Validity Study for Clinical Use of Hand-Held Spirometer in Patients with Chronic Obstructive Pulmonary Disease.

A spirometer is a medical device frequently used clinically for the diagnosis and prediction of lung disease. This study aimed to investigate the clinical usefulness of a hand-held spirometer (The Spirokit), compared with conventional spirometry in patients with chronic obstructive pulmonary disease (COPD). This study was conducted from February 2022 to October 2022. Measurements from 80 patients with COPD (male: 53, female: 27) were obtained using The Spirokit and PC-based pulmonary function test equipment, and the resulting values were compared and analyzed. For the concurrent validity comparison of The Spirokit, the intra-class correlation (ICC 2, 1), coefficients of variation (CVME), 95% limits of agreement (95% LOA), and Cohen's Kappa Index were analyzed. The Spirokit showed high agreement (ICC: 0.929-0.989; 95% LOA: -0.525 to 2.559; and CVME: 0.05-0.08) with the PC-based pulmonary function tester. Using the Cohen's kappa coefficients, the device showed high sensitivity, specificity, and accuracy scores of Pa: 0.90, Pc: 0.52, and K: 0.79, respectively, indicating considerable agreement. The Spirokit, a portable pulmonary function test device, is a piece of equipment with high validity and portability, with high potential for replacing PC-based pulmonary function test equipment.

Effect of complicated, untreated and uncontrolled diabetes and pre-diabetes on treatment outcome among patients with pulmonary tuberculosis.

BACKGROUND AND OBJECTIVE: Patients with tuberculosis and diabetes have a higher risk of unfavourable anti-tuberculosis treatment outcomes. In the present study, we aimed to evaluate the effects of various diabetes statuses on the outcomes of patients with pulmonary tuberculosis. METHODS: Among the patients with pulmonary tuberculosis enrolled in the Korea Tuberculosis Cohort (KTBC) registry and the multicentre prospective cohort study of pulmonary tuberculosis (COSMOTB), those with diabetes and complicated diabetes were identified. The primary and secondary outcomes were unfavourable outcomes and mortality, respectively. The effect of diabetes and complicated diabetes on the outcomes was assessed using multivariable logistic regression analysis. Using COSMOTB, subgroup analyses were performed to assess the association between various diabetes statuses and outcomes. RESULTS: In the KTBC, diabetes (adjusted odds ratio [aOR] = 1.93, 95% CI = 1.64-2.26) and complicated diabetes (aOR = 1.96, 95% CI = 1.67-2.30) were significantly associated with unfavourable outcomes, consistent with the COSMOTB data analysis. Based on subgroup analysis, untreated diabetes at baseline was an independent risk factor for unfavourable outcomes (aOR = 2.72, 95% CI = 1.26-5.61). Prediabetes and uncontrolled diabetes increased unfavourable outcomes and mortality without statistical significance. CONCLUSION: Untreated and complicated diabetes at the time of tuberculosis diagnosis increases the risk of unfavourable outcomes and mortality.

The Matrix Stiffness Coordinates the Cell Proliferation and PD-L1 Expression via YAP in Lung Adenocarcinoma.

The extracellular matrix (ECM) exerts physiological activity, facilitates cell-to-cell communication, promotes cell proliferation and metastasis, and provides mechanical support for tumor cells. The development of solid tumors is often associated with increased stiffness. A stiff ECM promotes mechanotransduction, and the predominant transcription factors implicated in this phenomenon are YAP/TAZ, ß-catenin, and NF-κB. In this study, we aimed to investigate whether YAP is a critical mediator linking matrix stiffness and PD-L1 in lung adenocarcinoma. We confirmed that YAP, PD-L1, and Ki-67, a marker of cell proliferation, increase as the matrix stiffness increases in vitro using the lung adenocarcinoma cell lines PC9 and HCC827 cells. The knockdown of YAP decreased the expression of PD-L1 and Ki-67, and conversely, the overexpression of YAP increased the expression of PD-L1 and K-67 in a stiff-matrix environment (20.0 kPa). Additionally, lung cancer cells were cultured in a 3D environment, which provides a more physiologically relevant setting, and compared to the results obtained from 2D culture. Similar to the findings in 2D culture, it was confirmed that YAP influenced the expression of PD-L1 and K-67 in the 3D culture experiment. Our results suggest that matrix stiffness controls PD-L1 expression via YAP activation, ultimately contributing to cell proliferation.

Do patients attempt and succeed in quitting smoking during tuberculosis treatment? A prospective cohort study.

BACKGROUND: Despite a well-known relation between smoking tobacco and the tuberculosis epidemic, the factors associated with smoking cessation in tuberculosis patients are unclear. This study aims to examine the cascade of smoking cessation and the factors associated with persistent smoking among tuberculosis patients. METHODS: We conducted a prospective cohort study enrolling adult patients with pulmonary tuberculosis between 2016 and 2019 in the Republic of Korea. We examined the smoking status at baseline, followed the current smokers, re-examined their smoking status after 6 months of anti-tuberculosis treatment, and identified the factors associated with persistent smoking. RESULTS: Of the 419 enrolled patients, 109 (26.0%) were current smokers at baseline. Of the 79 current smokers who completed the 6-month survey, 24 (30.4%) succeeded in quitting smoking after 6 months of treatment. The adjusted odds ratio for persistent smoking was 6.57 (95% confidence interval [CI], 1.76-27.83) for drinking and 0.15 (95% CI, 0.03-0.68) for diabetes comorbidity. CONCLUSION: Drinking alcohol and diabetes comorbidity were important factors in smoking cessation. Only one third of the tuberculosis patients in our study cohort succeeded in quitting smoking during the 6-month treatment period. More aggressive interventions for smoking cessation should be adopted within the national anti-tuberculosis program.

Metabolic Disorders Are Associated With Drug-Induced Liver Injury During Antituberculosis Treatment: A Multicenter Prospective Observational Cohort Study in Korea.

Background: Drug-induced liver injury (DILI) may lead to the discontinuation of antituberculosis (anti-TB) treatment (ATT). Some studies have suggested that metabolic disorders increase the risk of DILI during ATT. This study aimed to identify risk factors for DILI, particularly metabolic disorders, during ATT. Methods: A multicenter prospective observational cohort study to evaluate adverse events during ATT was conducted in Korea from 2019 to 2021. Drug-susceptible patients with TB who had been treated with standard ATT for 6 months were included. The patients were divided into 2 groups depending on the presence of 1 or more metabolic conditions, such as insulin resistance, hypertension, obesity, and dyslipidemia. We monitored ATT-related adverse events, including DILI, and treatment outcomes. The incidence of DILI was compared between individuals with and without metabolic disorders, and related factors were evaluated. Results: Of 684 patients, 52 (7.6%) experienced DILI, and 92.9% of them had metabolic disorders. In the multivariable analyses, underlying metabolic disorders (adjusted hazard ratio [aHR], 2.85; 95% CI, 1.01-8.07) and serum albumin <3.5 g/dL (aHR, 2.26; 95% CI, 1.29-3.96) were risk factors for DILI during ATT. In the 1-month landmark analyses, metabolic disorders were linked to an elevated risk of DILI, especially significant alanine aminotransferase elevation. The treatment outcome was not affected by the presence of metabolic disorders. Conclusions: Patients with metabolic disorders have an increased risk of ATT-induced liver injury compared with controls. The presence of metabolic disorders and hypoalbuminemia adversely affects the liver in patients with ATT.

Delphi Survey on the Current and Future Korean Guidelines for Isoniazid-Monoresistant Tuberculosis.

Purpose: Isoniazid-monoresistant tuberculosis (Hr-TB) has emerged as a global challenge, necessitating detailed guidelines for its diagnosis and treatment. We aim to consolidate the Korean guidelines for Hr-TB management by gathering expert opinions and reaching a consensus. Patients and Methods: A conventional Delphi method involving two rounds of surveys was conducted with 96 experts selected based on their clinical and research experience and involvement in nationwide tuberculosis studies and development of the Korean guidelines on tuberculosis. The survey consisted of three sections of questionnaires on diagnosis, treatment, and general opinions on Hr-TB. Results: Among the 96 experts, 72 (75%) participated in the two rounds of the survey. A majority of experts (96%) strongly agreed on the necessity of molecular drug susceptibility testing (DST) for isoniazid and rifampin resistance in all tuberculosis patients and emphasized the importance of interpreting mutation types (inhA or katG) and additional molecular DST for fluoroquinolones for confirmed isoniazid-resistant cases. Over 95.8% of experts recommended treating Hr-TB with a combination of rifampin, ethambutol, pyrazinamide, and levofloxacin for six months, without exceeding 12 months unless necessary. They also acknowledged the drawbacks of long-term pyrazinamide use due to its side effects and agreed on shortening its duration by extending the duration of the rest of the treatment with a modified combination of choice. Conclusion: This Delphi survey enabled Korean tuberculosis experts to reach a consensus on diagnosing and treating Hr-TB. These findings will be valuable for developing the upcoming revised Korean guidelines for Hr-TB management.

Contralateral bone conducted sound wave propagation on the skull bones in fresh frozen cadaver.

The study aimed to investigate the efficient pathway for BC sound transmission by measuring vibrations on the opposite side of the skull bone, referred to as the mastoid position. The realistic contralateral transmission pathway of bone conduction (BC) vibrations is investigated through each osseous structure in the midlines of the fresh-frozen whole head. BC stimulation is applied to the mastoid using a bone vibrator, and acceleration responses are observed on the contralateral mastoid bone and seven midline points of skull bones using triaxial accelerometers. The study finds that the range showing the highest contralateral transmission efficiency of bone vibration is the intermediate frequency range with contralateral direction. Within this range, a significant amplitude of acceleration response is measured at the face-side points and the back and upper parts of the head. The thesis suggests that signal transmission from the specific midline to the mastoid can be more efficient than the conventional configuration of BC from the mastoid to the mastoid.

The first case report of Paragonimus westermani infection diagnosed by transbronchial lung cryobiopsy.

We report a case of pulmonary paragonimiasis diagnosed by transbronchial lung cryobiopsy (TBLC). TBLC is likely to be a superior method to transbronchial forceps biopsy because TBLC can get larger specimens, resulting in a higher chance of containing the eggs. A male patient aged 57 years presented with hemoptysis and dyspnea on exertion. His initial chest computed tomography scans showed a cavitary nodule with a peripheral ground-glass appearance, leading to a prescription of an oral antibiotic, with an initial assumption of pneumonia. A follow-up chest computed tomography, however, revealed an appearance of a new nodule adjacent to the original nodule. TBLC and transbronchial forceps biopsy were done to rule out lung cancer and eventually, the eggs of Paragonimus westermani were found using TBLC. Praziquantel was prescribed, showing improvements in symptoms and chest X-ray findings. TBLC has more potential to be utilized as a diagnostic method than transbronchial forceps biopsy because it has a better chance to confirm pulmonary paragonimiasis, which can be initially suspected as pulmonary tuberculosis or lung cancer.

Comparative Analysis of Preoperative High Frequency Color Doppler Ultrasound versus MR Lymphangiography versus ICG Lymphography of Lymphatic Vessels in Lymphovenous Anastomosis.

BACKGROUND: Despite the extensive use of various imaging modalities, there is limited literature on comparing the reliability between indocyanine green (ICG) lymphography, MR Lymphangiogram (MRL), and high frequency color Doppler ultrasound (HFCDU) to identify lymphatic vessels. METHOD: In this study of 124 patients, the correlation between preoperative image findings to the actual lymphatic vessel leading to lymphovenous anastomosis (LVA) was evaluated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and simple detection were calculated. Subgroup analysis was also performed according to the severity of lymphedema. RESULTS: Total of 328 LVAs were performed. The HFCDU overall had significantly higher sensitivity for identifying lymphatic vessels (99%) over MRL (83.5%) and ICG lymphography (82.3%)(p < 0.0001). Both ICG lymphography and HFCDU had 100% specificity and PPV. The NPV was 3.6%, 6.5% and 57.1% respectively for MRL, ICG lymphography, and HFCDU. All modalities showed high sensitivity for early stage 2 lymphedema while HFCDU showed a significantly higher sensitivity for late stage 2 (MRL:79.7%, ICG:83.1%, HFCDU:97%) and stage 3 (MRL:79.7%, ICG:79.7%, HFCDU:100%) over the other two modalities (p < 0.0001). CONCLUSION: This study demonstrated while all three modalities are able to provide good information, the sensitivity may alter as the severity of lymphedema progresses. The HFCDU will provide the best detection for lymphatic vessels throughout all stages of lymphedema. However, as each modality provides different and unique information, combining and evaluating the data according to the stage of lymphedema will be able to maximize the chance for a successful surgical outcome.

Gardnerella vaginalis in Recurrent Urinary Tract Infection Is Associated with Dysbiosis of the Bladder Microbiome.

Recent studies on the urine microbiome have highlighted the importance of the gut-vagina-bladder axis in recurrent urinary tract infection (rUTI). In particular, the role of Gardnerella as a covert pathogen that activates E. coli in animal experiments has been reported. Herein, we conducted a human bladder microbiome study to investigate the effect of Gardnerella on rUTI. Urine 16S ribosomal RNA gene sequencing via transurethral catheterization was conducted in the normal control group (NC) (n = 18) and rUTI group (n = 78). The positive detection rate of Gardnerella species did not differ between the NC and rUTI groups (22.2% vs. 18.0%, p = 0.677). In addition, the Gardnerella-positive NC and Gardnerella-positive rUTI groups showed similar levels of microbiome diversity. The Gardnerella-positive group was categorized into three subgroups: the Escherichia-dominant group, Gardnerella-dominant group, and Lactobacillus-dominant group. All of the Escherichia-dominant groups were associated with rUTI. The Gardnerella-dominant or Lactobacillus-dominant groups expressed rUTI with symptoms when risk factors such as the degree of Gardnerella proliferation or causative agents of bacterial vaginosis were present. The presence of Gardnerella in the urine is considered to be related to rUTI depending on other risk factors. New guideline recommendations regarding antibiotic selection based on a novel method to detect the cause of rUTI may be required to reduce antibiotic resistance.

Fully portable continuous real-time auscultation with a soft wearable stethoscope designed for automated disease diagnosis.

Modern auscultation, using digital stethoscopes, provides a better solution than conventional methods in sound recording and visualization. However, current digital stethoscopes are too bulky and nonconformal to the skin for continuous auscultation. Moreover, motion artifacts from the rigidity cause friction noise, leading to inaccurate diagnoses. Here, we report a class of technologies that offers real-time, wireless, continuous auscultation using a soft wearable system as a quantitative disease diagnosis tool for various diseases. The soft device can detect continuous cardiopulmonary sounds with minimal noise and classify real-time signal abnormalities. A clinical study with multiple patients and control subjects captures the unique advantage of the wearable auscultation method with embedded machine learning for automated diagnoses of four types of lung diseases: crackle, wheeze, stridor, and rhonchi, with a 95% accuracy. The soft system also demonstrates the potential for a sleep study by detecting disordered breathing for home sleep and apnea detection.

Early detection of delayed pneumothorax using lung ultrasound after transthoracic needle lung biopsy: A prospective pilot study.

OBJECTIVES: Delayed pneumothorax can cause an emergency room visit and be life-threatening in case of tension pneumothorax after transthoracic needle biopsy. We hypothesized that most delayed pneumothoraces are diagnosed by later enlargement of occult pneumothorax due to the low diagnostic accuracy of a chest X-ray. Lung ultrasound is a highly accurate tool for detection of pneumothorax. The aim of this study is to evaluate the diagnostic accuracy of lung ultrasound for prediction of delayed pneumothorax on chest X-ray. METHODS: This prospective pilot study was performed between April 2020 and July 2020 in Chungnam National University Hospital. The participants underwent chest X-rays and lung ultrasound before, immediately after, and 3 h after transthoracic needle biopsy, respectively. The presence or absence of lung sliding at each anterior BLUE-point on an ultrasound and pneumothorax on a chest X-ray was recorded. RESULTS: Pneumothorax occurred in 17 (35.4%) participants, and three of them underwent chest tube replacement. Of the 17 (35.4%) cases of pneumothorax, five participants (10.4%) were diagnosed with delayed pneumothorax. Three out of five participants showed loss of lung sliding on lung ultrasound before the diagnosis of delayed pneumothorax. Therefore, the sensitivity of lung sliding on lung ultrasound for early detection of delayed pneumothorax was 60%. Two undetected cases were asymptomatic, and the pneumothoraces were exceedingly small and recovered spontaneously. Thus, sensitivity for detection of clinically meaningful delayed pneumothorax requiring chest tube replacement was 100% (2/2). CONCLUSION: Lung ultrasound can probably predict clinically meaningful delayed pneumothorax after transthoracic needle lung biopsy.

Burnout of Faculty Members of Medical Schools in Korea.

BACKGROUND: There is no national survey on medical school faculty members' burnout in Korea. This study aimed to investigate burnout levels and explore possible factors related to burnout among faculty members of Korean medical schools. METHODS: An anonymous online questionnaire was distributed to 40 Korean medical schools from October 2020 to December 2020. Burnout was measured by a modified and revalidated version of the Maslach Burnout Inventory-Human Service Survey. RESULTS: A total of 996 faculty members participated in the survey. Of them, 855 answered the burnout questions, and 829 completed all the questions in the questionnaire. A significant number of faculty members showed a high level of burnout in each sub-dimension: 34% in emotional exhaustion, 66.3% in depersonalization, and 92.4% in reduced personal accomplishment. A total of 31.5% of faculty members revealed a high level of burnout in two sub-dimensions, while 30.5% revealed a high level of burnout in all three sub-dimensions. Woman faculty members or those younger than 40 reported significantly higher emotional exhaustion and depersonalization. Long working hours (≥ 80 hours/week) showed the highest reduced personal accomplishment scores (F = 4.023, P = 0.018). The most significant stressor or burnout source was "excessive regulation by the government or university." The research was the most exasperating task, but the education was the least stressful. CONCLUSION: This first nationwide study alerts that a significant number of faculty members in Korean medical schools seem to suffer from a high level of burnout. Further studies are necessary for identifying the burnout rate, related factors, and strategies to overcome physician burnout.

Respiratory sound classification for crackles, wheezes, and rhonchi in the clinical field using deep learning.

Auscultation has been essential part of the physical examination; this is non-invasive, real-time, and very informative. Detection of abnormal respiratory sounds with a stethoscope is important in diagnosing respiratory diseases and providing first aid. However, accurate interpretation of respiratory sounds requires clinician's considerable expertise, so trainees such as interns and residents sometimes misidentify respiratory sounds. To overcome such limitations, we tried to develop an automated classification of breath sounds. We utilized deep learning convolutional neural network (CNN) to categorize 1918 respiratory sounds (normal, crackles, wheezes, rhonchi) recorded in the clinical setting. We developed the predictive model for respiratory sound classification combining pretrained image feature extractor of series, respiratory sound, and CNN classifier. It detected abnormal sounds with an accuracy of 86.5% and the area under the ROC curve (AUC) of 0.93. It further classified abnormal lung sounds into crackles, wheezes, or rhonchi with an overall accuracy of 85.7% and a mean AUC of 0.92. On the other hand, as a result of respiratory sound classification by different groups showed varying degree in terms of accuracy; the overall accuracies were 60.3% for medical students, 53.4% for interns, 68.8% for residents, and 80.1% for fellows. Our deep learning-based classification would be able to complement the inaccuracies of clinicians' auscultation, and it may aid in the rapid diagnosis and appropriate treatment of respiratory diseases.

Relationship between disability self-awareness and cognitive and daily living function in schizophrenia.

We investigated the relationship between disability self-awareness and cognitive and daily living functions in 49 patients with schizophrenia. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS) self-report was used to identify patient-rated global function. A clinician-rated measure of global function was obtained using the Personal and Social Performance Scale (PSP); disability self-awareness was calculated using two global function scores. The Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS) were used to evaluate clinical symptoms, while the MATRICS consensus cognitive battery (MCCB) and the UCSD Performance-based Skills Assessment (UPSA) were applied to assess cognitive and daily living functionality, respectively. The WHODAS scores correlated significantly with the MCCB verbal learning, visual learning, and social cognition domains, and with the UPSA communication domain. The PSP correlated significantly with all MCCB and UPSA domains. Disability self-awareness demonstrated positive correlation with most domains of MCCB and UPSA. The findings of this study indicate that the lower the cognitive and daily living function in patients with schizophrenia, the more positively they perceive their own disability.

Perceptions on good-life, good-death, and advance care planning in Koreans with non-cancerous chronic diseases.

AIMS: This study explored perceptions on a good-life, good-death, and advance care planning in Koreans with non-cancerous chronic diseases with the goal to develop a culture-specific advance care planning intervention in this population. DESIGN: A qualitative descriptive design was used. METHODS: Data collections were conducted between September 2017 - June 2018. Twenty-nine patients aged 41-82 years (85.8% men) participated in the interviews lasting 40-60 min. The verbatim transcriptions of the semi-structured interview data were analysed using conventional content analysis. RESULTS: Good-life was described as 'present with physical and financial independence,' 'not burdensome to the family,' 'completed life responsibility', and 'helping others.' Some participants described good-death as 'prepared death' while others considered it as 'sudden death during sleep.' All participants wanted to have a painless death and not burden the family. Advance care planning was a new concept to many participants. It was likened to 'insurance.' Some participants believed that decision-making on life-sustaining treatment should be done by their family, not themselves, because of economic or emotional distress. Some participants wanted to discuss medical and non-medical care services to reduce the burden on self and family. CONCLUSION: Family is key when it comes to the meaning of good-life and good-death. Cultural adaptation is necessary to meet the advance care planning needs of Koreans with non-cancerous chronic diseases. IMPACT: Successfully implementing advance care planning in Koreans with non-cancerous chronic diseases depends on how it is adapted to the disease-specific characteristics compared with cancer, and the cultural norms and social context. Nurses need to be prepared to offer advance care planning to persons with non-cancerous chronic diseases based on a keen sense of and empathetic cultural competence.

Clinical profiles of subclinical disease among pulmonary tuberculosis patients: a prospective cohort study in South Korea.

BACKGROUND: Subclinical tuberculosis (TB) is a potential target for public health intervention because its early identification may reduce TB transmission. We aimed to describe the clinical and laboratory findings of subclinical disease among pulmonary TB patients and compared treatment outcomes for subclinical and active diseases. METHODS: In this prospective cohort study, we enrolled adult patients aged ≥ 19 years with pulmonary TB between 2016 and 2018. Subclinical TB was defined as radiographic or microbiologic test results consistent with TB without clinical symptoms. We implemented a two-stage symptom assessment using a predefined TB symptom checklist. Demographic, clinical, and laboratory data were compared between subclinical and active diseases using multivariable binary logistic regression analysis. We evaluated treatment outcomes in the drug-susceptible cohort. RESULTS: Among 420 enrolled patients, 81 (19.3%) had subclinical TB. Multivariable analysis showed that age < 65 years was the only variable significantly associated with subclinical disease. Subclinical disease had a significantly lower proportion of acid-fast bacilli smear and culture positivity and multiple lobe involvement compared to active disease. The white blood cell counts, platelet counts, and C-reactive protein levels were significantly higher among patients with active disease than among those with subclinical disease. Among 319 patients with treatment success in the drug-susceptible cohort, six (1.9%) recurrent cases were identified, and all were active disease. Patients with subclinical disease had a higher proportion of favourable outcomes; however, its odds ratio was insignificant. CONCLUSIONS: Nearly one-fifth of tuberculosis cases were subclinical in South Korea. Despite its milder clinical presentation and lower level of inflammatory markers, the treatment outcomes of subclinical TB were not significantly different from that of active disease.

Negative school experiences of Late Millennial Korean medical students: a qualitative study using the critical incident technique.

PURPOSE: Today's students have distinctive generational characteristics and increased psychopathology and generational tension. The authors investigated the negative experiences of Late Millennial students in medical school to draw implications for student support. METHODS: The authors explored medical students' negative experiences using the critical incident technique. The authors conducted semi-structured in-depth interviews with 13 medical students, between February and May 2016. The authors focused on occurrences that significantly influenced medical students' school lives negatively from the students' perspective. All interviews were recorded and transcribed. The authors classified incidents into frames of reference for the use of faculty development for student support. RESULTS: The authors extracted 22 themes from a total 334 codes and classified them into eight subcategories. Finally, four categories emerged from frames of reference. Students manipulate relationships and colluding for better specialty choice. They experience uncontrolled rifts in interpersonal relationships between peers including lawsuits, sexual assaults, and social network service conflicts. Today's students feel resentment towards dependent hierarchical relationships with seniors. They struggle with gender discrimination but perpetuate outdated gender role toward the opposite gender. CONCLUSION: Faculty members should understand today's students' level of career stress and desire for work life balance. They should motivate students' professional identity, promote assertiveness against unfair authorities, and focus on mental health, teamwork, and relationship building. All generations need to understand other generations and develop appropriate leadership and gender sensitivity.