Risk Factors and Emergency Department Outcomes in Methamphetamine-Associated Cardiomyopathy: A Case-Control Study.

BACKGROUND: Methamphetamine-associated cardiomyopathy (MACM) is a known complication of methamphetamine use; however, risk factors and outcomes of patients with MACM are not well understood. STUDY OBJECTIVES: This study aims to identify risk factors, emergency department (ED) interventions, and outcomes for MACM. METHODS: This case-control study was conducted between 2012 and 2020 at two academic EDs. ED patients ≥18 years with an index visit that included documented methamphetamine use were included. Patients with documented MACM during follow-up (3 months-3 years) were considered cases (MACM). A control group comprised of patients with documented methamphetamine use but no known MACM was matched at a 2:1 ratio. Logistic regression was used to model risk factors for MACM. RESULTS: A total of 9833 patients with methamphetamine use were identified. From this, 160 MACM patients were matched to 322 controls. The mean age was 48.4 years, and 143 patients (29.7%) were female. MACM patients were more likely to be admitted on their index visit (45.6% vs. 34.8%, p = 0.021). Significant variables associated with MACM included: admission at the index visit (odds ratio [OR] 1.51), diabetes (OR 3.02), kidney disease (OR 5.47), and pulmonary disease (OR 2.39). MACM patients had more ED visits in the follow-up period (10.1 vs. 7, p = 0.009) and were admitted at a higher rate across all visits (32.5% vs. 15.4%, p = 0.009). Additionally, MACM patients had significantly longer hospital stays than controls (mean 18 additional days, p = 0.009). CONCLUSION: Patients who developed MACM had traditional risk factors for heart failure and experienced significantly more ED visits, more hospitalizations, and longer hospital stays than matched controls.

4th Generation HIV screening in the emergency department: net profit or loss for hospitals?

ABSTRACTThe objective of this study was to determine hospital costs and revenue of universal opt-out HIV ED screening. An electronic medical record (EMR)-directed, automated ED screening program was instituted at an academic medical center in San Diego, California. A base model calculated net income in US dollars for the hospital by comparing annual testing costs with reimbursements using payor mixes and cost variables. To account for differences in payor mixes, testing costs, and reimbursement rates across hospitals in the US, we performed a probabilistic sensitivity analysis. The base model included a total of 12,513 annual 4th generation HIV tests with the following payor mix: 18% Medicare, 9% MediCal, 28% commercial and 8% self-payers, with the remainder being capitated contracts. The base model resulted in a net profit for the hospital. In the probabilistic sensitivity analysis, universal 4th generation HIV screening resulted in a net profit for the hospital in 81.9% of simulations. Universal 4th generation opt-out HIV screening in EDs resulted in a net profit to an academic hospital. Sensitivity analysis indicated that ED HIV screening results in a net-profit for the majority of simulations, with higher proportions of self-payers being the major predictor of a net loss.

Perceptions and Practices of Cannabis Use Among Emergency Department Patients.

BACKGROUND: Nationally, in states where cannabis has been legalized, increases in cannabis-related hospitalizations and emergency department (ED) visits have also been observed. OBJECTIVES: This study aims to: 1) Describe the sociodemographic characteristics of cannabis users presenting to two academic EDs in California; 2) Assess cannabis-related behaviors; 3) Assess perceptions of cannabis; 4) Identify and describe reasons for cannabis-related ED utilization. METHODS: This is a cross-sectional study of patients visiting one of two academic EDs between February 16, 2018 and November 21, 2020. Eligible participants completed a novel questionnaire developed by the authors. Basic descriptive statistics, Pearson correlation coefficients, and logistic regression were used for statistical analysis of responses. RESULTS: The questionnaire was completed by 2577 patients. A quarter were categorized as Current Users (n = 628, 24.4%). Current, Regular Users were evenly divided across gender, were relatively younger (18-34 years, 48.1%), and were largely non-Hispanic Caucasian. Over half of all respondents believed that the use of cannabis was less harmful than tobacco or alcohol use (n = 1537, 59.6%). One in five Current Users (n = 123, 19.8%) reported driving while using cannabis in the past month. A small proportion (n = 24, 3.9%) of Current Users reported ever visiting the ED for a cannabis-related chief complaint. CONCLUSIONS: Overall, many ED patients are currently using cannabis; few report utilizing the ED due to cannabis-related problems. Current, Irregular Users may represent the ideal target group for ED-based educational efforts aimed at improving knowledge of safe cannabis use.

Impacts of United States Medical Licensing Examination Step 1 Scoring Change on Emergency Medicine Applicant Screening.

BACKGROUND: The U.S. Medical Licensing Examination (USMLE) Step 1 has been used as a screening tool for residency selection. In February 2020, Step 1 numerical scoring changed to pass/fail. OBJECTIVE: Our aim was to survey emergency medicine (EM) residency program attitudes towards the new Step 1 scoring change and to identify important applicant screening factors. METHODS: A 16-question survey was distributed through the Council of Residency Directors in Emergency Medicine listserv from November 11 through December 31, 2020. Given the Step 1 scoring change, the survey questioned the importance of EM rotation grades, composite standardized letters of evaluation (cSLOEs), and individual standardized letters of evaluation, using a Likert scale. Descriptive statistics of demographic characteristics and selection factors were performed along with a regression analysis. RESULTS: Of the 107 respondents, 48% were program directors, 28% were assistant or associate program directors, 14% were clerkship directors, and 10% were in other roles. Sixty (55.6%) disagreed with pass/fail Step 1 scoring change and, of those, 82% believed that numerical scoring was a good screening tool. The cSLOEs, EM rotation grades, and interview were the most important selection factors. Residencies with 50 or more residents had 5.25 odds (95% CI 1.25-22.1; p = 0.0018) of agreeing with pass/fail scoring and those who ranked cSLOEs as the most important selection factor had 4.90 odds (95% CI 1.125-21.37; p = 0.0343) of agreeing with pass/fail scoring. CONCLUSIONS: Most EM programs disagree with pass/fail scoring of Step 1 and will most likely use Step 2 score as a screening tool. The cSLOEs, EM rotation grades, and interview are considered the most important selection factors.

Physiological Effects of a Spit Restraint Device Saturated With Artificial Saliva.

BACKGROUND: Spit restraint devices, also referred to as spit hoods, spit masks, or spit socks, are used by law enforcement and medical personnel to minimize transmission of communicable disease from bodily fluids from agitated individuals. Several lawsuits have implicated spit restraint devices as contributing to the death of individuals who are physically restrained by means of asphyxiation due to saturation of the mesh restraint device with saliva. OBJECTIVES: This study aims to evaluate whether a saturated spit restraint device has any clinically significant effects on the ventilatory or circulatory parameters of healthy adult subjects. METHODS: Subjects wore a spit restraint device dampened with 0.5% carboxymethylcellulose, an artificial saliva. Baseline vitals were taken, and a wet spit restraint device was then placed over the subject's head, and repeat measurements were taken at 10, 20, 30, and 45 min. A second spit restraint device was placed 15 min after the first. Measurements at 10, 20, 30, and 45 min were compared with baseline using paired t-tests. RESULTS: The mean age of 10 subjects was 33.8 years, and 50% were female. There was no significant difference between baseline and while wearing the spit sock for 10, 20, 30, and 45 min for the measured parameters including heart rate, oxygen saturation, end-tidal CO2, respiratory rate, or blood pressure. No subject indicated respiratory distress or had to terminate the study. CONCLUSIONS: In healthy adult subjects, there were no statistically or clinically significant differences in ventilatory or circulatory parameters while wearing the saturated spit restraint.

Procalcitonin as a Predictive Tool for Death and ICU Admission among Febrile Neutropenic Patients Visiting the Emergency Department.

Background and Objectives: Risk stratification tools for febrile neutropenia exist but are infrequently utilized by emergency physicians. Procalcitonin may provide emergency physicians with a more objective tool to identify patients at risk of decompensation. Materials and Methods: We conducted a retrospective cohort study evaluating the use of procalcitonin in cases of febrile neutropenia among adult patients presenting to the Emergency Department compared to a non-neutropenic, febrile control group. Our primary outcome measure was in-hospital mortality with a secondary outcome of ICU admission. Results: Among febrile neutropenic patients, a positive initial procalcitonin value was associated with significantly increased odds of inpatient mortality after adjusting for age, sex, race, and ethnicity (AOR 9.912, p < 0.001), which was similar, though greater than, our non-neutropenic cohort (AOR 2.18, p < 0.001). All febrile neutropenic patients with a positive procalcitonin were admitted to the ICU. Procalcitonin had a higher sensitivity and negative predictive value (NPV) in regard to mortality and ICU admission for our neutropenic group versus our non-neutropenic control. Conclusions: Procalcitonin appears to be a valuable tool when attempting to risk stratify patients with febrile neutropenia presenting to the emergency department. Procalcitonin performed better in the prediction of death and ICU admission among patients with febrile neutropenia than a similar febrile, non-neutropenic control group.

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.

The effects of a morphine shortage on emergency department pain control.

OBJECTIVE: In 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition. METHODS: This was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17-6/30/17 and our study period (without morphine) was 4/1/18-6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition. RESULTS: We identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study -3.30, control -3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01). CONCLUSIONS: Removing IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.

Barriers to medication adherence in the emergency department: A cross-sectional study.

BACKGROUND: Medication nonadherence is a common problem that leads to increased healthcare utilization. It is unclear how patient insight and attitude towards their medications affect adherence in the ED. Furthermore, it is unclear how perceived medication importance differs between patients and ED physicians. METHODS: We conducted a cross sectional study of adult patients presenting to 2 academic emergency departments from April 2015 to October 2016. Demographic data were collected and questions were asked regarding medication knowledge, perceived importance, and adherence. We also compared perceived importance of medications between patients and two physician raters. Inter-rater agreement was reported as raw percentages, and categorical data were compared using chi-squared analysis. RESULTS: We identified 1268 patients, representing 4634 individual medications. We identified a significant association between knowledge of medications and perceived importance (p < .05). Secondarily, importance level was highly associated with medication adherence (p < .05). When ranking those medications that were considered "least" and "most" important among each patient's med list, our two physicians agreed with patients only 34.1% and 37% of the time respectively, as opposed to 62% and 62.8% agreement between each other. CONCLUSIONS: These data suggest that there is a difference in perceived medication importance between ED physicians and ED patients. Knowledge of a medication's purpose is significantly associated with perceived importance, while this importance appears to be significantly associated with compliance. These results suggest that concerted efforts by ED physicians and staff to educate patients on the utility and importance of their medications may improve adherence.

Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position.

BACKGROUND: The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise. METHODS: Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences. RESULTS: We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001). CONCLUSIONS: In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.

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.

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

BACKGROUND: There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). OBJECTIVE: To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. METHODS: A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. RESULTS: Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. CONCLUSION: Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.

The political economy of state responses to infectious disease.

How can public policy best deal with infectious disease? In answering this question, scholarship on the optimal control of infectious disease adopts the model of a benevolent social planner who maximizes social welfare. This approach, which treats the social health planner as a unitary "public health brain" standing outside of society, removes the policymaking process from economic analysis. This paper opens the black box of the social health planner by extending the tools of economics to the policymaking process itself. We explore the nature of the economic problem facing policymakers and the epistemic constraints they face in trying to solve that problem. Additionally, we analyze the incentives facing policymakers in their efforts to address infectious diseases and consider how they affect the design and implementation of public health policy. Finally, we consider how unanticipated system effects emerge due to interventions in complex systems, and how these effects can undermine well-intentioned efforts to improve human welfare. We illustrate the various dynamics of the political economy of state responses to infectious disease by drawing on a range of examples from the COVID-19 pandemic.

Trends in emergency physician opioid prescribing practices during the United States opioid crisis.

BACKGROUND: Prescription opioid related deaths have increased dramatically over the past 17 years. Although emergency physicians (EPs) have not been the primary force behind this rise, previous literature have suggested that EPs could improve their opioid prescribing practices. We designed this study to evaluate the trend in emergency department (ED) opioid prescriptions over time during the US opioid epidemic. METHODS: We conducted a retrospective cohort study from July 1, 2012 to June 30, 2018, evaluating all adult patients who presented to two study EDs for a pain-related complaint and received an analgesic prescription upon ED discharge. We compared these data to trends in lay media and medical literature regarding the opioid epidemic. We also evaluated the incidence of repeat ED visits based on the type of analgesic prescriptions provided. RESULTS: Opioid prescriptions decreased from 37.76% to 13.29% over the six year study period. This coupled with an increase in non-opioid medications from 6.12% to 11.33% and an increase in "no prescription" from 56.12% to 75.37%. This corresponded with an increase in the number of publications on the opioid epidemic within the lay-public and medical literature. Additionally, those patients that received no opiates were less likely to require a repeat ED visit. CONCLUSIONS: ED physicians are prescribing less opiates, while increasing the amount of non-narcotic analgesic prescriptions. This may be in response to the literature suggesting that prescription opioids play a large role in the opioids crisis. This decrease in opioid prescriptions did not increase the need for repeat ED visits.

Management of Chimeric Antigen Receptor (CAR) T-Cell Toxicities: A Review and Guideline for Emergency Providers.

BACKGROUND: Chimeric antigen receptor (CAR) T-cell therapy is an adoptive cellular immunotherapy that is being utilized more frequently due to its initial success in advanced-stage cancers. Unfortunately, CAR T-cell therapy is often associated with acute systemic toxicities, including cytokine release syndrome (CRS) and CAR T-cell-associated neurotoxicity (neurotoxicity). OBJECTIVE: We created a review that addresses the potential common emergency department (ED) presentations associated with CAR T-cell therapy. We reviewed the relevant research and clinical guidelines to develop a guide tailored toward addressing the needs of the emergency medicine community to manage these complications. In addition, a case is presented and the evaluation and management of CRS and neurotoxicity are reviewed in detail. DISCUSSION: Despite CAR T-cell designs showing promising results, the risk of acquiring an acute toxicity is high, with CRS and neurotoxicity reported most often. The systemic toxicities associated with these adverse events can lead to end-organ damage and compromise the patient acutely or jeopardize the continuation in treatment of their underlying malignancy. Depending on the severity of the toxicity, treatment typically starts with vigilant supportive care, but may include administration of tocilizumab and possibly high-dose corticosteroids if the toxicity is deemed of high severity. CONCLUSIONS: With the increasing administration of CAR T-cell therapy, emergency physicians will likely encounter more patients with associated adverse events, including CRS and neurotoxicity. It is increasingly important that emergency physicians are aware of these potential toxicities in order to rapidly diagnose and treat patients undergoing CAR T-cell therapy.

Physiological effects of a spit sock.

OBJECTIVES: Healthcare providers and law enforcement utilize spit socks to prevent exposure to communicable diseases transmitted by bodily fluid projection from agitated individuals. There are cases in which death is reported due to breathing being limited by a spit sock. There are no formally published studies on their use and safety. The aim of this study was to evaluate whether wearing a spit sock causes a clinically significant impact on breathing. METHODS: Subjects sat with the spit mask over their heads for 15 min and their vital signs and ventilatory parameters were recorded after 5 min, 10 min and 15 min. Data were compared to baseline using Student's t-test with 95% confidence intervals using SPSS. RESULTS: The median age of the 15 subjects was 28 years and 53% were male. There was no significant difference between baseline and wearing the spit sock for 5, 10 or 15 min for heart rate (p = 0.250, p = 0.181, p = 0.546), oxygen saturation (p = 0.334, p = 1.00, p = 0.173), end-tidal pCO2 (p = 0.135, p = 0.384, p = 0.187), and diastolic blood pressure (p = 0.485, p = 0.508, p = 0.915). The respiratory rate was not significantly different after 5 and 10 min (p = 0.898, p = 0.583), but decreased at 15 min (p = 0.048). The systolic blood pressure was lower after 5 and 10 min (p = 0.028, p = 0.045), but not significantly different at 15 min (p = 0.146). No subject indicated distress nor did the study need to be terminated due to pre-determined concerning vital signs or ventilatory parameters. CONCLUSIONS: In healthy subjects there were no clinically significant changes in the physiologic parameters of breathing while wearing a spit sock.

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.

Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for Emergency Physicians.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are a novel class of drugs used in cancer immunotherapy that are becoming more commonly used among advanced-stage cancers. Unfortunately, these therapies are sometimes associated with often subtle, potentially fatal immune-related adverse events (irAEs). OBJECTIVES: We conducted a review of relevant primary research and clinical guidelines in oncology, pharmacology, and other literature, and synthesized this information to address the needs of the emergency physician in the acute management of irAEs. DISCUSSION: Although the antitumor effects of immunotherapies are desirable, the inhibition of immune checkpoints may also lead to loss of peripheral tolerance and a subsequent unleashing of the immune system on nontumor cells, leading to unintended tissue damage, which manifests as multisystem organ dysfunction. This tissue damage can affect nearly every organ system, with the dermatologic, gastrointestinal, endocrine, and pulmonary systems being the most commonly affected. Treatment may range drastically, depending on the severity of the irAE, starting with supportive care and moving toward high-dose steroids and additional immune modulators such as infliximab or intravenous immunoglobulin. CONCLUSION: With the increasing success and popularity of ICIs, emergency physicians will inevitably encounter increasing numbers of patients on these medications as well as the associated side effects. It is important that emergency physicians become aware of these irAEs and improve the detection of these processes to prevent inappropriate discharges, emergency department revisits, and downstream complications.

Management of Cancer-Associated Venous Thromboembolism in the Emergency Department.

Patients with cancer are at increased risk of venous thromboembolism, and emergency physicians can play a significant role in addressing one of the leading causes of morbidity and mortality in this patient population. However, there are no comprehensive guidelines addressing the approach to cancer-associated venous thromboembolism in the emergency department. Here, we review the guidelines put forth by various national and international cancer societies and highlight how emergency physicians can help institute appropriate treatment and prevent the recurrence of venous thromboembolism in cancer patients. We also address areas of controversy and highlight topics that require further research.

Application of the MASCC and CISNE Risk-Stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department.

STUDY OBJECTIVE: Although validated risk-stratification tools have been used to send low-risk febrile neutropenic patients home from clinic and inpatient settings, there is a dearth of research evaluating these scores in the emergency department (ED). We compare the predictive accuracy of the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores for patients with chemotherapy-induced febrile neutropenia and presenting to the ED. METHODS: We conducted a retrospective cohort study to evaluate all patients with febrile neutropenia (temperature ≥38°C [100.4°F], absolute neutrophil count <1,000 cells/µL) who presented to 2 academic EDs from June 2012 through January 2015. MASCC and CISNE scores were calculated for all subjects, and each visit was evaluated for several outcome variables, including inpatient length of stay, upgrade in level of care, clinical deterioration, positive blood culture results, and death. Descriptive statistics are reported and continuous variables were analyzed with Wilcoxon rank sum. RESULTS: During our study period, 230 patients presented with chemotherapy-induced febrile neutropenia. The CISNE score identified 53 (23%) of these patients as low risk and was highly specific in the identification of a low-risk cohort for all outcome variables (98.3% specific, 95% confidence interval [CI] 89.7% to 99.9%; positive predictive value 98.1%, 95% CI 88.6% to 99.9%). Median length of stay was shorter for low-risk versus high-risk CISNE patients (3-day difference; P<.001). The MASCC score was much less specific (54.2%; 95% CI 40.8% to 67.1%) in the identification of a low-risk cohort. CONCLUSION: Our results suggest that the CISNE score may be the most appropriate febrile neutropenia risk-stratification tool for use in the ED.