Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN).

PURPOSE: Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS: We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS: The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS: Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Accuracy of Parental-Reported Tetanus Vaccination Status for Children With Lacerations.

OBJECTIVES: The aim of this study was to determine whether emergency department (ED) providers are able to accurately assess whether a child with a laceration needs tetanus prophylaxis. METHODS: We conducted an 8-month prospective cross-sectional study of children presenting with a laceration to a pediatric ED. We asked ED providers whether tetanus prophylaxis was necessary. An ED pharmacist accessed the Utah Statewide Immunization Information System (USIIS), and we assessed the accuracy of the ED provider's determination of necessary tetanus prophylaxis compared with USIIS records. RESULTS: Among 375 patients aged 5 months to 17 years, ED providers made an inaccurate assessment of necessary tetanus prophylaxis in 33 cases (8.8%; 95% confidence interval [CI], 6.3%-12.1%). Emergency department providers would have inappropriately administered tetanus prophylaxis in 5 cases (1.3%; 95% CI, 0.5%-3.2%) and would have missed the need for tetanus prophylaxis in 28 cases (7.5%; 95% CI, 5.2%-10.6%). Emergency department providers were more likely to provide an inaccurate recommendation in older children (8.3 vs 4.8 years; P < 0.001), in patients with a dirty wound (45.5% vs 11.7%; P < 0.001), and in children who had fewer than 3 vaccines recorded in the USIIS (54.5% vs 1.2%; P < 0.001). CONCLUSIONS: Emergency department providers may inaccurately assess the need for tetanus prophylaxis in children. Special attention should be paid to cases of dirty wounds and cases in which fewer than 3 tetanus-containing vaccines have been given.

Pediatric Appendicitis: Association of Chief Complaint With Missed Appendicitis.

OBJECTIVES: We evaluated the association between the emergency department (ED) triage chief complaint and rate of missed appendicitis in children. METHODS: We performed a retrospective chart review of patients who presented to a pediatric ED and were diagnosed with appendicitis over 5 years (July 1, 2009 to June 30, 2014). We reviewed the medical record for any additional ED visits in the 7 days preceding the diagnosis of appendicitis. Triage chief complaints were classified as "suggestive of appendicitis" (abdominal pain, right lower quadrant pain, or rule out appendicitis) or "nonspecific" (fever, vomiting, dehydration, etc). We evaluated the association between triage chief complaint and missed diagnosis of appendicitis. RESULTS: We reviewed 1680 patients with appendicitis. In 67 (4%) cases, patients had at least 1 additional ED visit during the week preceding the diagnosis of appendicitis. When comparing those diagnosed with appendicitis at their initial ED visit to those diagnosed after multiple visits, we found no difference in age (9.9 vs 10.1 years, P = 0.665), sex (55.7% vs 49.3% male, P = 0.291), white blood cell count (14.4 vs 12.3 × 103/L, P = 0.115), or presence of fever (19.9% vs 19.4%, P = 0.920). Of patients with a triage chief complaint that was suggestive of appendicitis, 3.8% were missed on their initial ED visit versus 8.8% of those with a nonspecific triage chief complaint (odds ratio, 2.46; 95% confidence interval, 1.1-5.6). CONCLUSIONS: A triage chief complaint less suggestive of appendicitis was associated with a higher rate of missed appendicitis in a pediatric ED. Our findings further confirm the potential impact of anchoring bias by a triage chief complaint when attempting to diagnose appendicitis.

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer.

BACKGROUND: Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. OBJECTIVES: We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. METHODS: We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality. RESULTS: Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. CONCLUSION: ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

Prospective evaluation of outcomes among geriatric chest pain patients in an ED observation unit.

OBJECTIVE: Because of concerns of high admission rates and adverse events in geriatric patients, hospitals may exclude this group from emergency department observation unit (EDOU) chest pain protocols. We sought to evaluate characteristics and outcomes of geriatric chest pain patients treated in an EDOU. METHODS: We performed a prospective, observational study of chest pain patients admitted to our EDOU over a 36-month period. We recorded baseline demographics and risk factors as well as outcomes related to the EDOU stay. We performed 30-day follow-up using telephone contact and review of the electronic medical record. RESULTS: Over the 36-month study period, 1276 chest pain patients agreed to participate in the study. Two hundred seventy-six patients (21.6%) were 65 years and older. Geriatric patients in the EDOU were more likely to report a history of coronary artery disease than nongeriatric patients (27.1% vs 11.6%, P<.001). There were no clinically significant adverse events nor deaths among geriatric patients. The proportion of geriatric patients who experienced myocardial infarction, stent, or coronary artery bypass graft during the EDOU stay or follow-up period was 4.7% vs 2.7% for nongeriatric patients (P=.09). Inpatient admission rates were significantly higher for geriatric patients (15.6% vs 9.7%, P=.006). Similarly, geriatric patients had higher rates of cardiac catheterization than did nongeriatric patients (13.4% vs 7.9%, P=.005). CONCLUSION: Geriatric patients with chest pain may represent a higher-risk group for evaluation in the EDOU. In our experience, however, these patients were safely evaluated in the EDOU setting and their inpatient admission rate fell within generally accepted guidelines.

Predictors of patient adherence to follow-up recommendations after an ED visit.

BACKGROUND: It is unclear whether factors identified during the emergency department (ED) visit predict noncompliance with ED recommendations. STUDY OBJECTIVE: We sought to determine predictors of adherence to medical recommendations after an ED visit. METHODS: We conducted a prospective, observational study at a single urban medical center. Eligible ED patients provided baseline demographic data as well as information regarding insurance status, whether they had a primary care physician (PCP), and the impact of cost of care on their ability to follow medical recommendations. Patients were contacted at least 1 week after the ED visit and answered questions regarding adherence to medical recommendations. RESULTS: Four hundred twenty-two patients agreed to participate in the study. At follow-up, 89.7% of patients reported that they had complied with recommendations made during the ED visit. Patients who were adherent to follow-up recommendations were more likely to have a primary care provider (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.1), have an annual income of greater than $35000 (OR, 2.9; 95% CI, 1.2-7.2), and report a non-Hispanic ethnicity or race (OR, 2.8; 95% CI, 1.1-7.1). Individuals who reported that cost "sometimes" or "always" impacts their ability to follow their physician's recommendations were significantly less likely to comply with ED recommendations (OR, 2.7; 95% CI, 1.3-5.6). CONCLUSION: Individuals who reported that cost affects their ability to follow their physician's recommendations and those who did not have a PCP were less likely to follow ED recommendations. Identification of predictors of noncompliance during the ED visit may aid in ensuring compliance with ED recommendations.

Emergency physician knowledge of reimbursement rates associated with emergency medical care.

STUDY OBJECTIVE: We investigated emergency physician knowledge of the Centers for Medicare & Medicaid Services (CMS) reimbursement for common tests ordered and procedures performed in the emergency department (ED), determined the relative accuracy of their estimation, and reported the impact of perceived costs on physicians' ordering and prescribing behavior. METHODS: We distributed an online survey to 189 emergency physicians in 11 EDs across multiple institutions. The survey asked respondents to estimate reimbursement rates for a limited set of medical tests and procedures, rate their level of current cost knowledge, and determine the effect of health expenditures on their medical decision making. We calculated relative accuracy of cost knowledge as a percent difference of participant estimation of cost from the CMS reimbursement rate. RESULTS: Ninety-seven physicians participated in the study. Most respondents (65%) perceived their knowledge of costs as inadequate, and 39.3% indicated that beliefs about cost impacted their ordering behavior. Eighty percent of physicians surveyed were unable to estimate 25% of the costs within ±25%, and no physicians estimated at least 50% of costs within 25% of the CMS reimbursement and only 17.3% of medical services were estimated correctly within ±25% by 1 or more physicians. CONCLUSION: Most emergency physicians indicated they should consider cost in their decision making but have a limited knowledge of cost estimates used by CMS to calculate reimbursement rates. Interventions that are easily accessible and applicable in the ED setting are needed to educate physicians about costs, reimbursement, and charges associated with the care they deliver.

Emergency Medicine resident anesthesia training in a private vs. academic setting.

BACKGROUND: Airway management is an essential part of any Emergency Medicine (EM) training program. Academic centers typically provide training to many learners at various training levels in a number of medical specialties during anesthesiology rotations. This potentially creates competition for intubation procedures that may negatively impact individual experiences. OBJECTIVES: We hypothesized that residents would report higher numbers of intubations and improved educational value in a private practice, rather than an academic, anesthesiology rotation. METHODS: EM residents' anesthesiology training was evaluated pre and post a change in training setting from an academic institution to a private practice institution. Outcome measures included the number of self-reported intubations, resident ratings of the rotation, and the number of positive comments. Residents' evaluation was measured with: a 14-item evaluation; subjective comments, which two blinded reviewers rated as positive, negative, or neutral; and transcripts from structured interviews to identify themes related to training settings. RESULTS: The number of intubations increased significantly in the private practice setting (4.6 intubations/day vs. 1.5 intubations/day, p < 0.001). Resident evaluations improved significantly with the private practice experience (mean scores of 3.83 vs. 2.23, p-values <0.05). Residents' impressions were also significantly higher for the private practice setting with respect to increased educational value, greater use of adjunct airway devices, and directed teaching. CONCLUSIONS: Number of intubations performed and residents' rating of the educational value were more favorable for a private practice anesthesiology rotation. Alternative settings may provide benefit for training in areas that have competition among trainees.

Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study.

INTRODUCTION: Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer. MATERIALS AND METHODS: Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017. RESULTS: Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics. DISCUSSION: We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.

Palliative Care Needs and Clinical Outcomes of Patients with Advanced Cancer in the Emergency Department.

Background: Older adults with cancer use the emergency department (ED) for acute concerns. Objectives: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. Design: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. Settings/Subjects: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. Measurements: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. Results: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0-7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0-3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2-10.4]). Conclusions: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.

Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN.

PURPOSE: Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS: We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS: Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION: In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.

Gender-based Barriers to the Advancement of Women in Academic Emergency Medicine: A Multi-Institutional Survey Study.

INTRODUCTION: Leadership positions occupied by women within academic emergency medicine have remained stagnant despite increasing numbers of women with faculty appointments. We distributed a multi-institutional survey to women faculty and residents to evaluate categorical characteristics contributing to success and differences between the two groups. METHODS: An institutional review board-approved electronic survey was distributed to women faculty and residents at eight institutions and were completed anonymously. We created survey questions to assess multiple categories: determination; resiliency; career support and obstacles; career aspiration; and gender discrimination. Most questions used a Likert five-point scale. Responses for each question and category were averaged and deemed significant if the average was greater than or equal to 4 in the affirmative, or less than or equal to 2 in the negative. We calculated proportions for binary questions. RESULTS: The overall response rate was 55.23% (95/172). The faculty response rate was 54.1% (59/109) and residents' response rate was 57.1% (36/63). Significant levels of resiliency were reported, with a mean score of 4.02. Childbearing and rearing were not significant barriers overall but were more commonly reported as barriers for faculty over residents (P <0.001). Obstacles reported included a lack of confidence during work-related negotiations and insufficient research experience. Notably, 68.4% (65/95) of respondents experienced gender discrimination and 9.5% (9/95) reported at least one encounter of sexual assault by a colleague or supervisor during their career. CONCLUSION: Targeted interventions to promote female leadership in academic emergency medicine include coaching on negotiation skills, improved resources and mentorship to support research, and enforcement of safe work environments. Female emergency physician resiliency is high and not a barrier to career advancement.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021.

OBJECTIVES: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. METHODS: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. RESULTS: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). CONCLUSION: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

The Eyes Have It: A Low-Cost Model for Corneal Foreign Body Removal Training.

Audience: This corneal foreign body simulator is designed to instruct junior emergency medicine (EM) residents and medical students with an interest in emergency medicine. Introduction: Eye complaints are common in the emergency department (ED), accounting for approximately 2 million ED visits each year.1 Corneal foreign bodies (CFB) account for approximately 7.5% of these presentations, and many EM providers are uncomfortable with removal procedures.1-3 Simulation has been demonstrated to improve provider comfort with this skill.4,5 Previous models for CFB removal have been created using wax over glass spheres, molded materials with silicone and ballistics gel, bovine eyes, cardboard glove boxes with ink stains simulating foreign bodies and rust rings, and agar plates with pepper-corns. 4-9 Often, these models are expensive or time-consuming to create or lack spatial realism.We propose that a simple, inexpensive model will be effective in increasing emergency provider comfort with CFB removal under slit lamp magnification in addition to increasing provider comfort using a slit lamp. Educational Objectives: By the end of the session, the learner should be able to adequately focus a slit lamp in order to identify and magnify a corneal foreign body and demonstrate safe technique for removal of a corneal foreign body under slit lamp guidance. Educational Methods: We created a low-fidelity CFB simulator for approximately $15 utilizing a Styrofoam ball, toothpicks, grapes, novelty glasses, and magnesium shavings. Toothpicks secured grapes into simulated orbits, scooped out of a Styrofoam ball. We fastened the Styrofoam ball to the slit lamp using medical tape. We added novelty glasses to simulate working around facial features. A senior resident instructor then used forceps to insert small magnesium shavings into the grapes to simulate foreign bodies. Participants received an introduction on techniques for successful CFB removal using the bevel of a needle under slit lamp guidance.10,11 They practiced using the models under supervision of an instructor. Research Methods: We conducted a prospective trial using a convenience sample of 19 learners at a university-based EM residency program, including EM interns, one emergency advanced-practice clinician, and fourth-year medical students participating in an EM sub-internship. We analyzed results using a Fisher's exact test. Results: Before training, few participants (36.8%) had observed a corneal foreign body removal, and only 15.8% had performed the procedure. More than half (52.6%) of participants said they were somewhat or very comfortable using a slit lamp before the training and 89.5% were somewhat or very comfortable after training (p=0.029). None of the participants were somewhat or very comfortable removing CFBs before the training and 84.2% were somewhat or very comfortable post-training (p<0.001). Discussion: Results suggest that simulation with this low-cost model effectively improves provider comfort in CFB removal in addition to improving comfort using a slit lamp. Topics: Eye exam, eye injury, ocular injury, corneal injury, corneal foreign body, slit lamp, corneal foreign body removal.

Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments.

Importance: Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective: To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants: This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures: The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results: Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance: This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

Statin therapy interacts with cytomegalovirus seropositivity and high C-reactive protein in reducing mortality among patients with angiographically significant coronary disease.

BACKGROUND: Seropositivity to cytomegalovirus (CMV) and elevated C-reactive protein (CRP) may jointly predict increased mortality rates in patients with coronary artery disease (CAD). Therapy with statins reduces lipid levels but may also have other beneficial (eg, antiinflammatory) effects. This study prospectively evaluated the effect of statins on CMV-and CRP-associated death among patients with significant, angiographically defined CAD. METHODS AND RESULTS: We monitored 2315 patients with angiographically significant CAD (stenosis > or =70%) for an average of 2.4 years (maximum, 5.8 years). Anti-CMV IgG antibody levels and CRP concentrations were measured at baseline, and statin prescription was recorded. As previously reported, mortality rate was higher for CMV seropositivity (+) with high CRP (hazard ratio [HR], 2.0) and lower for statins (HR, 0.50). Compared with CMV(-)/low CRP (mortality rate, 5% with statin versus 4% without statin), the protective effect of statin therapy was markedly greater for CMV(+)/low CRP (mortality rate, 2% versus 7%; HR, 0.44; 95% CI, 0.16 to 1.3), CMV negative (-)/high CRP (mortality rate, 1% versus 8%; HR, 0.16), and CMV(+)/high CRP (mortality rate, 6% versus 17%; HR, 0.42; 95% CI, 0.25 to 0.70). After adjustment, interactions were found for statin therapy with CMV(+)/low CRP (P for interaction=0.065), CMV(-)/high CRP (P for interaction=0.051), and CMV(+)/high CRP (P for interaction=0.024). CONCLUSIONS: The survival benefit of statins interacted with CMV seropositivity and high CRP to significantly reduce mortality rates among patients with CAD. This finding supports the hypothesis that statins have beneficial, "lipid-independent," antiinflammatory effects. The mechanism of statin benefit associated with CMV seropositivity remains to be determined.

Significance of an Indeterminate Troponin I in Patients Evaluated for Chest Pain in an Emergency Department Observation Unit.

BACKGROUND: Previous studies have suggested that patients with an indeterminate troponin I (TnI) in the emergency department (ED) are significantly more likely to be diagnosed with acute myocardial infarction (MI). The role of the ED observation unit (EDOU) in the evaluation of these patients is unclear. OBJECTIVE: We sought to determine the risk of MI and revascularization in chest pain patients with an indeterminate TnI in the ED, who were placed in an EDOU. METHODS: We performed a prospective evaluation with 30-day follow-up for all chest pain patients placed in the University of Utah EDOU between June 1, 2009 and May 31, 2012. The EDOU excludes patients with a positive TnI, significant electrocardiogram changes, or active chest pain; however, the EDOU is utilized for further evaluation of patients who have an initial indeterminate TnI (0.06 ng/mL-0.49 ng/mL) with serial TnI measurements, cardiology consult, and potential provocative testing. We identified all patients who had an indeterminate TnI on initial testing in the ED. Primary outcomes were MI, revascularization with cardiac stent or coronary artery bypass graft, and death. RESULTS: We evaluated 1276 chest pain patients in the EDOU over the 3-year study period (average age: 54.1 years, 54% female). Fifty-eight patients (4.5%) had an initial indeterminate TnI. There were no deaths or adverse outcomes in the EDOU among those with an indeterminate TnI, and none of these patients developed a positive TnI during their hospital stay or 30-day follow-up. Patients with an indeterminate TnI had a higher rate of inpatient admission from the EDOU (24.1% vs. 10.3%; P=0.001). Among those with an indeterminate TnI, 8.6% underwent revascularization, while the rate of revascularization or MI was 2.9% among those who did not have an initial indeterminate TnI (P=0.032). CONCLUSION: Patients evaluated in our EDOU for chest pain with an initial indeterminate TnI did not develop subsequent MI. However, these patients had an increased rate of revascularization and inpatient admission compared with controls. While our experience suggests that patients with an indeterminate TnI may be safely evaluated in an observation setting, EDOUs which treat only low-risk chest pain patients may wish to recommend inpatient admission for this patient group.