The "Difficult" Inpatient, a Qualitative Study of Physician Perspectives.

BACKGROUND: Previous studies exploring difficult inpatients have mostly focused on psychiatric inpatients. OBJECTIVE: To explore the characteristics of difficult medicine inpatients. DESIGN: Qualitative study using focus groups and semi-structured interviews. Transcripts were recorded, transcribed, and coded (MAXQDA) using thematic content analysis. PARTICIPANTS: Medicine inpatient providers at a tertiary care facility. KEY RESULTS: Our sample consisted of 28 providers (6 hospitalists, 10 medicine attendings, 6 medicine residents, and 6 interns). Theme 1: Provider experience: Difficult inpatients were time-consuming and evoked emotional responses including frustration and dysphoria. Theme 2: Patient characteristics: Included having personality disorders or mental health issues, being uncooperative, manipulative, angry, demanding, threatening, or distrustful. Difficult patients also had challenging social situations and inadequate support, unrealistic care expectations, were self-destructive, tended to split care-team messages, and had unclear diagnoses. Theme 3: Difficult families: Shared many characteristics of difficult patients including being distrustful, demanding, manipulative, threatening, or angry. Difficult families were barriers to care, disagreed with the treatment plan and each other, did not act in the patient's best interest, suggested inappropriate treatment, or had unrealistic expectations. STRATEGIES: Approaches to dealing with difficult patients or families included building trust, being calm, and having a consistent message. Communication approaches included naming the emotion, empathetic listening, identifying patient priorities and barriers, and partnering. CONCLUSIONS: Difficult patients induced emotional responses, dysphoria, and self-doubt among providers. Underlying personality disorders were often mentioned. Difficult patients and families shared many characteristics. Communication and training were highlighted as key strategies.

An inexpensive foramen magnum decompression training tool: Feasibility and validation study.

Foramen magnum decompression (FMD) is a standard neurosurgical procedure, typically utilized to treat Chiari malformation. The aim of this educational project was to develop and validate a low-cost FMD simulation training model. Mold-based methods were used to develop a prototype. Feasibility was tested during an FMD training session for 17 neurosurgery trainees. Face and content validity were assessed through a Likert Scale. The perceived training benefit was determined using the Physician Performance Diagnostic Inventory Scale (PPDIS). A total of 87.5% successfully removed the C1 arch, 81.3% successfully performed an FMD, and 68.8% avoided injury to the underlying structures. The model scored highly for visual and tactile realism. The median confidence rating on PPDIS significantly improved from early learner to competent. We demonstrate feasibility, content, and face validity. Furthermore, this is a low-cost, portable model that can be easily replicated and used for simulation training.

European Medical Students' Views on Neurosurgery, with Emphasis on South-East Europe (Albania, Greece, Serbia, and Turkey).

BACKGROUND: Neurosurgery, an intricate and dynamic surgical specialty, faces challenges in attracting medical graduates. Despite its potential appeal, a decreasing trend in medical students opting for surgical specialties, including neurosurgery, is noted. This study aims to assess European medical students' perceptions of neurosurgery, focusing on South-East Europe, and address concerns about the declining interest in this field. METHODS: A comprehensive digital survey, comprising 33 questions, was distributed to 1115 medical students across 17 European countries. The survey, conducted over 9 months, gathered responses through European neurosurgical societies, the European Association of Neurosurgical Societies (EANS), and university channels. Statistical analysis utilized IBM Statistical Package for the Social Sciences, presenting data through counts, proportions, and χ2 tests. RESULTS: The study reveals that, over the survey period, 834 medical students completed the questionnaire, with a predominant representation from South-East Europe. While 43.2% of participants were considering a surgical career, neurosurgery emerged as the most preferred specialty (26.37%). Despite this interest, 80.2% reported insufficient knowledge about pursuing a neurosurgical career, with limited exposure during medical education. Concerns about work-life balance, heavy workload, and hierarchical structures were prominent among respondents. CONCLUSIONS: The findings underscore the need for targeted interventions to address concerns influencing medical students' decisions regarding neurosurgery. Improving neurosurgical education, dispelling misconceptions, and creating a supportive work environment are crucial steps to attract and retain diverse talented individuals in neurosurgery. These efforts will be vital in narrowing the gap between the demand for neurosurgeons and the number of medical graduates entering the field, ensuring a sustainable future for this essential surgical specialty.

A toxicological assessment of spermidine trihydrochloride produced using an engineered strain of Saccharomyces cerevisiae.

Spermidine is a polyamine consumed in the diet, endogenously biosynthesized in most cells, and produced by the intestinal microbiome. A variety of foods contribute to intake of spermidine along with other polyamines. Spermidine trihydrochloride (spermidine-3HCl) of high purity can be produced using an engineered strain of Saccharomyces cerevisiae. Spermidine has a demonstrated history of safe use in the diet; however, limited information is available in the public literature to assess the potential toxicity of spermidine-3HCl. To support a safety assessment for this spermidine-3HCl as a dietary source of spermidine, authoritative guideline and good laboratory practice (GLP) compliant in vitro genotoxicity assays (bacterial reverse mutation and mammalian micronucleus assays) and a 90-day oral (dietary) toxicity study in rats were conducted with spermidine-3HCl. Spermidine-3HCl was non-genotoxic in the in vitro assays, and no adverse effects were reported in the 90-day oral toxicity study up to the highest dose tested, 12500 ppm, equivalent to 728 mg/kg bw/day for males and 829 mg/kg bw/day for females. The subchronic no observed adverse effect level (NOAEL) is 728 mg/kg bw/day.

Comprehensive safety assessment of serendipity berry sweet protein produced from Komagataella phaffii.

Serendipity berry plant (Dioscoreophyllum cumminsii (Stapf) Diels) is the source of a naturally sweet protein referred to as monellin. The safety of serendipity berry sweet protein (SBSP) containing single polypeptide monellin (MON) expressed in Komagataella phaffii (formerly Pichia pastoris) and produced via precision fermentation was examined comprehensively through assessments of in vitro and in silico protein digestion, in silico allergenicity, in vitro genotoxicity (reverse mutation and mammalian micronucleus assays), and 14-day and 90-day oral (dietary) toxicity studies in rats. There was no indication of allergenicity for SBSP in the in silico analyses. Results from both in vitro and in silico protein digestibility assessments indicated that SBSP is digested upon ingestion and would therefore be unlikely to pose a toxigenic or allergenic risk to consumers. SBSP was non-genotoxic in in vitro assays and showed no adverse effects in the 14-day or 90-day toxicity studies up to the highest dose tested. The 90-day toxicity study supports a NOAEL for SBSP of 1954 mg/kg bw/day, which corresponds to a NOAEL for MON of 408 mg/kg bw/day.

The benefits of difference-education interventions in lower-resourced institutions.

Difference-education is an intervention that addresses psychological barriers that can undermine the academic performance of first-generation college students (i.e., those who have parents without 4-year degrees). Difference-education interventions improve first-generation students' performance by empowering them to navigate higher education environments more effectively. They also improve students' comfort with social group difference. However, these benefits have only been documented in higher-resourced institutions. The present research asks two questions about whether these benefits also extend to lower-resourced institutions-that is, schools with fewer resources to invest in students than the universities where prior difference-education interventions were delivered. First, is difference-education effective in improving first-generation students' academic performance in lower-resourced institutions, and does it do so by increasing empowerment? Second, does difference-education improve comfort with social group difference in lower-resourced institutions, and is it unique in its ability to do so? With students from four lower-resourced institutions, we examined these questions by comparing the results of a difference-education intervention to a control condition and social-belonging intervention. We found that while some benefits of difference-education interventions extend to lower-resourced institutions, others do not. First, like prior interventions, difference-education improves first-generation students' academic performance and comfort with social group difference. Unlike prior interventions, these effects did not persist beyond the first term and students' academic performance benefits were not explained by empowerment. We also found partial evidence that the benefits for comfort with social group difference were unique compared to a social-belonging intervention. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Buprenorphine Use in the United States, 2010-2019.

BACKGROUND: Buprenorphine is effective for the treatment of opioid use disorder and chronic pain, has a safer pharmacological profile than full mu-opioid agonists, and can now be prescribed by any US provider with a Drug Enforcement Administration license. This study aimed to examine a decade of buprenorphine prescribing patterns in the United States. METHODS: We abstracted opioid and buprenorphine prescribing patterns, including patient characteristics, from the 2010-2019 National Ambulatory Medical Care Survey, a national probability sample of non-federal, ambulatory encounters. DISCUSSION: Among 248,164 ambulatory encounters, opioids were prescribed 2.6%-4.3% of the time with a rate that peaked in 2013 and has been steadily declining. Buprenorphine was infrequently prescribed. Patients receiving buprenorphine were predominantly male (59%), white (70%), younger in age, and had higher rates of substance use disorder (72%). CONCLUSION: Buprenorphine is infrequently used, despite being effective for pain and safer than full mu-opioid agonists. The Drug Enforcement Administration recently ended the requirement for prescribers to obtain an X-waiver, which may increase the rate of buprenorphine use among US practitioners.

Motivated Knowledge Acquisition: Implicit Self-Theories and the Preference for Knowledge Breadth or Depth.

Implicit self-theories posit that individuals ascribe to one of two beliefs regarding the self: an incremental theory motivated by learning goals and an entity theory motivated by performance goals. This work proposes that these theories-and their underlying motivations-reflect individuals' preferences for different knowledge types. Specifically, we propose that incremental theorists prefer knowledge that expands their understanding of diverse experiences within a category (i.e., knowledge breadth), whereas entity theorists prefer knowledge that refines their understanding of a preferred experience within a category (i.e., knowledge depth). Five studies show the effect of implicit self-theories on individuals' preferences for knowledge breadth and depth and the role of learning and performance goals in motivating these knowledge preferences. We address alternative explanations related to general openness, risk-seeking, and perceived quality differences, and we demonstrate the role of negative feedback in reversing these knowledge preferences.

Effects of matching personal and organizational mindsets on belonging and organizational interest.

Growth mindsets are beliefs that abilities, like intelligence, are mutable. Although most prior work has focused on people's personal mindset beliefs, a burgeoning literature has identified that organizations also vary in the extent to which they communicate and endorse growth mindsets. Organizational growth mindsets have powerful effects on belonging and interest in joining organizations, suggesting that they may be a productive way to intervene to improve individual and societal outcomes. Yet, little is known about for whom organizational mindset interventions might be more or less effective, a critical question for effective implementation and theory. We examine whether people's personal mindset beliefs might determine the effect of organizational growth mindsets, and if so, whether this moderation reflects a matching or mismatching pattern. Three experiments manipulated the espoused mindset of an organization and found that organizational growth mindsets primarily increased belonging and interest in joining among participants who personally endorsed matching growth mindset beliefs. An additional field study provided ecological validity to these findings, replicating them with students' experiences of belonging in classrooms. This study also revealed a divergent mismatching pattern on grades: rather than bolstering the grades of students with growth mindsets, growth mindset classroom contexts primarily enhanced the grades of students with more fixed mindsets. By clarifying for whom organizational growth mindsets are beneficial and in what manner, the current work provides theoretical and practical insight into the psychological dynamics of organizational growth mindsets. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Investigating intentional cranial modification: A hybridized two-dimensional/three-dimensional study of the Hirota site, Tanegashima, Japan.

Intentional cranial modification has a long history, being a ubiquitous practice in many cultures around the world for millennia. The crania excavated at the Hirota site on Tanegashima Island, Kagoshima Prefecture, Japan, has been previously noted to have a marked tendency toward a short head and a flattened occipital bone, which has been suggested to be the result of artificial cranial deformation. However, whether this deformation was intentional or caused by unintentional habits remains unclear. This study aimed to investigate the characteristics of the cranial shape of the Hirota site to clarify whether the crania were intentionally modified. In the examination of Hirota crania, Kyushu Island Jomon and Doigahama Yayoi crania were added as comparative data and contrasted with three-dimensional (3D) surface scan imaging and two-dimensional outline-based geometric morphometric analysis, combined with objective assessments of potential cranial modification. The results showcased Hirota's short and flattened cranial morphology, indicating clear alignment with our hypothesis that Hirota samples are morphologically different from Doigahama and Jomon samples. No sex-based differences were found. Morphological abnormalities in cranial sutures were visually assessed utilizing novel 3D visualization methods of cranial outer surfaces. Based on a comprehensive review of the results, we concluded that Hirota site crania were intentionally modified. Although the motivation of the practice is unclear, the Hirota people may have deformed their crania to preserve group identity and possibly aid in the long-distance trade of shellfish, as seen archaeologically.

Shifting the mindset culture to address global educational disparities.

Educational outcomes remain highly unequal within and across nations. Students' mindsets-their beliefs about whether intellectual abilities can be developed-have been identified as a potential lever for making adolescents' academic outcomes more equitable. Recent research, however, suggests that intervention programs aimed at changing students' mindsets should be supplemented by programs aimed at the changing the mindset culture, which is defined as the shared set of beliefs about learning in a school or classroom. This paper reviews the theoretical and empirical origin of the mindset culture and examines its potential to reduce group-based inequalities in education. In particular, experiments have identified two broad ways the mindset culture is communicated by teachers: via informal messages about growth (e.g., that all students will be helped to learn and succeed), and formal opportunities to improve (e.g., learning-focused grading policies and opportunities to revise and earn credit). New field experiments, applying techniques from behavioral science, have also revealed effective ways to influence teachers' culture-creating behaviors. This paper describes recent breakthroughs in the U.S. educational context and discusses how lessons from these studies might be applied in future, global collaborations with researchers and practitioners.

Trusting relationships between patients with non-curative cancer and healthcare professionals create ethical obstacles for informed consent in clinical trials: a grounded theory study.

BACKGROUND: Clinical trial participation for patients with non-curative cancer is unlikely to present personal clinical benefit, which raises the bar for informed consent. Previous work demonstrates that decisions by patients in this setting are made within a 'trusting relationship' with healthcare professionals. The current study aimed to further illuminate the nuances of this relationship from both the patients' and healthcare professionals' perspectives. METHODS: Face-to-face interviews using a grounded theory approach were conducted at a regional Cancer Centre in the United Kingdom. Interviews were performed with 34 participants (patients with non-curative cancer, number (n) = 16; healthcare professionals involved in the consent process, n = 18). Data analysis was performed after each interview using open, selective, and theoretical coding. RESULTS: The 'Trusting relationship' with healthcare professionals underpinned patient motivation to participate, with many patients 'feeling lucky' and articulating an unrealistic hope that a clinical trial could provide a cure. Patients adopted the attitude of 'What the doctor thinks is best' and placed significant trust in healthcare professionals, focusing on mainly positive aspects of the information provided. Healthcare professionals recognised that trial information was not received neutrally by patients, with some expressing concerns that patients would consent to 'please' them. This raises the question: Within the trusting relationship between patients and healthcare professionals, 'Is it possible to provide balanced information?'. The theoretical model identified in this study is central to understanding how the trusting professional-patient relationship influences the decision-making process. CONCLUSION: The significant trust placed on healthcare professionals by patients presented an obstacle to delivering balanced trial information, with patients sometimes participating to please the 'experts'. In this high-stakes scenario, it may be pertinent to consider strategies, such as separation of the clinician-researcher roles and enabling patients to articulate their care priorities and preferences within the informed consent process. Further research is needed to expand on these ethical conundrums and ensure patient choice and autonomy in trial participation are prioritised, particularly when the patient's life is limited.

A synthetic model simulator for intracranial aneurysm clipping: validation of the UpSurgeOn AneurysmBox.

Background and objectives: In recent decades, the rise of endovascular management of aneurysms has led to a significant decline in operative training for surgical aneurysm clipping. Simulation has the potential to bridge this gap and benchtop synthetic simulators aim to combine the best of both anatomical realism and haptic feedback. The aim of this study was to validate a synthetic benchtop simulator for aneurysm clipping (AneurysmBox, UpSurgeOn). Methods: Expert and novice surgeons from multiple neurosurgical centres were asked to clip a terminal internal carotid artery aneurysm using the AneurysmBox. Face and content validity were evaluated using Likert scales by asking experts to complete a post-task questionnaire. Construct validity was evaluated by comparing expert and novice performance using the modified Objective Structured Assessment of Technical Skills (mOSATS), developing a curriculum-derived assessment of Specific Technical Skills (STS), and measuring the forces exerted using a force-sensitive glove. Results: Ten experts and eighteen novices completed the task. Most experts agreed that the brain looked realistic (8/10), but far fewer agreed that the brain felt realistic (2/10). Half the expert participants (5/10) agreed that the aneurysm clip application task was realistic. When compared to novices, experts had a significantly higher median mOSATS (27 vs. 14.5; p < 0.01) and STS score (18 vs. 9; p < 0.01); the STS score was strongly correlated with the previously validated mOSATS score (p < 0.01). Overall, there was a trend towards experts exerting a lower median force than novices, however, these differences were not statistically significant (3.8 N vs. 4.0 N; p = 0.77). Suggested improvements for the model included reduced stiffness and the addition of cerebrospinal fluid (CSF) and arachnoid mater. Conclusion: At present, the AneurysmBox has equivocal face and content validity, and future versions may benefit from materials that allow for improved haptic feedback. Nonetheless, it has good construct validity, suggesting it is a promising adjunct to training.

Where and with whom does a brief social-belonging intervention promote progress in college?

A promising way to mitigate inequality is by addressing students' worries about belonging. But where and with whom is this social-belonging intervention effective? Here we report a team-science randomized controlled experiment with 26,911 students at 22 diverse institutions. Results showed that the social-belonging intervention, administered online before college (in under 30 minutes), increased the rate at which students completed the first year as full-time students, especially among students in groups that had historically progressed at lower rates. The college context also mattered: The intervention was effective only when students' groups were afforded opportunities to belong. This study develops methods for understanding how student identities and contexts interact with interventions. It also shows that a low-cost, scalable intervention generalizes its effects to 749 4-year institutions in the United States.

Nanosensitive optical coherence tomography for detecting structural changes in stem cells.

Mesenchymal stromal cells (MSCs) are adult stem cells that have been widely investigated for their potential to regenerate damaged and diseased tissues. Multiple pre-clinical studies and clinical trials have demonstrated a therapeutic response following treatment with MSCs for various pathologies, including cardiovascular, neurological and orthopaedic diseases. The ability to functionally track cells following administration in vivo is pivotal to further elucidating the mechanism of action and safety profile of these cells. Effective monitoring of MSCs and MSC-derived microvesicles requires an imaging modality capable of providing both quantitative and qualitative readouts. Nanosensitive optical coherence tomography (nsOCT) is a recently developed technique that detects nanoscale structural changes within samples. In this study, we demonstrate for the first time, the capability of nsOCT to image MSC pellets following labelling with different concentrations of dual plasmonic gold nanostars. We show that the mean spatial period of MSC pellets increases following the labelling with increasing concentrations of nanostars. Additionally, with the help of extra time points and a more comprehensive analysis, we further improved the understanding of the MSC pellet chondrogenesis model. Despite the limited penetration depth (similar to conventional OCT), the nsOCT is highly sensitive in detecting structural alterations at the nanoscale, which may provide crucial functional information about cell therapies and their modes of action.

Not such a complainer anymore: Confrontation that signals a growth mindset can attenuate backlash.

We report the first investigation of whether observers draw information about mindsets from behavior, specifically prejudice confrontation. We tested two questions across 10 studies (N = 3,168). First, would people who observe someone confront a biased comment (vs. remain silent) see them as endorsing more growth (vs. fixed) mindsets about prejudice and bias? If so, would the growth mindset perceptions that arise from confrontation (vs. remaining silent) attenuate the backlash that observers exhibit against confronters? We investigated these questions using scenarios (Studies 1, 2a-b, 4, 5a-d), naturalistic confrontations of national, race, and gender stereotypes reported retrospectively (Study 3), and an in-person laboratory experiment of actual confrontations of racial bias (Study 6). Correlational and experimental methods yielded support for our core hypotheses: People spontaneously imbue someone who confronts a biased comment with more growth mindset beliefs about prejudice and bias (Studies 1, 2a-b, 4, 6), regardless of whether participants observe the confrontation (Studies 1, 2a-b, 5a-d) or are being confronted themselves (Studies 2a-4, 6). The growth mindset perceptions arising from these confrontations suppress backlash, assessed by classic interpersonal perceptions (Studies 4-5) and judgments of interpersonal warmth and willingness to interact again in the future (Study 6), both when the confronter was a target of the biased behavior (Studies 1-5), and when they were an ally (Study 6), in both correlational studies (Study 3-4) and when growth mindset (about personality, Study 5; about prejudice, Study 6) was manipulated, confirming causality. We discuss implications for the study of mindsets, confrontation, and intergroup relations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).