The Social and Economic Impact of Covid-19 on Family Functioning and Well-Being: Where do we go from here?

A growing body of research demonstrates that COVID-19 has had a profound impact on family functioning and well-being in a range of countries. The fear and uncertainty of the health risks, in addition to the stress from ensuing restrictions and constraints on everyday life caused major disruptions, impacting the financial, emotional, and physical well-being of adults and children alike. In this report, we summarize the current literature on the impact of COVID-19 disruption to family functioning and economic well-being as a context for this special issue. Our findings indicate that while the pandemic may have caused a reallocation of intra-familial tasks, a large gender disparity remains regarding the proportion of domestic work and childcare. The pandemic disproportionally impacted lower-income families, families from ethnic minority and vulnerable groups, and women. Finally, the financial impacts of the emergence in Spring of 2020 have strained family relationships, although the effects depend to a large extent on quality of the relationships and family well-being before COVID-19. To address the long-term bidirectional effects of the pandemic on family well-being and the well-being of the global economy calls for research that crosses disciplinary divides.

Caregivers' Perspectives of the Florida Guardianship Assistance Program and Its Impact on the Children in Their Care

This mixed methods study examined kinship caregivers' perspectives of the Florida Guardianship Assistance Program (GAP) to understand how the program initially supported the needs of the child, caregiver, and family as they navigate permanent guardianship. Specifically, this study examined caregivers' knowledge of the GAP; decision to apply for the GAP; perceptions of the GAP from families who had successfully closed cases to permanent guardianship; perceptions of the GAP from families who held active cases and had not yet closed to permanent guardianship; and perceptions of how children were adjusting in their home, comparing licensed and non-licensed foster care homes. Findings indicate that 47% of respondents first heard about the GAP when the child was initially placed with them, while 16% had never heard of the GAP until receiving the survey letter for this evaluation. The majority (56%) of those who had heard about the GAP were first told about it by the child's caseworker. Among respondents who both knew about the GAP and who indicated whether or not they pursued GAP, 87% decided to apply for the GAP, and 90% of those who applied for licensing were eligible. Of those caregivers whose children's cases had closed to permanent guardianship, the majority (63%) indicated that the licensing process was very easy or somewhat easy. Overall, the majority of caregivers indicated that the children were doing better since being initially placed in their care, but caregivers who were not licensed reported a slightly higher percentage of children who were doing worse.

Parents' employment, income, and finances before and during the COVID-19 pandemic

The COVID-19 pandemic brought grave financial concerns for families in the United States as they attempted to navigate the multifaceted impacts of the pandemic. The present descriptive study examined Florida families' employment characteristics, credit card debt, savings characteristics, use of savings based on employment and income variables, and patterns of use of the first 2020 economic impact payment during the early stages of the COVID-19 pandemic. Responses to an online questionnaire were collected from 526 Florida residents, age 18 or older, who were parents of minor children during the time the study was conducted. Findings are indicative of varying financial impacts on families based on gender, marital status, income level, and employment status related to COVID-19. Implications are presented for employers, educators, researchers, policymakers, and families.

Behavioral and mental health problems in adolescents with ADHD: Exploring the role of family resilience

BACKGROUND

Family resilience and its role in behavioral and mental health problems has not been well documented among U.S. adolescents, especially those with ADHD.

METHODS

Using data from the 2016 and 2017 National Survey of Children's Health (NSCH), we examined associations between family resilience connection index (FRCI) and conduct problems, depression, anxiety, and substance abuse in adolescents with ADHD aged 11-17 (n=4,169). Data were analyzed using multivariate logistic regression and chi-square tests.

RESULTS

Adolescents with ADHD who had a lower FRCI score were more likely to have conduct problems (OR:1.64, CI:1.13-2.38) and depression (OR: 3.08, CI: 2.12-4.49). There were small differences between adjusted and unadjusted odds after controlling for adverse childhood experience and other covariates.

LIMITATION

We could not assert prediction or causation, only associations among variables, due to the cross-sectional design of the 2016-2017 NSCH; however, a major advantage of the NSCH is that it includes a nationally representative sample of children and allows inferences to be made for understanding of the adolescents with ADHD in the U.S.

CONCLUSION

Findings suggest that family resilience may serve as a protective factor that leads to decreasing conduct problems, despite experiencing adversity in childhood. Targeting family resilience, in terms of teaching families ways to cope with adversities such as: a child's diagnosis of ADHD; behavioral problems, and/or other adverse experiences in children's environments, has great potential to reduce adolescents' conduct and mental health problems.

Do Financial Constraints Affect Depressive Symptomatology Among Mid-Aged and Older Adults?

The relationship between financial constraints and depressive symptomatology among adults aged 50 and greater was examined. The mediating effect of perceived control over one's financial circumstances on this relationship was assessed. Ordinary least square hierarchical regression models were estimated using data from the Health and Retirement Study. As an aggregated measure, financial constraints were positively associated with depression in mid-age and late life, and this relationship was partially accounted for by the pathway of perceived control over one's financial circumstances. When disaggregated as a measure, financial constraints at the individual level had a significant effect on depression, while financial constraints at the family and public levels did not have a significant effect. When added to the model, perceived control over one's financial circumstances had a significant effect on depressive symptomatology, financial constraints remained significant at the individual level.

Effects of Fostamatinib on the Pharmacokinetics of Oral Contraceptive, Warfarin, and the Statins Rosuvastatin and Simvastatin: Results From Phase I Clinical Studies

BACKGROUND AND OBJECTIVES

Fostamatinib is a spleen tyrosine kinase inhibitor that has been investigated as therapy for rheumatoid arthritis and immune thrombocytopenic purpura. The present studies assessed the potential for pharmacokinetic interaction between fostamatinib and the commonly prescribed medications oral contraceptive (OC), warfarin, and statins (rosuvastatin, simvastatin) in healthy subjects.

METHODS

The OC study was a crossover study over two 28-day treatment periods (Microgynon(®) 30 plus placebo or fostamatinib). Concentrations of OC constituents (ethinyl estradiol/levonorgestrel) were measured. Effects on warfarin pharmacokinetics and pharmacodynamics were assessed (21-day study). Warfarin was administered on days 1 and 14, fostamatinib on days 8-20. The statin study was a two-period, fixed-sequence study of the effects of fostamatinib on exposure to rosuvastatin or simvastatin (single doses). Safety was assessed throughout.

RESULTS

Fostamatinib co-administration with OC increased exposure to ethinyl estradiol [area under the plasma concentration-time curve at steady state (AUCss) 28% [confidence interval (CI 90%) 21-36]; maximum plasma concentration (Cmax) at steady state (Cmax,ss) 34% (CI 26-43)], but not levonorgestrel (AUCss 5%; Cmax,ss -3%), while exposure to luteinizing hormone and follicle-stimulating hormone decreased (≈ 20%). Fostamatinib did not affect the pharmacokinetics/pharmacodynamics of warfarin to a clinically relevant extent, but caused an upward trend in AUC for both R- and S-warfarin [18% (CI 13-23) and 13% (CI 7-19)]. Fostamatinib increased rosuvastatin AUC by 96% (CI 78-115) and Cmax by 88% (CI 69-110), and increased simvastatin acid AUC by 74% (CI 50-102) and Cmax by 83% (CI 57-113).

CONCLUSION

Fostamatinib exhibits drug-drug interactions when co-administered with OC, simvastatin, or rosuvastatin, with the AUC of statins almost doubling. Fostamatinib did not exhibit a clinically relevant DDI on warfarin.

Effects of receipt of Social Security retirement benefits on older women's employment

Labor force participation of women has declined since 1999; however, labor force participation of women 62+ has increased. The 2000-2006 waves of Health and Retirement Study (HRS) data, the initial years of the continuing upward trajectory, were used to test the effects of receipt of Social Security retirement benefits on older women's employment. The models tested: (a) the effect of receipt of Social Security retirement benefits on whether employed; and (b) for women receiving Social Security retirement benefits, the effect of age elected receipt of benefits on whether employed. Both models included the effects of human capital characteristics and income sources. Receipt of Social Security benefits, pension income, and current age reduced the likelihood of employment; while educational level, good to excellent health, and nonmarried marital status increased the likelihood of employment. The older the woman was when she elected Social Security benefits, the more likely she was to be employed.

Women's receipt of Social Security retirement benefits: expectations compared to elections

This research contributes knowledge regarding the options of early, normal, or delayed receipt of Social Security retirement benefits and research-based findings regarding women's expected and actual timing of election of Social Security retirement benefits. First, descriptive analyses of alternative retirement options, based on Social Security retirement benefit rules, are provided. Second, the 2000, 2002, 2004, and 2006 waves of Health and Retirement Study (HRS) data are used to analyze women's anticipated and actual election of Social Security retirement benefits. Third, based on these considerations, recommendations are made regarding Social Security retirement benefit receipt alternatives.

Social security survivors benefits: the effects of reproductive pathways and intestacy law on attitudes

Most minor children are eligible for Social Security survivors benefits if a wage-earning parent dies, but eligibility of children not in utero at the time of death is more nuanced. The purpose of this study was to examine attitudes concerning access to Social Security survivors benefits in the context of posthumous reproduction. A probability sample of 540 Florida households responded to a multiple-segment factorial vignette designed to examine the effects of state intestacy laws and five reproductive pathways - normative, posthumous birth, cryopreserved embryo, cryopreserved gametes, and posthumous gamete retrieval - on attitudes toward eligibility for the Social Security survivors benefits. Broad support was found for the survivors benefits following normative and posthumous birth pathways, but attitudes were decidedly less favorable when the child was not in utero at the time of parental death. In addition, in stark contrast to the recent U.S. Supreme Court decision in Astrue v. Capato, the vast majority of respondents did not believe state intestacy laws should determine eligibility for Social Security survivors benefits.

Functional recovery following musculoskeletal injury in hospital workers

BACKGROUND

Hospital workers are at high risk of work-related musculoskeletal disorders (WRMSDs), but outcomes following such injuries have not been well studied longitudinally.

AIMS

To ascertain functional recovery in hospital workers following incident WRMSDs and identify predictors of functional status.

METHODS

Cases (incident WRMSD) and matched referents from two hospitals were studied at baseline and at 2 year follow-up for health status [SF-12 physical component summary (PCS)], lost workdays, self-rated work effectiveness and work status change (job change or work cessation). Predictors included WRMSD and baseline demographics, socio-economic status (SES), job-related strain and effort-reward imbalance. Logistic regression analysis tested longitudinal predictors of adverse functional status.

RESULTS

The WRMSD-associated risk of poor (lowest quartile) PCS was attenuated from a baseline odds ratio (OR) of 5.2 [95% confidence interval (CI) 3.5-7.5] to a follow-up OR of 1.5 (95% CI 1.0-2.3) and was reduced further in multivariate modelling (OR = 1.4; 95% CI 0.9-2.2). At follow-up, WRMSD status did not predict significantly increased likelihood of lost workdays, decreased effectiveness or work status change. In multivariate modelling, lowest quintile SES predicted poor PCS (OR = 2.0; 95% CI 1.0-4.0) and work status change (OR = 2.5; 95% CI 1.1-5.8). High combined baseline job strain/effort-reward imbalance predicted poor PCS (OR = 1.7; 95% CI 1.1-2.7) and reduced work effectiveness (OR = 2.6; 95% CI 1.6-4.2) at follow-up.

CONCLUSIONS

Baseline functional deficits associated with incident WRMSDs were largely resolved by 2 year follow-up. Nonetheless, lower SES and higher combined job strain/effort-reward imbalance predicted adverse outcomes, controlling for WRMSDs.

Sex redefined: the reclassification of oral-genital contact

CONTEXT

Although partially anecdotal, some evidence suggests that oral-genital contact is increasingly excluded from young people's notions of what behaviors constitute sex. Such a shift may have implications for STD prevention.

METHODS

In 2007, a convenience sample of 477 university students participated in a survey that included the question "Would you say you 'had sex' with someone if the most intimate behavior you engaged in was" each of 11 behaviors. Chi-square tests and independent samples t tests were used to assess gender differences, and chi-square analyses were used to compare the data with similar data collected in 1991. Predictors of beliefs concerning the classification of oral-genital contact were assessed using logistic regression analysis.

RESULTS

The majority of respondents indicated that penile-vaginal intercourse and penile-anal intercourse constitute sex (98% and 78%, respectively), but only about 20% believed the same was true of oral-genital contact. The proportion classifying oral-genital contact as sex in 2007 was about half that in 1991. This difference was consistent for both sexes and for both giving and receiving oral-genital stimulation. Responses did not vary by respondents' sexual experience or demographic characteristics.

CONCLUSIONS

Sociocultural conceptualizations of oral-genital contact have shifted in a way that may leave people who engage in this activity unmindful of its potential health risks. Sex education programs, which generally focus on penile-vaginal contact, could help STD prevention efforts by explaining the risks associated with oral-genital stimulation and the measures that can be taken to minimize those risks.

Older Women and Poverty Transition

Older single women are disproportionately vulnerable to poverty. Using data from the 2002 and 2004 waves of the Health and Retirement Study of 5,799 women age 65 or older, this study investigated the effect of change in income sources by recent spousal loss on poverty transition. The focus is on (a) the effect of widowhood on income source change and (b) how such change affects poverty transition of recently widowed older women. Findings indicate that widowhood greatly decreases income from every source. Specifically, a $10 increase in social security benefits decreased the probability of poverty transition for recently widowed older women by 67.2%. These findings call for reconsidering social security survivor benefit rules and women's education with regard to financial security in retirement.

Effect of age and gender on the pharmacokinetics of ebastine after single and repeated dosing in healthy subjects

OBJECTIVES

Ebastine is a potent and selective H1-receptor antagonist indicated for allergic rhinitis which undergoes extensive first pass metabolism by CYP3A4 to form an active metabolite, carebastine. The purpose of the study was to determine age- and gender-related differences in the pharmacokinetics of ebastine and carebastine.

METHODS

The upper recommended oral dose of 20 mg once daily was administered to 12 healthy young (22 to 38 years) and 12 healthy elderly (50 to 92 years; 8 m and 4 f) subjects for 5 days. Plasma concentrations of ebastine and carebastine were determined for 24 hours following the initial dose on Day 1 and for 72 hours following the dose on Day 5 using a sensitive LC/MS/MS assay. The minimum quantifiable limit (MQL) for the assay was 0.05 ng/ml and 1.0 ng/ml for ebastine and carebastine, respectively.

RESULTS

Mean area under the curve and Cmax values on Day 1 and Day 5 were similar for ebastine but approximately doubled for carebastine due to its longer half-life. Mean carebastine concentrations were approximately 10 to 20 fold higher than mean ebastine concentrations. For young subjects, the mean (%CV) ebastine t(1/2) was 5.76 (28.47) h and 20.38 (46.19) h on Day 1 and Day 5, respectively. Similarily, for young subjects, the mean (%CV) for carebastine t(1/2) was 7.03 (23.21) h and 26.12 (23.39) h on Day 1 and Day 5, respectively. This apparent prolongation of t(1/2) was probably due to lack of proper estimation of terminal half-life on Day 1 as fewer samples were collected for a shorter duration on Day 1. Using a multicomparison test for Cmin values, it was determined that steady state conditions were achieved by Day 5 for both age groups for ebastine and in young subjects for carebastine. The variability in ebastine pharmacokinetic parameters was higher than carebastine. A 50% increase in ebastine AUC(0-24) and Cmax values in elderly subjects, with no changes in t(1/2), could be explained by either increased absorption of ebastine in elderly subjects or due to a decrease in first pass metabolism. As ebastine shows a high first-pass effect, even a small change in this first pass can cause large changes in plasma exposure. The ebastine pharmacokinetic parameters for elderly subjects in this study lie between the values reported in young subjects in earlier studies. Hence, the apparent age-related pharmacokinetic difference for ebastine is probably due to the inherent variability in ebastine pharmacokinetics. There were no gender-related differences in either young or elderly subjects for mean AUC, Cmax, tmax and t(1/2) ebastine and carebastine values. Ebastine was absorbed rapidly with a median tmax of 1.25 to 2.25 h for both healthy young and elderly males and females on Day 1 and Day 5. There was a delayed appearance of carebastine as expressed by median tmax of 4.0 to 5.0 h, which did not change with age, gender or repeated administration. There were no clinically relevant differences between the groups of subjects with respect to adverse events or safety parameters.

CONCLUSIONS

Thus, ebastine can be safely administered to elderly subjects with no clinically important age- or gender related differences in the pharmacokinetics of ebastine/carebastine.

A review of the cardiac systemic side-effects of antihistamines: ebastine

The cardiac safety of ebastine, a long-acting, non-sedating antihistamine, has been thoroughly assessed in phase I-III clinical studies. Ebastine alone at the recommended doses of 10 mg and 20 mg has no clinically relevant effect on QTc interval in adults and in special patient populations (elderly, children or subjects with hepatic or renal impairment). Ebastine administered at 60 and 100 mg/day (3-5 times the maximum recommended dose) for 1 week had statistically significantly smaller effects (3.7 and 10.3 msec, respectively) on the QTc interval than terfenadine (18 msec) at three times the recommended dose (360 mg/day). The mean QTc interval prolongation observed with ebastine 100 mg/day was small and not clinically meaningful, although the results were statistically significant vs. placebo. The effect of ebastine 60 mg/day was not statistically different from placebo. Steady-state drug interaction studies demonstrated that the co-administration of ebastine 20 mg with ketoconazole or erythromycin produced significant increases in systemic exposure for ebastine, which were accompanied by small increases in QTc (approximately 10 msec above ketoconazole or erythromycin alone). Results from individual studies suggest that, when coadministered with ketoconazole, ebastine produces similar changes in QTc interval measurements compared to loratadine and cetirizine. Pooled data from clinical efficacy trials of ebastine 1-30 mg/day administered for 2-3 weeks showed no clinically relevant cardiac effects as assessed by serial electrocardiographs and Holter monitoring. The overall cardiac safety profile based on currently available information suggests that ebastine, like loratadine and cetirizine, has a lower potential for causing adverse cardiovascular effects than terfenadine.

Injuries from construction falls. Functional limitations and return to work

Finding a measure that distinguishes well between the severity levels of less serious injuries such as those found in occupational settings has been problematic. In this study of 255 construction workers who sustained nonfatal falls at work, two measures of injury severity were used--the Injury Severity Score (ISS) and the disability index of the Stanford Health Assessment Questionnaire (HAQ), a functional limitation measure. The HAQ scores were more normally distributed than the ISS and provided useful information about the degree to which workers were disabled from falls during their first week of recovery. The mean HAQ score was 1.46 (SD = 0.75) on a scale of 0 to 3, with higher numbers representing more limited functioning. With regard to individual tasks, participants reported having the most difficulty performing heavy chores (mean = 1.89; SD = 1.02), dressing themselves (mean = 1.54; SD = 1.05), and bending to pick up clothing from the floor (mean = 1.40; SD = 1.02). The HAQ scores were significantly and moderately correlated with days lost from work (r = .52; p < .001). Unexpectedly, 97 workers reported that they were able to return to light or modified duty following their falls.

Injury severity associated with nonfatal construction falls

This study evaluated injury severity in a group of construction workers who sustained nonfatal falls at work. The sample consisted of 255 adults who were identified from Doctor's First Reports (DFRs) submitted to the California Department of Industrial Relations. For those that fell from heights (n = 195), the mean height of fall was 9.2 feet (SD = 7.1). The mean number of lost work days was 44.3 days (SD = 58.6) and the median was 10 days. Two measures of injury severity were used--the Injury Severity Score and the disability section of the Health Assessment Questionnaire (HAQ). Seventeen participants (7%; 95% CI, 4-10%) were deemed permanently disabled. A simultaneous multiple regression model, using five independent variables, explained approximately 21% of the variance in HAQ scores. Nonunion status and safety climate scores indicating increased risk were positively correlated with higher functional limitation as measured by HAQ scores, as were greater heights and impact on concrete surface. Higher scores on both injury severity measures were significantly and moderately associated with a greater number of days lost from work. These findings suggest that injury severity and permanent disability associated with falls in construction are notable, and identify key target areas for intervention and prevention.

Surveillance and investigation of homicides at work: California fatality assessment and control evaluation program

The authors describe California's Fatality Assessment and Control Evaluation program, a state-based surveillance and investigation program for traumatic occupational fatalities. FACE has identified occupational homicides as a priority for targeted prevention efforts to reduce the incidence of work-related fatalities.

Predictors of carbon monoxide and hydrogen cyanide exposure in smoke inhalation patients

OBJECTIVE

A prospective study of civilian (nonfirefighter) smoke inhalation patients was carried out to test the hypotheses that: 1) absorption of carbon monoxide and hydrogen cyanide from smoke can be predicted by clinical examination and historical data; and, more specifically 2) a history of exposure to burning synthetic polymers is an important predictor of systemic cyanide levels.

METHODS

The study was conducted over a three-year period at six urban hospitals. Patients with or without burns who were exposed to smoke within five hours of hospital arrival were sampled for carboxyhemoglobin, whole blood cyanide, urine cotinine and urine creatinine. Controls consisted of a smaller group of smoking status-matched, nonsmoke-exposed burn patients.

ANALYSIS

Historical information was obtained on SMOKING status, FIRETYPE (structural vs other), MATERIAL burned (natural vs synthetic) and LAGTIME (from exposure to sampling). A smoke inhalation SCORE (0-10) was assigned to each case, based on physical examination findings and changes on chest X ray, and carboxyhemoglobin and cyanide levels were entered into various multivariate linear regression models.

RESULTS

A total of 40 cases and 9 controls were recruited, ranging in age from 15 to 92 years. Thirty-four cases were discharged alive and six expired in-hospital. Observed carboxyhemoglobin levels ranged from 1.2% to 41.6% in cases (mean 8.6%), and from 0.5 to 7.3% in controls (mean 2.9%). Observed cyanide levels ranged from nondetectable (< 0.05 micrograms/mL) to 2.79 micrograms/mL in cases (mean 0.25 micrograms/mL), and from nondetectable to 0.11 micrograms/mL in controls (mean 0.03 micrograms/mL). Among cases, linear regression models explained up to 35% of the observed variance in carboxyhemoglobin levels (p < 0.001) and up to 48% of the variance in cyanide levels (p = 0.0001).

CONCLUSIONS

SCORE was the strongest predictor of both carboxyhemoglobin and cyanide levels; LAGTIME also explained significant variance for [log-transformed] carboxyhemoglobin. Historical factors, such as FIRETYPE, MATERIAL, and SMOKING status, did not explain significant variance in most of the statistical models employed.

Work disability in adults with cystic fibrosis

Greater numbers of persons with cystic fibrosis (CF) reach adulthood and, therefore, actively participate in the labor force. In this study, we estimated labor force participation rates and determined risk factors for work disability among persons with CF. We recruited 49 (73%) of 67 adults followed at one of two hospital-based CF centers. We ascertained employment history and CF-attributed work disability by structured questionnaire. Independently, we reviewed medical records for demographics and illness severity indicators. We analyzed potential risk factors for work disability by logistic regression analysis. All of those studied reported past or present labor force participation, consistent with high work motivation. Complete cessation of work attributed to CF was reported by 17 (35%; 95% CI, 21 to 49%). Although 23 (47%; 95% CI, 32 to 60%) of those surveyed stated that CF had affected career choice, only nine respondents had ever received career counselling and 16 had ever discussed job choice with their physicians. After adjusting for standard measures of disease severity by multiple logistic regression, age, adult diagnosis of CF, female gender, and single marital status, analyzed as a group, provided significant additional explanatory power to a predictive model of disability risk (model chi square [4 d.f.] = 11.5, p < 0.05). Health care professionals who design interventions targeted at work disability among persons with CF should address demographic factors as well as illness severity and should assess the vocational needs of persons with CF and the potential benefit of career counselling.

Occupational bladder cancer in textile dyeing and printing workers: six cases and their significance for screening programs

Occupational bladder cancer due to aniline dye intermediates such as beta-naphthylamine and benzidine has long been known; benzidine congeners (o-tolidine and o-dianisidine) are highly suspect. Among 400 men from the Amalgamated Clothing and Textile Workers Union (ACTWU) Dyers locals in New York and New Jersey screened over a 4-year period, two cases of bladder cancer were detected. (Microscopic hematuria, not cytological evaluation, prompted further investigation.) Before a 1984 ACTWU screening program in North Carolina, three workers from the same plant self-reported bladder cancers. Another member, with inconclusive screening results, was diagnosed 2 years later. For these six cases, the mean age at detection was 56.5 years (age range, 38 to 79 years), a decade earlier than age at diagnosis of nonoccupational bladder cancer in men. The average latency from onset of exposure to diagnosis was 23.3 years. These cancers provide evidence to support the initiation of screening programs for high-risk workers. To overcome the emotional and economic disincentives faced by potential victims of occupational bladder cancer, training programs are needed. Worker involvement is required, through trade union representation where possible, to assure reliable training and the equitable distribution of screening and treatment costs.

A strategy for educating health care providers about AIDS: the California Nurses Association's AIDS Train the Trainer Program

The AIDS epidemic is increasing the demand on all levels of health care staff to provide care compassionately and safely to people with AIDS and HIV infection. Only appropriate, ongoing education of all health care workers will maintain an effective health care system as the number of cases rises. However, the fear engendered by the word AIDS can be a serious deterrent to effective care. Adult learning principles and fear reduction techniques provide the foundation for AIDS education. A train the trainer approach provides immediate AIDS expertise to health care providers within their institution or department. With adequate resources and training, health care professionals who are already in the workplace are in the best position to quell hysteria, educate health care workers about appropriate protective measures, and ensure that humane, compassionate care is provided to persons with AIDS and HIV infection.

Inspiratory pressure generation: comparison of subjects with COPD and age-matched normals

We continuously monitored esophageal (Pes) and gastric (Pga) pressures and used these measurements in a three-component model to estimate instantaneous diaphragmatic (DIA), inspiratory accessory muscle (IAM), and postexpiratory recoil (PER) pressures at various times during inspiration. We validated our model both by volume-pressure relationships of the respiratory system (Vrc-Pga and Vab-Pga, where Vrc and Vab are the rib cage and abdominal volumes, respectively) as well as electromyography of the respiratory muscles. Measurements were carried out at rest and during graded treadmill exercise in 11 subjects with chronic obstructive pulmonary disease (COPDs) and 8 age-matched normal subjects (AMNs). AMNs were 59 +/- 2 (SE) yr and had a forced expiratory volume at 1 s (FEV1.0) of 3.6 +/- 0.2 liters; COPDs were 66 +/- 2 yr and had a FEV1.0 of 1.0 +/- 0.1 liters. We noted the following. At rest, both AMNs and COPDs exhibited an increasing DIA pressure (PDIA) across inspiratory time (TI) at rest. As expired minute ventilation increased with exercise intensity, AMNs continued to maintain this PDIA ramp across inspiration; in contrast, COPDs exhibited higher values of PDIA during the first half of TI than during the second half. At all intensities of exercise, COPDs exhibited higher IAM and PER pressures than the AMNs.

Diaphragmatic pressure waveform can predict electromyographic signs of diaphragmatic fatigue

To evaluate the relationship between diaphragmatic pressure (Pdi) waveform and electromyographic (EMG) signs of diaphragmatic fatigue (DF), 11 chronic obstructive pulmonary disease (COPD) subjects underwent a 12-stage graded treadmill exercise test (GXT). No COPD subjects completed the GXT; all stopped exercising due to dyspnea. We then used the crural diaphragmatic EMG (EMGdi) to divide the COPD subjects into a group that exhibited EMGdi signs of fatigue during the GXT (i.e., F group) and one that did not (i.e., NF group); three COPD subjects were classified as F, and eight COPD subjects were classified as NF. At end exercise, F and NF groups did not differ with respect to peak inspiratory Pdi swing (peak Pdi); however, they did differ with respect to percent of peak Pdi manifest at 50 and 90% of inspiratory time (TI). At 50% TI, NF = 88 +/- 3%, F = 60 +/- 1%, P less than 0.01; likewise at 90% TI, NF = 58 +/- 5%, F = 12 +/- 10%, P less than 0.01. Since peak Pdi occurred in both groups during the initial 50% of TI, these data indicate that the F group maintained Pdi less well than the NF group during the latter half of TI. Based on the above results and other data in the manuscript, we suggest that this change in Pdi waveform can predict EMG signs of DF.

Description and validation of an ECG removal procedure for EMGdi power spectrum analysis

We describe a cross-correlation procedure for removing contaminating electrocardiogram (ECG) complexes from the diaphragmatic electromyogram (EMGdi). First, the operator selects ECG templates from the EMGdi signal during expiratory intervals. Second, these templates are used to locate ECG complexes occurring during inspiratory EMGdi activity. Third, at the point of maximum correlation between the template and these ECG complexes, the template is adjusted in size and offset to "match" the ECG complex, and adjustments are determined by the linear regression coefficients. Finally, the modified template is subtracted from the EMGdi signal. To evaluate our method, we compared the power spectral density (PSD) obtained from processing EMGdi signals by our method with those obtained from the EMGdi signal in which ECG complexes had been removed by gating. Our results indicate that PSD obtained by these two different methods shows no statistically significant differences with respect to the following features: centroid frequency, median frequency, total power, standard deviation, skewness, and kurtosis.