A National, County-Level Evaluation of the Association Between COVID-19 and Sexually Transmitted Infections within the United States in 2020

BACKGROUND

Shifts in public health infrastructure to respond to one emerging health threat may have unanticipated consequences for pre-existing diseases. Also, previous research evaluating the impact of COVID-19 on sexually transmitted infections (STIs) has been conducted nationally, with little exploration of the impact on a granular geospatial level. This ecological study seeks to quantify the association between COVID-19 cases or deaths and chlamydia, gonorrhea, and syphilis cases for all United States (US) counties in 2020.

METHODS

Separate, adjusted multivariable quasi-Poisson models with robust standard errors modeled the county-level association between 2020 COVID-19 cases and deaths per 100,000 and 2020 chlamydia, gonorrhea, or syphilis cases per 100,000. Models were adjusted for sociodemographic characteristics.

RESULTS

Every 1,000 additional COVID-19 cases per 100,000 was associated with a 1.80% increase in the average number of chlamydia cases (P < .001) and 5.00% increase in the average number of gonorrhea cases (P < .001). Every 1,000 additional COVID-19 deaths per 100,000 was associated with a 57.9% increase in the average number gonorrhea cases (P < .001) and 74.2% decrease in the average number of syphilis cases (P = .004).

CONCLUSIONS

Higher rates of COVID-19 cases and deaths were associated with increased rates of some STIs at the US county-level. The underlying reasons for these associations could not be established by this study. The emergency response to an emerging threat may have unanticipated influence on pre-existing diseases that varies by level of governance.

Obesity-Related Discourse on Facebook and Instagram Throughout the COVID-19 Pandemic: Comparative Longitudinal Evaluation

BACKGROUND

COVID-19 severity is amplified among individuals with obesity, which may have influenced mainstream media coverage of the disease by both improving understanding of the condition and increasing weight-related stigma.

OBJECTIVE

We aimed to measure obesity-related conversations on Facebook and Instagram around key dates during the first year of the COVID-19 pandemic.

METHODS

Public Facebook and Instagram posts were extracted for 29-day windows in 2020 around January 28 (the first US COVID-19 case), March 11 (when COVID-19 was declared a global pandemic), May 19 (when obesity and COVID-19 were linked in mainstream media), and October 2 (when former US president Trump contracted COVID-19 and obesity was mentioned most frequently in the mainstream media). Trends in daily posts and corresponding interactions were evaluated using interrupted time series. The 10 most frequent obesity-related topics on each platform were also examined.

RESULTS

On Facebook, there was a temporary increase in 2020 in obesity-related posts and interactions on May 19 (posts +405, 95% CI 166 to 645; interactions +294,930, 95% CI 125,986 to 463,874) and October 2 (posts +639, 95% CI 359 to 883; interactions +182,814, 95% CI 160,524 to 205,105). On Instagram, there were temporary increases in 2020 only in interactions on May 19 (+226,017, 95% CI 107,323 to 344,708) and October 2 (+156,974, 95% CI 89,757 to 224,192). Similar trends were not observed in controls. Five of the most frequent topics overlapped (COVID-19, bariatric surgery, weight loss stories, pediatric obesity, and sleep); additional topics specific to each platform included diet fads, food groups, and clickbait.

CONCLUSIONS

Social media conversations surged in response to obesity-related public health news. Conversations contained both clinical and commercial content of possibly dubious accuracy. Our findings support the idea that major public health announcements may coincide with the spread of health-related content (truthful or otherwise) on social media.

Recall of food marketing on videogame livestreaming platforms: Associations with adolescent diet-related behaviours and health

Digital media has become an integral part of adolescents' lives. Mirroring this trend, food and non-alcoholic beverage (hereafter: food) brands increasingly promote products in digital media to maximise reach with young consumers. Videogame livestreaming platforms, where individuals can broadcast or watch streamed videogame footage, are a growing form of digital media. The top three platforms (market share by hours watched) are Twitch (72%), YouTube Gaming (13%), and Facebook Gaming Live (9%), with a combined 34.6 billion hours watched in 2021. These platforms represent a hybridisation of two popular digital trends amongst teenagers: viewing online video content and playing videogames. On these platforms, gaming influencers promote food brands and products, with energy drinks and fast-food restaurants representing the most frequently promoted categories. Evidence suggests that food marketing via Twitch is associated with food craving, purchasing and consumption in adults. Yet, despite the evident teenage appeal and prevalence of food marketing on these platforms, research is yet to explore its associations with adolescent eating behaviour. Adolescents (n = 490, M_age = 16.81, 30.2% female) completed an online cross-sectional questionnaire exploring their recall of food marketing on the top three videogame livestreaming platforms, and relevant behavioural (purchase, consumption) and health (Body Mass Index) outcomes. Structural equation modelling was used to explore hierarchical relationships between the key variables. Results showed that recall of unhealthy food marketing on these platforms was significantly associated with purchase and consumption of marketed food categories. Attitudes towards unhealthy foods mediated this relationship. Findings are the first to demonstrate the relationships between unhealthy food marketing via videogame livestreaming platforms and adolescent eating behaviours, which has implications for the design of policies to restrict digital food marketing to young people.

Minimally Invasive Autologous Fascia Sling at the Midurethra: A Case Series

STUDY OBJECTIVE

The primary objective was to determine the improvement in stress urinary incontinence symptoms using autologous fascia lata sling placed at the midurethra. The secondary objective was to determine the presence of leg pain after harvest of fascia lata graft.

DESIGN

Case series.

SETTING

Rural academic tertiary care center.

PATIENTS

All women who underwent an autologous fascia midurethral sling over a 1-year period between June 2019 and September 2020.

INTERVENTIONS

Autologous fascia lata midurethral sling.

MEASUREMENTS

Incontinence severity index, urodynamic distress inventory-6, and Likert pain scale.

MAIN RESULTS

Nineteen women received an autologous fascial sling at the midurethra using the described technique-16 fascia lata and 3 rectus fasciae. Mean improvement in incontinence severity index score was 6 points. Mean improvement in urodynamic distress inventory-6 and SUI subscale scores was 14 and 53, respectively, surpassing the minimally important difference for each. Median follow-up time was 9 months (range 2-16). Leg pain at the harvest site was bothersome in 1 patient beyond 6 weeks. Median time to passing voiding trial was 4 days (range 1-13 days). Four patients (21%) had postoperative voiding dysfunction, 3 of which resolved after sling loosening at a mean of 60 days after sling placement.

CONCLUSION

Midurethral autologous fascial sling placement significantly improves symptoms of SUI but carries a risk of voiding dysfunction. Harvesting fascia lata using a fascial stripper is associated with minimal postoperative morbidity.

Abstract P4-09-08: Shared-patient physician networks and their impact on the uptake of genomic testing in early-stage breast cancer

Background: Oncotype DX (ODX) or 21-gene recurrence score genomic testing is used to stratify risk and determine appropriate treatment in women with early-stage breast cancer (BC). Diffusion of ODX by way of physician networks has not been studied.

Objective: To determine the association between physician network connections, defined by shared patients, and the use of ODX testing.

Methods: SEER-Medicare claims from 2008-2012 were used to identify a cohort of woman with a diagnosis of BC from registry/ICD codes, continuously enrolled in Medicare fee-for-service Part A and B one year prior to and one year following diagnosis. We identify receipt of ODX from the associated CPT code, claim reimbursement, and performing NPI. To look at the influence of network connections on ODX use, we split the study into two time periods: early adoption from 2008-2009, and late from 2010-2012. Medical oncologists with a BC-related claim in the cohort above, and any rendered BC-related service are considered 'connected' if they shared two or more BC patients. Analyses describe these connections and explore the association between connectedness to an early adopting medical oncologist and ODX use in parallel physician and patient-level analyses using generalized linear mixed models with a hospital referral region-specific random effect. Models control for physician and patient-level characteristics where applicable.

Results:24,463 women met study criteria; 12,874 were diagnosed with BC in the early adoption time period (1,790 received ODX) and 11,589 were diagnosed in the late period (2,334 received ODX). 2,073 medical oncologists treated these patients from 2008-2009. The mean number of BC patients treated per medical oncologist was 86.8 during the early adoption period, and medical oncologists had a median number of peer connections of 11 (IQR: 7-18). Early adopting medical oncologists had higher numbers of peer connections and higher average patient counts than non-early adopters. A higher percentage of female medical oncologists were early adopters (39%) then male medical oncologists (33%) (p&lt;0.02). Among non-early adopting oncologists, peer connection to at least two early adopting providers in 2008-2009 is associated with a 3.2 (95% CI: 2.0-4.9) times increase in the odds of ordering ODX in 2010-2012 after adjustment for physician gender and time in practice. In patient-level models with controls for physician and patient characteristics, seeing a medical oncologist with connections to at least two early adopting physicians is associated with a 1.6 times (95% CI: 1.1-2.2) increase in the odds of receiving ODX testing in 2010-2012.

Conclusions: We observe a positive adjusted association between connectedness to an early-adopting physician and ODX prescribing/use in both physician-level and patient-level analyses. These results suggest that provider networks may help diffuse new technologies, and that BC genomic testing is likely to be an area of shared practices between providers. Efforts to increase testing, where appropriate, may benefit from a range of peer-to-peer connection strategies.

Citation Format: Rotter J, Wilson L, Greiner M, Pollack C, Dinan M. Shared-patient physician networks and their impact on the uptake of genomic testing in early-stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-09-08.

Heliox for nonintubated acute asthma patients

BACKGROUND

Helium and oxygen mixtures (heliox), have been used sporadically in respiratory medicine for decades. Their use in acute respiratory emergencies such as asthma has been the subject of considerable debate. Despite the lapse of more than 60 years since it was first proposed, the role of heliox in treating patients with severe acute asthma remains unclear.

OBJECTIVES

To determine the effect of the addition of heliox to standard medical care on the course of acute asthma, as measured by pulmonary function testing and clinical endpoints.

SEARCH STRATEGY

Randomised controlled trials were identified from the Cochrane Airways Group Specialised Register. In addition, we contacted primary authors and experts and searched reference lists of articles. Searches are current to August 2005.

SELECTION CRITERIA

1) randomised, single or double blind, controlled trials; 2) children or adults with a clinical diagnosis of acute asthma seen in emergency departments or equivalent acute care settings; and 3) compared treatment with inhaled heliox to placebo (oxygen or air).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and quality assessment; disagreement was resolved by a third review author and consensus.

MAIN RESULTS

This review has been updated in 2006 to include four new trials giving atotal of ten trials involving 544 acute asthma patients. Seven studies involved adults and three studies dealt solely with children. Three were assessed as high quality (Jadad score > 3). Pulmonary function tests were recorded during heliox administration (15 to 60 min). Pooling of the eight trials contributing data to this review showed no significant group differences (standardised mean differences -0.28; 95% confidence interval (CI) -0.56 to 0.01). There was significant heterogeneity among the studies. Heliox use did improve pulmonary function only in the subgroup of patients with the most severe baseline pulmonary function impairment; however, this conclusion is based on a small number of studies. There were no significant differences between groups when adults versus children, and high versus low heliox dose studies were compared. Finally, at the end of treatment, participants treated with heliox showed no significant different risk of admission to hospital (RR 0.83 (95%CI 0.66 to 1.08, P = 0.17, I(2) = 0%).

AUTHORS' CONCLUSIONS

The existing evidence does not provide support for the administration of helium-oxygen mixtures to all ED patients with acute asthma. At this time, heliox treatment does not have a role to play in the initial treatment of patients with acute asthma. Nevertheless, new evidence suggests certain beneficial effects in patients with more severe obstruction. Since these conclusions are based upon between-group comparisons and small studies, they should be interpreted with caution.

Heliox for nonintubated acute asthma patients

BACKGROUND

Helium and oxygen mixtures (heliox), have been used sporadically in respiratory medicine for decades. Their use in acute respiratory emergencies such as asthma has been the subject of considerable debate. Despite the lapse of more than 60 years since it was first proposed, the role of heliox in treating patients with acute severe asthma remains unclear.

OBJECTIVES

To determine the effect of the addition of heliox to standard medical care on the course of acute asthma, as measured by pulmonary function testing and clinical endpoints.

SEARCH STRATEGY

Randomised controlled trials were identified from the Cochrane Airways Review Group Asthma Register which is a compilation of systematic searches of CINAHL, EMBASE, MEDLINE, and CENTRAL and hand searching of the 20 most productive respiratory care journals. In addition, primary authors and experts were contacted to identify eligible studies. References from included studies, known reviews and texts were also searched.

SELECTION CRITERIA

Studies were selected for inclusion in the review if they met the following inclusion criteria: 1) randomised, single or double blind, controlled trials; 2) children or adults with a clinical diagnosis of acute asthma seen in emergency departments or equivalent acute care settings; and 3) compared treatment with inhaled heliox to placebo (oxygen or air). Two reviewers independently assessed the studies for inclusion and quality assessment; disagreement was resolved by a third reviewer and consensus.

DATA COLLECTION AND ANALYSIS

Data from all included trials were combined using the Review Manager (Version 4.1) using random effects weighted mean (WMD) and standardised mean differences (SMD), with 95% confidence intervals (95% CI). Homogeneity of effect sizes were tested with the Dersimonian and Laird method with p<0.1 as the cut point for significance. Sensitivity analyses were performed on age (adults vs. children), different helium-oxygen mixtures (80/20, vs. 70/30 or 60/40), methodological quality (Jadad score >2 vs. <3) and method of heliox use (studies designed to washout air in the lungs and replace it with heliox versus studies that used heliox to deliver nebulized therapy).

MAIN RESULTS

This review has been updated in 2002 to include two new trials. A total of six randomised controlled trials were selected for inclusion with a total of 369 acute asthma patients. Five studies involved adults and one study dealt solely with children. Two were assessed as high quality (Jadad score >3). The main outcome variable was spirometric measurements (PEF % predicted, PEF L/min, FEV1 % of predicted, FEV1L). Heliox use did not improve pulmonary functions compared to standard care (SMD = 0.13; 95% CI: -0.09 to 0.34). All pulmonary function tests were recorded during heliox administration (15 to 60 min). The test of homogeneity was not significant (p=0.25). There were no significant differences between groups when adults vs. children, high vs. low quality, and high vs. low heliox dose studies were compared.

REVIEWER'S CONCLUSIONS

The existing evidence does not provide support for the administration of helium-oxygen mixtures to ED patients with moderate to severe acute asthma. At this time, heliox treatment does not have a role to play in the initial treatment of patients with acute asthma. Since these conclusions are based upon between-group comparisons and small studies, they should be interpreted with caution. Additional research in this setting is needed.

Heliox for treatment of exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Due to its low density properties, helium-oxygen mixtures have the potential to decrease the work of breathing and possibly avoid the need for intubation and mechanical ventilation in patients with respiratory failure.

OBJECTIVES

To determine the effect of the addition of helium/oxygen mixtures (heliox) to standard medical care during ventilated and nonventilated acute exacerbations of COPD.

SEARCH STRATEGY

Randomized controlled trials were identified from the Cochrane Airways Review Group asthma Register. Primary authors and experts were contacted. References from included and excluded studies, known reviews and texts were also searched.

SELECTION CRITERIA

Studies were selected for inclusion if they compared treatment with heliox to placebo (oxygen or air) in randomized controlled trials in adults with an exacerbation of COPD.

DATA COLLECTION AND ANALYSIS

Data from all trials were combined using the Review Manager (version 4.1). We planned to perform: 1) random effects weighted mean difference (WMD), with 95% confidence intervals (95% CI), 2) Homogeneity of effect sizes with the Dersimonian and Laird method with p<0.1 as the cut point for significance, and 3) sensitivity analysis on different helium-oxygen mixtures (80/20 vs 70/30), and 4) methodological quality (Jadad score >2 vs. <3).

MAIN RESULTS

Four studies, all published between 1997 and 2000 met the inclusion criteria. Two studies compared heliox-oxygen vs. air-oxygen in decompensated COPD patients who were not ventilated. One study was performed in mechanical ventilated patients and one in patients undergoing noninvasive pressure support (NIPSV) ventilated patients. Data could be obtained for only two of the studies. One was a randomized crossover study of 70:30 helium-oxygen vs air-oxygen that involved nineteen patients with acute severe COPD, hospitalized in an intensive care unit for NIPSV. In the patients receiving heliox, arterial PCO2 fell more; WMD 0.8 kPa (95% CI 0.26, -1.34). The second was a randomized trial involved 47 patients with acute COPD, who presented to an Emergency Department randomized to receive updraft nebulization of albuterol and ipratropium bromide using 80% helium and 20% oxygen or compressed air as the driving gas. Treatments were administered at 0, 20, 40, and 120 minutes after randomization. There were no significant differences in the change of FEV1 and FVC between the two groups by either the 1 or 2 hours point. although a small improvement in FEF 25-75 was significantly greater in the heliox group than in the air group.

REVIEWER'S CONCLUSIONS

There is currently insufficient evidence to support the use of helium-oxygen mixtures to treat acute exacerbations of COPD in either ventilated or nonventilated patients. Suitably designed randomised controlled trials with the endpoint being the avoidance of mechanical ventilation may be justified.

Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification

BACKGROUND

Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release.

OBJECTIVE

To test the hypothesis that ED chest pain patients with a Goldman risk of < or =4% and a single negative cTnI (< or =0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization].

METHODS

A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days.

RESULTS

Of 2,322 patients evaluated, 998 had both a Goldman risk < or =4% and a cTnI < or =0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation.

CONCLUSIONS

The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or =0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.

A new system for sternal intraosseous infusion in adults

BACKGROUND

Intraosseous (IO) infusion provides an alternative route for the administration of fluids and medications when difficulty with peripheral or central lines is encountered during resuscitation of critically ill and injured patients.

OBJECTIVE

To report the first 50 uses of a new system for emergency IO infusion into the sternum in adults, the Pyng F.A.S.T.1 IO infusion system.

METHODS

Six emergency departments and five prehospital emergency medical services (EMS) sites in Canada and the United States provided clinical and/or research data on their use of the IO system in a pilot study of success rates, insertion times, and complications. Indications for use included adult patient, urgent need for fluids or medications, and unacceptable delay or inability to achieve standard vascular access. A basic data set was standardized for all sites, and some sites collected additional data.

RESULTS

The overall success rate for achieving vascular access with the system was 84%. Success rates were 74% for first-time users, and 95% for experienced users. Failure to achieve vascular access occurred most frequently in patients (5 of 9) described subjectively by the user as "very obese," in whom there was a thick layer of tissue overlying the sternum. Mean time to achieve vascular access was 77 seconds. Flow rates of up to 80 mL/min were reported for gravity drip, and more than 150 mL/min by syringe bolus. Pressure cuffs were also used successfully, although fluid rate was controlled by clamping the line. Further research on flow rates is needed. No complications or complaints were reported at two-month follow-up.

CONCLUSION

These early data indicate that sternal IO infusion using the new F.A.S.T.1 IO system may provide rapid, safe vascular access and may be a useful technique for reducing unacceptable delays in the provision of emergency treatment.

Intravenous methotrexate as initial treatment for primary central nervous system lymphoma: response to therapy and quality of life of patients

In anticipation of a consortium study of methotrexate (MTX) therapy provided to patients with primary central nervous system lymphoma (PCNSL) we have provided intravenous MTX without irradiation therapy to 31 nonimmunosuppressed individuals. Twenty (65%) achieved complete response and 11 (35%) partial response to therapy. For the 31 patients the median survival was 30.43 months with an actuarial median follow-up time of 30.69 months. The 2+ year survival was 63% for all patients and 90% for complete responders. Of 375 drug cycles, grade 3 leukopenia was identified in 3 cycles, mucositis in 6 cycles and delayed drug clearance in 47 cycles. Recurrences included brain (9/20) and/or spinal fluid (2/20). The median Karnofsky scale improved from 40 (10-80) prior to therapy to 90 after treatment. Eleven patients, in complete response for a median of 22+ months after diagnosis were evaluated using 4 instruments that assess Quality of Life Functional Assessment of Cancer Therapy - Brain (FACT-BR) modified, Symptom Questionnaire, Social Adjustment Scale-Self-Report and Problem Solving Inventory. Their psychosocial adjustment, well-being and stress coping abilities were comparable to the normative groups. Further there was no evidence of any MTX-induced, Magnetic Resonance Imaging (MRI)-detected encephalopathy in these individuals and there was preservation of clinical cognition and memory. We conclude that therapy with MTX, without radiation can be used in PCNSL patients without limitations of age or pretreatment Karnofsky scores. Further rates of response and median survival approach those of therapies using multiple drugs and radiation, but with a less likely risk of dementia.

Building a nursing management analysis capacity in a teaching hospital

The authors describe one institution's efforts to create the capacity to use standard hospital information systems to address clinical and operational nursing questions. This work involved not only technical aspects of information management system creation but also building the human currency to make the information available and useful. Because the information available to nursing comes from the same data sources that feed operational management and finance departments, nursing can now speak in the same language at the policy tables.

Feasibility study of the use of bilevel positive airway pressure for respiratory support in the emergency department

STUDY OBJECTIVE

To determine the feasibility of bilevel positive airway pressure (BiPAP) support for acute respiratory distress (ARD) in the emergency department.

METHODS

A convenience sample of patients in ARD as a result of any nontraumatic cause was recruited for a prospective, noncontrolled clinical trial in the ED of an urban tertiary care teaching hospital. Hemodynamically unstable patients and those requiring immediate endotracheal intubation were excluded. After an initial arterial blood gas (AGB) analysis was obtained, the patient was placed on BiPAP (Bi-PAP S/T noninvasive ventilator; Respironics, Incorporated) by nose mask or face mask to provide noninvasive pressure support at 5 cm H20. Settings were titrated to patient tolerance and satisfactory pulse oximetry. After at least 30 minutes on a stable setting, arterial blood gases were remeasured. The cause of respiratory distress, vital signs, assessment of need for intubation, arterial blood gas results, and patient disposition were recorded. Success of noninvasive support was defined as the presence of (1) improvement in ABG parameters, (2) clinical improvement and decrease in evident dyspnea, and (3) avoidance of endotracheal intubation and mechanical ventilation.

RESULTS

Fifty patients were studied. Causes of ARD included acute congestive heart failure (CHF; n=16), exacerbation of chronic obstructive pulmonary disease (COPD; n=9), mixed COPD/CHF (n=3), pneumonia (n=10), status asthmaticus (n=6), and other causes of acute respiratory failure (eg, stroke, overdose; n=6). Noninvasive management was successful in 43 patients (86%), with patients in all etiologic categories being equally likely to respond favorably to therapy. All patients were admitted to the hospital, but 52.5% of those who ordinarily would have required ICU beds were admitted to lower (and less costly) levels of care. Three patients were eventually intubated, all after admission to the ICU on BiPAP. Two patients did not tolerate BiPAP, and two others were considered ED treatment failures but were not intubated because of advance directives.

CONCLUSION

As has been reported from other critical care settings, use of BiPAP is feasible and has potential utility in the management of ARD in the ED.

Finding nursing management data

Hospitals have been collecting and storing patient information for many years. Although these data are used for reporting purposes, they are often overlooked as a rich source for the clinical and administrative management of patients. Nurse managers better then anyone recognize the diversity and complexity of patient care. Examples illustrate how an investigation of these data can provide the nurse manager with a wealth of important information critical in effectively managing within an acute care institution.

Probing the phagolysosomal environment of human macrophages with a Ca2+-responsive operon fusion in Yersinia pestis

Several microorganisms, including Yersinia sp., Salmonella sp., Brucella sp., Mycobacterium sp. and Leishmania sp., have successfully adapted to grow within macrophage phagolysosomes. Infections caused by these intracellular pathogens are among the most difficult to treat. As part of an antimicrobial strategy directed at modifying the phagolysosomal environment to the disadvantage of these important pathogens, we are defining the ambient conditions within the organism-containing phagolysosome. To probe this environment, we have used Yersinia pestis, whose expression of several virulence attributes is highly dependent on the Ca2+ concentration in its growth environment. We first genetically engineered a strain of Y. pestis which responds to a low-calcium environment by transcription of inserted structural genes of the Escherichia coli lac operon. Using this mutant organism as a relevant biological probe, we demonstrate here that the calcium concentration in Y. pestis-containing phagolysosomes is sufficiently low to permit virulence gene expression; this resolves the question of where Y. pestis might express its Ca2+-regulated genes in vivo.