, while the rest of the patients had tissue flaps with good appearance and soft texture and no recurrence of pressure ulcers.Conclusions:Based on the characteristics of wound shape, size, and depth after debridement of stage Ⅳ pressure ulcers in the sacrococcygeal region, individualized selection of flap, myocutaneous flap, or a combination of flap and gluteus maximus muscle flap based on the perforating branch of the superior gluteal artery perforator can achieve good clinical repair results. The postoperative tissue flap survived well, with a good appearance, soft texture, and less recurrence of pressure ulcers.

AIM:This study aimed to investigate whether Xiang-Sha-Liujunzi decoction(XSLJZD)prevents ethanol-induced gastric ulcer(GU)in rats by inhibiting nucleotide-binding oligomerization domain-like receptor protein 3(NLRP3)inflammasome activation-mediated pyroptosis.METHODS:A total of 60 rats were randomly divided into 5 groups:normal control group,model group,positive control(0.33 mg/kg rabeprazole)group,low-dose(3.40 g/kg)XSLJZD group and high-dose(6.80 g/kg)XSLJZD group,with 12 rats per group.Prior to the induction of GU,all rats received their respective treatments via intragastric gavage for 3 d.The GU model was established in all groups except the normal control group using the anhydrous ethanol method.The ulcer index and ulcer inhibition rate were measured.Hematoxylin-eosin staining was performed to observe pathological changes of gastric tissues,and periodic acid-Schiff staining was used to evaluate the mucus content.Scanning electron microscopy and transmission electron microscopy were employed to inves-tigate ultrastructural changes of gastric tissues.Enzyme-linked immunosorbent assay was conducted to measure the levels of interleukin-4(IL-4),IL-10,IL-1β,IL-18,prostaglandin E2(PGE2)and nitric oxide(NO).Additionally,visible spectrophotometric assay was used to determine the levels of malondialdehyde(MDA),glutathione(GSH)and superoxide dismutase(SOD).The protein levels of NLRP3,apoptosis-associated speck-like protein containing a caspase recruitment domain(ASC),caspase-1,gasdermin D(GSDMD),phosphorylated nuclear factor-κB(p-NF-κB)and phosphorylated NF-κB inhibitor β(p-IκBβ)were assessed using immunofluorescence staining.RESULTS:Compared with model group,XSLJZD significantly alleviated gastric tissue injury,reduced the ulcer index,and enhanced the ulcer inhibition rate in GU rats.Treatment with XSLJZD markedly increased the levels of SOD,GSH,IL-4,IL-10,PGE2 and NO in gas-tric tissue,but significantly decreased the levels of MDA,IL-1β and IL-18.At the molecular level,XSLJZD significantly down-regulated the protein levels of NLRP3,ASC,caspase-1,GSDMD,p-NF-κB and p-IκBβ in gastric tissues.CON-CLUSION:Treatment with XSLJZD demonstrates a significant preventive effect against ethanol-induced GU in rats.Its mechanisms may involve the inhibition of NLRP3 inflammasome activation,reduction of the inflammatory response,pre-vention of pyroptosis in gastric mucosal epithelial cells,and enhancement of antioxidant levels.

AIM:This study aimed to investigate whether Xiang-Sha-Liujunzi decoction(XSLJZD)prevents ethanol-induced gastric ulcer(GU)in rats by inhibiting nucleotide-binding oligomerization domain-like receptor protein 3(NLRP3)inflammasome activation-mediated pyroptosis.METHODS:A total of 60 rats were randomly divided into 5 groups:normal control group,model group,positive control(0.33 mg/kg rabeprazole)group,low-dose(3.40 g/kg)XSLJZD group and high-dose(6.80 g/kg)XSLJZD group,with 12 rats per group.Prior to the induction of GU,all rats received their respective treatments via intragastric gavage for 3 d.The GU model was established in all groups except the normal control group using the anhydrous ethanol method.The ulcer index and ulcer inhibition rate were measured.Hematoxylin-eosin staining was performed to observe pathological changes of gastric tissues,and periodic acid-Schiff staining was used to evaluate the mucus content.Scanning electron microscopy and transmission electron microscopy were employed to inves-tigate ultrastructural changes of gastric tissues.Enzyme-linked immunosorbent assay was conducted to measure the levels of interleukin-4(IL-4),IL-10,IL-1β,IL-18,prostaglandin E2(PGE2)and nitric oxide(NO).Additionally,visible spectrophotometric assay was used to determine the levels of malondialdehyde(MDA),glutathione(GSH)and superoxide dismutase(SOD).The protein levels of NLRP3,apoptosis-associated speck-like protein containing a caspase recruitment domain(ASC),caspase-1,gasdermin D(GSDMD),phosphorylated nuclear factor-κB(p-NF-κB)and phosphorylated NF-κB inhibitor β(p-IκBβ)were assessed using immunofluorescence staining.RESULTS:Compared with model group,XSLJZD significantly alleviated gastric tissue injury,reduced the ulcer index,and enhanced the ulcer inhibition rate in GU rats.Treatment with XSLJZD markedly increased the levels of SOD,GSH,IL-4,IL-10,PGE2 and NO in gas-tric tissue,but significantly decreased the levels of MDA,IL-1β and IL-18.At the molecular level,XSLJZD significantly down-regulated the protein levels of NLRP3,ASC,caspase-1,GSDMD,p-NF-κB and p-IκBβ in gastric tissues.CON-CLUSION:Treatment with XSLJZD demonstrates a significant preventive effect against ethanol-induced GU in rats.Its mechanisms may involve the inhibition of NLRP3 inflammasome activation,reduction of the inflammatory response,pre-vention of pyroptosis in gastric mucosal epithelial cells,and enhancement of antioxidant levels.

Objective:To explore the application strategies and clinical effects of superior gluteal artery perforator tissue flaps in repairing stage Ⅳ pressure ulcers in the sacrococcygeal region.Methods:This study was a retrospective observational study. From July 2019 to April 2024, 89 patients with stage Ⅳ pressure ulcers in the sacrococcygeal region who met the inclusion criteria were admitted to the First Affiliated Hospital of Nanchang University, including 59 males and 30 females, aged 21 to 84 years. There were 89 sacrococcygeal pressure ulcers, with an area of 5.0 cm×4.0 cm-21.0 cm×21.0 cm after debridement. According to the shape, size, and depth of the wounds after debridement, combined with the elasticity and texture of the skin around the wounds, and the principle of minimizing damage to the donor area, the appropriate forms of superior gluteal artery perforator tissue flaps were cut for wound repair in the following three conditions. (1) For wounds with a round shape, an area of 5.0 cm×5.0 cm-21.0 cm×21.0 cm, and a depth of 1.0-3.5 cm, the superior gluteal artery perforator propeller flap or myocutaneous flap, bilobed superior gluteal artery perforator relay flap, and bilateral superior gluteal artery perforator rotational flap were used. (2) For wounds with an oval shape, an area of 5.0 cm×4.0 cm-18.5 cm×10.5 cm, and a depth of 1.0-3.0 cm, the superior gluteal artery perforator propeller flap or myocutaneous flap, unilateral superior gluteal artery perforator propeller flap combined with contralateral superior gluteal artery perforator V-Y advanced flap or keystone flap were used. (3) For wounds with a fusiformis shape, an area of 7.0 cm×4.0 cm-17.5 cm×6.0 cm, and a depth of 1.5-5.0 cm, the unilateral or bilateral superior gluteal artery perforator V-Y advanced flap, superior gluteal artery perforator keystone flap, or superior gluteal artery perforator keystone flap combined with gluteus maximus muscle flap were used. In this group of patients, a total of 40 superior gluteal artery perforator propeller flaps (with an resection area of 11.0 cm×6.0 cm-17.0 cm×11.0 cm), 22 superior gluteal artery perforator propeller myocutaneous flaps (with an resection area of 10.0 cm×5.0 cm-14.0 cm×8.0 cm), 7 bilobed superior gluteal artery perforator relay flaps (with a main flap resection area of 5.5 cm×5.5 cm-18.0 cm×11.5 cm and a side flap resection area of 4.5 cm×3.0 cm-11.0 cm×6.5 cm), 5 bilateral superior gluteal artery perforator rotational flaps (with a total resection area of 20.0 cm×16.0 cm-26.0 cm×21.0 cm on both sides), 14 superior gluteal artery perforator V-Y advanced flaps (with an resection area of 12.0 cm×10.0 cm-18.0 cm×18.0 cm), 13 superior gluteal artery perforator keystone flaps (with an resection area of 13.0 cm×6.5 cm-19.0 cm×18.0 cm), and 3 gluteus maximus muscle flaps (with an resection area of 8.0 cm×3.0 cm-15.0 cm×4.5 cm). The donor area wounds were all directly sutured. The survival of tissue flaps was observed and the incidence rate of delayed wound healing in the reception area was calculated, and wound healing in the donor area was observed. The appearance and texture of tissue flaps and recurrence of pressure ulcers were followed up.Results:After surgery, all bilateral superior gluteal artery perforator rotational flaps, superior gluteal artery perforator V-Y advanced flaps, superior gluteal artery perforator keystone flaps, and gluteus maximus muscle flaps survived well. There were 6 cases of delayed wound healing in the reception area after surgery, with an incidence rate of 6.7% (6/89). Two patients had incision dehiscence in the donor area wounds due to postoperative bleeding, the wounds healed after debridement, vacuum sealing drainage, and dressing change. The wounds in the donor area of the remaining patients healed well. Six patients were lost to follow-up. Eighty-three patients were followed up for 3-48 months, of whom 4 patients died. Among the remaining 79 patients, 3 cases had pressure ulcers recur due to improper nursing, while the rest of the patients had tissue flaps with good appearance and soft texture and no recurrence of pressure ulcers.Conclusions:Based on the characteristics of wound shape, size, and depth after debridement of stage Ⅳ pressure ulcers in the sacrococcygeal region, individualized selection of flap, myocutaneous flap, or a combination of flap and gluteus maximus muscle flap based on the perforating branch of the superior gluteal artery perforator can achieve good clinical repair results. The postoperative tissue flap survived well, with a good appearance, soft texture, and less recurrence of pressure ulcers.

ObjectiveTo conduct a systematic review of the effect of active music therapy on cognitive function for older adults with cognitive impairment based on International Classification of Diseases, the 11th Revision (ICD-11), and International Classification of Functioning, Disability and Health (ICF). MethodsA PICO framework was constructed. Thematic keyword searches were conducted in databases including PubMed, Web of Science, Embase, CNKI, VIP, and Wanfang data, for literature on the effect of active music therapy on cognitive function for older adults with cognitive impairment, published up to November 5th, 2023. Information on authors, countries, publication date, sample characteristics, study designs, intervention methods, measurement tools and outcomes were extracted. The methodological quality of the researches was evaluated using the Physiotherapy Evidence Database (PEDro) scale. ResultsEight researches from six countries were included, which were all randomized controlled trials involving 356 older adults with mild cognitive impairment and dementia. The articles were published from 2014 to 2020, with an average of 7.4 of the PEDro scale. Active music therapy was used by singing and playing instruments. Interventions took place in hospitals, nursing homes, and health centers. The intervention duration ranged from mostly 30 to 60 minutes a time, with a few 120 minutes a time. Interventions were implemented mostly one to three times a week, lasting from eight to twelve weeks. Health outcomes focused on cognitive function, including overall cognitive function, executive function, attention function and memory function. ConclusionA theoretical framework for the benefits of active music therapy on the cognitive function for older adults with cognitive impairment has been constructed based on ICD-11 and ICF. Active music therapy can improve overall cognitive function, executive function, attention function and memory function for older adults with cognitive impairment.

ObjectiveTo conduct a systematic review of the health benefits of mindfulness interventions for older adults with insomnia disorders. MethodsThematic keyword search was conducted in databases including Web of Science, PubMed, Embase, EBSCO, CNKI, VIP and Wanfang data, for literature on the impact of mindfulness intervention on sleep quality in older adults with insomnia disorders, published up to August, 2023. The methodological quality of the researches was evaluated using the Physiotherapy Evidence Database (PEDro) scale. Insomnia disorders, sleep function and mindfulness interventions were coded using International Classification of Diseases 11th Revision, International Classification of Functioning, Disability and Health, and International Classification of Health Interventions Beta-3； and a systematic review was conducted following the PRISMA. ResultsNine researches from four countries were included, involving 800 participants, and all the researches were randomized controlled trials. The average score of PEDro scale was 7.1. The health-related conditions were insomnia disorders and insomnia disorders complicated with mild cognitive impairment. Mindfulness interventions used included mindfulness-based therapy for insomnia, mindfulness-based stress reduction, mindfulness-based cognitive therapy and mindfulness meditation. Interventions were implemented in institutions or health centers, care facilities, and community health service centers, varying from six to eight weeks. Health benefits of mindfulness intervention included improvements in sleep quality and psychological and behavioral health. ConclusionMindfulness interventions effectively improve sleep quality in older adults with insomnia disorders, alleviate negative emotional states such as depression, anxiety and perceived stress, and improve the quality of life.

Objective:To investigate the effects of the "TECK" (theoretical class, experimental course, case discussion, and knowledge reinforcement) teaching model oriented by post competency in clinical pathology internship teaching.Methods:The intern students from 2015 to 2019 in the pathology direction of clinical medicine in the School of Pathology, Qiqihar Medical College, who were enrolled in the internship from 2019 to 2023, were selected as the research objects.We enrolled 32 medical students from grades 2017, 2018, and 2019 (research group) and 24 medical students from grades 2015 and 2016 (control group) who would participate in pathology internships. The control group adopted the traditional internship mode, while the research group adopted the competency-oriented "TECK" teaching mode. After the internship, the two groups were compared for internship assessment score and surveyed for post competency. With the use of SPSS 18.0 statistical software. Continuous data were presented as (mean±standard deviation) and t-test was used for comparison between groups. Count data were expressed in the number of cases, and chi-square test was used for comparison between groups.The significance level α was 0.05. Results:The research group showed significantly higher scores of skill assessment (82.81±4.20 vs. 79.58±5.09) and pathological diagnosis assessment (80.28±4.23 vs. 76.21±4.58) than the control group (both P<0.05), with no significant difference in the score of theoretical knowledge ( P>0.05). In terms of post competency, the research group was superior to the control group in clinical skills and medical care ability (12.38±0.94 vs. 11.35±0.76), disease prevention and health promotion ability (6.28±0.92 vs. 4.48±0.93), interpersonal communication and information management ability (19.81±1.09 vs. 17.00±1.28), and teamwork and scientific research ability (11.44±1.27 vs. 9.25±0.87; all P<0.05). There were no significant differences between the two groups in core values and professional literacy and medical knowledge and lifelong learning (both P>0.05). Conclusions:In undergraduate internships, the competency-oriented "TECK"teaching mode can significantly improve students' clinical operation and pathological diagnosis ability, and effectively cultivate their abilities of clinical skills and medical care, disease prevention and health promotion, interpersonal communication and information management, teamwork and scientific research.