The problem with confidence: too much and too little results in poorer achievement, inner conflict, and social inhibition.

Introduction: Confidence is defined as the feelings and thoughts people have during a task that result in judgments about their performance. Evidence suggests that confidence is trait-like, but thus far research on the relative match between confidence and accuracy has been primarily restricted to over-confidence effects, and subject to the methodological flaws involved with using difference scores. We sought to answer an exploratory question in this research, whether discrepancies in ability and confidence in either direction reliably predicted individual differences on a broad-spectrum and commercially available personality test, the California Psychological Inventory (CPI260). Methods: Participants were 220 employed adults who had previously taken the CPI260 for career development purposes. They were invited to complete a measure of cognitive ability and confidence in return for feedback on the same. Data were modeled using polynomial regression and response surface analysis, to determine whether and how CPI260 personality traits were associated with matches or mismatches between accuracy and confidence in the same test. Results: We identified negative curvilinear effects along the line of disagreement for four CPI260 scales, suggesting that both under- and over-confidence were associated with personality. Discussion: In contrast to our expectations, individuals who were under-confident and those who were over-confident had lower achievement potential, less social confidence, and more inner conflict than other individuals in this sample. Although preliminary, these findings suggest that both over-confident and under-confident individuals are aware of potential weaknesses that impede their functioning.

Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.

BACKGROUND: In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes. METHODS: Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter. RESULTS: Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity. CONCLUSIONS AND RELEVANCE: This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.

Opioid stewardship training during the transition to residency to prepare medical students to recognize and treat opioid use disorder.

Background: With a drastic shortage of addiction medicine specialists-and an ever-growing number of patients with opioid use disorder (OUD)-there is a dire need for more clinicians to feel confident in prevention and management of OUD and obtain a DEA-X waiver to prescribe medications to treat OUD. Here we determine if it is feasible to certify 4th year medical students with DEA-X waiver training as a component of the PROUD (Prevent and Reduce Opioid Use Disorder) curriculum, and if PROUD enhanced preparedness for medical students to manage OUD as interns. Methods: We implemented a sequential mixed-methods IRB approved study to assess feasibility (completing all required components of DEA-X waiver training) and impact of PROUD (measured by knowledge growth, enhancement for residency, and utilization of training during internship). Students completed 11 hours of required OUD training. Quantitative data included pre-/post- knowledge and curriculum satisfaction assessments as well as long-term impact with follow up survey as interns. Qualitative data was collected by survey and semi-structured focus groups. Results: All 120 graduating medical students completed the required components of the curriculum. Knowledge improved on the Provider Clinical Support Services (12.9-17.3, p < 0.0001) and Brief Opioid Overdose Knowledge assessments (10.15-10.81, p < 0.0001). Course satisfaction was high: 90% recommended online modules; 85% recommended training overall. Six qualitative themes emerged: (1) curriculum content was practical, (2) online modules allowed flexibility, (3) in-person seminars ensured authenticity, (4) timing at the transition to residency was optimal, (5) curriculum enhanced awareness and confidence, and (6) training was applicable to future careers. At 3 months, 60% reported using their training during internship; 64% felt more prepared to treat OUD than peers. Conclusions: PROUD trained 4th year medical students in opioid stewardship. As interns, students felt ready to serve as change agents to prevent, diagnose, and treat OUD.

Investigating the educational experiences of transnational students: Differences in academic integration, social integration, and institutional and goal commitment.

BACKGROUND: Despite the growing popularity of transnational education, there is a dearth of quantitative research regarding how transnational students experience higher education. AIMS: This comparative study sought to explore differences in educational experiences between transnational and onshore domestic students enrolled either at the Australian (domestic) or Singapore (transnational) campus of an Australian university. SAMPLE AND METHODS: An online survey gathered responses from 199 domestic students and 313 transnational students. RESULTS: Results indicated transnational students to be significantly lower than domestic students on social and academic integration, institutional commitment, and satisfaction. No group differences were found in persistence intentions. A series of regression analyses showed integration and commitment significantly predicted student persistence intentions, across both cohorts, beyond demographic and course characteristics. CONCLUSIONS: This study offers several recommendations for how universities can better foster integration and commitment in their transnational students, including better funding the development of student societies and providing realistic course previews and career advice to students upon entry into their courses. Further, universities are encouraged to reconsider their transnational staffing models to provide more opportunities for academic support and student consultation beyond the classroom.

Treatment of Kratom Withdrawal and Dependence With Buprenorphine/Naloxone: A Case Series and Systematic Literature Review.

INTRODUCTION: Some opioid use disorder (OUD) patients attempt to self-treat using herbal remedies such as kratom. However, kratom use itself can paradoxically cause physical dependence and OUD. Currently, there are no guidelines for treating patients with OUD stemming from kratom use. Our empirically-based hypothesis was that there would be a correlation between the amount of kratom used and the amount of buprenorphine-naloxone required for opioid agonist therapy. METHODS: This study includes a systematic review assessing treatment of kratom-dependent patients with buprenorphine-naloxone; a case series of our kratom-dependent patients; calculation of the correlation between the kratom dose and the buprenorphine-naloxone dose required to treat kratom-associated OUD; and our proposed starting doses for using buprenorphine-naloxone to treat kratom OUD. RESULTS: The OVID MEDLINE (1946-2020) database was searched using the terms "kratom," "buprenorphine," and "case report." This search yielded 3 relevant cases of patients having kratom OUD who were treated with buprenorphine-naloxone with the amounts of all substances reported. Review of the bibliographies, citing articles, and Google Scholar turned up three additional cases, yielding 6 literature cases that were analyzed. We also analyzed 2 patients from our clinic, giving a total of 8 patients included in the Pearson correlation coefficient calculation. We found a strong correlation of 0.84 between these variables, consistent with our hypothesis. CONCLUSIONS: Based on our analysis, patients using <20 g of kratom/d could be initiated on opioid agonist therapy with 4/1 mg-8/2 mg buprenorphine-naloxone/d, while patients using kratom doses >40 g/d could be initiated with 12/3 mg-16/4 mg of buprenorphine-naloxone/day.

Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider.

INTRODUCTION: There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. OBJECTIVES: We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. METHODS: Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. RESULTS: Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. CONCLUSIONS: There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients.

Improving our understanding of multi-tasking in healthcare: Drawing together the cognitive psychology and healthcare literature.

Multi-tasking is an important skill for clinical work which has received limited research attention. Its impacts on clinical work are poorly understood. In contrast, there is substantial multi-tasking research in cognitive psychology, driver distraction, and human-computer interaction. This review synthesises evidence of the extent and impacts of multi-tasking on efficiency and task performance from health and non-healthcare literature, to compare and contrast approaches, identify implications for clinical work, and to develop an evidence-informed framework for guiding the measurement of multi-tasking in future healthcare studies. The results showed healthcare studies using direct observation have focused on descriptive studies to quantify concurrent multi-tasking and its frequency in different contexts, with limited study of impact. In comparison, non-healthcare studies have applied predominantly experimental and simulation designs, focusing on interleaved and concurrent multi-tasking, and testing theories of the mechanisms by which multi-tasking impacts task efficiency and performance. We propose a framework to guide the measurement of multi-tasking in clinical settings that draws together lessons from these siloed research efforts.

Emergency doctors' strategies to manage competing workload demands in an interruptive environment: An observational workflow time study.

An observational workflow time study was conducted involving doctors in the emergency department (ED) of a large Australian hospital. During 121.7 h across 58 sessions, we observed interruptive events, conceptualised as prompts, and doctors' strategies to handle those prompts (task-switching, multitasking, acknowledgement, deferral and deflection) to assess the role of multiple work system factors influencing doctors' work in the ED. Prompt rates varied vastly between work scenarios, being highest during non-verbal solo tasks. The propensity to use certain strategies also differed with task type, prompt type and location within the department, although task-switching was by far the most frequent. Communicative prompts were important in patient treatment and workload management. Clinicians appear to adjust their communication strategies in response to contextual factors in order to deliver patient care. Risk due to the interruptive nature of ED communication is potentially outweighed by the positive effects of timely information transfer and advice provision.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol.

INTRODUCTION: Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. METHODS AND ANALYSIS: The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED.

A Descriptive Analysis of Incidents Reported by Community Aged Care Workers.

Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care.

Phosphorylation regulates coilin activity and RNA association.

The Cajal body (CB) is a domain of concentrated components found within the nucleus of cells in an array of species that is functionally important for the biogenesis of telomerase and small nuclear ribonucleoproteins. The CB is a dynamic structure whose number and size change during the cell cycle and is associated with other nuclear structures and gene loci. Coilin, also known as the marker protein for the CB, is a phosphoprotein widely accepted for its role in maintaining CB integrity. Recent studies have been done to further elucidate functional activities of coilin apart from its structural role in the CB in an attempt to explore the rationale for coilin expression in cells that have few CBs or lack them altogether. Here we show that the RNA association profile of coilin changes in mitosis with respect to that during interphase. We provide evidence of transcriptional and/or processing dysregulation of several CB-related RNA transcripts as a result of ectopic expression of both wild-type and phosphomutant coilin proteins. We also show apparent changes in transcription and/or processing of these transcripts upon coilin knockdown in both transformed and primary cell lines. Additionally, we provide evidence of specific coilin RNase activity regulation, on both U2 and hTR transcripts, by phosphorylation of a single residue, serine 489. Collectively, these results point to additional functions for coilin that are regulated by phosphorylation.

Coilin phosphomutants disrupt Cajal body formation, reduce cell proliferation and produce a distinct coilin degradation product.

Coilin is a nuclear phosphoprotein that accumulates in Cajal bodies (CBs). CBs participate in ribonucleoprotein and telomerase biogenesis, and are often found in cells with high transcriptional demands such as neuronal and cancer cells, but can also be observed less frequently in other cell types such as fibroblasts. Many proteins enriched within the CB are phosphorylated, but it is not clear what role this modification has on the activity of these proteins in the CB. Coilin is considered to be the CB marker protein and is essential for proper CB formation and composition in mammalian cells. In order to characterize the role of coilin phosphorylation on CB formation, we evaluated various coilin phosphomutants using transient expression. Additionally, we generated inducible coilin phosphomutant cell lines that, when used in combination with endogenous coilin knockdown, allow for the expression of the phosphomutants at physiological levels. Transient expression of all coilin phosphomutants except the phosphonull mutant (OFF) significantly reduces proliferation. Interestingly, a stable cell line induced to express the coilin S489D phosphomutant displays nucleolar accumulation of the mutant and generates a N-terminal degradation product; neither of which is observed upon transient expression. A N-terminal degradation product and nucleolar localization are also observed in a stable cell line induced to express a coilin phosphonull mutant (OFF). The nucleolar localization of the S489D and OFF coilin mutants observed in the stable cell lines is decreased when endogenous coilin is reduced. Furthermore, all the phosphomutant cells lines show a significant reduction in CB formation when compared to wild-type after endogenous coilin knockdown. Cell proliferation studies on these lines reveal that only wild-type coilin and the OFF mutant are sufficient to rescue the reduction in proliferation associated with endogenous coilin depletion. These results emphasize the role of coilin phosphorylation in the formation and activity of CBs.