Saint Louis University Hospital

Fostamatinib is available in France since October 2021 for the treatment of adult chronic immune thrombocytopenia (ITP). French health authorities requested a 3-year, prospective, multicenter registry to provide real-world evidence about the effectiveness and safety of fostamatinib. Patients' characteristics, treatment response (ongoing exposure to fostamatinib and a platelet count ≥ 30 × 109/L with no rescue in the previous 4 weeks) after 3, 6, 12, and 24 months (M); bleeding; fostamatinib discontinuation; adverse drug reactions (ADRs) and other events of interest have been analyzed. In total, 164 patients were included (median age: 59 years; 55.5% women; 84.1% had previous bleeding; 30 had secondary ITP; 89.0% had chronic ITP). The median ITP duration was 7.2 years and the median number of previous ITP treatments was 6. The response rate was 44.0% (70/159) at M3, 41.9% (62/148) at M6, 32.4% (44/136) at M12 and 20.0% (21/105) at M24. Concomitant treatment (mostlyTPO-RA) was used in > 60.0% of responders at each endpoint. The cumulative discontinuation rate at each endpointwas, respectively, 27.0%, 44.6%, 55.9%, and 76.2%. Seventy-one (43.3%) patients experienced at least one bleeding duringfostamatinib exposure; none was fatal. One hundred adverse drug reactions (8 serious) were observed in 61 (36.7%)patients, including diarrhea in 28 (17.1%) patients, arterial hypertension in 17 (10.4%). Seven thrombosis (4.3%) and40 infections (12 serious) were reported in 25 patients (15.2%), mostly in patients with known risk factors. In conclusion,fostamatinib in combination with TPO-RA should be considered in difficult-to-treat ITP patients. No new safety signal was observed.

Research on relatives' experiences with controlled donation after circulatory determination of death (cDCDD) is limited. This study aims to explore the challenges and experiences of relatives whose loved ones die under cDCDD, focusing on how they navigate the process. A qualitative study using semi-structured, in-depth interviews conducted 6 months post-death. This research is part of a larger quantitative multicenter study on the psychologic burden in relatives of cDCDD patients. Relatives of patients in the cDCDD process were purposively sampled and invited to participate in qualitative interviews. Thematic analysis was used to explore the phenomenon from the participants' perspectives. This study was conducted in France between November 2022 and November 2023. Family members of ICU patients identified as potential cDCDD donors. None. Of 23 family members approached, 19 (mean age 53 yr; 11 women) agreed to participate. The mean interview duration was 43 minutes. In three cases, organ retrieval was not possible. Thematic analysis revealed three key themes: 1) "Two decisions, two worlds"-discussing the decision to withdraw life-sustaining therapies and the organ donation request; 2) "Waiting for death"-the period between the decision and its implementation; and 3) "A controlled death"-dying and death in a monitored and technical environment. Relatives can be deeply engaged in cDCDD when well-prepared. However, additional support is needed during the waiting period, as families witness their loved one's decline. Proper preparation for dying is crucial to prevent perceptions of suffering, thereby reducing distress. Healthcare professionals must balance emotional, ethical, and medical considerations to facilitate informed choices in a highly regulated system.

Mechanical circulatory support (MCS) devices can be helpful to maintain hemodynamic stability during high-risk percutaneous coronary intervention (PCI). Iliofemoral arterial disease limits the use of transfemoral MCS devices. Impella 5.5, a surgical transaxillary MCS device, represents a viable option for MCS-protected PCI. We report a 74-year-old man with prior endovascular aneurysm repair (EVAR), severe peripheral artery disease (PAD), and newly diagnosed NSTEMI was found to have three-vessel and left main coronary disease with an ejection fraction (EF) of 13%. Due to aortoiliac occlusion, transfemoral MCS was not feasible. Instead, an Impella 5.5 was implanted via a right axillary artery graft, enabling successful orbital atherectomy and bifurcation PCI. In summary, axillary Impella 5.5 insertion is a viable option in anatomically complex patients where femoral access is contraindicated. This approach allows full left ventricular hemodynamic support for revascularization in otherwise inoperable patients.

Assessment of quality and safety indicators (QSIs) remains often based on time-consuming manual Electronic Health Record (EHR) review. As part of a pilot study to examine the feasibility of automating the calculation of French national QSIs using a Clinical Data Warehouse (CDW), we focused on the measure of door-to-imaging time (DTI time) in stroke management, i.e., the time interval between arrival at the hospital and the first stroke diagnostic imaging, through a retrospective observational study of patients hospitalized in the Greater Paris University Hospitals (AP-HP) for an acute stroke in 2022. We automatically computed the DTI time for more than 6,000 medical records in the CDW using a systematic approach and validated this method by matching the results against the manual AP-HP EHR review from the 2022 French national QSI audit. In this Matched population, CDW and manual EHR review methods agreed on estimating overall indicators, but showed discrepancies in the case-by-case analysis, mainly because of human variability both in EHR completion and manual reviewing. Automation looks promising in a context of limited professional resources but requires structured and validated data, interoperability in the case of inter-institutional stays, and validly measurable QSI.

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.

Tisagenlecleucel (tisa-cel), an autologous anti-CD19 CAR T-cell therapy, has significantly improved outcomes in pediatric, adolescents and young adults with relapsed/refractory B-cell precursor acute lymphoblastic leukemia (R/R BCP-ALL). However, 30-50% experience early failure or relapse. We retrospectively analyzed 52 cases of early failures (n = 13) or relapses (n = 39), evaluating post-tisa-cel outcomes and prognostic factors. CD19 antigen loss was the only factor associated with a lower complete remission rate after salvage therapy (OR = 0.16, 95%CI [0.03-0.90], p = 0.04). Median overall survival (OS) was 14.5 months, with a 2-year OS of 37.4% (95%CI [24.4-50.4]), similar between early failure (38.5%) and relapse (37.0%) groups (p = 0.78). Patients with measurable residual disease only at salvage initiation had significantly improved 2-year OS (61.9%, (95%CI [38.1-78.8])) compared to those with overt disease (20.7%, (95%CI [8.4-36.7], p = 0.008)). Factors associated with inferior OS included high pre-infusion tumor burden (HR = 3.57, p < 0.01), and prior inotuzumab ozogamicin exposure (HR = 3.81, p < 0.01). Although salvage therapies and hematopoietic stem cell transplantation benefit some patients, 5 of 18 transplanted patients died from treatment-related toxicity, underscoring the significant associated risks. These findings highlight the poor prognosis of tisa-cel failures and the urgent need for novel strategies.