Saint Louis University Hospital,SSM Health Care

BACKGROUND:Caring for a loved one in the intensive care unit (ICU) during a critical illness can place significant emotional strain on families, often resulting in anxiety and depression. Central to this experience is waiting-a defining, yet understudied, component of ICU life. Few studies have explored how the intensity and uncertainty of the ICU environment shape the challenges associated with waiting. AIM:This study explores relatives' lived experience of waiting in the ICU, focussing on its emotional, spatial and relational dimensions. STUDY DESIGN:We employed a two-phase qualitative design. The first phase involved exploratory observations across three ICUs to gain contextual insights and identify themes relevant to ICU visitors. These findings informed the development of a semi-structured interview guide for the second phase. In the second phase, we conducted qualitative interviews with family members in two ICUs. Interviews were audio-recorded, transcribed verbatim, anonymized and analysed using thematic analysis. FINDINGS:Observations were carried out over 5 days in June 2024, involving informal contact with 39 relatives and 14 interviews. In the second phase, 17 of 21 invited participants were interviewed over 4 months. Four key themes emerged: Waiting in the ICU-shaped by personal histories and the patient's condition; What we wait for-highlighting diverse expectations; The experience of waiting-a fragile balance of apprehension, understanding and coping; and The waiting room-both a refuge and a site of socialization and concern. CONCLUSIONS:Waiting in the ICU is an active, emotionally charged process shaped by institutional structures, personal strategies and ethical ties. RELEVANCE TO CLINICAL PRACTICE:Recognizing families' dependence on the care team, affirming their agency and designing inclusive, humane waiting environments are essential to supporting families and promoting family-centred care in the ICU.

Information about Diamond-Blackfan anemia syndrome (DBAS), a ribosomopathy associated with anemia, congenital anomalies and cancer predisposition is limited in adults. Using the French DBAS registry, 235 adult patients with DBAS were analyzed for hematological outcomes. At last follow-up, anemia, neutropenia, thrombocytopenia, and pancytopenia affected respectively 78%, 31%, 15%, and 11% of the patients. There was no severe aplastic anemia outside of clonal evolution. Among patients without DBAS-specific treatment (e.g., steroids or red blood cell transfusions), the incidence of anemia, neutropenia, and thrombocytopenia was 52%, 35%, and 10%, highlighting that treatment independence does not mean hematologic remission. Four patients developed myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML), all associated with poor-risk features and dismal outcomes. Observed to expected ratios were 155 for MDS and 55.4 for AML, confirming a major risk-excess despite stringent criteria for MDS diagnosis. With a median follow-up of 32.2 years (IQR 26-44), overall survival (OS) was 98.0% (95% CI, 95.8-100), 90.6% (95% CI, 84.2-97.5), and 70.7% (95% CI, 57.3-87.2) at 30, 40, and 50 years respectively. Solid and hematologic cancers were the main cause of death. This study demonstrates, in a large cohort of adults with DBAS, that cytopenias beyond anemia are frequent and persistent. Myeloid neoplasms occur with a high incidence and dismal outcomes. These findings highlight the need for risk stratification, tailored surveillance, and optimized therapeutic strategies in this vulnerable population.

For clinicians, conflict in the intensive care unit (ICU) is both common and expected owing to the nature of critical illness and its treatment. Examination of conflict in this context has been conceptually diffuse. Studies of moral distress, psychological safety, ethical climate, and other fields offer valuable insights that can be challenging to synthesize cohesively, due to differences in concepts, methods, and disciplinary perspectives. This narrative review integrates this literature using a task-process-relationship framework from organizational psychology. Conflict in the ICU arises in two principal arenas: between clinical teams and patients, families, or surrogates, and within and across clinical teams. Patients who retain decision-making capacity are a distinct and often overlooked party to conflict, as the focus has primarily been on the families and surrogates who speak for those who cannot. The task-process-relationship framework suggests a recurring escalation pattern for both arenas. Genuine task disagreements about treatment, prognosis, or goals of care can become destructive in the presence of process gaps or failures. These include role ambiguity, inconsistent messaging, and perceived unfairness. From there, conflict can enter the relationship domain wherein mistrust or identity threat makes resolution far harder, and two implications follow. First, much of what clinicians may describe as a “difficult family” can often be a response to antecedent process failures rather than a purely interpersonal problem, emphasizing the importance of engineering robust processes and systems in the ICU to avoid conflict reaching the relationship domain. Second, family and team conflict are linked in that unresolved team disagreement can reach families as contradictory recommendations and mixed messaging. Challenging family situations can expose team misalignment and damage collegial relationships. Evidence-based interventions, organized by conflict type and escalation stage, suggest that the most promising investments are structural, namely those built into rounds, improving role clarity, ensuring pre-conference team alignment, and fostering ethical climate. When conflict becomes entrenched, formal supports such as mediation and ethics consultation are matched to the nature of the dispute. While disagreement in intensive care is inevitable, destructive conflict is not.

A 38-year-old white male presented for Mohs Micrographic Surgery (MMS) consultation with a biopsy proven basal cell carcinoma (BCC) on the right infraorbital cheek encroaching upon the lower eyelid. During MMS, glandular proliferation and goblet cell hyperplasia were visualized on histologic sections, raising concern for an adnexal or mucinous carcinoma. Following referral for expert dermatopathological consultation, a final diagnosis of pseudoglandular hyperplasia of the conjunctiva (PHC) in the setting of chronic conjunctivitis was made, likely having developed in response to longstanding irritation from the nearby BCC. This case represents only the sixth reported case of PHC in the literature and the first identified incidentally during MMS of an adjacent cutaneous neoplasm. PHC is an uncommon, benign reactive proliferation characterized by invagination of the conjunctival epithelium into the stroma, forming gland-like structures. Due to its histological resemblance to invasive neoplasms, such as mucoepidermoid carcinoma, PHC poses a significant diagnostic and clinical conundrum. Only a handful of cases of PHC have been described and a diagnostic framework has yet to be sufficiently established. This report highlights the importance of increasing the awareness of this benign phenomenon and defining its histologic features to distinguish it from resemblant malignancies and avoid unnecessary surgery.

Febrile neutropenia (FN) is an oncologic emergency requiring prompt evaluation for infection and empiric broad spectrum antibiotics; however, blood culture diagnostic yield in FN is low. Increasing culture positivity and reducing time to organism identification can improve antimicrobial use and may reduce risk of subsequent multidrug resistant organisms (MDROs) infections. The BACT/ALERT® VIRTUO®, a fully automated, enclosed blood culture processing system shown to reduce time to positive results, was adopted in January 2022. This retrospective quasi-experimental study aimed to examine the impact of this system on blood culture positivity in patients with FN and hematologic malignancies. Blood culture positivity (first set of cultures within 24 hours of FN) in adult patients hospitalized with FN and hematologic malignancy from 1/2021-6/2024 was compared pre- and post- BACT/ALERT® VIRTUO® implementation. Patients were excluded if no blood cultures were collected. Secondary endpoints were time from blood culture collection to culture positivity, time from first fever to active antimicrobial therapy, prevalence of MDROs, 14-day mortality, and adherence to National Comprehensive Cancer Network (NCCN) guideline directed antimicrobial therapy. Patients with FN were most often diagnosed with acute myeloid leukemia and multiple myeloma and 52% received hematologic stem cell transplant (Table 1). Culture positivity did not differ significantly pre/post intervention (22% (11/50) vs 17% (17/103); p= 0.504). No differences in median time to culture positivity (13 vs 13 hours), median time to active therapy (1.2 vs 1.5 hours), 14-day mortality (2% (1/50) vs 2% (2/103)) or MDRO prevalence were observed (Table 2), though numerically, more MDRO organisms were identified in the post-implementation group (Table 3). Therapy was concordant with NCCN guidelines in 76% of patients. The BACT/ALERT® VIRTUO® system did not improve blood culture positivity rates; however, opportunities were identified for improved adherence to NCCN guideline directed therapy and increased monitoring for MDROs in FN. Yvonne Burnett, PharmD, BCIDP, InflaRx: Honoraria|Melinta Therapeutics: Honoraria Robin R. Chamberland, PhD D(ABMM), bioMerieux: Advisor/Consultant|Pattern Bioscience, Inc.: Advisor/Consultant|Pattern Bioscience, Inc.: Grant/Research Support Christian Gill, PharmD, BCIDP, Cepheid: Grant/Research Support|Cumberland: Grant/Research Support|Entasis: Grant/Research Support|Everest Medicines: Grant/Research Support|Shionogi: Grant/Research Support