Pain and fatigue as mediators of the relationship between mobility aid usage and depressive symptomatology in ambulatory individuals with SCI.

STUDY DESIGN: Cross-sectional cohort study. OBJECTIVES: To investigate a mediational model where pain (intensity and interference) and fatigue mediate the relationship between the use of mobility aids and moderate-to-severe depressive symptomatology among ambulatory participants with spinal cord injury (SCI). SETTING: A medical university in the southeastern United States. METHODS: Ambulatory adults (N=652) with chronic SCI responded to a mail-in survey. The Patient Health Questionnaire-9 was used to assess moderate-to-severe depressive symptomatology. The Brief Pain Inventory was used to assess pain intensity and interference, and the Modified Fatigue Impact Scale-5-item version was used to assess fatigue. Participants self-reported use of mobility aids. RESULTS: On examining mobility aids used for ambulation, 65% were found to have used at least one aid. Severe pain intensity was reported by 11%, and 14% reported severe pain interference. Disabling fatigue was reported by 10% of the participants. Twenty-one percent (n=138) reported moderate-to-severe levels of depressive symptoms. On examining the relationships between mobility aids and depressive symptomatology, using people as a mobility aid was associated with increased odds of depressive symptomatology (2.6) and always using a wheelchair was associated with lower odds (0.3). However, these relationships were no longer significant after controlling for the mediating variables pain intensity, pain interference and fatigue. CONCLUSIONS: Pain and fatigue mediate the relationship between usage of certain mobility aids and depressive symptomatology. The use of people to assist in ambulation is associated with greater odds of moderate-to-severe depressive symptomatology, while always using a wheelchair is associated with lower odds.

Pediatric subspecialty training, certification, and practice: who's doing what.

OBJECTIVE: To examine the extent of pediatric subspecialty training, certification, and practice among general and subspecialty pediatricians and to determine how the diversity of pediatric careers may affect physician workforce supply estimates. METHOD: A sample of 4,000 self-designated pediatricians and pediatric subspecialists from the American Medical Association's Physician Masterfile were surveyed in 1991 by the American Academy of Pediatrics. Seventy-six percent of the sample responded to the 6-page questionnaire on practice characteristics, training, and demographic information. RESULTS: Two-thirds of pediatricians are not subspecialty trained (66.3%), 15.1% are certified subspecialists, 11.3% are trained but not subboard certified, and 7.3% are subspecialty trained in an area with no certification exam. Subspecialty training did not always predict subspecialty practice; 19% of pediatricians without subspecialty training spend some time in a subspecialty, and 13% of those who are subspecialty trained practice general pediatrics exclusively. Certified subspecialists and those who cannot as yet become certified are most likely to practice their subspecialty. One-fourth of those trained in a certifiable subspecialty but who remain uncertified practice general pediatrics exclusively. The proportion of direct patient care time spent overall, and the proportion of direct patient care time spent in the subspecialty are also related to subspecialty certification and training/practice consistency. CONCLUSION: Pediatric workforce supply projections should incorporate more than certification and training information in calculating estimates, as the practice of general and subspecialty pediatrics is very diverse and accommodating of integrative styles.

Career plans of new pediatricians: results from a survey of residency program directors.

Directors of pediatric residency programs in the United States, Puerto Rico, and Canada were surveyed regarding plans of graduating residents to determine whether new pediatricians experienced problems finding employment in light of a decreasing growth rate in the child population. Nearly 90% of directors responded, providing information on 1915 residents. Of the 1782 nonmilitary residents in the United States, 815 were entering general pediatric practice and one third (596) were entering subspecialty training. Nearly one half (379) of residents entering general pediatric practice were joining a small group practice, almost one fourth (184) were joining a larger group, 6% (48) were becoming solo practitioners, 7% (57) were joining a health maintenance organization, and nearly 8% (62) were joining a hospital or academic staff. Most residents in the United States experienced no difficulty finding a position and received multiple offers for jobs. Canadian residents were similar to residents in the United States, whereas the postresidency situations of graduates of military and Puerto Rican programs were very different. Despite manpower predictions to the contrary, comments by program directors indicated a demand for general pediatricians. This paper presents only the viewpoint of program directors; whether this perceived need illustrates an avid market for young general pediatricians merits further study.

Preschool vision screening in pediatric practice: a study from the Pediatric Research in Office Settings (PROS) Network. American Academy of Pediatrics.

In this cross-sectional study, the vision-screening process is described for 8417 children aged 3 to 5 seen for health supervision in a group of 102 pediatric practices in 23 states and Puerto Rico. Three hundred forty children who failed screening (63% of those who failed) were followed up 2 months after initial screening. The sample was 52% male, 86% white, 9% black, 3% Hispanic, and 1% Asian. Vision screening was attempted on 66% of children overall. Pediatricians' reasons for not screening were "not routine" (44%), "too young" (40%), and "screening done previously" (17%). Younger children were less likely to be screened than older children (39% of those aged 3), and Hispanics were less likely to be screened than other ethnic groups (P less than .001). Thirty-three percent of children received no screening for latent strabismus. Two months later, 50% of parents whose child had failed a vision test were unaware of this fact on questionnaire follow-up. Eighty-five percent of children referred to an eye specialist had made or kept an appointment. It is concluded that pediatricians need to increase vision screening among younger preschool children and communicate more effectively to parents the results of screening failure.

The respective racial and ethnic diversity of US pediatricians and American children.

BACKGROUND: Much effort has been directed toward increasing the training of physicians from underrepresented minority groups, yet few direct comparisons have examined the diversity of the racial/ethnic backgrounds of the physicians relative to the patient populations they serve, either currently or into the future. This has been particularly true in the case of pediatrics, in which little information has emerged regarding the racial/ethnic backgrounds of pediatricians, yet evidence points to ever-growing diversity in the US child population. OBJECTIVE: We embarked on a comparative analysis to examine trends in the racial and ethnic composition of pediatricians vis-a-vis the patient population they serve, America's infants, children, adolescents, and young adults. METHODS: Data on US pediatricians sorted by racial/ethnic group came from Association of American Medical Colleges distribution data and is based on the cohort of pediatricians graduating from US medical schools between 1983 and 1989 extrapolated to the total number of pediatricians actively practicing in 1996. Data on the demographic diversity of the US child population came from the US Census Bureau. We derived pediatrician-to-child population ratios (PCPRs) specific to racial/ethnic groups to measure comparative diversity between and among groups. RESULTS: Our results show that the black PCPR, currently less than one third of the white PCPR, will fall from 14.3 pediatricians per 100 000 children in 1996 to 12 by 2025. The Hispanic PCPR will fall from 16.9 in 1996 to 9.2 in 2025. The American Indian/Alaska Native PCPR will drop from 7.8 in 1996 to 6.5 by the year 2025. The PCPR specific to the Asian/Pacific Islander group will decline from 52.9 in 1996 to 26.1 in 2025. For whites, the PCPR will increase from 47.8 to 54.2 during this period. For 1996, each of the 5 PCPRs is significantly different from the comparison ratio. The same is true for 2025. For the time trend comparison (between 1996 and 2025), there is a significant difference for each ratio except for American Indian/Alaska Native. CONCLUSION: The racial and ethnic makeup of the US child population is currently far more diverse than that of the pediatricians who provide their health care services. If child population demographic projections hold true, and no substantial shifts transpire in the composition of the pediatric workforce, the disparities will increase substantially by the year 2025.

Minority and nonminority pediatricians' care of minority and poor children.

BACKGROUND: Although it has been established that minority physicians tend to see more minority and more poor or uninsured patients, pediatrics as a specialty has not been studied in this regard. OBJECTIVE: To determine if minority pediatricians disproportionately provide care to minority children and to poor and uninsured children, relative to nonminority pediatricians, while controlling for possible confounding variables (socioeconomic background, sex, use of non-English languages in practice, and subspecialty training). METHODS: In 1996, a stratified random sample of 1044 pediatricians, half of whom were underrepresented minorities (URMs) (African, Native, and Mexican Americans, mainland Puerto Ricans, and other Hispanics) and half of whom were Asian or Pacific Islanders, commonwealth Puerto Ricans, and whites (non-URMs), were surveyed about personal, practice, and patient characteristics. RESULTS: Multivariate analyses reveal that, independent of other variables, being a URM pediatrician is significantly (P = .001) and positively associated with caring for a greater proportion of minority and Medicaid-insured or uninsured patients. Underrepresented minority pediatricians saw 24 percentage points more minority patients and 13 percentage points more Medicaid-insured or uninsured patients than did non-URM pediatricians. CONCLUSIONS: Compared with what non-URM pediatricians report, URM pediatricians report caring for significantly (P =.001) more minority and poor and uninsured patients. Given the few pediatricians who are URM, non-URM pediatricians should be adequately prepared to provide care for minority patients, as the proportion of minority children is high and will be increasing significantly in the next several years. Most important, efforts to ensure a racially and ethnically diverse health care workforce should be greatly enhanced, as its diversity, and hence representativeness, will improve the health care system for all Americans.

General pediatricians, pediatric subspecialists, and pediatric primary care.

OBJECTIVE: To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care. DESIGN AND METHODS: A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care. RESULTS: Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001). CONCLUSION: Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.

Effect of tidal volume and PEEP in ethchlorvynol-induced asymmetric lung injury.

We examined the effects of positive end-expiratory pressure (PEEP) and tidal volume on the distribution of ventilation and perfusion in a canine model of asymmetric lung injury. Unilateral right lung edema was established in 10 animals by use of a selective infusion of ethchlorvynol. Five animals were tested in the supine position (horizontal asymmetry) and five in the right decubitus position (vertical asymmetry). Raising PEEP from 5 to 12 cmH2O improved oxygenation despite a redistribution of blood flow toward the damage lung and a consistent decrease in total respiratory system compliance. This improvement paralleled a redistribution of tidal ventilation to the injured lung. This was effected primarily by a fall in the compliance of the noninjured lung due to hyperinflation. The effects of higher tidal volume were additive to those of PEEP. We propose that the major effect of PEEP in inhomogeneous lung injury is to restore tidal ventilation to a population of alveoli recruitable only at high airway pressures.

Myocardial biochemical and hemodynamic adaptations to chronic tachycardia.

The purpose was to determine the biochemical and hemodynamic adaptations of the myocardium to chronic tachycardia. Cardiac pacemakers were implanted in Yorkshire pigs and set at a rate of 180 beats/min for a period of 35-42 days. Animals were then anesthetized with pentobarbital sodium. Myocardial blood flow and hemodynamics were determined at three different heart rates (i.e., 120, 180, and 220 beats/min). Tissue samples were then taken for microsphere and biochemical analyses. Chronically paced hearts maintained better cardiac function and had consistently higher left ventricular blood flow with a higher endocardial-to-epicardial ratio. The activities of citrate synthase and 3-hydroxyacyl-CoA dehydrogenase were 23 and 45% greater in the paced hearts, respectively. The sarcoplasmic reticulum adenosinetriphosphatase activity was 55% greater in the paced hearts, whereas the myosin adenosinetriphosphatase was the same as in the control hearts. Polyacrylamide gels of the ventricular myosin isoforms showed only the V3 type to be present in both the control and paced hearts. These findings show that the heart of a large mammal adapts to chronic tachycardia (i.e., 180 beats/min) by elevating the aerobic and calcium-sequestering capacities without altering its myosin type.

The relationship of indebtedness, race, and gender to the choice of general or subspecialty pediatrics.

BACKGROUND: Little research has examined indebtedness and the choice of continued subspecialty training. Concerns about a decline in the proportion of primary care physicians obliges medical educators to understand factors that influence the choice of subspecialty training. METHOD: Survey data on 437 pediatricians who graduated between the years 1981 and 1987 were collected in 1991. Logistic regression was used to examine the influences of sex, race, graduation year, type of medical school, and educational debt (adjusted for inflation) on whether a pediatrician had trained in a subspecialty. RESULTS: Three variables were associated with subspecialty training. Men and whites were significantly more likely to have trained in subspecialties, as were earlier graduates. Type of medical school and debt did not enter the equation. CONCLUSION: Other variables were found to be more influential than indebtedness in the career decisions of primary care and subspecialty pediatricians. Distinguishing between subspecialties that have noticeably higher incomes and those that serve to enhance primary care pediatrics may be illuminating. That men and whites were more likely to train in subspecialty pediatrics suggests that financial considerations, if present, may be masked under other cultural and societal factors.

Practice of pediatric pulmonology: results of the Future of Pediatric Education Project (FOPE)

In 1996, the Future of Pediatric Education (FOPE) Project of the American Academy of Pediatrics (AAP) developed surveys to describe the nature of pediatric practices, recent trends in clinical practice, and anticipated workforce needs for both pediatric generalists and pediatric sub-specialists. A survey was specifically developed to describe the features of pediatric pulmonology as self-reported by pediatric pulmonologists. The survey was distributed to members of the AAP Pulmonology Section, the Pediatric Assembly of the American Thoracic Society, and certified pediatric pulmonologists recognized by the American Board of Pediatrics. Of the 535 respondents (67% of those invited to respond), the responses of 388 certified and 94 trained but not board-certified pulmonologists were included in the results. The characteristics of certified and non-certified respondents were the same for most survey questions. Clinical activities occupy 73 +/- 29% of professional time. Most pulmonologists work in urban, inner city, or suburban settings and 85% are affiliated with a medical school. One third are in private practice. As a group, research activities occupy less than 15% of their time. Most pediatric pulmonologists maintain a referral practice and use physician extenders to provide care. Patients with asthma and cystic fibrosis comprise 60-70% of patient volume. Both the volume and complexity of patients are increasing, as is competition for pediatric sub-specialty services. Pediatric pulmonary practices vary in size and in volume of patients that they manage in various settings. Forty percent of respondents identify allergists and other pediatric pulmonologists as sources of competition. Sixty-nine percent of respondents do not believe that there is a current need for additional pediatric pulmonologists in their respective communities. Only 15% of respondents plan to retire in the next decade.

Compensatory adaptation of the heart to chronic rate overload: increase in calcium transport ATPase activity of myocardial sarcoplasmic reticulum.

This study was undertaken to test the hypothesis that a compensatory response of the heart to a chronic and continuous, metabolic and heart rate overload was an increase in the calcium sequestering activity of the myocardial sarcoplasmic reticulum. Calcium sequestering activity was estimated by determination of the calcium-dependent ATPase (Ca2+-ATPase) activity of isolated microsomes. Chronic rate overload was modelled by comparing: dysthyroid and control rats; control swine and swine with implanted cardiac pacemakers set at 180 beats/min; and different species of mammals with widely different heart rates. The myocardial sarcoplasmic reticulum Ca2+-ATPase pump activity was significantly increased by 39% for hyperthyroid rats compared to control rats and by 87% for control rats compared to thyroidectomized rats; by 63% for paced swine compared to control swine; and by 43% for rats compared to guinea pigs, by 140% for guinea pigs compared to dogs and by 120% for dogs compared to cows. These data indicate that calcium sequestering activity of myocardial sarcoplasmic reticulum increases in equivalent proportion to the chronotropic demand and that heart rate is a hemodynamic correlate of the sarcoplasmic reticulum Ca2+-ATPase activity.

Nursing role orientation of three groups: from the naive to the realistic.

A comparison was made of the responses of nursing students, non-nursing students, and nurses to an instrument designed to measure nursing-role orientations. In addition, the nursing students were evaluated on this instrument before and after taking a professional role development course. Factor analyses indicated that, in general, this instrument did not measure the orientations as planned; however, it did reveal a "nursing awareness" continuum. The factors generated by the responses of the non-nursing students reflected naiveté regarding nursing, while the nurses were realistic. The nursing students were similar to the non-nursing students before taking the professional role development course and similar to the nurses after the course. Although there were no significant pretest-posttest differences, the nursing students' factors indicated greater knowledge of nursing professionalism after completing the course. Nursing role orientations should not be considered fixed entities, but conceptions affected by nursing experience. The failure of the instrument to measure nursing role orientations as intended supports suggestions that nursing role orientations have changed in recent years. More "modern" orientations may be appropriate at this time.

An interdisciplinary educational approach to assessing the health care and health educational needs of the elderly in a South Carolina community.

This article describes work from an allied health project grant that resulted in an interdisciplinary geriatric educational experience for health professions faculty and students (health information administration, occupational therapy, physical therapy, and health professions education) at an academic health sciences center. The educational experience centered on the process of designing, administering, and analyzing the results of a comprehensive needs assessment for clients attending a senior citizen center. This process enabled faculty and students to integrate education, service, and research activities into their curricula, and to work as an interdisciplinary team in assessing the health care needs of elderly adults in the community.

Liaison old age psychiatry service in a medical setting: description of the newcastle clinical service.

Liaison Old Age Psychiatry services (LOAP) have begun to emerge in the UK and further development of the service is supported by the latest health policies. Since qualitative and quantitative studies in this area are lacking, we have undertaken a detailed quantitative prospective review of referrals to the Newcastle LOAP to evaluate the clinical activity of the service. We report high referral rates and turnover for the LOAP service. Reasons for referral are diverse, ranging from requests for level of care and capacity assessments and transfer to other clinical services to management of behaviour, diagnosis, and treatment. We outline the value of a multidisciplinary model of LOAP activity, including the important role of the liaison nursing team, in providing a rapid response, screening, and followup of high number of clinical referrals to the service.