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Introduction Acute respiratory distress syndrome (ARDS) is a known predictor of poor outcomes in critically ill patients. We sought to examine the role ARDS plays in outcomes in subarachnoid hemorrhage (SAH) patients. Prior studies investigating the incidence of ARDS in SAH patients did not control for SAH severity. Hence, we sought to determine the incidence ARDS in patients diagnosed with aneurysmal SAH and investigate the predisposing risk factors and impact upon outcomes. Methods A retrospective cohort study was conducted using the National Inpatient Sample (NIS) database for the years 2008 to 2014. Multivariate stepwise regression analysis was performed to identify the risk factors and outcome associated with developing ARDS in the setting of SAH. Results We identified 170,869 patients with non-traumatic subarachnoid hemorrhage, of whom 6962 were diagnosed with ARDS and of those 4829 required mechanical ventilation. ARDS more frequently developed in high grade SAH patients (1.97 ± 0.05 vs. 1.15 ± 0.01; p Conclusion Patients with SAH who developed ARDS were less likely to be discharged home, more likely to need rehabilitation and had a significantly higher risk of mortality. The identification of risk factors contributing to ARDS is helpful for improving outcomes and resource utilization.

BACKGROUND Cerebral vasospasm is an alarming complication of acute bacterial meningitis with potentially devastating consequences. It is essential for providers to recognize and treat it appropriately. Unfortunately, there is no well-established approach to the management of postinfectious vasospasm, which makes it especially challenging to treat these patients. More research is needed to address this gap in care. OBSERVATIONS Here, the authors describe a patient with postmeningitis vasospasm that was refractory to induced hypertension, steroids, and verapamil. He eventually responded to a combination of intravenous (IV) and intra-arterial (IA) milrinone followed by angioplasty. LESSONS To our knowledge, this is the first report of successfully using milrinone as vasodilator therapy in a patient with postbacterial meningitis-associated vasospasm. This case supports the use of this intervention. In future cases of vasospasm after bacterial meningitis, IV and IA milrinone should be trialed earlier with consideration of angioplasty.

Background Prevalence and etiology of unconsciousness are uncertain in hospitalized patients with coronavirus disease 2019 (COVID-19). We tested the hypothesis that increased inflammation in COVID-19 precedes coma, independent of medications, hypotension, and hypoxia. Methods We retrospectively assessed 3203 hospitalized patients with COVID-19 from March 2 through July 30, 2020, in New York City with the Glasgow Coma Scale and systemic inflammatory response syndrome (SIRS) scores. We applied hazard ratio (HR) modeling and mediation analysis to determine the risk of SIRS score elevation to precede coma, accounting for confounders. Results We obtained behavioral assessments in 3203 of 10,797 patients admitted to the hospital who tested positive for SARS-CoV-2. Of those patients, 1054 (32.9%) were comatose, which first developed on median hospital day 2 (interquartile range [IQR] 1–9). During their hospital stay, 1538 (48%) had a SIRS score of 2 or above at least once, and the median maximum SIRS score was 2 (IQR 1–2). A fivefold increased risk of coma (HR 5.05, 95% confidence interval 4.27–5.98) was seen for each day that patients with COVID-19 had elevated SIRS scores, independent of medication effects, hypotension, and hypoxia. The overall mortality in this population was 13.8% (n = 441). Coma was associated with death (odds ratio 7.77, 95% confidence interval 6.29–9.65) and increased length of stay (13 days [IQR 11.9–14.1] vs. 11 [IQR 9.6–12.4]), accounting for demographics. Conclusions Disorders of consciousness are common in hospitalized patients with severe COVID-19 and are associated with increased mortality and length of hospitalization. The underlying etiology of disorders of consciousness in this population is uncertain but, in addition to medication effects, may in part be linked to systemic inflammation. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01256-7.

Introduction: Delayed cerebral ischemia (DCI) secondary to vasospasm is a determinate of outcomes following non-traumatic subarachnoid hemorrhage (SAH). SAH patients are monitored using transcranial doppler (TCD) to measure cerebral blood flow velocities (CBFv). However, the accuracy and precision of manually acquired TCD can be operator dependent. The NovaGuide robotic TCD system attempts to standardize acquisition. This investigation evaluated the safety and efficacy of the NovaGuide system in SAH patients in a Neuro ICU.Methods: We retrospectively identified 48 NovaGuide scans conducted on SAH patients. Mean and maximum middle cerebral artery (MCA) CBFv were obtained from the NovaGuide and the level of agreement between CBFv and computed tomography angiography (CTA) for vasospasm was determined. Safety of NovaGuide acquisition of CBFv was evaluated based on number of complications with central venous lines (CVL) and external ventricular drains (EVD) Results: There was significant agreement between the NovaGuide and CTA (Cohen’s Kappa = 0.74) when maximum MCA CBFv ≥120 cm/s was the threshold for vasospasm. 27/48 scans were carried out with CVLs and EVDs present without negative outcomes. Conclusions: The lack of adverse events associated with EVDs/CVLs and the strong congruence between maximal MCA CBFv and CTA illustrates the diagnostic utility of the NovaGuide.

Rationale & Objective: Hepatitis B virus (HBV) transmission in hemodialysis units has become a rare event since implementation of hemodialysis-specific infection control guidelines: performing hemodialysis for hepatitis B surface antigen (HBsAg)-positive patients in an HBV isolation room, vaccinating HBV-susceptible (HBV surface antibody and HBsAg negative) patients, and monthly HBsAg testing in HBV-susceptible patients. Mutations in HBsAg can result in false-negative HBsAg results, leading to failure to identify HBsAg seroconversion from negative to positive. We describe 4 unique cases of HBsAg seroconversion caused by mutant HBV infection or reactivation in hemodialysis patients. Study Design: Following identification of a possible HBsAg seroconversion and mutant HBV infection, public health investigations were launched to conduct further HBV testing of case patients and potentially exposed patients. A case patient was defined as a hemodialysis patient with suspected mutant HBV infection because of false-negative HBsAg testing results. Confirmed case patients had HBV DNA sequences demonstrating S-gene mutations. Setting & Participants: Case patients and patients potentially exposed to the case patient in the respective hemodialysis units in multiple US states. Results: 4 cases of mutant HBV infection in hemodialysis patients were identified; 3 cases were confirmed using molecular sequencing. Failure of some HBsAg testing platforms to detect HBV mutations led to delays in applying HBV isolation procedures. Testing of potentially exposed patients did not identify secondary transmissions. Limitations: Lack of access to information on past HBsAg testing platforms and results led to challenges in ascertaining when HBsAg seroconversion occurred and identifying and testing all potentially exposed patients. Conclusions: Mutant HBV infections should be suspected in patients who test HBsAg negative and concurrently test positive for HBV DNA at high levels. Dialysis providers should consider using HBsAg assays that can also detect mutant HBV strains for routine HBV testing. Index Words: hemodialysis, hepatitis B virus infection, hepatitis B virus mutation, hepatitis B surface antigen mutation, hepatitis B surface antigen seroconversion

OBJECTIVE Studies examining the risk factors and clinical outcomes of arterial vasospasm secondary to cerebral arteriovenous malformation (cAVM) rupture are scarce in the literature. The authors used a population-based national registry to investigate this largely unexamined clinical entity. METHODS Admissions for adult patients with cAVM ruptures were identified in the National Inpatient Sample during the period from 2015 to 2019. Complex samples multivariable logistic regression and chi-square automatic interaction detection (CHAID) decision tree analyses were performed to identify significant associations between clinical covariates and the development of vasospasm, and a cAVM–vasospasm predictive model (cAVM-VPM) was generated based on the effect sizes of these parameters. RESULTS Among 7215 cAVM patients identified, 935 developed vasospasm, corresponding to an incidence rate of 13.0%; 110 of these patients (11.8%) subsequently progressed to delayed cerebral ischemia (DCI). Multivariable adjusted modeling identified the following baseline clinical covariates: decreasing age by decade (adjusted odds ratio [aOR] 0.87, 95% CI 0.83–0.92; p < 0.001), female sex (aOR 1.68, 95% CI 1.45–1.95; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.34, 95% CI 1.01–1.79; p = 0.045), intraventricular hemorrhage (aOR 1.87, 95% CI 1.17–2.98; p = 0.009), hypertension (aOR 1.77, 95% CI 1.50–2.08; p < 0.001), obesity (aOR 0.68, 95% CI 0.55–0.84; p < 0.001), congestive heart failure (aOR 1.34, 95% CI 1.01–1.78; p = 0.043), tobacco smoking (aOR 1.48, 95% CI 1.23–1.78; p < 0.019), and hospitalization events (leukocytosis [aOR 1.64, 95% CI 1.32–2.04; p < 0.001], hyponatremia [aOR 1.66, 95% CI 1.39–1.98; p < 0.001], and acute hypotension [aOR 1.67, 95% CI 1.31–2.11; p < 0.001]) independently associated with the development of vasospasm. Intraparenchymal and subarachnoid hemorrhage were not associated with the development of vasospasm following multivariable adjustment. Among significant associations, a CHAID decision tree algorithm identified age 50–59 years (parent node), hyponatremia, and leukocytosis as important determinants of vasospasm development. The cAVM-VPM achieved an area under the curve of 0.65 (sensitivity 0.70, specificity 0.53). Progression to DCI, but not vasospasm alone, was independently associated with in-hospital mortality (aOR 2.35, 95% CI 1.29–4.31; p = 0.016) and lower likelihood of routine discharge (aOR 0.62, 95% CI 0.41–0.96; p = 0.031). CONCLUSIONS This large-scale assessment of vasospasm in cAVM identifies common clinical risk factors and establishes progression to DCI as a predictor of poor neurological outcomes.

OBJECTIVE Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult. METHODS Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters. RESULTS Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97–0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12–2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49–11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02–1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97–6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34–3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26–2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45–0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78–4.48; p < 0.001), but not with mortality. CONCLUSIONS This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.

A 38-year-old construction worker with no medical history presented with back pain, urinary retention, and flaccid lower extremity paralysis. Three weeks prior to presentation, he fell from a ladder with no immediate injury. Two weeks after the fall, he presented to another hospital for back pain and urinary retention. MRI of the lumbar, cervical, and thoracic spine without contrast were reportedly normal, and his back pain improved with an oral methylprednisolone dose pack (figure). The urinary retention remained, and he was discharged with an indwelling catheter. Within a week of the initial urinary symptoms, he developed ascending lower extremity numbness and paralysis, and was seen emergently at our hospital.

Elevated intracranial pressure (ICP) is often an emergency condition that requires prompt intervention.

Background: Palliative care improves quality of life in patients with malignancy; however, it may be underutilized in patients with high-grade gliomas (HGGs). We examined the practices regarding palliative care consultation (PCC) in treating patients with HGGs in the neurological intensive care unit (NICU) of an academic medical center. Methods: We conducted a retrospective cohort study of patients admitted to the NICU from 2011 to 2016 with a previously confirmed histopathological diagnosis of HGG. The primary outcome was the incidence of an inpatient PCC. We also evaluated the impact of PCC on patient care by examining its association with prespecified secondary outcomes of code status amendment to do not resuscitate (DNR), discharge disposition, 30-day mortality, and 30-day readmission rate, length of stay, and place of death. Results: Ninety (36% female) patients with HGGs were identified. Palliative care consultation was obtained in 16 (18%) patients. Palliative care consultation was associated with a greater odds of code status amendment to DNR (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 5.01-65.73), which remained significant after adjustment for confounders (OR: 27.20, 95% CI: 5.49-134.84), a greater odds of discharge to hospice (OR: 24.93, 95% CI: 6.48-95.88), and 30-day mortality (OR: 6.40, 95% CI: 1.96-20.94). Conclusion: In this retrospective study of patients with HGGs admitted to a university-based NICU, PCC was seen in a minority of the sample. Palliative care consultation was associated with code status change to DNR and hospice utilization. Further study is required to determine whether these findings are generalizable and whether interventions that increase PCC utilization are associated with improved quality of life and resource allocation for patients with HGGs.

Background and purpose Automated computed tomography perfusion (CTP) is recommended to inform selection of stroke patients for thrombectomy >6 hours from last known normal (LKN). However, artifacts on automated perfusion output may overestimate the tissue at risk leading to misclassification of thrombectomy eligibility in some patients. Methods We conducted a retrospective multisite study of consecutive patients with anterior large vessel occlusion (LVO) undergoing CTP (6/2017-12/2017). The primary outcome was the RAPID automated Tmax > 6 seconds volume that was discordant with clinical symptoms and vessel imaging, manually assessed by two independent readers. The discordant penumbral volume was compared to the automated output and corrected mismatch ratios were generated. Results Of 410 consecutive patients who underwent CTP for suspected stroke, 60 (15%) had acute anterior circulation LVO. Of these, 26 (43%) had Tmax > 6 seconds abnormalities discordant with clinical symptoms and vessel imaging. There was strong interrater agreement on artifact volume (r2 = 0.927). Among patients with discordant Tmax imaging, the median artifactual volume was 12cc (IQR 3-21cc), accounting for a median of 8% of the automated Tmax > 6 seconds volume (IQR 3-16%, range 1-64%). Recalculation of the Tmax > 6 seconds volume resulted in 1 patient being reclassified as having an "unfavorable" mismatch ratio (2.04-1.40). Conclusion Nearly half of patients had evidence of artifactual penumbral imaging on automated CTP, which rarely lead to misclassification of thrombectomy eligibility. Although artifactual findings are reliably identified by trained raters, our results emphasize the need to evaluate CTP results with knowledge of the patient's clinical symptoms and vascular imaging.

Background: Automated computed tomography perfusion (CTP) is effective at identifying salvageable penumbra in patients with acute ischemic stroke due to large vessel occlusion (LVO). Perfusion imaging is now recommended for the selection of thrombectomy candidates in the extended window (>6 hours) which may incorporate the penumbra mismatch ratio (T max >6s:rCBF1.7. However automated perfusion output may include artifactual findings that are discordant with a patient’s symptoms and vessel imaging, overestimating the tissue at risk. Hypothesis: Artifactual findings on automated CTP penumbral assessment (T max >6s) will misclassify thrombectomy eligibility in some patients. Methods: We reviewed a retrospective multi-site consecutive cohort of patients undergoing CTP for suspected acute ischemic stroke ≤24 hours from onset (6/2017-12/2017). The primary outcome was the volume of any discordant T max >6s abnormality on RAPID automated perfusion CT imaging, calculated by two independent readers using manual assessment (ImageJ, NIH). The discordant penumbral volume was compared to the automated output and corrected mismatch ratios were generated. Results: Of 410 consecutive patients who underwent CTP, 60 (14.6%) had acute LVO of the anterior circulation and were included. The median age was 78 years (IQR 64-84), 36 (60.0%) were female, and 25 (41.7%) were White. Fifteen patients (26.3%) had T max >6s abnormalities that were discordant with the clinical symptoms or anticipated vascular distribution, with strong inter-rater agreement (r 2 =0.927). The median difference between manual and automated T max >6s volumes was 18.4cc (IQR 10.80-35.77) accounting for 11.3% of the automated volume (IQR 7.8-46.7%). Following manual recalculation of the T max >6s volume, 1 patient was reclassified as having an “unfavorable” mismatch ratio (1.7%, 95%CI 0.2-11.5%). Conclusion: About one quarter of patients had discordant penumbral imaging on automated CTP, which may lead to misclassification of thrombectomy eligibility. While artifactual findings are reliably identified by trained raters, our results emphasize the need to evaluate CTP results with knowledge of the patient’s clinical symptoms and vascular imaging.

Background: Automated computed tomography perfusion (CTP) imaging is proven effective at selecting patients with acute large vessel occlusion (LVO) for endovascular intervention in the extended time window (>6 hours after last known normal [LKN]). However, there are limited data on the likelihood of identifying core infarct-penumbral mismatch in the late time window. Hypothesis: Automated CTP mismatch ratios (Time-to-maximum residue function [T max ] >6s: relative cerebral blood flow [rCBF] Methods: We reviewed a retrospective registry of consecutive patients with LVO who underwent CTP within 24h of LKN at 3 academic hospitals between 06/2017 - 12/2017. Unenhanced CT and CTP parameters were compared between patients who presented within 12h of LKN versus 12-24h of LKN. Results: Among 60 included patients, the median age was 78 years (IQR 64-84), 36 (60.0%) were female, and 39 (65.0%) underwent thrombectomy. Patients who presented at 12-24h had poorer ASPECTS scores than patients who presented Conclusions: As time progresses in acute anterior LVO, the unenhanced CT may be more sensitive than rCBFFigure caption: ASPECTS and rCBF

A 70-year-old man presented in late summer with rapidly progressive weakness and respiratory failure. He was in his usual state of health until 1 week prior to presentation, when he developed malaise, headache, and fevers, followed by right leg weakness, prompting admission to a local hospital. Over the next 3 days, his weakness progressed to involve his right arm, then his extraocular, facial, and bulbar muscles, followed by his left arm and leg. On the fourth day of hospitalization (2 weeks after the onset of constitutional symptoms), he was intubated due to an inability to clear oral secretions and was transferred to our institution.

A 19-year-old woman presented with altered mental status and progressive quadriparesis. One week prior to admission, she experienced headaches and behavior changes, including social withdrawal and a fixation on electronics. The day prior to admission, she developed weakness in both arms, and was unable to lift them above her head, followed shortly thereafter by proximal leg weakness and difficulty climbing stairs. The next day, she was intermittently unresponsive and unable to stand without assistance. Her medical history was notable for supraventricular tachycardia and depression. She was on an estrogen-containing oral contraceptive and fluvoxamine, which had been started for depression 6 weeks prior to admission. She had also recently completed a course of amoxicillin for bronchitis. She had no pertinent family history. Her social history was significant for IV heroin use approximately 2 months prior to admission. Her initial examination was notable for disorientation to time and place and impaired concentration and short term memory, with intact language and cranial nerves. There was 2/5 strength in both her arms and legs, with preserved sensation to light touch and vibration, and 2+ reflexes, although a Babinski sign was present bilaterally.

Objective.To assess antimicrobial stewardship programs (ASPs) and strategies in California general acute care hospitals and to describe the effect of state legislation (Senate Bill 739) requiring hospitals to develop processes for evaluating the judicious use of antimicrobials.Design.Web-based survey of general acute care hospitals.Participants.All 422 general acute care hospital campuses in California were invited to participate.Results.Responses from 223 (53%) of California's general acute care hospital campuses were included and were statistically representative of all acute care hospital campuses by region but not bed size or rurality. Community hospitals represented 73% of respondents. Fifty percent of hospitals described a current ASP and 30% reported planning an ASP; of these, 51% reported measuring outcomes. Twenty percent of hospitals reported no planned ASP or uncertainty whether an ASP existed and described barriers including staffing constraints (47%), lack of funding (42%), and lack of initiation of a formal proposal to start an ASP (42%). Of 135 responding hospitals, 22% reported that Senate Bill 739 influenced initiation of their ASP.Conclusions.Although many studies have been published that describe hospital-specific ASPs, most have been described within academic centers, and there are limited assessments of ASP strategies across hospital systems. Our study verifies that many ASPs exist in California, particularly in community settings where a scarcity of antimicrobial restriction was thought to exist. Additionally, Senate Bill 739 appears to have played a role in initiating many hospital ASPs, which supports the adoption of similar legislation in other states and nationally.

Background Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization. Study Design Outbreak investigation, including matched case-control study. Setting & Participants Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization. Predictors Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice. Outcomes Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing. Results 17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility's reprocessing procedure. Limitations Limited statistical power and overmatching; few patient isolates and dialyzers available for testing. Conclusions This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.

Across 366 California hospitals, we identified hospital-level characteristics predicting increased hospital-associated Clostridium difficile infection (HA-CDI) rates including more licensed beds, teaching and long-term acute care (LTAC) hospitals, and polymerase chain reaction testing. Adjustment for these characteristics impacted rankings in 24% of teaching hospitals, 13% of community hospitals, and 11% of LTAC hospitals.Infect Control Hosp Epidemiol 2015;00(0): 1–3

Background Legionnaires’ disease (LD) causes significant morbidity and mortality to hospital patients and residents of skilled nursing facilities (SNF). In California, LD is reportable to local health departments via the California Reportable Disease Information Exchange (CalREDIE) surveillance system. Cases are classified as suspected or confirmed using Centers for Disease Control and Prevention (CDC) definitions. The California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program maintains a database of healthcare-associated LD (HA-LD) and consults with local public health departments for single cases and outbreaks. Methods We described characteristics of confirmed HA-LD cases in 2015–2017. We classified HA-LD as definite if patient had continuous exposure in a facility for 2–10 days prior to symptom onset and possible if patient had overnight exposure in a facility for a portion of 2–10 days prior to symptom onset. Results From 2015 to 2017, 125 (8%) of 1,554 confirmed LD cases were HA-LD. Of these, 73 (58%) were definite HA-LD and 52 (42%) were possible HA-LD. The majority of HA-LD cases (N = 99, 79%) occurred in southern California. SNF were associated with 57 cases (46%) and hospitals with 44 cases (35%); 23 cases (18%) had exposures in both SNF and hospitals during the incubation period. Among the definite HA-LD cases, 50 cases (68%) had exposures in a single SNF. The median age of patients with HA-LD was 77 years. The HAI Program consulted with 15 local public health agencies on 33 HA-LD investigations, including 7 outbreaks and 26 single-case investigations. Conclusion HA-LD represented a small but important percentage of LD in California; the majority occurred in SNF. To prevent HA-LD, California hospitals and skilled nursing facilities should implement water management programs, as recommended by CDC and required by the Centers for Medicare and Medicaid Services (CMS) since June 2017. Public health agencies should respond rapidly to investigate HA-LD cases and control outbreaks. Disclosures All authors: No reported disclosures.

Human metapneumovirus (hMPV), a recently discovered paramyxovirus, is thought to be primarily a winter-spring pathogen affecting young children with a clinical presentation similar to that of respiratory syncytial virus. In June-July 2006, a respiratory outbreak in a long-term-care facility was reported to the local health department and investigated. Surveillance identified 26 residents and 13 staff with acute respiratory illness; 8 residents (31%) developed radiographically confirmed pneumonia, and 2 (5%) were hospitalized. Five of 14 respiratory specimens were positive by polymerase chain reaction assay for hMPV; sequencing identified genotype A. In institutionalized elderly persons, hMPV may be an important cause of respiratory outbreaks year-round.

During a 6-week period in 2003, 56 residents and 26 staff developed respiratory illness in a long-term facility; 12 residents died. Seven of 13 respiratory specimens were culture-positive for rhinovirus; 6 of the isolates were serotype 82. In elderly populations, severe illness may be associated with organisms typically considered to be “benign,” such as rhinovirus.

To our knowledge, previous population-based surveys have not assessed misconceptions about antibacterial drug use over time. We documented a 26.3% decline in a key misconception in California women in 2003 compared to 2000; declines varied significantly by education level. Educational campaigns specifically designed to influence important subpopulations are needed.

Objective:To determine the magnitude of van-comycin-resistant enterococci (VRE) in three counties in the San Francisco Bay area.Design:Active laboratory-based surveillance for VRE from January 1995 through December 1996 and a laboratory-based and hospital-based questionnaire survey for 1993 to 1994 and 1997 to 1998.Setting:All 33 general acute care hospitals in three counties in the San Francisco Bay area.Participants:Laboratories and infection control professionals serving these hospitals, and staff of the California Emerging Infections Program.Results:The number of hospitals reporting 1 or more patient clinical VRE isolates was 1 (3%) in 1993, 7 (21%) in 1994, 31 (94%) in 1995, and 33 (100%) in 1996 to 1998. The number of patient isolates increased from 1 in 1993 to 24 in 1994, 176 in 1995,429 in 1996, 730 in 1997, and 864 in 1998. Most VRE isolates in 1995 and 1996 were from urine and were not associated with serious clinical disease. However, the number of isolates from blood increased from 9 (6% of total) in 1995 to 44 (12% of the total) in 1996, 90 (14%) in 1997, and 100 (13%) in 1998.Conclusions:Our data document the rapid emergence and increase of VRE in all hospitals in three counties in the San Francisco Bay area during 1994 to 1998. Infection control measures for VRE together with antibiotic utilization programs should be implemented to limit further spread.

Background and purpose: Recanalization reduces final infarct volume, an important predictor of clinical outcome. Lesion location is also a determinant of outcome, however, the extent to which recanalization affects lesion topography has yet to be explored. Are there brain regions more likely to be spared if recanalization occurs? We investigated this question by using voxel-based lesion mapping to examine the effect of recanalization on infarct topography in middle cerebral artery (MCA) occlusion. Methods: Consecutive patients with acute stroke from MCA occlusion were examined to identify brain regions characteristically spared with recanalization (R+) (TICI 2a to 3), but damaged in patients with persistent occlusions (R-). The lesions were drawn directly on the MRI or CT images and then transformed into stereotaxic space using MRIcroN software. Lesions were superimposed to create voxel-based lesion plots for each group. A leibemeister test was performed comparing the two groups at every brain voxel, with Bonferroni correction. Results: Twenty-one patients were included: 11 had endovascular recanalization (R+) and 10 received no or unsuccessful treatment (R-). The figure shows the lesion overlay plots and the statistical map resulting from the analysis. In total, 5,250,682 voxels were tested, yielding a Bonferroni corrected P 0.1). Conclusions: Our analysis did not reveal brain regions characteristically spared with recanalization. Prior studies have shown reduced infarct volume after recanalization; ours did not, and this may be the underlying reason why no salvage pattern was observed. The effect of recanalization on stroke topography remains an important, unexplored area. We have shown that voxel-based lesion mapping has potential as a biomarker in endovascular therapy.

Objective:To identify exposures associated with acute hepatitis B virus (HBV) infection among residents with diabetes in a skilled nursing facility.Design:Residents from Unit 3 and other skilled nursing facility residents with diabetes were tested for serologic evidence of HBV infection. Two retrospective cohort studies were conducted. Potential routes of HBV transmission were evaluated by statistical comparison of attack rates.Setting:A 269-bed skilled nursing facility.Participants:All skilled nursing facility residents with diabetes and skilled nursing facility residents who lived on the same unit as the index case (Unit 3) for some time during the case's incubation period.Results:All 5 residents with acute HBV infection had diabetes and resided in Unit 3. The attack rate among the 12 patients with diabetes in Unit 3 was 42%, compared with 0% among 43 patients without diabetes (relative risk, 37.2; 95% confidence interval, 4.7 to ∞). Acutely infected patients with diabetes received more morning insulin doses (P = .05), and more insulin doses (P = .03) and finger sticks (P = .02) on Wednesdays than did noninfected patients with diabetes. Two chronically infected patients with diabetes in Unit 3 were positive for hepatitis B e antigen and regularly received daily insulin and finger sticks. Of the 4 acute and 3 chronically infected residents from whom HBV DNA was amplified, all were genotype F and had an identical 678-bp S region sequence. Although no component of the lancets or injection devices was shared among residents, opportunities for HBV contamination of diabetes care supplies were identified.Conclusions:Contamination of diabetes care supplies resulted in resident-to-resident transmission of HBV. In any setting in which diabetes care is performed, staff need to be educated regarding appropriate infection control practices.

Objective.To investigateAcinetobacter baumanniiinfection, colonization, and transmission related to a long-term care facility (LTCF) providing subacute care (facility A).Methods.We reviewed facility A and affiliated local hospital records for facility A residents withA. baumanniiisolated during the period January 2009 through February 2010 and comparedA. baumanniiantimicrobial resistance patterns of residents with those of hospital patients. During March 2010, we implemented a colonization survey of facility A residents who received respiratory support or who could provide sputum samples and looked forA. baumanniicolonization risks. Available clinical and survey isolates underwent pulsed-field gel electrophoresis (PFGE); PFGE strains were linked with overlapping stays to identify possible transmission.Results.During the period January 2009 through February 2010, 33 facility A residents hadA. baumanniiisolates; all strains were multidrug resistant (MDR), which was a significantly higher prevalence of MDR strains than that found among isolates from hospital patients (81 [66%] of 122 hospital patient isolates were MDR;P< .001). The sputum survey found that 14 (20%) of 70 residents hadA. baumanniicolonization, which was associated with ventilator use (adjusted odds ratio, 4.24 [95% confidence interval, 1.06–16.93]); 12 (86%) of 14 isolates were MDR. Four facility A resident groups clustered with 3 PFGE strains and overlapping stays. One of these facility A residents also clustered with 3 patients at an affiliated hospital.Conclusions.We documented substantial MDRA. baumanniiinfections and colonization with probable intra- and interfacility spread associated with a single LTCF providing subacute care. Given the limited infection prevention and antimicrobial stewardship resources in such settings, regional collaborations among facilities across the spectrum of health care are needed to address this MDR threat.

Foodborne botulism occurred among inmates at 2 prisons in California in 2004 and 2005. In the first outbreak, 4 inmates were hospitalized, 2 of whom required intubation. In the second event, 1 inmate required intubation. Pruno, an alcoholic drink made illicitly in prisons, was the novel vehicle for these cases.

In order to determine whether hospital-based clinical laboratories conducting active surveillance for vancomycin-resistant enterococci in three San Francisco Bay area counties (San Francisco, Alameda, and Contra Costa counties) were accurately reporting vancomycin resistance, five vancomycin-resistant enterococcal strains and one vancomycin-susceptible beta-lactamase-producing enterococcus were sent to 31 of 32 (97%) laboratories conducting surveillance. Each strain was tested by the laboratory's routine antimicrobial susceptibility testing method. An Enterococcus faecium strain with high-level resistance to vancomycin (MIC, 512 microg/ml) was correctly reported as resistant by 100% of laboratories; an E. faecium strain with moderate-level resistance (MIC, 64 microg/ml) was correctly reported as resistant by 91% of laboratories; two Enterococcus faecalis strains with low-level resistance (MICs, 32 microg/ml) were correctly reported as resistant by 97 and 56% of laboratories, respectively. An Enterococcus gallinarum strain with intrinsic low-level resistance (MIC, 8 microg/ml) was correctly reported as intermediate by 50% of laboratories. A beta-lactamase-producing E. faecalis isolate was correctly identified as susceptible to vancomycin by 100% of laboratories and as resistant to penicillin and ampicillin by 68 and 44% of laboratories, respectively; all 23 (74%) laboratories that tested for beta-lactamase recognized that it was a beta-lactamase producer. This survey indicated that for clinically significant enterococcal isolates, laboratories in the San Francisco Bay area have problems in detecting low- to moderate-level but not high-level vancomycin resistance. Increasing accuracy of detection and prompt reporting of these isolates and investigation of cases are the next steps in the battle for control of the spread of vancomycin resistance.

Healthcare professionals often are presented with data that appear to indicate an upward or downward trend over time. For example, admissions of acquired immunodeficiency syndrome (AIDS) patients appear to be increasing, cesarean section rates appear to be decreasing, or nosocomial pneumonia rates appear to be increasing. Critical decisions sometimes are based on such trends, which often are presented without a statistical analysis. Those responsible for decision making may be left wondering whether these apparent trends represent only chance variation. Graphs showing trends over time generally present one of three kinds of outcome data: counts (eg, three AIDS admissions), proportions (eg, 10 cesarean sections per 100 total deliveries), or person-time data (eg, 13 cases of nosocomial pneumonia per 10,000 patient days). Using familiar examples and a minimum of technical language, we illustrate the analysis of time trends.

BackgroundInfluenza vaccination among health care personnel (HCP) is a key measure to prevent influenza infection and transmission in health care settings. This study described influenza vaccination coverage among employees in various health care settings in California and examined factors associated with HCP influenza vaccination.MethodsThis study analyzed data from 111 facilities recruited through statewide invitation. Data on facility characteristics, vaccination programs, and vaccination receipt within and outside facilities were collected using Web-based questionnaires. Employees were defined as all persons in the facility payroll system regardless of patient contact. Facility-level employee vaccination coverage was calculated for 91facilities.ResultsThe mean employee influenza vaccination coverage was 60.7% overall: 64.0% for acute care hospitals (n=30), 54.7% for long-term care facilities (n=22), 59.4% for ambulatory surgery centers (n=8), 58.6% for dialysis centers (n=25), and 77.2% for physician practices (n=6). Vaccination promotion methods such as risk-benefit education, personal reminders, and vaccination data tracking and feedback were significantly associated with increased vaccination coverage.ConclusionThe study findings suggest some variations in HCP vaccination coverage by type of health care setting as well as substantial challenges in reaching the Healthy People 2020 goal of 90%. Health care facilities need to use comprehensive promotion methods to improve HCP influenza vaccinations.

Human induced pluripotent stem cells (iPSCs) have become an intriguing approach for neurological disease modeling, because neural lineage-specific cell types that retain the donors' complex genetics can be established in vitro. The statistical power of these iPSC-based models, however, is dependent on accurate diagnoses of the somatic cell donors; unfortunately, many neurodegenerative diseases are commonly misdiagnosed in live human subjects. Postmortem histopathological examination of a donor's brain, combined with premortem clinical criteria, is often the most robust approach to correctly classify an individual as a disease-specific case or unaffected control. In this study, we describe iPSCs generated from a skin biopsy collected postmortem during the rapid autopsy of a 75-year-old male, whole body donor, defined as an unaffected neurological control by both clinical and histopathological criteria. These iPSCs were established in a feeder-free system by lentiviral transduction of the Yamanaka factors, Oct3/4, Sox2, Klf4, and c-Myc. Selected iPSC clones expressed both nuclear and surface antigens recognized as pluripotency markers of human embryonic stem cells (hESCs) and were able to differentiate in vitro into neurons and glia. Statistical analysis also demonstrated that fibroblast proliferation was significantly affected by biopsy site, but not donor age (within an elderly cohort). These results provide evidence that autopsy donor-derived fibroblasts can be successfully reprogrammed into iPSCs, and may provide an advantageous approach for generating iPSC-based neurological disease models.

After identification of pandemic 2009 influenza (pH1N1) in the United States, the Centers for Disease Control and Prevention (CDC) worked with state and local health officials to characterize infections among healthcare personnel (HCP). Detailed information, including likely routes of exposure, was reported for 70 HCP from 22 states. Thirty-five cases (50%) were classified as being infected in healthcare settings, 18 cases (26%) were considered to have been infected in community settings, and no definitive source was identified for 17 cases (24%). Of the 23 HCP infected by ill patients, only 20% reported using an N95 respirator or surgical mask during all encounters and more than half worked in outpatient clinics. In addition to community transmission, likely patient-to-HCP and HCP-to-HCP transmission were identified in healthcare settings, highlighting the need for comprehensive infection control strategies including administration of influenza vaccine, appropriate management of ill HCP, and adherence to infection control precautions.

Background. In June 2001, following the report of 4 patients with Serratia marcescens meningitis who received epidural injections of betamethasone compounded at a community pharmacy, we initiated an outbreak investigation. Methods. All patients who received injections of betamethasone from the production lot common to the 4 patients were evaluated. A case patient was defined as a patient who received compounded betamethasone and had S. marcescens isolated from a sterile site or clinical and laboratory evidence of infection. We cultured all recovered betamethasone, environmental specimens from the pharmacy, and medications recovered from an ambulatory surgery center. The California Board of Pharmacy reviewed the procedures used to prepare the betamethasone. Results. We identified 11 patients with culture-confirmed S. marcescens (8 patients) or clinical infection (3 patients) following injection of compounded betamethasone from 25 May through 31 May 2001. Case patients had meningitis (5 patients, with 3 deaths), epidural abscesses (5 patients), or an infected hip (1 patient). S. marcescens was isolated from 35 (69%) of 51 betamethasone vials recovered, from pharmacy specimens of 1% carboxymethylcellulose stock solution, from pharmacy surfaces, and from multiple parenteral materials used at the ambulatory surgery center. Pulsed-field gel electrophoresis patterns of S. marcescens isolates of representative specimens from patients, the betamethasone, the pharmacy, and the ambulatory surgery center were identical. Deficient practices in compounding of betamethasone included inadequate autoclaving temperatures and failure to perform terminal sterilization. Conclusions. This outbreak of serious S. marcescens infection followed improper compounding of betamethasone in a community pharmacy. Enforceable national standards for pharmaceutical compounding are needed to reduce the risk of such outbreaks.

Objective:To investigate a perceived increase in central venous catheter (CVC)–associated bloodstream infections (BSIs) among pediatric hematology–oncology outpatients.Design:A case–control study.Setting:A pediatric hematology–oncology outpatient clinic at Fresno Children's Hospital.Patients:Pediatric hematology–oncology clinic outpatients with CVCs at Fresno Children's Hospital between November 1994 and October 1997.Methods:A case-patient was defined as any hematology–oncology outpatient with a CVC-associated BSI at Fresno Children's Hospital from November 1996 to October 1997 (study period) without a localizable infection. To identify case-patients, we reviewed Fresno Children's Hospital records for all hematology–oncology clinic patients, those with CVCs and those with CVCs and BSIs. Control-patients were randomly selected hematology–oncology outpatients with a CVC but no BSI during the study period. Case-patient and control-patient demographics, diagnoses, caretakers, catheter types, catheter care, and water exposure were compared.Results:Twenty-five case-patients had 42 CVC-associated BSIs during the study period. No significant increase in CVC-associated BSI rates occurred among pediatric hematology–oncology patients. However, there was a statistically significant increase in nonendogenous, gram-negative (eg, Pseudomonas species) BSIs during summer months (May–October) compared with the rest of the year. Case-patients and control-patients differed only in catheter type; case-patients were more likely than control-patients to have a transcutaneous CVC. Summertime recreational water exposures were similar and high in the two groups.Conclusions:Hematology–oncology clinic patients with transcutaneous CVCs are at greater risk for CVC-associated BSI, particularly during the summer. Caretakers should be instructed on proper care of CVCs, particularly protection of CVCs during bathing and recreational summer water activities, to reduce the risk of nonendogenous, gram-negative BSIs.

Pandemic influenza A(H1N1) emerged rapidly in California in April 2009. Preliminary comparisons with seasonal influenza suggest that pandemic 2009 influenza A(H1N1) disproportionately affects younger ages and causes generally mild disease.To describe the clinical and epidemiologic features of pandemic 2009 influenza A(H1N1) cases that led to hospitalization or death.Statewide enhanced public health surveillance of California residents who were hospitalized or died with laboratory evidence of pandemic 2009 influenza A(H1N1) infection reported to the California Department of Public Health between April 23 and August 11, 2009.Characteristics of hospitalized and fatal cases.During the study period there were 1088 cases of hospitalization or death due to pandemic 2009 influenza A(H1N1) infection reported in California. The median age was 27 years (range,1-92 years) and 68% (741/1088) had risk factors for seasonal influenza complications. Sixty-six percent (547/833) of those with chest radiographs performed had infiltrates and 31% (340/1088) required intensive care. Rapid antigen tests were falsely negative in 34% (208/618) of cases evaluated. Secondary bacterial infection was identified in 4% (46/1088). Twenty-one percent (183/884) received no antiviral treatment. Overall fatality was 11% (118/1088) and was highest (18%-20%) in persons aged 50 years or older. The most common causes of death were viral pneumonia and acute respiratory distress syndrome.In the first 16 weeks of the current pandemic, the median age of hospitalized infected cases was younger than is common with seasonal influenza. Infants had the highest hospitalization rates and persons aged 50 years or older had the highest mortality rates once hospitalized. Most cases had established risk factors for complications of seasonal influenza.

Present methods of disposal of today's hazardous household chemicals in the United States are frequently not acceptable because of pathways to groundwater, surface water, and the atmosphere. This report identifies potentially hazardous liquid waste in the household, notes current disposal practices, and recommends an improved management plan that utilizes consumer education, manufacturer cooperation, and governmental intervention. Laws requiring uniform disposal labeling on packaging are critical. Local, county, and state governments must be encouraged to coordinate the necessary infrastructure. Managing hazardous household wastes now will mitigate potential disposal problems.