Oncologic emergencies and urgencies: A comprehensive review.

Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.

Concordance Between Electronic Health Record-Recorded Race and Ethnicity and Patient Report in Emergency Department Patients.

OBJECTIVE: We assessed the concordance of patient-reported race and ethnicity for emergency department (ED) patients compared with what was recorded in the electronic health record. METHODS: We conducted a single-center, prospective, observational study of 744 ED patients (English- and/or Spanish-speaking), asking them to describe their race and ethnicity. We compared the distributions of ethnicity and race between patient-reported and electronic health record data using McNemar's test. We calculated percent agreement and Cohen's kappa, with 95% confidence intervals (CI), for the concordance of patient-reported race and ethnicity with electronic health record data. RESULTS: Of 744 ED patients, 731 participants who completed the survey reported their ethnicity, resulting in 98.2% of electronic health records obtained ethnicities matched self-reported data (kappa = 0.95; 95% CI: 0.92 to 0.98). For those who self-reported as Hispanic, only 92.3% agreement was observed between the self-reported and electronic health record values. For all patients who had race recorded, 85.4% agreement was observed (kappa = 0.75; 95% CI 0.71 to 0.79). High rates of agreement were observed for Black or African American patients (98.7%) and White patients (96.6%), with low rates for those who identified as "More than one race" (22.9%) or "Other" race (1.8%). In the subset of Hispanic patients, low rates of agreement (25.0%) were observed for race (kappa = 0.10; 95% CI 0.01 to 0.19). CONCLUSIONS: Documentation discordance regarding race and ethnicity exists between electronic health records and self-reported data for our ED patients, particularly for ethnically Hispanic and Latino/a patients. Future efforts should focus on ensuring that demographic information in the electronic health record is accurately collected.

Pilot intervention to increase uptake of lung cancer screening through the emergency department.

INTRODUCTION: The goal of this study is to demonstrate the feasibility of referring patients for lung cancer screening (LCS) from the emergency department (ED) as a method to increase the uptake of LCS. METHODS: This is a single-arm pilot study at a large safety-net ED. ED LCS-eligible patients were offered a referral to our LCS clinic upon ED discharge. The primary outcome was the frequency at which patients connected with the LCS clinic. RESULTS: During the study period, 105 patients were approached; 26 (24.8%) participated. Reasons for non-enrollment include 29 (27.6%) who were not interested in research, 10 (9.5%) who did not speak English, and 40 (38.1%) who did not meet the pack-years criteria. Seventeen patients (65.4%, 17/26) connected with the LCS clinic, with 10 (38.5%) having been seen in the clinic and received a low dose computed tomography (LDCT) scan. Of the 17 that were connected with the clinic, 7 (26.9%) had a non-LDCT chest CT scan in the past year. Of those that were not seen in the clinic (n = 9), 4 (44.4%) were unreachable via 3 phone calls and a post-marked letter, and 3 (33.3%) did not attend the scheduled appointment, and 2 (22.2%) were delayed due to COVID-19. Of those that had CT scans over the study period (n = 17), 0 scans were normal, one patient (5.9%) had asymptomatic lung cancer, 7 (41.2%) had pulmonary nodules, 11 (64.7%) had emphysema, and 9 (52.9%) had coronary artery disease. CONCLUSION: This pilot study suggests the feasibility and suggests initial indications of the efficacy of referring ED patients for LCS.

Retrospective review of patients with lung cancer presenting emergently.

BACKGROUND: A significant proportion of lung cancer patients receive their diagnosis as part of an emergency presentation (EPs) to emergency departments (EDs). OBJECTIVES: This study aimed to describe EPs of lung cancer at a safety-net hospital system. METHODS: We conducted a retrospective analysis of patients with lung cancer at a safety-net ED. EP was defined as a diagnosis of lung cancer due to an acute presentation with symptoms of undiagnosed lung cancer (e.g., cough, hemoptysis, shortness of breath). Non-EPs were the result of either incidental findings (trauma pan-scan) or as part of lung cancer screening. RESULTS: A total of 333 patient charts were reviewed who had lung cancer. Of those, 248 (74.5%) were defined as having an EP. EPs were more likely stage IV than non-EPs (50.4% vs 32.9%). The percent mortality was higher for EP versus non-EP, 60.0% vs 49.4%. which is driven by a high mortality rate for stage IV EPs (77.5%). Most patients with an EP were seen in the ED (177, 71.4%) as the location of initial visit that had a workup concerning for lung cancer. Most of the EPs were admitted for completion of either their diagnostic work up and/or for symptom management (117, 66.5%). Logistic regression identified significant predictors for an EP including stage IV at diagnosis (OR 2.49, 95% CI 1.39-4.48) and lack of primary care (OR 0.07, 95% CI 0.009-0.53). CONCLUSION: Most patients with lung cancer present acutely as an EP with advanced stage in a safety-net health care setting. The ED plays an important role in the initial diagnosis of lung cancer and coordinating subsequent cancer care.

Lower extremity pain and numbness.

CLINICAL INTRODUCTION: A 45-year-old man with no past medical history presents with bilateral lower extremity pain and perineal numbness after walking 10-15 min. The pain starts in his bilateral buttocks and radiates down into his thigh and into his toes. He has no back pain, fever, difficulty urinating or stooling, incontinence or trauma. Social history is positive for smoking. Physical examination was only remarkable for non-dopplerable lower extremity pulses, and he was unable to ambulate down the ED hallway without becoming symptomatic. Ultrasound of his abdominal aorta (figure 1) was performed.emermed;35/7/419/F1F1F1Figure 1Transverse view of distal abdominal aorta, just proximal to the bifurcation. (A) The aorta without Doppler. (B) The same image with Doppler mode activated. QUESTION: What is the most likely diagnosis based on the image?A. Lumbar stenosisB. Abdominal aortic aneurysmC. Aortic thrombusD. Aortic dissection.

Intensive care unit design and mortality in trauma patients.

BACKGROUND: The architecture of medical care facilities ca affect the safety of a patient, but it is unknown if the architecture affects outcomes. We hypothesized that patients in rooms who are more visible from the central nursing station would experience better outcomes than those patients in less visible rooms. MATERIALS AND METHODS: A total of 773 patients admitted to the trauma intensive care service over a 12-mo period were retrospectively evaluated. Outcomes were hospital mortality and intensive care unit (ICU) length of stay (LOS). The unit is designed with a bank of high-visibility rooms (HVRs) directly across from the nursing station and two side sections of low-visibility rooms (LVRs). No formal triage occurs, but patients are prioritized to HVRs as available. RESULTS: Patients in the HVRs had a 16% mortality (52 of 320); meanwhile, the patients in the LVRs experienced an 11% mortality (49 of 448, P = 0.03). ICU mortality did not differ significantly when controlling for age, Charlson Comorbidity Index (CCI), Head Abbreviated Injury Score, and the Injury Severity Score (ISS) (P = 0.076). Age, CCI, Head Abbreviated Injury Score, and ISS did individually correlate with mortality (age: P = 0.0008; CCI: P = 0.017; and ISS: P < 0.0001). Visibility was not a predictor of ICU LOS or complications among survivors (mean ICU HVR LOS = 4.8 d; mean ICU LVR LOS = 4.7; P = 0.88, n = 661). Only ISS was a significant predictor of ICU LOS and complications (P < 0.0001). CONCLUSIONS: Trauma patient room placement within the ICU does not relate to mortality rate significantly when corrected for patient acuity. Instead, variables such as age, ISS, and CCI are associated with mortality. A policy of placing more critically ill patients in HVRs may prevent increased mortality in high-acuity patients.

Current gaps in emergency medicine core content education for oncologic emergencies: A targeted needs assessment.

Objective: The core content of emergency medicine (EM) residency training includes the management of oncologic emergencies; however, documented knowledge gaps continue to exist in this subtopic. This study represents a targeted needs assessment as indicated by Step 2 of Kern's curriculum design to determine the specific training gaps to be addressed within the oncologic EM curriculum. Methods: A multi-institutional cross-sectional survey of oncologists (surgical and medical) and emergency physicians (attendings and residents) was conducted during 2023 at five institutions. The voluntary survey consisted of general and specialty-specific questions exploring gaps in oncologic emergency-specific training/education topics. Descriptive statistics reported responses as frequencies and percentages. Results: Of the 833 surveys sent across the five sites, 302 (36.3%) were accessed by link; of these, 271 (89.7%) surveys were completed. There were no differences in the responses between early and later respondents and no differences in the characteristics of respondents between sites. A vast majority of the oncologist and EM groups (91.2% and 83.0%, respectively) reported a belief that emergency physicians would benefit from additional oncologic emergency training. Our survey identified 16 important topics for inclusion in an oncologic EM curriculum, including five topics not present on the 2022 Model of Clinical Practice of Emergency Medicine. Conclusions: Based on this needs assessment, an oncologic EM curriculum should include the topics listed under oncologic emergencies in the 2022 Model of the Clinical Practice of Emergency Medicine along with our respondent-identified topics of radiation therapy adverse effects, stem cell transplant complications, and the management of cancer-specific postsurgical complications, pain, and common diseases in patients with cancer.

Worsened outcomes of newly diagnosed cancer in patients with recent emergency care visits: A retrospective cohort study of 3699 adults in a safety net health system.

INTRODUCTION: Many patients receive a suspected diagnosis of cancer through an emergency department (ED) visit. Time to treatment for a new diagnosis of cancer is directly associated with improved outcomes with little no describing the ED utilization prior to the diagnosis of cancer. We hypothesize that patients that have an ED visit in proximity to a diagnosis of cancer will have worse outcomes, including mortality. METHODS: This study is a retrospective cohort study of all patients with cancer diagnosed at Eskenazi Health (Indiana) between 2016 and 2019. Individual health characteristics, ED utilization, cancer types, and mortality were studied. We compared those patients seen in the ED within 6 months prior to their diagnosis (cases) to patients not seen in the ED (controls). RESULTS: A total of 3699 patients with cancer were included, with 1239 cases (33.50%). Patients of black race had higher frequencies in the cases vs. controls (46.57% vs. 40.68%). Lung cancer was the most frequently observed cancer among cases vs. controls (11.70% vs. 5.57%). For the cases, 232 patients were deceased (18.72%) compared with 247 patients among the controls (10.04%, p < 0.0001, OR 2.06 95% confidence interval [CI] 1.70-2.51). An ED visit in past 6 months (OR = 1.73, 95% CI 1.38-2.18) and Medicaid insurance type (versus commercial, OR = 4.16, 95% CI 2.45-7.07) were associated with of mortality. Female gender (OR = 0.76, 95% CI 0.67-0.88), tobacco use (OR = 1.62, 95% CI 138-1.90), and Medicaid insurance type (versus commercial, OR = 2.56, 95% CI 2.07-3.47) were associated with prior ED use. CONCLUSIONS: Over one third of patients with cancer were seen in the ED within 6 months prior to their cancer diagnosis. Higher mortality rates were observed for those seen in the ED. Future studies are needed to investigate the association and impact that the ED has on eventual cancer diagnoses and outcomes.

Multicenter Study of Outcomes Among Persons With HIV Who Presented to US Emergency Departments With Suspected SARS-CoV-2.

BACKGROUND: There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SETTING: Multicenter registry of patients from 116 emergency departments in 27 US states. METHODS: Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status. RESULTS: Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01). CONCLUSIONS: Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.