Myocarditis, Myositis, and Myasthenia Gravis Overlap Syndrome Associated with Immune Checkpoint Inhibitors: A Systematic Review.

Immune checkpoint inhibitors (ICIs) have significantly transformed cancer treatment, but their use is linked to immune-related adverse events (irAEs), including the rare ICI-associated myocarditis, myositis, and myasthenia gravis (MMM) overlap syndrome. This systematic review aims to highlight MMM's clinical implications in emergency departments. PubMed and Embase were searched using a specific search strategy. Reports were eligible for inclusion if all three conditions were present and associated with the use of an ICI. Data were extracted by independent reviewers using the Rayyan web application for systematic reviews. Descriptive statistics and qualitative synthesis were used to summarize demographic, clinical, and treatment data for the reported cases. Among 50 cases, predominantly associated with melanoma, lung cancer, and renal cancer, the in-hospital mortality rate was 38.0%. The most commonly presenting symptoms were ptosis (58%), dyspnea (48%), diplopia (42%), or myalgia (36%). The median time from ICI initiation to MMM presentation was 21 days (interquartile range: 15-28 days). Corticosteroids were the primary treatment for the irAEs. MMM, a rare but potentially fatal complication of ICI therapy, requires prompt recognition in emergency settings. Corticosteroids should be initiated if suspected, without waiting for confirmation. Multidisciplinary collaboration is vital for diagnosis and treatment planning. Research on MMM's link to specific cancers and ICIs is imperative for better risk assessment and interventions.

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.

Emergency department use by patients who received chimeric antigen receptor T cell infusion therapy.

Background: Chimeric antigen receptor T cell infusion (CAR T) therapy has revolutionized the treatment of hematologic malignancies, but treatment-related toxicities are of concern. Understanding the timing and reasons for which patients present to the emergency department (ED) after CAR T therapy can assist with the early recognition and management of toxicities. Methods: A retrospective observational cohort study was conducted for patients who had undergone CAR T therapy in the past 6 months and visited the ED of The University of Texas MD Anderson Cancer Center between 04/01/2018 and 08/01/2022. The timing of presentation after CAR T product infusion, patient characteristics, and outcomes of the ED visit were examined. Survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. Results: During the period studied, there were 276 ED visits by 168 unique patients. Most patients had diffuse large B-cell lymphoma (103/168; 61.3%), multiple myeloma (21/168; 12.5%), or mantle cell lymphoma (16/168; 9.5%). Almost all 276 visits required urgent (60.5%) or emergent (37.7%) care, and 73.5% of visits led to admission to the hospital or observation unit. Fever was the most frequent presenting complaint, reported in 19.6% of the visits. The 30-day and 90-day mortality rates after the index ED visits were 17.0% and 32.2%, respectively. Patients who had their first ED visit >14 days after CAR T product infusion had significantly worse overall survival (multivariable hazard ratio 3.27; 95% confidence interval 1.29-8.27; P=0.012) than patients who first visited the ED within 14 days of CAR T product infusion. Conclusion: Cancer patients who receive CAR T therapy commonly visit the ED, and most are admitted and/or require urgent or emergent care. During early ED visits patients mainly present with constitutional symptoms such as fever and fatigue, and these early visits are associated with better overall survival.

Characteristics and Outcomes of Patients with Cancer Pain Placed in an Emergency Department Observation Unit.

Pain remains an undertreated complication of cancer, with poor pain control decreasing patients' quality of life. Traditionally, patients presenting to an emergency department with pain have only had two dispositions available to them: hospitalization or discharge. A third emerging healthcare environment, the emergency department observation unit (EDOU), affords patients access to a hospital's resources without hospitalization. To define the role of an EDOU in the management of cancer pain, we conducted a retrospective study analyzing patients placed in an EDOU with uncontrolled cancer pain for one year. Patient characteristics were summarized using descriptive statistics and predictors of disposition from the EDOU and were identified with univariate and multivariate analyses. Most patients were discharged home, and discharged patients had low 72-hour revisit and 30-day mortality rates. Significant predictors of hospitalization were initial EDOU pain score (odds ratio (OR) = 1.12; 95% CI 1.06−1.19; p < 0.001) and supportive care (OR = 2.04; 95% CI 1.37−3.04; p < 0.001) or pain service (OR = 2.67; 95% CI 1.63−4.40; p < 0.001) consultations. We concluded that an EDOU appears to be the appropriate venue to care for a subsegment of patients presenting to an emergency department with cancer pain, with patients receiving safe care as well as appropriate consultation and admission when indicated.

A modified emergency severity index level is associated with outcomes in cancer patients with COVID-19.

OBJECTIVE: To evaluate a modified emergency severity index (mESI)-based triage of cancer patients with coronavirus disease 2019 (COVID-19) in the emergency department (ED) and determine the associations between mESI level and ED disposition, hospital length of stay, and overall survival. METHODS: Medical records were retrospectively reviewed for all patients who presented to our institution's ED between March 22, 2020, and March 12, 2021, and tested positive for SARS-CoV-2. RESULTS: A total of 306 cancer patients tested positive for SARS-CoV-2, with 45% of patients triaged to level 2 (emergent) and 55% to level 3 (urgent). Among all patients, 61.8% were admitted to the hospital, 15.7% were admitted to the intensive care unit, 2.9% were sent for observation, and 19.6% were discharged. Although demographic and clinical characteristics did not significantly vary by triage level, we observed significant differences in ED length of stay (urgent = 6.67 h, emergent = 5.97 h; p < 0.01). Hospital and intensive care unit admission rates were also significantly higher among emergent patients than among urgent patients (p < 0.05). There were 75 deaths (urgent = 32; emergent = 43), and the 30-day mortality rate was significantly higher among emergent patients (urgent = 8%, emergent = 15%; p < 0.05). The mESI level persisted as a significant factor associated with overall survival (hazard ratio = 1.7, 95% confidence interval = 1.09-2.81) in multivariable analysis. CONCLUSION: The mESI level is associated with ED disposition, ED length of stay, and overall survival in cancer patients presenting with COVID-19. These results indicate that the mESI triage tool can be effectively used in cancer patients with COVID-19, whose condition can rapidly deteriorate.

The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain.

PURPOSE OF REVIEW: Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain. RECENT FINDINGS: Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.

Outcomes of Patients Placed in an Emergency Department Observation Unit of a Comprehensive Cancer Center.

PURPOSE: Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. METHODS: We performed a retrospective observational study that included all patients age 18 years and older who presented to our emergency department (ED) and were placed in the EDOU between March 1, 2019, and February 29, 2020. The patients' electronic medical records were queried for demographics, comorbidities, diagnosis at the time of placement in the EDOU, length of stay, disposition from the EDOU, ED return within 72 hours after discharge from the EDOU, and mortality outcomes at 14 and 30 days. RESULTS: A total of 2,461 visits were eligible for analysis. Cancer-related pain was the main reason for observation in more than one quarter of the visits. The median length of stay in the EDOU was approximately 23 hours, and 69.6% of the patients were discharged. The ED return rate for unscheduled visits at 72 hours was 1.9%. The 14- and 30-day mortality rates were significantly higher for patients who were admitted than for those who were discharged (14 days: 1.7% v 0.3%, P < .001; 30 days: 5.9% v 1.8%, P < .001). CONCLUSION: Our data suggest that placing patients with cancer in EDOUs is safe, reduces admissions, and reserves hospital resources for patients who can receive the most benefit without compromising care.

Evaluation and Management of Genitourinary Emergencies in Patients with Cancer.

BACKGROUND: Genitourinary emergencies in cancer patients are common. Most cancer treatments are administered in the outpatient setting, and patients with complications often visit the emergency department. However, there is no recent emergency medicine literature review focusing on genitourinary emergencies in the oncologic population. Objective of the review. To increase awareness of common genitourinary emergencies in patients with cancer and enable the prompt recognition and appropriate management of these conditions. Discussion. Genitourinary emergencies in patients with cancer require a multidisciplinary approach to treatment. The most common genitourinary emergencies in patients with cancer are related to infection, obstructive uropathy, hemorrhagic cystitis, and complications associated with urinary diversions. The treatment approach in patients with infections, including viral infections, is similar to those without cancer. Understanding the changes in the anatomy of patients with urinary diversions or fistulas can help with the management of genitourinary emergencies. CONCLUSIONS: Familiarization with the uniqueness of genitourinary emergencies in patients with cancer is important for emergency physicians.

A Model Oncologic Emergency Medicine Curriculum for Residency Training.

Background Emergency medicine (EM) resident training in oncologic emergencies is limited, and significant gaps have been identified. Although 90% of emergency medicine residency program directors recognize the importance of residency training in oncologic emergencies, there is no standardized oncologic emergency curriculum. Objective We propose a focused oncologic EM curriculum that serves as a complement to existing EM didactics curriculums to prepare EM residents to recognize and manage the most common oncologic emergencies. It will also allow for familiarization with constantly evolving therapies, such as chimeric antigen receptor cellular therapy and immune checkpoint inhibitors.Discussion This curriculum consists of 10 hours of didactic instruction, which can be incorporated into an already existing didactic curriculum. The curriculum encompasses education on the recognition, rapid diagnosis, and management of oncologic emergencies, with the goal of improving the EM resident's understanding of cancer complications. The suggested topics can be delivered in a variety of methods, allowing for flexible integration in an already existing emergency education curriculum. The proposed curriculum should be introduced during the first postgraduate year and then in the second or third year of the residency to reinforce the learning points.Conclusions Our proposal of a focused, standardized 10 hour program curriculum aims to help to fill the gaps in knowledge of oncologic emergencies. To assist in wide dissemination and standardization of these curriculum topics, outlines for each module are given in the article and we also propose creation of open access online lectures and content to be shared for education purposes.

Diagnosis and management of immune-related adverse effects of immune checkpoint therapy in the emergency department.

Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first-line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune-related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune-related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment-related toxicities.

Depression and survival outcomes after emergency department cancer pain visits.

OBJECTIVES: Pain and depression frequently co-occur in patients with cancer. Although pain is a common reason for emergency department (ED) presentation by these patients, depression frequently goes unrecognised during an ED visit. In this study, we assessed the risk for depression in patients with cancer presenting to the ED for uncontrolled pain and assessed the extent to which the risk for depression was associated with survival in this population. METHODS: Participants were consecutive patients with cancer taking Schedule II opioids (n=209) who presented to the ED of a tertiary cancer centre for uncontrolled pain. Risk for depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D), excluding the somatic symptoms. Survival was calculated from date of ED visit to date of death/last follow-up. RESULTS: The CES-D was completed by 197 of 209 participants (94.3%); of these, 81 of 197 (41.1%) had high risk for depression (CES-D ≥10). The mean survival time for the entire sample was 318 days (SD=33), with 84 deaths. Cox proportional hazards regression modeling showed that risk for depression and disease stage (CES-D ≥10: HR=1.75, 95% CI 1.11 to 2.78, p=0.016; disease stage: HR=2.52, 95% CI 1.20 to 5.30, p<0.001) were significant factors for survival. CONCLUSIONS: Risk for depression was prevalent and associated with survival outcomes in patients with cancer presenting to the ED with uncontrolled pain. Screening for risk for depression in the ED may identify patients who need referral for clinical assessment of depression. Diagnosis and adequate treatment could improve health outcomes and survival rates for these patients.

Cardiopulmonary resuscitation outcomes in a cancer center emergency department.

BACKGROUND: Cardiopulmonary resuscitation (CPR) after cardiac arrest is utilized indiscriminately among unselected populations. Cancer patients have particularly low rates of return of spontaneous circulation (ROSC) and survival to hospital discharge after CPR. Our study determines rates of ROSC and survival to hospital discharge among cancer patients undergoing CPR in our cancer center. We examined whether these rates have changed over the past decade. METHODS: This IRB-approved retrospective observational study was conducted in our cancer center. The ED and cancer center provide medical care for ≥ 115,000 patients annually. Cases of CPR presenting to the cancer center for years 2003-2012 were identified using Institutional CPR and Administrative Data for Resuscitation and Billing databases. Age, gender, ethnicity, ROSC and Discharge Alive using a modified Utsein template was used to compare proportions achieving ROSC and survival to hospital discharge for two time periods: 2003-2007 (Group 1) and 2008-2012 (Group 2), using traditional Pearson chi-square statistics. RESULTS: One hundred twenty-six cancer center patients received CPR from 2003-2012. Group 1 (N = 64) and Group 2 (N = 62) were similar; age (60 vs. 60 years), gender (63% vs. 58% male), and race/ethnicity (67% vs. 56% White). Proportions achieving ROSC were similar in the two time periods (36% Group 1 vs. 45% Group 2, OR = 1.47, 95% CI 0.72 - 3.00) as was survival to hospital discharge (11% Group 1 vs. 10% Group 2, OR 0.87, 95% CI 0.28 - 2.76). CONCLUSIONS: ROSC after CPR in cancer patients and survival to hospital discharge did not change over time.

Exploratory study of emergency physicians' use of a prescription monitoring program using a framework of technology acceptance.

Emergency physicians (EPs) are faced with significant challenges regarding pain management, while preventing abuse of prescription opioids. Prescription monitoring programs (PMPs) are increasingly used to help allay the abuse of controlled substances. The objective of this study was to determine EPs' intention to use the Texas PMP within the framework of the Technology Acceptance Model. A cross-sectional, 24-item survey instrument was developed and distributed to EPs attending an emergency medicine conference. PMP nonusers reported a positive intention to use the PMP in the future, with attitude (ß = 0.61, p < 0.01) as the only statistically significant predictor of intention. PMP users reported a positive intention to use the PMP, with perceived usefulness (ß = 0.62, p < 0.01) as the only statistically significant predictor of intention for PMP users. This exploratory study provides a basis for understanding EPs' intention to use a PMP. The use of PMPs by EPs may lead to a decrease in prescription opioid abuse and improve patient safety related to opioid prescribing in the emergency department setting.

Prescription opioid guidelines and the emergency department.

On January 10, 2013, Mayor Michael Bloomberg announced a set of recommendations intended to guide opioid analgesic prescribing in New York City emergency departments. The intent and scope of these guidelines are discussed through an interview by an emergency medicine fellow with an expert in emergency medicine pain management and one of the authors of the guidelines. The guidelines are appended to the commentary.

Mustard gas or sulfur mustard: an old chemical agent as a new terrorist threat.

Sulfur mustard is a member of the vesicant class of chemical warfare agents that causes blistering to the skin and mucous membranes. There is no specific antidote, and treatment consists of systematically alleviating symptoms. Historically, sulfur mustard was used extensively in inter-governmental conflicts within the trenches of Belgium and France during World War I and during the Iran-Iraq conflict. Longitudinal studies of exposed victims show that sulfur mustard causes long-term effects leading to high morbidity. Given that only a small amount of sulfur mustard is necessary to potentially cause an enormous number of casualties, disaster-planning protocol necessitates the education and training of first-line healthcare responders in the recognition, decontamination, triage, and treatment of sulfur mustard-exposed victims in a large-scale scenario.