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Background Our objective was to determine if the addition of ultraviolet-C (UV-C) light to daily and discharge patient room cleaning reduces healthcare-associated infection rates of vancomycin-resistant enterococci (VRE) and Clostridioides difficile in immunocompromised adults. Methods We performed a cluster randomized crossover control trial in 4 cancer and 1 solid organ transplant in-patient units at the Johns Hopkins Hospital, Baltimore, Maryland. For study year 1, each unit was randomized to intervention of UV-C light plus standard environmental cleaning or control of standard environmental cleaning, followed by a 5-week washout period. In study year 2, units switched assignments. The outcomes were healthcare-associated rates of VRE or C. difficile. Statistical inference used a two-stage approach recommended for cluster-randomized trials with Results In total, 302 new VRE infections were observed during 45787 at risk patient-days. The incidence in control and intervention groups was 6.68 and 6.52 per 1000 patient-days respectively; the unadjusted incidence rate ratio (IRR) was 0.98 (95% confidence interval [CI], .78 − 1.22; P = .54). There were 84 new C. difficile infections observed during 26118 at risk patient-days. The incidence in control and intervention periods was 2.64 and 3.78 per 1000 patient-days respectively; the unadjusted IRR was 1.43 (95% CI, .93 − 2.21; P = .98). Conclusions When used daily and at post discharge in addition to standard environmental cleaning, UV-C disinfection did not reduce VRE or C. difficile infection rates in cancer and solid organ transplant units.

OBJECTIVE To identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion. MATERIALD AND METHODS This is a case–control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion. RESULTS In total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m2 (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m2 (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]). CONCLUSION Smoking status, age under 55 years, BMI below 30 kg/m2, fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Introduction: Stroke after cardiac surgery is associated with poor outcome but there are limited data on the impact on cost and length of stay (LOS). Methods: We performed a retrospective matched cohort study of patients who underwent cardiothoracic surgery at our tertiary referral center, identifying 44 strokes and 568 non-stroke controls matched by procedure and age (within 5 years of the max and min of stroke patients). Stroke severity was assessed by NIHSS. Results: The cohorts were well-matched, 34% of the stroke patients were female, compared to 37% of controls without stroke, p=0.71. Patients with stroke were younger than patients without stroke, median 68 vs 74 years, p=0.008. Strokes were severe, median NIHSS was 18 (interquartile range [IQR] 9 - 29). Patients with stroke had a higher risk of in-hospital mortality, 25% vs 9.5%%, OR 3.2, 95% CI 1.5 - 6.6, p=0.002 and were less likely to be discharged home 11% vs 63%, OR 0.06, 05% CI 0.02 - 0.016, p Conclusions: Stroke complicating cardiac surgery is associated with enormous increases in cost and length of stay, which is related to stroke severity.

Objective: Transcranial Doppler is commonly used to calculate cerebral autoregulation, but measurements are typically restricted to a single cerebral artery. In exploring topographic heterogeneity, this study reports the first thorough comparison of autoregulation in all major cerebral vessels.Methods: In forty healthy adults, flow velocity was monitored in the anterior, middle, and posterior cerebral arteries, and synchronized with arterial blood pressure. A transfer function analysis provided characteristics of autoregulation by quantifying the relationship between blood pressure and cerebral blood flow velocity.Results: Phase, which quantifies the time course of autoregulation, was similar in all vessels. Gain, which quantifies the magnitude of hemodynamic regulation, was lower in posterior cerebral artery, indicative of tighter regulation. However, after adjusting for baseline flow differences in each vascular territory, normalized gain was similar in all vessels.Conclusions: Discriminating dynamic cerebral autoregulation between cerebrovascular territories is feasible with a transcranial doppler based approach. In the posterior cerebral artery of healthy volunteers, absolute flow is more tightly regulated, but relative flow regulation is consistent across cerebrovascular territories.Significance: The methodology can be applied to focal disease states such as stroke or posterior reversible encephalopathy syndrome, in which the topographic distribution of autoregulation may be particularly critical.

Introduction: In-hospital stroke is associated with worse outcomes and fewer stroke interventions compared to patients with community-acquired stroke. We assessed factors associated with delays in symptom identification and stroke team alerting, and use of acute interventions for in-hospital strokes. Methods: The local Get With The Guidelines-Stroke and an in-hospital quality improvement database at our tertiary care hospital were screened over a 26-month period ending 10/2019, yielding 98 in-hospital strokes. Results: Strokes were more common on surgery services (70%), were predominantly ischemic (83%), and were moderate-to-severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from the time of last known normal (LKN) until stroke symptom identification (SxID) (median 5.1 hours, IQR 1.0-19.7 hours) and from SxID to stroke alert (median 2.1 hours, IQR 0.5-9.9 hours). In univariable analysis, being in an ICU, being intubated, being on a surgical service, having no lateralized weakness or neglect, and higher NIHSS were associated with delays; in multivariable analysis only intubation was associated with being above median from LKN to SxID (OR 4.3, 95% CI 1.2-16.2, p=0.03) and above median for SxID to stroke alert (OR 8.5, 95% CI 2.0-36.4). Acute stroke interventions were given to 15 patients (15%), including 3 (3%) who received IV tPA and 12 (12%) who underwent IA thrombectomy. Patients who received stroke interventions had shorter times from last normal to SxID (median 0.7 vs 8.2 hours, p=0.002) and times from SxID to stroke alert (median 0.2 vs 3.4 hours, p=0.006). Urgent vascular imaging occurred in 68/98 (69%) of patients and 23/68 (34%) had a large vessel occlusion (LVO). Of those patients with an LVO, 78% had lateralizing arm weakness or neglect on exam. Conclusions: There are long delays from LKN to SxID and from SxID to stroke alert in hospitalized patients leading to low rates of acute stroke treatment. Intubation was a robust risk factor for delays and protocols should be established to monitor these patients more carefully. Despite these delays, 1/3 of patients who had vascular imaging had an LVO identified that might have been eligible for intervention.

In-hospital stroke is associated with poor outcomes. Reasons for delays, use of interventions, and presence of large vessel occlusion are not well characterized.A retrospective single center cohort of 97 patients with in-hospital stroke was analyzed to identify factors associated with delays from last known normal to symptom identification and to stroke team alerting. Stroke interventions and presence of large vessel occlusion were also assessed.Strokes were predominantly on surgery services (70%), ischemic (82%), and severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from last known normal to symptom identification (median 5.1 hours, IQR 1.0-19.7 hours), symptom identification to stroke team alerting (median 2.1 hours, IQR 0.5-9.9 hours), and total time from last known normal to alerting (median 11.4 [IQR 2.7-34.2] hours). In univariable analysis, being on a surgical service, in an ICU, intubated, and higher NIHSS were associated with delays. In multivariable analysis only intubation was independently associated with time from last known normal to symptom identification (coefficient 20 hours, IQR 0.2 - 39.8, p=0.047). Interventions were given to 17/80 (21%) ischemic stroke patients; 3 (4%) received IV tPA and 14 (18%) underwent thrombectomy. Vascular imaging occurred in 57/80 (71%) ischemic stroke patients and 21/57 (37%) had large vessel occlusion.Hospitalized patients with stroke experience long delays from symptom identification to stroke team alerting. Intubation was strongly associated with delay to symptom identification. Although stroke severity was high and large vessel occlusion common, many patients did not receive acute interventions.

We compared the fluorescent gel removal rate using fewer high-touch surfaces (HTSs) and rooms and determined the optimum number of HTSs and rooms needed to ensure accuracy using 2,942 HTSs in 228 rooms on 13 units. Randomly selecting 3 HTS in 2 rooms predicted the optimal removal rate.

This is a pilot study designed to examine the frequency of asthma in obese children who have exertional dyspnea. Obese children who complained of breathlessness with exercise and who denied asthma were invited to enroll. If there was evidence of airflow limitation on spirometry, nebulized albuterol was administered and spirometry was repeated. If there was no significant improvement or if the baseline spirometry was normal, exercise testing was performed. A total of 20 patients (ages from 8 to 16 years) with BMI from 22 to 61 were enrolled. Of the 19 who completed the study, 9 (47.3%) met criteria for asthma. Recognizing and treating asthma may lead to improved exercise tolerance and improved weight status in these obese individuals.