The Role of Pain Catastrophizing, Emotional Intelligence, and Pain Intensity in the Quality of Life of Cancer Patients with Chronic Pain.

Pain catastrophizing (PC) is a negative cognitive distortion to actual or anticipated pain. This study aims to investigate the relationship between pain catastrophizing, emotional intelligence, pain intensity, and quality of life (QoL) in cancer patients with chronic pain. Eighty-nine outpatients with chronic pain attending pain clinics and palliative care units were recruited. Participants were men (42.7%) and women (57.3%) with an average age of 56.44 years (SD = 14.82). Self-report psychological measures were completed, including a measure of emotional intelligence, a standard measure of PC, a scale assessing pain intensity, and a scale measuring QoL. The PC scale was found to assess three correlated yet different dimensions of pain catastrophizing (helplessness, magnification, and rumination). Moreover, as expected, patients with PC scale scores ≥ 30 had lower scores in functional QoL dimensions and higher scores in the fatigue, pain, and insomnia symptom dimensions. Regression analyses demonstrated that PC (B = - 0.391, p = 0.004), pain intensity (B = - 1.133, p < 0.001), and education (B = 2.915, p = 0.017) remained the only significant variables related to QoL, when controlling for demographic and clinical confounders. Regarding mediating effects, PC and pain intensity were jointly found to be significant mediators in the relationship between emotional intelligence and QoL. Results are discussed in the context of the clinical implications regarding interventions designed to improve cancer patients' quality of life and offer new insight, understanding, and evaluation targets in the field of pain management.

Factors associated with health-related quality of life of informal caregivers of older patients and the mediating role of subjective caregivers' burden.

BACKGROUND: Caregiving has been associated with increased subjective burden and decreased health-related quality of life (HRQOL) for caregivers. The aim of the study was to clarify the precise relationship between caregivers' burden, caregivers' HRQOL, and other risk factors, considering that subjective burden was a risk factor for poor HRQOL, which may also mediate the effects of some known risk factors. METHODS: In this cross-sectional study, patients' and their informal caregivers' characteristics were recorded for 311 patient-caregiver dyads. Subjective caregiver burden and caregivers' HRQOL were assessed using the Zarit Burden Interview and the 12-item Short-Form Health Survey (SF-12), respectively. Mediation analysis was used to examine the relationships between variables. Caregivers' mental component summary (MCS) and physical component summary (PCS) scores were regarded as outcome variables, caregivers' subjective burden was considered the mediator, and patients' and caregivers' characteristics were treated as predictors. RESULTS: Caregivers' subjective burden was negatively related to both PCS and MCS of caregivers' HRQOL, after controlling for the effects of demographic and clinical variables. Moreover, significant associations, mostly indirect via caregivers' subjective burden, existed between caregivers' socio-demographic characteristics, duration of caregiving, patients' frailty status, patients' co-morbidity, and caregivers' HRQOL. CONCLUSION: Caregivers' subjective burden plays a major and mediating role on influencing caregivers' HRQOL. Our findings may direct future research and promote the implementation of interventions to reduce caregivers' burden and improve caregivers' HRQOL.

Percutaneous Arteriovenous Fistula Creation with the WavelinQ 4-French EndoAVF System: A Single-Center Retrospective Analysis of 30 Patients.

PURPOSE: To retrospectively assess the safety and efficacy of percutaneous arteriovenous fistula (pAVF) creation with the WavelinQ 4-F EndoAVF System. MATERIALS AND METHODS: From February 2018 to June 2020, 30 pAVFs were created in 30 consecutive patients (men; age, 55.3 years ± 13.6). Of the 30 patients, 21 (70%) were already on hemodialysis using a central venous catheter. The primary outcome measures were technical success, complications, and cannulation rate. The secondary outcome measures included the number of secondary procedures needed for cannulation, maintenance time to cannulation, and pAVF survival. RESULTS: Technical success was 100%. The adverse event rate was 6.7% (2/30), including a pseudoaneurysm of the brachial artery that developed immediately after sheath removal and an aneurysm of the anastomosis 17 days after the procedure, which was treated with a covered stent placed in the arterial side. The mean follow-up was 547 days ± 315.7 (range, 14-1,071 days). The cannulation rate was 86.7% (26/30). The mean time to cannulation was 61.3 days ± 32.5 (range, 15-135 days). The mean follow-up after cannulation was 566.2 days ± 252.7 (range, 35-1,041 days). Four pAVFs were thrombosed after cannulation, with 2 of them successfully declotted. Sixteen interventions were needed to achieve cannulation after the index procedure in 15 patients (overall, 0.53 procedures/patient). Seven maintenance endovascular interventions (following cannulation) were performed during the follow-up period in 6 patients (overall, 0.27 procedures/patient, 0.17 procedures/patient-years). For the pAVFs that were cannulated, patency was 96% at 1 year, and 82% at 2 and 3 years, according to the Kaplan-Meier survival analysis. CONCLUSIONS: This initial experience suggests that pAVF creation is safe and can be successfully performed with high maturation and long-term patency rates. Larger-scale prospective studies are needed to validate the results.

Severity of heart failure and health-related quality of life in beta-thalassemia patients: a cross-sectional study.

Cardiovascular complications account for a substantial increase in morbidity and mortality in beta-thalassemia patients. Many patients have structural heart disease, and some of them present with symptomatic heart failure (HF). Quality of life (QOL) of beta-thalassemia patients is lower than that of the general population. The aim of our study was to explore the relationship between HF stages and QOL in beta-thalassemia patients. Seventy-three consecutive adult beta-thalassemia patients took part in this cross-sectional study. Stages of HF, classified with increasing severity as A, B, and C, were determined based on ACC/AHA guidelines. QOL was assessed using the SF-36 questionnaire. Fifteen patients had stage C HF, twenty-eight had stage B HF, and the remaining were considered stage A patients, as beta thalassemia is a predisposing factor for HF. All QOL domains except for bodily pain were significantly lower in stage C patients than in stage A patients. Stage C patients had significantly lower QOL scores for physical functioning, role physical, and social functioning domains than stage B patients. Stage B patients' QOL differed from stage A patients only in the vitality domain. In the multiple regression analysis which took several demographic and clinical factors into account, stage of HF was the most important factor associated with QOL, and negatively and significantly related to five QOL domains, namely physical functioning, role physical, general health, social functioning, and vitality. In conclusion, QOL is negatively affected by the severity of heart failure in beta-thalassemia patients.

Burden and Sleeping Disorders of Family Caregivers of Hemodialysis Patients with Chronic Kidney Disease-End Stage: A Cross-Sectional Study.

BACKGROUND: Chronic illnesses with high level of disability can affect not only the patients but also the main caregiver who supports them. The aim of this study was to investigate the burden and sleep disorders of family caregivers of hemodialysis patients. METHODS: This is a cross-sectional study. The sample of the study consisted of 310 family caregivers of hemodialysis patients. The tools used were the Pittsburgh Sleep Quality Index (PSQI) for sleep disorders assessment, the Zarit Burden Interview, and the Center for Epidemiologic Studies-Depression Scale (CES-D) for burden and depression assessment, respectively. RESULTS: The total burden of caregivers was serious at 35.5%, and this rate increased to 64.8% if we added the moderate burden. About 26.7% of caregivers were positive in depressive symptoms and 20% at risk (predisposition) for depression. The factor with the greatest correlation with the overall burden was personal strain (r = 0.952, p < 0.001) followed by the role strain factor (r = 0.901, p < 0.001). About half of the respondents (51.6%) had poor quality of sleep. The factors that were strongly related to the overall degree of sleep quality were the actual sleep duration and daytime dysfunctions. CONCLUSIONS: Caregivers of hemodialysis patients face an increased risk for burden and sleep disorders development. Continuous and regular assessment of the caregivers' quality of life and the provision of psychological support may reduce the burden of caregivers and improve the emotional disorders they face.

Sleeping Disorders and Health-Related Quality of Life in Hemodialysis Patients with Chronic Renal Disease in Greece.

INTRODUCTION: Increased life expectancy in patients with end-stage renal failure undergoing dialysis and the high prevalence of the chronic renal disease highlight the need to investigate the patients' quality of life. AIM: To investigate sleep disorders and the level of health-related quality of life in hemodialysis patients with chronic renal failure. MATERIAL AND METHOD: The sample of the study consisted of 420 hemodialysis patients. The Kidney Disease and Quality of Life™ Short Form questionnaire was used to assess the quality of life of patients, and the Pittsburgh Sleep Quality Index was used to investigate sleep disorders. RESULTS: The physical and mental health of the responders were found to be 36.9 and 39.6, respectively, while the burden and effects of chronic renal disease were found to be 40 and 44.9, respectively. There were strong positive correlations between the overall health assessment and the emotional well-being (r = 0.743), the physical function (r = 0.730), the burden of renal disease (0.626), the energy/fatigue (0.643), the social function (0.639), and the pain (0.595). The patients' quality of sleep was found poor (7.62). The major correlation was observed between the total score and the dimension of the sleep latency (0.681), followed by the sleep disturbances (0.624). CONCLUSIONS: The HRQOL of hemodialysis patients with CKD-FS remains poor, interacting with important functions such as sleep, vitality, cognition, and sexual function.

Compliance of Patients with Acute Coronary Syndrome with Treatment Following Their Hospitalization from the Cardiac Coronary Unit.

BACKGROUND: Low compliance rates with medication after an acute coronary syndrome (ACS) is a serious public health problem with adverse socioeconomic implications for both patients and their families as well as for health systems in general. The aims of the study are to measure the levels of compliance with medication in the treatment of patients who suffered from ACS and to investigate the factors contributing to the noncompliance. METHODS: The sample consisted of 100 patients hospitalized in the coronary care unit (CCU) of a general hospital. The compliance of patients with treatment, which was measured with the GR-SMAQ and ARMS scales, was measured at 3, 6, and 12 months after their hospitalization. The t-test and control X2 were used, and the value of statistical significance was set to 0.05. RESULTS: According to the GR-SMAQ and ARMS scales, compliance of patients at 3, 6, and 12 months after hospitalization is low (58%, 70%, 32% with ARMS scale and 54%, 58%, 38% with GR-SMAQ scale, respectively). Patients who were readmitted to CCU had 68.9% less chances of showing compliance, and patients who had normal levels of systolic blood pressure were 3.5 times more likely to adhere to their treatment. No correlation between compliance and social demographic data, such as gender, age, level of study, and family and occupational status, was found (p > 0.05). CONCLUSION: Compliance of patients who suffered from ACS is at low level. There is a need for closed monitoring and use of wearable devices in order to improve the compliance rates.

Attitudes Towards Seeking Psychological Help: An Integrative Model Based on Contact, Essentialist Beliefs About Mental Illness, and Stigma.

Based on intergroup contact theory, a proposed comprehensive model of attitudes towards seeking professional psychological help was tested, including both potential barriers to mental health help-seeking (i.e., public stigma and self-stigma of seeking help, prejudicial and essentialist beliefs about mental illness, intergroup anxiety) and potential facilitators (i.e., direct and extended contact with persons with mental illness). Relevant measures were completed by 119 community-dwelling participants. Path analysis showed that direct (but not extended) contact with mental illness, by reducing intergroup anxiety, led to less negative beliefs about mental illness and weaker essentialist beliefs about mental illness (the latter being directly and positively associated with negative beliefs about mental illness). Moreover, less negative beliefs about mental illness, by reducing perceptions of self (but not public) stigma of seeking psychological help, were related to more positive attitudes towards help-seeking. Results are discussed in the context of the (unintentional) adverse effects of biogenetic (essentialist) explanations of mental disorders, and the clinical implications regarding interventions that aim at improving help-seeking attitudes.

The Role of Optimism, Social Constraints, Coping, and Cognitive Processing in Psychosocial Adjustment Among Breast Cancer Survivors.

The social-cognitive processing model suggests that a socially constrained environment may impede adjustment to a chronic illness. The present study primarily investigated the mediating psychological pathways through which social constraints on cancer-related disclosure, low optimism, disengagement-oriented coping, and brooding could be associated with low levels of psychosocial adjustment. One hundred twenty-five female breast cancer survivors participated in a cross-sectional study. Path analysis was used to examine the proposed model. Low optimism, increased social constraints, and higher levels of brooding appeared to be risk factors for poor psychosocial adjustment to breast cancer. Disengagement-oriented coping and brooding partially mediated the relationship between social constraints and adjustment. Brooding totally mediated the relationship between disengagement-oriented coping and adjustment. The current findings provide support for the value of the social-cognitive processing model among breast cancer survivors. The mapping of psychological pathways of adjustment to breast cancer may have useful clinical implications for better adjustment outcomes.

Doctors' Perceptions and Practices of Breaking Bad News: A Qualitative Study From Greece.

There is limited information about doctors' communication behaviors and their salient beliefs with regard to bad news disclosure in Greece. In this qualitative study we investigated the self-reported practices of doctors on breaking bad news, their perceptions about the factors affecting the delivery of such news, and their beliefs about the most appropriate disclosure manner. A focus group discussion and individual interviews were conducted. Twenty-five resident and specialist doctors from primary health care and hospital settings participated. We analyzed the collected data with content analysis techniques. Participants were found to acknowledge the importance of appropriate and effective delivery of bad news; however, none of them reported the implementation of empirically informed communication practices. They described communication patterns mainly formed by their work experience and often guided by the patient's family requests. Doctor, patient, and family characteristics and organizational features and resources were reported to affect the delivery of bad news. Participants perceived the most appropriate disclosure manner as an individualized approach to each patient's unique needs. They suggested an interdisciplinary, collaborative management of the delivery process and the establishment of formal supportive services. These findings may provide useful information for the development of tailored, empirically informed curriculum interventions and educational programs in order to address several barriers to communication. Sociocultural characteristics that influence the disclosure practice, as well as physicians' perceptions that are consistent with the optimal information delivery, should be taken into account. System-level strategies that focus on the development of patient-centered communication also need to be prioritized.

Psychosocial Adjustment to Illness Scale: Factor structure, reliability, and validity assessment in a sample of Greek breast cancer patients.

The study and measurement of psychosocial adjustment is important for evaluating patients' well-being, and assessing the illness's course, treatment's success, and patients' recovery. In this study, internal consistency reliability and construct validity of the Greek version of the Psychosocial Adjustment to Illness Scale-Self-Report (PAIS-SR) were examined. Demographic and psychosocial data were collected from a sample of 243 women with breast cancer, recruited from September 2011 to December 2012. With some exceptions in specific items, the original conceptually-derived PAIS-SR subscales emerged in a seven-factor solution. Social Environment, Job and Household Duties, and Psychological Distress accounted for more of the total variance than other subscales. PAIS-SR showed good internal consistency reliability, with Cronbach's alpha coefficients >0.62. Correlations of PAIS-SR domains with measures of quality of life and posttraumatic stress symptoms supported the convergent validity of the PAIS-SR and its significance for cancer research. The Greek version of the PAIS-SR has acceptable internal consistency reliability and construct validity, as well as satisfactory convergent validity. Results provide some suggestions for the development of programs to evaluate adjustment status and implement psychosocial interventions among breast cancer survivors.

Time to get happy: associations of time perspective with indicators of well-being.

The present study examined associations of time perspective (TP) with indicators of well-being including satisfaction with life, anxiety and depression, after controlling for sociodemographic factors. Adult participants (N = 413) completed a web-based questionnaire that included a short version of the Zimbardo Time Perspective Inventory, the State-Trait Anxiety Inventory, and the Center for Epidemiologic Studies-Depression Scale. Life satisfaction was more strongly associated with the present hedonistic dimension, suggesting that the tendency to take risks and to fulfil one's desires may lead to experiencing pleasure in a 'seize the day' approach to life. The existence of depressive symptoms and elevated anxiety levels were associated with higher scores on the past present and the present fatalistic dimensions, suggesting that feeling hopeless, or dwelling on bad moments from the past may be largely related to feeling depressed and anxious. Considering the recently reported implications of TP in clinical and counseling settings, the present study contributes to the growing body of research that associates TP with mental health and psychological well-being.

Doctors' Attachment Orientations, Emotion Regulation Strategies, and Patient Satisfaction: A Multilevel Analysis.

Extending recent research on emotion regulation in doctor-patient interaction, the present study examined relationships between doctors' attachment orientations, their emotion regulation strategies, and patients' satisfaction with the encounter. Forty doctors completed scales of attachment orientations and emotion regulation strategies, and 160 of their patients reported on a standard measure of satisfaction with their doctor. Results from multilevel analyses showed that doctors' avoidant and anxious attachment orientations were independently associated with lower satisfaction for patients higher on serious illness perceptions. Doctors' emotion regulation strategies did not mediate insecure attachment orientation relationships with patients' satisfaction as anticipated, but these regulatory strategies were an independent factor associated with satisfaction levels of patients with higher illness severity perceptions. The study confirms predictions based on attachment theory that doctors' insecure attachment can have adverse effects for doctor-patient interaction.

Alexithymia and fertility-related stress.

The investigation of the relationship between alexithymia, the inability to identify and describe feelings and the absence of fantasies, and fertility-related distress is a relatively neglected area of research. The aims of this study were to examine: (1) the prevalence of alexithymia in a sample of infertile women, and (2) the association between alexithymia, coping strategies, and fertility-related stress. This study included 160 infertile women undergoing in vitro fertilization in a public fertility clinic from September of 2013 to December of 2013. Self-report instruments were used to measure alexithymia (Toronto Alexithymia Scale-20), coping (COPE), and fertility-related stress (Fertility Problem Inventory). Bivariate and multiple linear regression were used. A high alexithymia score was positively associated with age, infertility duration, and low educational and economic level. Multivariate analyses showed that, controlling for demographic factors, high avoidance coping, low problem-appraisal coping, and high alexithymia were positively associated with fertility-related stress (ß = 0.309, p < .001, ß = -0.203, p = .006, ß = 0.151, p = .050, respectively). Results of this study indicated that alexithymia during fertility treatment was associated with maladaptive coping strategies and psychological stress. In addition, the association between alexithymia and duration of infertility may be interpreted as secondary alexithymia acts as a coping strategy in infertile women.

Psychometric properties of the Greek version of the Social Constraints Scale in a sample of women with breast cancer.

This study evaluated the psychometric properties of the Greek version of the Social Constraints Scale, developed in English by Lepore and Ituarte (1999). The scale was culturally adapted in Greek and was then administered, along with measures of psychological distress and intrusions, to a sample of 202 women with breast cancer, recruited from July 2012 to October 2013. Although the scale has usually been treated as a unidimensional measure, exploratory factor analysis revealed three underlying factors in the Greek Social Constraints Scale: unsupportive behaviors, avoidant behaviors, and suggestions for pretense and distraction. The three-factor solution explained 55% of the total variance. Subscale reliability was satisfactory (Cronbach's alpha coefficients ranging from 0.77 to 0.88). All subscales were significantly related to intrusions and psychological distress. Thus, the Greek Social Constraints Scale is a reliable and valid multidimensional instrument. The results of the present study show that, among all kinds of social constraints, unsupportive behaviors are the most highly correlated with distress, while distraction/pretense is most correlated with intrusiveness. Findings suggested that health professionals should aim to educate both the patient to claim her right to express feelings and thoughts and her social network to adopt disclosure-facilitating behaviors to compensate for intrusiveness and distress.

Exploring the relationship between posttraumatic growth, cognitive processing, psychological distress, and social constraints in a sample of breast cancer patients.

Posttraumatic growth (the perception of positive life changes after an encounter with a trauma) often occurs among breast cancer patients and can be influenced by certain demographic, medical, and psychosocial parameters. Social constraints on disclosure (the deprivation of the opportunity to express feelings and thoughts regarding the trauma) and the cognitive processing of the disease seem to be involved in the development of posttraumatic growth. Through the present study the authors aim to: investigate the levels of posttraumatic growth in a sample of 202 women with breast cancer in Greece, explore the relationships between posttraumatic growth and particular demographic, medical, and psychosocial variables according to a proposed model, and test the role of social constraints in the relationship between automatic and deliberate cognitive processing of the trauma. The results showed that posttraumatic growth was evident in the majority of the sample and was associated inversely with age at diagnosis (ß = -0.174, p < .05) and psychological distress (ß = -0.394, p = .001), directly with time since diagnosis (ß = 0.181, p < .05), and indirectly with intrusions and psychological distress, through reflective rumination (ß = 0.323, p = .001). Social constraints were found to moderate the relationship between intrusions and reflective rumination. Implications of the results and suggestions for future research and practice are outlined.

Time to get healthy: associations of time perspective with perceived health status and health behaviors.

The present study examined the associations of time perspective (TP) with health behaviors including smoking, exercise, and body mass index (BMI), and perceptions of health status after controlling for sociodemographic factors. Participants (N = 413) completed a web-based questionnaire that included a short version of the Zimbardo Time Perspective Inventory, and reported their weight, height, smoking, and exercise frequency. Future TP was associated with more physical exercise, whereas past-negative and present-fatalistic dimensions were associated with higher BMI. Smoking was not associated with any of the TP dimensions. Additionally, all of the dimensions of TP were found to be associated with conceptually relevant perceptions of health status. Research on TP predominantly focuses on the future and the present orientation, but the findings of the present study suggest that all dimensions of TP should be used in health-related research. Also, issues regarding the role of the present-hedonistic dimension are discussed and directions for future research are proposed.

Factors associated with mental health status of medical residents: a model-guided study.

Residency is a stressful period in a physician's development, characterized by long work hours, time pressure, and excessive work load, that can exert negative effects on residents' mental health. Job burnout and negative work-home interference may play a major role in residents' mental health problems. The present study used the job demands-resources model as a theoretical framework to examine the way in which job demands (e.g., workload, emotional demands) and job resources (e.g., supervisor support, job autonomy) were associated with residents' mental health. From a pool of 290 medical residents, 264 (91 %) completed the questionnaires. Applying structural equation modeling techniques, the results showed that greater emotional exhaustion (ß = -.65, SE = .09, p < .001) and more work-home interference (ß = -.26, SE = .10, p < .05) were related to poor mental health. Specific job demands (i.e., high workload) and particular job resources (i.e., low opportunities for professional development and low supervisor support) were related to poor mental health not directly but only indirectly, via emotional exhaustion or work-home interference. Thus, through work-related emotional exhaustion, the impact of work conditions might be transmitted to and interfere with non-work related domains such as family life, as well as with domain-unspecific aspects of well-being, such as mental health and psychological distress. Implications of the results and suggestions for future research and practice are outlined.

Doctors' emotion regulation and patient satisfaction: a social-functional perspective.

Emotion regulation has been identified as an important component of medical consultation but there is limited research on the topic. Two studies tested expected relationships between doctors' emotion regulation (ER) skills and patient satisfaction and quality of doctor-patient interaction, focusing in particular on the role patient perceptions' of doctors' emotion regulation skills play in these associations. Study 1 comprised 100 patients reporting on their perceptions of doctors' overall emotion regulation skills, communication quality and nonverbal immediacy, and their satisfaction with the care provided. Patients' perceptions of doctors' emotion regulation skills were associated with patient satisfaction and communication quality; patient perceptions of doctors' nonverbal immediacy partially mediated these relationships. Study 2 collected data from 30 doctors who reported on their typical emotion regulation strategies of reappraisal and suppression and 139 of their patients who reported on satisfaction with the medical treatment and positive affect. As expected, doctors' self-reported reappraisal was positively associated with their patients' satisfaction and positive affect. Doctors' suppression was also positively associated with patient satisfaction, while patients' gender moderated these effects. The two studies empirically document proposed links between doctors' emotion regulation and patient satisfaction. Notably, the results underline the role of patients' perceptions of doctors' emotion regulation skills and emotion expressions for patient outcomes and are in line with functional models of emotion in social interaction.

Burnout in medical residents: a study based on the job demands-resources model.

PURPOSE: Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job. The purpose of our cross-sectional study was to estimate the burnout rates among medical residents in the largest Greek hospital in 2012 and identify factors associated with it, based on the job demands-resources model (JD-R). METHOD: Job demands were examined via a 17-item questionnaire assessing 4 characteristics (emotional demands, intellectual demands, workload, and home-work demands' interface) and job resources were measured via a 14-item questionnaire assessing 4 characteristics (autonomy, opportunities for professional development, support from colleagues, and supervisor's support). The Maslach Burnout Inventory (MBI) was used to measure burnout. RESULTS: Of the 290 eligible residents, 90.7% responded. In total 14.4% of the residents were found to experience burnout. Multiple logistic regression analysis revealed that each increased point in the JD-R questionnaire score regarding home-work interface was associated with an increase in the odds of burnout by 25.5%. Conversely, each increased point for autonomy, opportunities in professional development, and each extra resident per specialist were associated with a decrease in the odds of burnout by 37.1%, 39.4%, and 59.0%, respectively. CONCLUSIONS: Burnout among medical residents is associated with home-work interface, autonomy, professional development, and resident to specialist ratio.