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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

We compared total mercury (THg) concentrations in the fur of northern fur seals (Callorhinus ursinus) from the depleted Pribilof Islands population with those of both declining and thriving populations of Steller sea lions (Eumetopias jubatus) from Prince William Sound (PWS) and Southeast Alaska (SEA), respectively. Relatively low wet weight concentrations (ranges) of THg were detected in the fur of Steller sea lion (SSL) pups (0.90–3.14 μg/g) and juveniles (0.56–6.75 μg/g) from both areas in 1998 and 2000 compared to northern fur seal (NFS) pups (3.15–8.14 μg/g) in 2000. The mean concentration ± SD for SSLs sampled were 1.46±0.64 μg/g for pups (n=22) and 2.74±2.89 μg/g for juveniles (n=6). Analyses indicated higher THg concentrations from SSL pups from PWS compared to the SEA. Mean ± SD. THg in the NFS pups was 4.90±1.42 μg/g (n=34) and for post-partum dams was 7.84±1.78 μg/g (n=12). [Copyright &y& Elsevier]

Background: Prior studies associating acute kidney injury (AKI) with more rapid subsequent loss of kidney function had methodological limitations, including inadequate control for differences between patients who had AKI and those who did not., Objective: To determine whether AKI is independently associated with subsequent kidney function trajectory among patients with chronic kidney disease (CKD)., Design: Multicenter prospective cohort study., Setting: United States., Participants: Patients with CKD ( n  = 3150)., Measurements: Hospitalized AKI was defined by a 50% or greater increase in inpatient serum creatinine (SCr) level from nadir to peak. Kidney function trajectory was assessed using estimated glomerular filtration rate (eGFR) based on SCr level (eGFRcr) or cystatin C level (eGFRcys) measured at annual study visits., Results: During a median follow-up of 3.9 years, 433 participants had at least 1 AKI episode. Most episodes (92%) had stage 1 or 2 severity. There were decreases in eGFRcr (-2.30 [95% CI, -3.70 to -0.86] mL/min/1.73 m 2 ) and eGFRcys (-3.61 [CI, -6.39 to -0.82] mL/min/1.73 m 2 ) after AKI. However, in fully adjusted models, the decreases were attenuated to -0.38 (CI, -1.35 to 0.59) mL/min/1.73 m 2 for eGFRcr and -0.15 (CI, -2.16 to 1.86) mL/min/1.73 m 2 for eGFRcys, and the CI bounds included the possibility of no effect. Estimates of changes in eGFR slope after AKI determined by either SCr level (0.04 [CI, -0.30 to 0.38] mL/min/1.73 m 2 per year) or cystatin C level (-0.56 [CI, -1.28 to 0.17] mL/min/1.73 m 2 per year) also had CI bounds that included the possibility of no effect., Limitations: Few cases of severe AKI, no adjudication of AKI cause, and lack of information about nephrotoxic exposures after hospital discharge., Conclusion: After pre-AKI eGFR, proteinuria, and other covariables were accounted for, the association between mild to moderate AKI and worsening subsequent kidney function in patients with CKD was small., Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-3617.

Importance: Oxalate is a potentially toxic terminal metabolite that is eliminated primarily by the kidneys. Oxalate nephropathy is a well-known complication of rare genetic disorders and enteric hyperoxaluria, but oxalate has not been investigated as a potential contributor to more common forms of chronic kidney disease (CKD)., Objective: To assess whether urinary oxalate excretion is a risk factor for more rapid progression of CKD toward kidney failure., Design, Setting, and Participants: This prospective cohort study assessed 3123 participants with stages 2 to 4 CKD who enrolled in the Chronic Renal Insufficiency Cohort study from June 1, 2003, to September 30, 2008. Data analysis was performed from October 24, 2017, to June 17, 2018., Exposures: Twenty-four-hour urinary oxalate excretion., Main Outcomes and Measures: A 50% decline in estimated glomerular filtration rate (eGFR) and end-stage renal disease (ESRD)., Results: This study included 3123 participants (mean [SD] age, 59.1 [10.6] years; 1414 [45.3%] female; 1423 [45.6%] white). Mean (SD) eGFR at the time of 24-hour urine collection was 42.9 (16.8) mL/min/1.73 m2. Median urinary excretion of oxalate was 18.6 mg/24 hours (interquartile range [IQR], 12.9-25.7 mg/24 hours) and was correlated inversely with eGFR (r = -0.13, P < .001) and positively with 24-hour proteinuria (r = 0.22, P < .001). During 22 318 person-years of follow-up, 752 individuals reached ESRD, and 940 individuals reached the composite end point of ESRD or 50% decline in eGFR (CKD progression). Higher oxalate excretion was independently associated with greater risks of both CKD progression and ESRD: compared with quintile 1 (oxalate excretion, <11.5 mg/24 hours) those in quintile 5 (oxalate excretion, ≥27.8 mg/24 hours) had a 33% higher risk of CKD progression (hazard ratio [HR], 1.33; 95% CI, 1.04-1.70) and a 45% higher risk of ESRD (HR, 1.45; 95% CI, 1.09-1.93). The association between oxalate excretion and CKD progression and ESRD was nonlinear and exhibited a threshold effect at quintiles 3 to 5 vs quintiles 1 and 2. Higher vs lower oxalate excretion (at the 40th percentile) was associated with a 32% higher risk of CKD progression (HR, 1.32; 95% CI, 1.13-1.53) and 37% higher risk of ESRD (HR, 1.37; 95% CI, 1.15-1.63). Results were similar when treating death as a competing event., Conclusions and Relevance: Higher 24-hour urinary oxalate excretion may be a risk factor for CKD progression and ESRD in individuals with CKD stages 2 to 4.

Background: Insulin resistance contributes to the metabolic syndrome, which is associated with the development of kidney disease. However, it is unclear if insulin resistance independently contributes to an increased risk of chronic kidney disease (CKD) progression or CKD complications. Additionally, predisposing factors responsible for insulin resistance in the absence of diabetes in CKD are not well described. This study aimed to describe factors associated with insulin resistance and characterize the relationship of insulin resistance to CKD progression, cardiovascular events and death among a cohort of non-diabetics with CKD., Methods: Data was utilized from Chronic Renal Insufficiency Cohort Study participants without diabetes (N = 1883). Linear regression was used to assess associations with insulin resistance, defined using the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR). The relationship of HOMA-IR, fasting glucose, hemoglobin A1c (HbA1c), and C-peptide with CKD progression, cardiovascular events, and all-cause mortality was examined with Cox proportional hazards models., Results: Novel positive associations with HOMA-IR included serum albumin, uric acid, and hemoglobin A1c. After adjustment, HOMA-IR was not associated with CKD progression, cardiovascular events, or all-cause mortality. There was a notable positive association of one standard deviation increase in HbA1c with the cardiovascular endpoint (HR 1.16, 95% CI: 1.00-1.34)., Conclusion: We describe potential determinants of HOMA-IR among a cohort of non-diabetics with mild-moderate CKD. HOMA-IR was not associated with renal or cardiovascular events, or all-cause mortality, which adds to the growing literature describing an inconsistent relationship of insulin resistance with CKD-related outcomes.

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.

Background and Aims: Coronary artery calcification (CAC) is common among patients with chronic kidney disease (CKD) and predicts the risk for cardiovascular disease (CVD). We examined the associations of novel risk factors with CAC progression among patients with CKD., Methods: Among 1123 CKD patients in the Chronic Renal Insufficiency Cohort (CRIC) Study, CAC was measured in Agatston units at baseline and a follow-up visit using electron beam computed tomography or multidetector computed tomography., Results: Over an average 3.3-year follow-up, 109 (25.1%) participants without CAC at baseline had incident CAC and 124 (18.0%) participants with CAC at baseline had CAC progression, defined as an annual increase of ≥100 Agatston units. After adjustment for established atherosclerotic risk factors, several novel risk factors were associated with changes in CAC over follow-up. Changes in square root transformed CAC score associated with 1 SD greater level of risk factors were -0.20 (95% confidence interval, -0.31 to -0.10; p < 0.001) for estimated glomerular filtration rate, 0.14 (0.02-0.25; p = 0.02) for 24-h urine albumin, 0.25 (0.15-0.34; p < 0.001) for cystatin C, -0.17 (-0.27 to -0.07; p < 0.001) for serum calcium, 0.14 (0.03-0.24; p = 0.009) for serum phosphate, 0.24 (0.14-0.33; p < 0.001) for fibroblast growth factor-23, 0.13 (0.04-0.23; p = 0.007) for total parathyroid hormone, 0.17 (0.07-0.27; p < 0.001) for interleukin-6, and 0.12 (0.02-0.22; p = 0.02) for tumor necrosis factor-α., Conclusions: Reduced kidney function, calcium and phosphate metabolism disorders, and inflammation, independent of established CVD risk factors, may progress CAC among CKD patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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.

Background: The major hindrance to multidetector CT imaging of the left extraperitoneal space (LES), and the detailed spatial relationships to its related spaces, is that there is no obvious density difference between them. Traditional gross anatomy and thick-slice sectional anatomy imagery are also insufficient to show the anatomic features of this narrow space in three-dimensions (3D). To overcome these obstacles, we used a new method to visualize the anatomic features of the LES and its spatial associations with related spaces, in random sections and in 3D., Methods: In conjunction with Mimics® and Amira® software, we used thin-slice cross-sectional images of the upper abdomen, retrieved from the Chinese and American Visible Human dataset and the Chinese Virtual Human dataset, to display anatomic features of the LES and spatial relationships of the LES to its related spaces, especially the gastric bare area. The anatomic location of the LES was presented on 3D sections reconstructed from CVH2 images and CT images., Principal Findings: What calls for special attention of our results is the LES consists of the left sub-diaphragmatic fat space and gastric bare area. The appearance of the fat pad at the cardiac notch contributes to converting the shape of the anteroexternal surface of the LES from triangular to trapezoidal. Moreover, the LES is adjacent to the lesser omentum and the hepatic bare area in the anterointernal and right rear direction, respectively., Conclusion: The LES and its related spaces were imaged in 3D using visualization technique for the first time. This technique is a promising new method for exploring detailed communication relationships among other abdominal spaces, and will promote research on the dynamic extension of abdominal diseases, such as acute pancreatitis and intra-abdominal carcinomatosis.