Home emergency response team for the seriously ill palliative care patient: feasibility and effectiveness.

OBJECTIVES: To characterise trajectories associated with a new team organisation combining critical care and palliative care approaches at home. METHODS: We describe the pattern of an emergency response team 24/7 directed to patients with advanced illness presenting a distressing symptom at home, who wanted to stay at home and for whom hospitalisation was considered inappropriate by a shared medical decision-making process in an emergency situation. To assess preliminary impact of this Programme, we conducted a descriptive study on all consecutive patients receiving this intervention during the first year (between 6 September 2021 and 5 September 2022). RESULTS: Among the 352 patients included, main advanced illnesses were cancer (41%), dementia (28%) or chronic organ failure (10%). They were critically ill with acute failures: respiratory (52%), neurological (48%) or circulatory (20%). Main distressing symptoms were breathlessness (43%) and pain (17%). Median response time from call to home-visit (IQR) was 140 (90-265) min. Median length of follow-up (IQR) was 4 (2-7) days. Main outcomes were death at home (72%), improvement (19%) or hospitalisation (9%) including three visits to emergency department (1%). CONCLUSIONS: Our study supports that shared decision-making process and urgent care at home are feasible and might prevent undesired hospitalisations.

Predictive Factors of Response to Immunotherapy in Lymphomas: A Multicentre Clinical Data Warehouse Study (PRONOSTIM).

Immunotherapy (IT) is a major therapeutic strategy for lymphoma, significantly improving patient prognosis. IT remains ineffective for a significant number of patients, however, and exposes them to specific toxicities. The identification predictive factors around efficacy and toxicity would allow better targeting of patients with a higher ratio of benefit to risk. PRONOSTIM is a multicenter and retrospective study using the Clinical Data Warehouse (CDW) of the Greater Paris University Hospitals network. Adult patients with Hodgkin lymphoma or diffuse large-cell B lymphoma treated with immune checkpoint inhibitors or CAR T (Chimeric antigen receptor T) cells between 2017 and 2022 were included. Analysis of covariates influencing progression-free survival (PFS) or the occurrence of grade ≥3 toxicity was performed. In total, 249 patients were included. From this study, already known predictors for response or toxicity of CAR T cells such as age, elevated lactate dehydrogenase, and elevated C-Reactive Protein at the time of infusion were confirmed. In addition, male gender, low hemoglobin, and hypo- or hyperkalemia were demonstrated to be potential predictive factors for progression after CAR T cell therapy. These findings prove the attractiveness of CDW in generating real-world data, and show its essential contribution to identifying new predictors for decision support before starting IT.

[Emergency intervention of hospitalisation at home in nursing home during the pandemic period of Covid-19]. / Intervention en urgence de l'hospitalisation à domicile en établissement d'hébergement pour personnes âgées dépendantes pendant la période pandémique de la Covid-19.

BACKGROUND: In the context of the pandemic Covid-19, the Hospitalization A Home (HAH) of the Assistance Publique - Hôpitaux de Paris (APHP) has implemented a new organisation with emergency interventions to meet the needs of residents in palliative care in nursing home. The objective of the study was to describe their clinical characteristics, the modalities of the intervention and their care pathways during the HAH intervention. METHODS: This is a descriptive study on the emergency intervention of the HAH in 74 nursing home in the area of Ile-de-France during one month (April 2020) with a sample of 132 residents. The data collection included the socio-demographic and clinical characteristics of residents and on data about nursing home included. RESULTS: Emergency intervention of the HAH in nursing home involved very elderly residents with severe functional disabilities and with signs of respiratory failure linked to the Covid 19. The intervention took place mainly during the day and the week with a territorial heterogeneity and with a double medical validation between the prescribers and the HAH physician. Seventy per cent of the residents died at their living place. Among nursing home included, they were of medium size, mainly with private status and a large majority had already collaborated with the APHP's HAH. DISCUSSION/CONCLUSION: Emergency intervention of the HAH in nursing home was feasible and responded to an unmeet need for palliative care residents. These results should allow the ongoing development of this new organization for elderly population living in private homes.

Acute kidney injury in critical care: experience of a conservative strategy.

PURPOSE: Renal replacement therapy (RRT) is a major supportive treatment of acute kidney injury (AKI) in intensive care unit (ICU), but the timing of its initiation remains open to debate. MATERIALS AND METHODS: We retrospectively analyzed ICU patients who had AKI associated with at least one usual RRT criteria: serum creatinine concentration greater than 300 µmol/L, serum urea concentration greater than 25 mmol/L, serum potassium concentration greater than 6.5 mmol/L, severe metabolic acidosis (arterial blood pH<7.2), oliguria (urine output<135 mL/8 hours or <400 mL/24 hours), overload pulmonary edema. To estimate the risk of death associated with RRT adjusted for risk factors, we performed a marginal structural Cox model with inverse-probability-of-treatment-weighted estimator. RESULTS: Among 4173 patients admitted to the ICU, 203 patients fulfilled potential RRT criteria. Ninety-one patients (44.8%) received RRT and 112 (55.2%) did not. Non-RRT and RRT patients differed in terms of severity of illness: Simplified Acute Physiology Score II (55±17 vs 60±19, respectively; P<.05) and Sequential Organ Failure Assessment score (8 [5-10] vs 9 [7-11], respectively; P=.01). Crude analysis indicated a lower ICU mortality for non-RRT compared with RRT patients (18% vs 45%; P<.001). In the marginal structural Cox model, RRT was associated with increased mortality (P<.01). CONCLUSION: A conservative approach of AKI was not associated with increased mortality.