Mercy Medical Center

Introduction: Red blood cell (RBC) transfusions in critically ill patients are common but often overused, exposing patients to unnecessary risks without clear clinical benefit. Evidence-based guidelines recommend restrictive transfusion strategies, including single-unit transfusions and transfusion thresholds of hemoglobin (Hgb) < 7 g/dL. Despite these recommendations, practice variation persists. This quality improvement project aimed to enhance compliance with RBC transfusion best practices in the intensive care units (ICUs) at our institution by implementing a multifaceted educational and performance feedback intervention. Methods: In April 2025, a multidisciplinary intervention was launched targeting ICU faculty, fellows, and nursing staff. The intervention included: Education on RBC transfusion guidelines, weekly email communications summarizing team metrics with three primary goals (≥91% of transfusions being single-unit, ≥79% of transfusions given for Hgb < 7 g/dL, < 4% of transfusions given for Hgb ≥ 8 g/dL), and monthly distribution of both team and individual compliance reports. Outcomes from the post-intervention period (April–June 2025) were compared to a baseline period (April–June 2024). Key metrics included number of RBC units transfused, percentage of single-unit transfusions, transfusions given for Hgb < 7 g/dL, and transfusions given for Hgb ≥ 8 g/dL. Exclusions included patients on ECMO, those meeting massive transfusion criteria, cases of active bleeding, and transfusions administered in the operating room. Results: RBC transfusions decreased from 141 units to 100 units. The proportion of single-unit transfusions increased from 84% to 91% (p = 0.0001), transfusions for Hgb < 7 g/dL increased from 74% to 81% (p = 0.0002), and transfusions for Hgb ≥ 8 g/dL decreased from 9% to 7% (p = 0.09). Conclusions: This targeted quality improvement initiative significantly improved adherence to evidence-based transfusion practices in the ICU, resulting in reduced overall RBC utilization, increased compliance with single-unit transfusions, and improved alignment with transfusion thresholds. Regular education, real-time performance feedback, and transparent communication with ICU teams were key drivers of success and sustainability.

Introduction: Catheter-associated urinary tract infections (CAUTIs) are a significant source of morbidity in intensive care units (ICUs). This study evaluates the impact of bathing compliance utilizing a 4% chlorhexidine gluconate (CHG) product on CAUTI incidence across two 16-bed ICUs with differing Foley catheter utilization and infection outcomes. The Standardized Utilization Ratio (SUR) measures the ratio of observed to predicted device use, while the Standardized Infection Ratio (SIR) reflects the ratio of observed to predicted healthcare-associated infections (CAUTI). Methods: A retrospective comparative analysis was performed on two ICUs within the same institution. Each unit had 16 beds and evaluated 1,000 patients during calendar year 2024. CHG bathing compliance, Foley catheter utilization (SUR), and CAUTI incidence (SIR) were collected and analyzed. ICU 1 and ICU 2 were compared using descriptive statistics and p-values for statistical significance (threshold: p < 0.05). Our Foley utilization protocol is as follows: Remove the Foley catheter and place a Foley removal order on all patients except those who are (1) post-GU procedure, (2) prone position, (3) have chronic Foley use (changed regularly), or (4) require replacement only if intermittent straight catheterization is needed more than 3 times in 24 hours. Daily CHG application was performed using a foaming pump dispensed onto a damp washcloth or directly onto the patient’s skin, followed by rinsing with a second damp washcloth after appropriate contact time. Perineal cleansing was conducted using the same technique, and Foley catheters along with other tubes and drains were wiped with CHG foam. Results: ICU 1 had a lower Foley catheter utilization (SUR: 0.48 vs 0.8, p = 0.001) and CHG bathing compliance rate (85% vs 92 %, p = 0.001) compared to ICU 2. Despite increased catheter use, ICU 2 achieved a SIR of 0, indicating no CAUTIs, while ICU 1 had a SIR of 0.55 (p = 0.0001). Conclusions: Higher CHG bathing compliance was significantly associated with lower CAUTIs, even in the context of greater Foley catheter utilization. These results emphasize the importance of high CHG bathing adherence and Foley care protocols in reducing infection rates in patients who require a Foley in the ICU.

Introduction: Anti-N-Methyl-D-Aspartate receptor encephalitis (NMDARE) can present with acute, subacute neuropsychiatric manifestations. Etiologies can be autoimmune, paraneoplastic, or infectious following herpes simplex virus encephalitis. High index of suspicion needs to be maintained to make the accurate and timely diagnosis. We describe a case of NMDARE in a female who had undergone oophorectomy many years back for right complex ovarian cyst, pathology revealed a mature cystic teratoma. She failed conventional treatment and was subsequently found to have a teratoma in the remaining ovary despite negative imaging. Description: 44-year-old female presented with acute onset of altered mental status, hallucinations and seizures. Brain imaging was unrevealing. Her lumbar puncture revealed white blood cell count of 360, 95% lymphocytes, normal glucose and protein. NMDARE antibody came back positive. Patient underwent Computerized Tomography (CT) scan of the abdomen, Magnetic Resonance Imaging (MRI) of the abdomen failed to demonstrate any evidence of teratoma in the remaining ovary. She received high dose intravenous steroids, intravenous immunoglobulin, plasmapheresis without improvement in her neurologic state. She subsequently received Rituximab after failing initial treatment. Her hospital course was complicated by persistent seizures, dyskinetic movements, critical illness myo-neuropathy. Given her lack of neurologic improvement after several weeks and patient having completed her family, prophylactic oophorectomy of the remaining ovary was performed. The pathology came back as teratoma. Patient received a second round of plasmapheresis followed by Cyclophosphamide. Six months later she is interactive, oriented X 4 and following commands. Discussion: This case highlights the importance of having high index of suspicion for teratoma in females presenting with NMDARE. Even though her imaging including CT scan and MRI of the abdomen was unrevealing, oophorectomy led to the diagnosis of teratoma which explains lack of improvement following initial treatment and gradual improvement after oophorectomy. In females presenting with NMDARE with prior history of teratoma, prophylactic oophorectomy should be considered on a case-by-case basis, if there is lack of improvement with conventional treatment.

Abstract Background: Patients with residual triple negative breast cancer (TNBC) after neoadjuvant chemotherapy (NAC) have a higher risk of recurrence and worse survival outcomes. Prior studies have shown that higher stromal tumor-infiltrating lymphocytes (sTILs) post-NAC in patients with residual TNBC is associated with improved survival outcomes. In this secondary analysis of EA1131, we evaluated the association between sTILs, intrinsic subtype, and invasive disease-free survival (iDFS), stratified by race in patients with residual TNBC after completion of NAC. Patients and methods: EA1131 enrolled patients with clinical stage II or III TNBC with ≥1.0 cm residual disease (RD) in the breast post-NAC were randomly assigned to receive platinum (carboplatin or cisplatin) once every 3 weeks for four cycles or capecitabine on days 1-14 of a 21-day cycle for six cycles. Stromal TIL density was assessed on full-face hematoxylin and eosin (H&amp;E)-stained tumor sections. Patients were categorized into four groups based on sTILs level (&amp;lt;30% vs. ≥30%) and tumor intrinsic subtype (basal vs. non-basal): (1) low sTILs/basal, (2) low sTILs/non-basal, (3) high sTILs/basal, and (4) high sTILs/non-basal. Cox proportional hazard models were used to examine the association between sTILs and intrinsic subtype group and iDFS, adjusting for available baseline factors. The association between sTILs category and race and intrinsic subtype were examined using Fisher exact test. Results: Among 410 participants with TNBC and RD, H&amp;E slides were available for all 342 who had intrinsic subtype (264 basal, 78 non-basal). Most patients (93%, n=319) had low sTILs (&amp;lt;30%); only 23 (7%) had high sTILs (30-50%: n=17; 51-70%: n=3; &amp;gt;70%: n=3). There was no difference in sTILs by intrinsic subtype (p=0.31) or race (p=0.5). Compared to all groups, patients with low TILs and basal subtype (n=244) had the worst iDFS (p=0.005) and had numerically worse OS (p=0.084). Other significant risk factors for iDFS in this group included high histologic grade (vs intermediate and low), positive lymph node (vs negative), higher pathologic T stage (as a continuous variable). Differences according to race could not be analyzed due to small sample size. Conclusion: In the EA1131 clinical trial, patients with residual basal-like TNBC and low sTILs had the worse iDFS, delineating a particularly high-risk subgroup. These findings underscore the prognostic relevance of post-treatment immune microenvironment characteristics and suggest that patients with basal-like, TIL-low residual TNBC may derive limited benefit from current standard adjuvant therapies. Further investigation is warranted to identify and develop tailored therapeutic approaches for this biologically aggressive subgroup to improve long-term outcomes. Citation Format: S. S. Badve, F. Zhao, S. Reid, Y. Gokmen-Polar, I. Mayer, C. L. Arteaga, W. F. Symmans, B. H. Park, B. L. Burnette, D. F. Makower, M. Block, M. A. Kimberly, C. R. Jani, C. Mescher, S. J. Dewani, B. Tawfik, B. Tawfik, L. E. Flaum, E. L. Mayer, W. M. Sikov, E. T. Rodler, A. M. DeMichele, J. A. Sparano, A. C. Wolff, K. D. Miller, ECOG-ACRIN. Tumor infiltrating lymphocytes in post-NACT residual tumors in ECOG-ACRIN EA1131 - impact of intrinsic subtypes [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr RF3-06.

The advent of high-throughput data generation and artificial intelligence has transformed allergy research. Open-access database (OAD) and cohort-based database (CBD) provide essential resources for machine learning (ML)-driven algorithms for risk stratification and decision support. It is crucial for allergologists to understand their construction, strengths, and limitations. We review recently published databases with a focus on how these datasets can be combined to enhance research. OAD, including environmental monitoring resources, omics repositories, and electronic health records, offer scale, diversity, and opportunities for new hypotheses, but are often limited by sparse clinical annotation, heterogeneous data generation, and incomplete linkage to patient-level outcomes. CBD provide well-phenotyped patients, longitudinal follow up, and high-quality clinical and immunological measurements, yet face constraints in sample size, population diversity, and data sharing. Studies integrating OAD breadth with CBD label fidelity report improved predictive performance when paired with disciplined evaluation. Federated learning and portable feature specifications are emerging to enable privacy-preserving collaborations. Allergologists play a central role in building ML-ready resources. By ensuring rigorous clinical annotation, standardization of data, transparent methods, and independent validation, they can maximize the utility of OAD and CBD and their combination to accelerate progress toward precision allergy medicine.

Background/Objectives: Endoscopic submucosal dissection (ESD) is a state-of-the-art en bloc resection for early gastro-intestinal cancers and precursors developed and validated in Japan. Western expertise with this complex technique remains limited. Tutored training might be optimal for patients and ESD learning. We established ESD tutoring courses led by experienced Japanese experts to provide (i) optimal long-term curative outcomes and low complication rates for patients and (ii) hands-on training on difficult lesions for European endoscopists under direct expert supervision. Methods: Prospective data from 2011 to 2015 (follow-up to 12/2024) were analyzed. A total of 118 neoplasms (50% HGIEN and cancer) in 101 patients (median age 68 [37-91] years; 38% with significant comorbidities) were treated with expert or tutored ESD. Japanese experts performed 28 ESDs, while 22 trained beginners conducted 90 supervised procedures on difficult lesions during 5 live and 20 tutoring events (1-4 days each). Results: Analysis of the complete data showed curative and en bloc resection rates of 88% and 95%, respectively, with no recurrence after R0 resections during a median follow-up of 9.8 [1.5-14.9] years. Long-term survival remained recurrence-free after endoscopic resection of 3 recurrent adenomas (at R1/Rx) and curative surgery/2nd ESD for 5 non-curative ESDs. Adverse events occurred in 9.3% without emergency surgery or 30-day mortality. Comparing expert-only vs. tutored ESD procedures, beginners correctly applied curative ESD indications in 94% of 118 neoplasms. Experts resected larger lesions (22 cm2) at a rate of 9.3 cm2/h in 121 min. Tutored beginners achieved a 75% [25-100] self-completion rate on 33% smaller lesions in 112 min. Conclusions: ESD tutoring courses led by Japanese experts ensure excellent patient outcomes and standardized procedural training. This model may foster professional ESD performance across European referral centers.

Prematurity may place young children at increased risk for severe respiratory syncytial virus (RSV) disease because of differences in lung development. We describe characteristics of children aged less than 2years hospitalized with RSV by prematurity and bronchopulmonary dysplasia (BPD) status and examine both as risk factors for severe in-hospital outcomes. During 2016-2023, population-based surveillance was conducted at 7 medical centers for hospitalizations with RSV-associated acute respiratory illness in children. Poisson regression with robust variance was used to estimate adjusted relative risks (aRRs) of prolonged hospitalization (≥3days), intensive care unit (ICU) admission, and assisted ventilation by age in children with prematurity without and with BPD compared with term children after adjustment for surveillance site and palivizumab receipt. Among 5844 children, 4626 (79.2%) were term and 1218 (20.8%) were premature, including 1138 (93.4%) without BPD and 80 (6.6%) with BPD. Compared with term children, all premature children had greater risks for prolonged hospitalization (aRR = 1.3; 95% CI, 1.2-1.5), ICU admission (aRR = 1.4; 95% CI, 1.2-1.6), and assisted ventilation (aRR = 2.0; 95% CI, 1.4-2.8) at chronological age less than 6months. Premature children with BPD also had greater risk for prolonged hospitalization at all ages through 23months. Premature children accounted for 1 in 5 hospitalizations among children aged less than 2years hospitalized with RSV. Compared with term children, all premature children had increased risk for severe in-hospital outcomes in early infancy, and those with BPD remained at increased risk of prolonged hospitalization through age 23months.

Metal-on-metal (MoM) joint replacements were designed to improve durability in younger, active patients. However, cobalt-induced cardiomyopathy (CIC) has emerged as a rare but serious complication, often misattributed to idiopathic or ischemic causes. We systematically reviewed published case reports, case series, and laboratory studies describing CIC in patients with MoM implants. Data extraction included clinical presentation, diagnostic criteria, treatment, and outcomes. Methodological quality and risk of bias were assessed qualitatively. Eighteen cases were included. Implant wear and corrosion released systemic cobalt, which localised in myocardial tissue. Pathophysiological mechanisms included mitochondrial dysfunction, oxidative stress, impaired calcium handling, and apoptotic injury. Patients commonly presented with non-specific cardiac symptoms such as fatigue, dyspnoea, orthopnoea, arrhythmias, and heart failure, alongside extra-cardiac features including hearing loss, thyroid dysfunction, and neurocognitive changes. Diagnostic confirmation required serum cobalt levels typically exceeding 30–100 µg/L, with cardiac MRI demonstrating non-ischemic fibrosis and oedema. Chelation therapy reduced cobalt burden but was rarely effective alone. Revision of the MoM implant consistently led to clinical improvement when performed early; delayed intervention was associated with irreversible myocardial damage and poorer outcomes. CIC is an under-recognised but potentially reversible form of cardiomyopathy. Routine cobalt screening and early implant revision are essential to prevent progression to heart failure or sudden cardiac death. Multidisciplinary collaboration between cardiology and orthopaedics is critical for the timely diagnosis and management of these conditions.Graphical

IntroductionHaematological malignancies and their treatments are known for their significant adverse effects on health-related quality of life (QoL). During high-dose cytotoxic therapy in haematological intensive care units (HICU), adapted physical activity (APA) is recognised for its role in maintaining physical fitness and limiting fatigue. Psychological and emotional states are also impaired, with anxiety levels significantly increasing in this specific context. Limited information is available about this topic. However, APA has been shown to reduce anxiety in various populations, including oncological patients. Furthermore, adding new technology, such as exergaming or heart rate variability biofeedback (HRVB) relaxation tools, could be an effective way to regulate emotions during treatments while providing the health benefits of APA. APA, Exergaming and Relaxation by Biofeedback in Haematological Intensive Care Unit protocol is a randomised, controlled trial. Our study is designed to evaluate the effects of APA programmes during high-dose cytotoxic therapy in HICU on anxiety, fatigue level, functional capacities, immune system activity and global QoL. Additionally, we aim to analyse the added value of using specific devices, such as Exergaming and HRVB relaxation, on the aforementioned parameters. We expect a difference in effectiveness between the programmes concerning emotional regulation.Methods and analysis90 patients (18–75 years), with various forms of haematological malignancies admitted to HICU, with haematologist’s approval for APA, who have given their written informed consent, will be randomly allocated in a 1:1:1 ratio to three 3-week APA groups: APA only (APA), APA by exergaming (EXER), APA+Biofeedback relaxation (BIO) (30:30:30). APA sessions will consist of moderate aerobic training on cyclo-ergometer (classical stationary bicycle for APA, BIO and connected ergometer in EXER), three times per week. The HRVB training will consist of controlled breathing exercises with biofeedback of heart rate variability at the end of each APA session (BIO). The primary outcome is to evaluate the effect of three short APA programmes on state anxiety (Hospital Anxiety and Depression Scale and State and Trait Anxiety Inventory-YA (STAI-YA)). The secondary outcomes will assess the effects on fatigue (Multidimensional Fatigue Inventory–20), physical fitness (2-minute walk test; five-times sit to stand test), QoL (European Organisation for Research and Treatment of Cancer - Quality of Life Questionnary ; EORTC-QLQ-C30) and immune system functioning (blood samples). All of these assessments are evaluated initially (T0) and directly after intervention (T2).Ethics and disseminationApproval was obtained from the French South Mediterranean III ethical committee. Subjects are recruited after providing written consent after receiving the information provided by the investigator. According to French law and the French Data Protection Authority (Commission Nationale de l’Informatique et des Libertés ; CNIL), we are not authorised to publicly share individual participant data. The results of the Adapted Physical Activity, Exergaming and Relaxation by Biofeedback in Haematological Intensive Care Unit study will be disseminated through publication in peer-reviewed journals, presentations at scientific conferences and communication with stakeholders and participants.Trial registration numberFrench Sud Mediteranian III ethical committee and registered on ClinicalTrials.gov: NCT05475600.