Physician workforce in the United States of America: forecasting nationwide shortages.

BACKGROUND: Physicians play a critical role in healthcare delivery. With an aging US population, population growth, and a greater insured population following the Affordable Care Act (ACA), healthcare demand is growing at an unprecedented pace. This study is to examine current and future physician job surplus/shortage trends across the United States of America from 2017 to 2030. METHODS: Using projected changes in population size and age, the authors developed demand and supply models to forecast the physician shortage (difference between demand and supply) in each of the 50 states. Letter grades were then assigned based on projected physician shortage ratios (physician shortage per 100 000 people) to evaluate physician shortages and describe the changing physician workforce in each state. RESULTS: On the basis of current trends, the number of states receiving a grade of "D" or "F" for their physician shortage ratio will increase from 4 in 2017 to 23 by 2030, with a total national deficit of 139 160 physician jobs. By 2030, the West is forecasted to have the greatest physician shortage ratio (69 physician jobs per 100 000 people), while the Northeast will have a surplus of 50 jobs per 100 000 people. CONCLUSION: There will be physician workforce shortages throughout the country in 2030. Outcomes of this study provide a foundation to discuss effective and efficient ways to curb the worsening shortage over the coming decades and meet current and future population demands. Increased efforts to understand shortage dynamics are warranted.

United States Registered Nurse Workforce Report Card and Shortage Forecast.

Registered nurses (RNs) play a critical role in health care delivery. With an aging US population, health care demand is growing at an unprecedented pace. Using projected changes in population size and age, the authors developed demand and supply models to forecast the RN job shortage in each of the 50 states. Letter grades were assigned based on projected RN job shortage ratios. The number of states receiving a grade of "D" or "F" for their RN shortage ratio will increase from 5 in 2009 to 30 by 2030, for a total national deficit of 918 232 (725 619 - 1 112 112) RN jobs. There will be significant RN workforce shortages throughout the country in 2030; the western region will have the largest shortage ratio of 389 RN jobs per 100 000. Increased efforts to understand shortage dynamics are warranted.

United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit.

This is a reevaluation of registered nurse (RN) supply and demand from 2016 to 2030 using a previously published work forecast model and grading methodology with more recent workforce data. There will be a shortage of 154 018 RNs by 2020 and 510 394 RNs by 2030; the South and West regions will have higher shortage ratios than Northeast and Midwest regions. This reflects a nearly 50% overall improvement when compared with the authors' prior study, and the low-performing states have improved from 18 "D" and 12 "F" grades as published earlier to 13 "D" and 1 "F" in this study. Although progress has been made, efforts to foster the pipelines for improving the nursing workforce need to be continued.

Functional Magnetic Stimulation of Inspiratory and Expiratory Muscles in Subjects With Tetraplegia.

BACKGROUND: Respiratory complications are major causes of morbidity and mortality in persons with a spinal cord injury, partly because of respiratory muscle paralysis. Earlier investigation has demonstrated that functional magnetic stimulation (FMS) can be used as a noninvasive technology for activating expiratory muscles, thus producing useful expiratory functions (simulated cough) in subjects with spinal cord injury. OBJECTIVE: To evaluate the effectiveness of FMS for conditioning inspiratory and expiratory muscles in persons with tetraplegia. DESIGN: A prospective before and after trial. SETTING: FMS Laboratory, Louis Stokes Cleveland VA Medical Center, Cleveland, OH. PARTICIPANTS: Six persons with tetraplegia. METHOD: Each subject participated in a 6-week FMS protocol for conditioning the inspiratory and expiratory muscles. A magnetic stimulator was used with the center of a magnetic coil placed at the C7-T1 and T9-T10 spinous processes, respectively. Pulmonary function tests were performed before, during, and after the protocol. MAIN OUTCOME MEASUREMENTS: Respiratory variables included maximal inspiratory pressure (MIP), inspiratory reserve volume (IRV), peak inspiratory flow (PIF), maximal expiratory pressure (MEP), expiratory reserve volume (ERV), and peak expiratory flow (PEF). RESULTS: After 6 weeks of conditioning, the main outcome measurements (mean ± standard error) were as follows: MIP, 89.6 ± 7.3 cm H2O; IRV, 1.90 ± 0.34 L; PIF, 302.4 ± 36.3 L/min; MEP, 67.4 ± 11.1 cm H2O; ERV, 0.40 ± 0.06 L; and PEF, 372.4 ± 31.9 L/min. These values corresponded to 117%, 107%, 136%, 109%, 130%, and 124% of pre-FMS conditioning values, respectively. Significant improvements were observed in MIP (P = .022), PIF (P = .0001), and PEF (P = .0006), respectively. When FMS was discontinued for 4 weeks, these values showed decreases from their values at the end of the conditioning protocol, which suggests that continual FMS may be necessary to maintain improved respiratory functions. CONCLUSION: FMS conditioning of the inspiratory and expiratory muscles improved voluntary inspiratory and expiratory functions. FMS may be a noninvasive technology for respiratory muscle training in persons with tetraplegia.

U.S. Social Worker Workforce Report Card: Forecasting Nationwide Shortages.

Using age-based projected changes in population, the authors developed demand and supply models of the social worker workforce to project the shortage of social workers in all 50 states and assigned letter grades based on shortage ratios. According to the projections, the number of states with shortage ratios more severe than the current national ratio will increase from 11 states in 2012 to 30 states by 2030 and the nation will experience a total shortfall of over 195,000 social workers, with the most severe shortages occurring in the western and southern regions of the United States. Further efforts are recommended to investigate shortage dynamics and develop strategies to counter its causes.

Differential intensity-dependent effects of magnetic stimulation on the longest neurites and shorter dendrites in neuroscreen-1 cells.

OBJECTIVE: Magnetic stimulation (MS) is a potential treatment for neuropsychiatric disorders. This study investigates whether MS-regulated neuronal activity can translate to specific changes in neuronal arborization and thus regulate synaptic activity and function. APPROACH: To test our hypotheses, we examined the effects of MS on neurite growth of neuroscreen-1 (NS-1) cells over the pulse frequencies of 1, 5 and 10 Hz at field intensities controlled via machine output (MO). Cells were treated with either 30% or 40% MO. Due to the nature of circular MS coils, the center region of the gridded coverslip (zone 1) received minimal (∼5%) electromagnetic current density while the remaining area (zone 2) received maximal (∼95%) current density. Plated NS-1 cells were exposed to MS twice per day for three days and then evaluated for length and number of neurites and expression of brain-derived neurotrophic factor (BDNF). MAIN RESULTS: We show that MS dramatically affects the growth of the longest neurites (axon-like) but does not significantly affect the growth of shorter neurites (dendrite-like). Also, MS-induced changes in the longest neurite growth were most evident in zone 1, but not in zone 2. MS effects were intensity-dependent and were most evident in bolstering longest neurite outgrowth, best seen in the 10 Hz MS group. Furthermore, we found that MS-increased BDNF expression and secretion was also frequency-dependent. Taken together, our results show that MS exerts distinct effects when different frequencies and intensities are applied to the neuritic compartments (longest neurite versus shorter dendrite(s)) of NS-1 cells. SIGNIFICANCE: These findings support the concept that MS increases BDNF expression and signaling, which sculpts longest neurite arborization and connectivity by which neuronal activity is regulated. Understanding the mechanisms underlying MS is crucial for efficiently incorporating its use into potential therapeutic strategies.

Occupational Therapy Workforce in the United States: Forecasting Nationwide Shortages.

BACKGROUND: As the baby boomer generation retires in growing numbers, the demand for occupational therapists specializing in geriatrics will be particularly strong. Currently, there is evidence that a workforce shortage exists in the field of occupational therapy (OT), and few studies have been published in this area to systematically examine the status of the OT workforce. OBJECTIVE: To examine current and future OT job surplus/shortage trends within the United States. DESIGN: Forecast models and grading methodology were developed to evaluate individual state OT job shortages from 2008 to 2030. SETTING: Not applicable. PARTICIPANTS: Not applicable. MAIN OUTCOME MEASUREMENTS: OT shortages, OT shortage ratios, and a report card were generated and compared among the 50 states in the United States. RESULTS: On the basis of current trends, demand for OT services will outpace the supply of occupational therapists within the United States. Shortages are expected to increase for all 50 states through 2030. The number of states with a grade D or below will increase from 3 in 2010, to 18 in 2020, to 37 in 2030, respectively. By 2030, the 3 states with the greatest shortage ratios will be Arizona, Hawaii, and Utah. The 3 states with the largest OT shortages (the number of OT jobs) will be California, Florida, and Texas. States in the northeast are projected to have the smallest shortages whereas states in the south and west are projected to have the largest shortages. CONCLUSION: This study serves to provide health care professionals, policy makers, and stakeholders with a means of assessing current and future OT needs. Discussion of the issues surrounding OT shortages and ongoing assessment of supply and demand must ensue to mitigate the projected shortages.

Transcranial magnetic stimulation after spinal cord injury.

OBJECTIVE: To review the basic principles and techniques of transcranial magnetic stimulation (TMS) and provide information and evidence regarding its applications in spinal cord injury clinical rehabilitation. METHODS: A review of the available current and historical literature regarding TMS was conducted, and a discussion of its potential use in spinal cord injury rehabilitation is presented. RESULTS: TMS provides reliable information about the functional integrity and conduction properties of the corticospinal tracts and motor control in the diagnostic and prognostic assessment of various neurological disorders. It allows one to follow the evolution of motor control and to evaluate the effects of different therapeutic procedures. Motor-evoked potentials can be useful in follow-up evaluation of motor function during treatment and rehabilitation, specifically in patients with spinal cord injury and stroke. Although studies regarding somatomotor functional recovery after spinal cord injury have shown promise, more trials are required to provide strong and substantial evidence. CONCLUSIONS: TMS is a promising noninvasive tool for the treatment of spasticity, neuropathic pain, and somatomotor deficit after spinal cord injury. Further investigation is needed to demonstrate whether different protocols and applications of stimulation, as well as alternative cortical sites of stimulation, may induce more pronounced and beneficial clinical effects.

Frequency-dependent effects of contralateral repetitive transcranial magnetic stimulation on penicillin-induced seizures.

Transcranial magnetic stimulation (TMS) has been shown to modulate multiple brain functions, warranting further exploration in clinical applications. TMS treatment for epilepsy is particularly promising because of its anti-convulsive capabilities. However, TMS has been found to both inhibit and facilitate various experimental and clinical seizures, depending on the TMS parameters used. Repetitive TMS (rTMS) pulse frequency is recognized as one of the most influential parameters and thus was investigated in this study at 1, 5 and 10 Hz for its effects on a rat model of penicillin-induced seizures. High-dose penicillin-induced seizures were characterized by a combination of myoclonic and tonic-clonic (GTC) seizures. rTMS effects were analyzed with intracranial electroencephalographic (iEEG) data and video-captured behaviors. Animals treated with 1 and 5 Hz consistently showed evidence of anti-convulsive properties in their iEEG-based seizure profiles when compared to sham rTMS treatment. In contrast, data from 10 Hz rTMS suggested facilitative characteristics. Our results showed that 5 Hz rTMS consistently outperformed 1 Hz rTMS in seizure suppression. This re-emphasizes the importance in accurately characterizing TMS effects on seizure suppression due to the heterogeneous nature of seizures. Thus, finely tuned TMS treatment has great potential to become a powerful asset in combating epilepsy.

Nerve regeneration restores supraspinal control of bladder function after complete spinal cord injury.

A life-threatening disability after complete spinal cord injury is urinary dysfunction, which is attributable to lack of regeneration of supraspinal pathways that control the bladder. Although numerous strategies have been proposed that can promote the regrowth of severed axons in the adult CNS, at present, the approaches by which this can be accomplished after complete cord transection are quite limited. In the present study, we modified a classic peripheral nerve grafting technique with the use of chondroitinase to facilitate the regeneration of axons across and beyond an extensive thoracic spinal cord transection lesion in adult rats. The novel combination treatment allows for remarkably lengthy regeneration of certain subtypes of brainstem and propriospinal axons across the injury site and is followed by markedly improved urinary function. Our studies provide evidence that an enhanced nerve grafting strategy represents a potential regenerative treatment after severe spinal cord injury.

Bladder dysfunction changes from underactive to overactive after experimental traumatic brain injury.

Although bladder dysfunction is common after traumatic brain injury (TBI), few studies have investigated resultant bladder changes and the detailed relationship between TBI and bladder dysfunction. The goal of this study was to characterize the effects of TBI on bladder function in an animal model. Fluid-percussion injury was used to create an animal model with moderate TBI. Female Sprague-Dawley rats underwent TBI, sham TBI or were not manipulated (naïve). All rats underwent filling cystometry while bladder pressure and external urethral sphincter electromyograms were simultaneously recorded 1 day, 1 week, 2 weeks, and 1 month after injury. One day after injury, 70% of the animals in the TBI group and 29% of the animals in the sham TBI group showed no bursting activity during urination. Compared to naïve rats, bladder function was mainly altered 1 day and 1 week after sham TBI, suggesting the craniotomy procedure affected bladder function mostly in a temporary manner. Compared to either naïve or sham TBI, bladder weight was significantly increased 1 month after TBI and collagen in the bladder wall was increased. Bladder function in the TBI group went from atonic 1 day post-TBI to overactive 1 month post-TBI, suggesting that TBI significantly affected bladder function.

United States registered nurse workforce report card and shortage forecast.

Registered nurses (RNs) play a critical role in health care delivery. With an aging US population, health care demand is growing at an unprecedented pace. Using projected changes in population size and age, the authors developed demand and supply models to forecast the RN job shortage in each of the 50 states. Letter grades were assigned based on projected RN job shortage ratios. The number of states receiving a grade of "D" or "F" for their RN shortage ratio will increase from 5 in 2009 to 30 by 2030, for a total national deficit of 918 232 (725,619 - 1,112,112) RN jobs. There will be significant RN workforce shortages throughout the country in 2030; the western region will have the largest shortage ratio of 389 RN jobs per 100,000. Increased efforts to understand shortage dynamics are warranted.

Fibronectin inhibits chronic pain development after spinal cord injury.

Chronic pain following spinal cord injury (SCI) is a highly prevalent clinical condition that is difficult to treat. Using both von Frey filaments and radiant infrared heat to assess mechanical allodynia and thermal hyperalgesia, respectively, we have demonstrated that a one-time injection of fibronectin (50 µg/mL) into the spinal dorsal column (1 µL/min each injection for a total of 5 µL) immediately after SCI inhibits the development of mechanical allodynia (but not thermal hyperalgesia) over an 8-month observation period following spinal cord dorsal column crush (DCC). DCC will only induce mechanical Allodynia, but not thermal hyperalgesia or overt motor deficits. By applying various fibronectin fragments as well as competitive inhibitors, these effects were shown to be dependent on the connecting segment-1 (CS-1) motif of fibronectin. Furthermore, we found that acute fibronectin treatment diminished inflammation and blood-spinal cord barrier permeability, which in turn leads to enhanced fiber sparing and sprouting. In particular, the reduction of serotonin (5-HT) in the superficial dorsal horn, an important descending brainstem system in the modulation of pain, was blocked with fibronectin treatment. We conclude that treatment of SCI with fibronectin preserves sensory regulation and prevents the development of chronic allodynia, providing a potential therapeutic intervention to treat chronic pain following SCI.

A neural repair treatment with gait training improves motor function recovery after spinal cord injury.

Aimed to develop an effective approach for treating spinal cord injury (SCI), we investigated the effectiveness of a treatment strategy that combined peripheral nerve grafting, nerve growth factors and functional task based physical therapy on non-human primate models. SCI was by unilateral surgical hemi-section at the T8 spine level (approximately 4 mm gap). Two of the 4 subjects as treatment received the transplants of sural nerve segments as well as infused acidic fibroblast growth factor (aFGF) to the injured spinal cord. All four subjects received physical therapy and bipedal walking training on a treadmill to promote motor function recovery. A comprehensive evaluation system including general observation in the home cage, behavioral test and clinic score system was used to assess the effect of the treatment. The recovery of functional mobility in treated group is much faster than the control group. The treated group started to move around in their cages within a week and continued to improve in walking performance as measured by gait symmetry, while the control group developed spasticity and rigidity with a much slower and less functional recovery of mobility. All these results suggest that the treatment strategy of peripheral nerve grafting with aFGF combined with physical therapy is effective to treat SCI.

Physical therapy workforce in the United States: forecasting nationwide shortages.

OBJECTIVE: To examine current and future physical therapy (PT) job surplus/shortage trends across the United States. DESIGN: Forecast models and grading methodology previously published for nursing were used to evaluate individual state PT job shortages from 2008 to 2030. SETTING: Not applicable. PARTICIPANTS: Not applicable. METHODS: The forecast model used to project PT job supply and demand accounted for changes in age and population size on the basis of estimates from the U.S. Census Bureau for each of the 50 states. PT shortages were assigned letter grades on the basis of shortage ratios (difference between demand and supply per 10,000 people) to evaluate PT shortages and describe the changing PT workforce in each state. RESULTS: On the basis of current trends, demand for PT services will outpace the supply of PTs within the United States. Shortages are expected to increase for all 50 states through 2030. By 2030, the number of states receiving below-average grades for their PT shortages will increase from 12 to 48. States in the Northeast are projected to have the smallest shortages, whereas states in the south and west are projected to have the largest shortages. CONCLUSION: These data serve to provide health professionals, policy makers, and stakeholders with a means of assessing current and future PT needs. Discussion of the issues surrounding PT shortages and ongoing assessment of supply and demand must ensue to mitigate projected shortages. Although our model has several limitations and may be oversimplified, it is the first attempt to use available, creditable data to examine both supply and demand for the entire country. Follow-up studies that use more complex modeling are needed to adequately forecast future trends beyond that accomplished in the current article. Monitoring trends over time is critical to maintain an appropriate balance between PT supply and demand that meets the population needs.

Improvement of gait patterns in step-trained, complete spinal cord-transected rats treated with a peripheral nerve graft and acidic fibroblast growth factor.

The effects of peripheral nerve grafts (PNG) and acidic fibroblast growth factor (alpha FGF) combined with step training on the locomotor performance of complete spinal cord-transected (ST, T8) adult rats were studied. Rats were assigned randomly to five groups (N=10 per group): sham control (laminectomy only), ST only, ST-step-trained, repaired (ST with PNG and alpha FGF treatment), or repaired-step-trained. Step-trained rats were stepped bipedally on a treadmill 20 min/day, 5 days/week for 6 months. Bipolar intramuscular EMG electrodes were implanted in the soleus and tibialis anterior (TA) muscles of ST-step-trained (n=3) and repaired-step-trained (n=2) rats. Gait analysis was conducted at 3 and 6 months after surgery. Stepping analysis was completed on the best continuous 10-s period of stepping performed in a 2-min trial. Significantly better stepping (number of steps, stance duration, swing duration, maximum step length, and maximum step height) was observed in the repaired and repaired-step-trained than in the ST and ST-step-trained rats. Mean EMG amplitudes in both the soleus and TA were significantly higher and the patterns of activation of flexors and extensors more reciprocal in the repaired-step-trained than ST-step-trained rats. 5-HT fibers were present in the lumbar area of repaired but not ST rats. Thus, PNG plus alpha FGF treatment resulted in a clear improvement in locomotor performance with or without step training. Furthermore, the number of 5-HT fibers observed below the lesion was related directly to stepping performance. These observations indicate that the improved stepping performance in Repaired rats may be due to newly formed supraspinal control via regeneration.

Stimulation of the expiratory muscles using microstimulators.

Respiratory complications constitute a major cause of morbidity and mortality in patients with spinal cord injury. These complications arise in part due to the loss of supraspinal control over the expiratory muscles and the resultant difficulties in clearing airway secretions effectively. The purpose of the present study is to evaluate the efficacy of lower thoracic spinal nerve stimulation using wireless microstimulators in activating the expiratory muscles. Studies were performed on nine anesthetized dogs. A thoracic laminectomy was performed on each dog,and was followed by spinal cord transection at T2. A total of 16 microstimulators (supplied by the Alfred Mann Foundation, Santa Clarita, CA) were inserted percutaneously into the bilateral intercostal nerves approximately 1 to approximately 3 cm distal to the neuroforamen from T7 to L1 in each dog. The stimulation parameters were: frequency of 20 Hz, pulse width of 200 micros, and stimulation burst of 2 s. The stimulation intensities were 3.78, 5.4, 8.1, and 10.8 mA. The pressure-generating capacity of the expiratory muscles was evaluated by the change in airway pressure (Paw) at functional residual capacity, which was produced by the microstimulators during airway occlusion. As a general trend, the expiratory pressure generated using the microstimulators increased with increasing intensity and the number of spinal nerves recruited. The maximal expiratory pressures generated from one, two, three, four, five, six, seven, and eight pairs of spinal nerves were 8.4 +/- 0.8, 12.2 +/- 1.0, 14.6 +/- 1.4, 17.8 +/- 1.8, 23.0 +/- 1.8, 27.7 +/- 2.2, 35.2 +/- 2.7, and 40.4 +/- 2.9 cmH2O, respectively. Bilateral stimulation of seven (from T8 to L1) and eight spinal nerve levels (from T7 to L1) produced the highest changes in(Paw). Stimulation of six or less spinal nerve levels resulted in significantly lower (Paw). We conclude: 1) lower thoracic spinal nerve stimulation near the neuroforamen using microstimulators produces significant expiratory pressure, 2) percutaneous placement of the microstimulators near the neuroforamen is effective in producing expiratory pressure, and 3) percutaneous placement of the microstimulators for restoring cough may potentially be used as a relatively noninvasive clinical tool for patients with spinal cord injury, or other neurological or respiratory disorders. Further studies will be needed.

California regional registered nurse workforce forecast.

OBJECTIVE: To forecast the shortage of registered nurses (RNs) of the 24 Primary Metropolitan Statistical Areas (PMSA) and Metropolitan Statistical Areas (MSA) in California. BACKGROUND: A nursing shortage prevails nationally and is most serious in the state of California. Successful interventions in the alleviation of the RN shortage will require effective resource allocation and academic program development in various regions throughout the state. While various published studies have focused on nursing workforce development at the state and even regional levels, there are no studies focused on identifying RN shortages at the PMSA or MSA (P/MSA) level. In this report, a forecasting model is developed to systematically analyze the future supply and demand of the RN workforce within each California P/MSA. METHODS: Using accessible public databases, forecasting models were constructed to project the demand and supply of RN jobs in California P/MSAs. In the demand model, population age and size were used as determinants of regionally required RN jobs. In the RN jobs (supply) model, a region's supply of RNs was the net sum of factors increasing and decreasing the regional presence of RN jobs, including RN graduations, migration, and aging of the RN workforce. The combination of these supply and demand models was used to produce regional RN shortage forecasts for future years. RESULTS: Almost all regions exhibited growing shortages by 2020 at rates ranging from 3% to 600%. Using a modified version of the grading rubric of the California Regional Registered Nurse Workforce Report Card (Lin, Lee, Juraschek, & Jones, 2006), only two regions will receive a grade above "C" in 2020. The number of "F" grades will grow to nine. CONCLUSIONS: California has the lowest RN ratio in the United States (Fletcher, Guzley, Barnhill, & Philhour, 2004; Health Resources and Services Administration, 2004a) and this RN workforce forecasting model shows that over the next 15 years, the majority of P/MSAs in California will have increasing RN shortages. This analysis has significant policy implications including the need to create specific plans to mitigate the effect of the California shortage.