Recognition and evaluation of oncology-related symptoms in the emergency department

Abdominal Emergencies in Cancer Patients

Abdominal emergencies in cancer patients encompass a wide spectrum of oncologic conditions caused directly by malignancies, paraneoplastic syndromes, reactions to the chemotherapy or often represent the first clinical manifestation of an unknown malignancy. Not rarely, clinical symptoms are the tip of an iceberg. In this scenario, the radiologist is asked to exclude the cause responsible for the patient's symptoms, to suggest the best way to manage and to rule out the underlying malignancy. In this article, we discuss some of the most common abdominal oncological emergencies that may be encountered in an emergency department.

First Presentation and Diagnosis of a Rare Advanced Gynaecological Cancer in Emergency Department: A Case Report

A case of rare endometrial carcinosarcoma with locoregional spread and sigmoid fistula presenting for the very first time at a hospital emergency department (ED). A 56-year-old female presented with abdominal pain, diarrhea, fever, and pancytopenia, which was diagnosed as advanced gynaecological cancer following assessment, imaging, and tissue biopsy. Increased pressure on the ED owing to coronavirus disease 2019 pandemic may cause the first presentation of gynae-oncology cases to ED physician. A full return of all primary care services may reduce such pressure, improve early detection of gynaecological malignancies, allow early multidisciplinary team care, and result in better patient experience in the long run.

CT Imaging Findings in Patients with Ovarian Cancer and Acute Abdominal Symptoms: Experience at a Tertiary Cancer Center

PURPOSE

To evaluate computed tomography (CT) findings in patients with ovarian cancer presenting to a comprehensive cancer center's urgent care unit with acute abdominal symptoms.

METHODS

This retrospective study included consecutive patients with ovarian cancer who underwent abdominal CT at a comprehensive cancer center's urgent care unit between January 1, 2018, and January 14, 2020, due to acute abdominal symptoms. Two abdominal radiologists reviewed the abdominal CT reports, categorizing imaging findings as follows: (a) no new or acute finding, (b) new or increased bowel or gastric obstruction, (c) new or increased ascites, (d) new or increased peritoneal carcinomatosis, (e) new or increased nonperitoneal metastases, (f) new inflammatory or infectious changes, (g) new or increased hydronephrosis, (h) new or increased biliary dilatation, (i) new vascular complications, or (j) new bowel perforation.

RESULTS

A total of 200 patients (mean age, 59 years; range, 22-87) underwent a total of 259 abdominal CT scans, of which 217/259 (83.8%) scans were found to have new or increased findings. A total of 115/259 (44.4%) scans had only one finding while 102/259 (39.4%) scans had 2 or more findings. Altogether, 382 new or increased findings were detected: findings were most commonly related to bowel or gastric obstruction (92/382, 24.1%) with small bowel obstruction being the most common finding (80/382, 20.9%); ascites (78/382, 20.4%); peritoneal carcinomatosis (62/382, 16.2%); and nonperitoneal metastases (62/382, 16.2%). Inflammatory or infectious findings accounted for 30/382 (7.9%) findings.

CONCLUSION

Most patients with ovarian cancer presenting with acute abdominal had relevant positive findings on abdominal CT, with small bowel obstruction being the most common finding.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care

BACKGROUND

Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies.

PURPOSE

To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency.

METHODS

This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period.

RESULTS

The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital.

CONCLUSION

Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.

Evaluation of the frequency of patients with cancer presenting to an emergency department

OBJECTIVE

This study aims to determine the demographic characteristics of cancer patients admitted to an emergency department and determine the relationship between the frequency of admission to the emergency department and oncological emergencies and their effect on mortality.

METHODS

This observational, prospective, diagnostic accuracy study was performed in the ED of a tertiary care hospital. Patients over the age of 18 who were previously diagnosed with cancer and admitted to the emergency service for medical reasons were included in the study. We recorded baseline characteristics including age, gender, complaints, oncological diagnosis, metastasis status, cancer treatments received, the number of ED admissions, structural and metabolic oncological emergency diagnoses in the ED, discharge status, length of hospital stay, and mortality status.

RESULTS

In our study, 1205 applications related to the oncological diagnosis of 261 patients were examined. 55.6% of the patients were male, and 44.4% were female. The most common metabolic oncological emergency was anemia (19.5%), and the most common structural oncological emergency was bone metastasis-fracture (4.6%.) The mean score of admission of patients to the emergency department was four times (min: 1 max: 29) during the study period. A total of 49.4% (n: 129) of the patients included in the study died during follow-up, and the median time of death was 13 days after the last ED admission.

CONCLUSION

The palliation of patient symptoms in infusion centers that will be established in the palliative care center will contribute to the decrease in the frequency of use of emergency services.

Clinical characteristics and outcomes of bone marrow transplantation patients presenting to the ED of a tertiary care center

BACKGROUND

Bone marrow transplantation is a breakthrough in the world of hematology and oncology. In our region, there is scarce literature studying emergency department visits among BMT patients, as well as their predictors of mortality.

OBJECTIVES

This study aimed to assess the frequency, reasons, clinical characteristics and outcomes of patients presenting to the ED after a BMT, and to study the predictors of mortality in those patients. This study also compares those variables among the different types of BMT.

METHODS

This was a retrospective cohort study conducted on all adult patients who have completed a successful BMT and visited the ED.

RESULTS

Our study included 115 BMT patients, of whom 17.4% died. Those who died had a higher median number of ED visits than those who did not die. Around 36.5% presented with fever/chills with 29.6% diagnosed with pneumonia on discharge. We found that the odds of mortality were significantly higher among those who presented with dyspnea (p < .0005) and AMS (p = .023), among septic patients (p = .001), those who have undergone allogeneic BMT (p = .037), and those who were admitted to the ICU (p = .002). Moreover, the odds of mortality were significantly higher among hypotensive (p ≤0005) and tachycardic patients (p = .015).

CONCLUSION

In our study, we have shown that BMT patients visit the ED very frequently and have high risk of in-hospital mortality. Moreover, our study showed a significant association between mortality and patients with dyspnea, AMS, sepsis, allogeneic BMT type, ICU admission, hypotension and tachycardia.

EPICANCER-Cancer Patients Presenting to the Emergency Departments in France: A Prospective Nationwide Study

Background: We aimed to estimate the prevalence of cancer patients who presented to Emergency Departments (EDs), report their chief complaint and identify the predictors of 30-day all-cause mortality. Patients and methods: we undertook a prospective, cross-sectional study during three consecutive days in 138 EDs and performed a logistic regression to identify the predictors of 30-day mortality in hospitalized patients. Results: A total of 1380 cancer patients were included. The prevalence of cancer patients among ED patients was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal disorders (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of cases, of which 13.4% died at day 30. Variables independently associated with a higher mortality at day 30 were male gender (Odds Ratio (OR), 1.63; 95% CI, 1.04–2.56), fatigue (OR, 1.65; 95% CI, 1.01–2.67), poor performance status (OR, 3.00; 95% CI, 1.87–4.80), solid malignancy (OR, 3.05; 95% CI, 1.26–7.40), uncontrolled malignancy (OR, 2.27; 95% CI, 1.36–3.80), ED attendance for a neurological disorder (OR, 2.38; 95% CI, 1.36–4.19), high shock-index (OR, 1.80; 95% CI, 1.03–3.13) and oxygen therapy (OR, 2.68; 95% CI, 1.68–4.29). Conclusion: Cancer patients showed heterogeneity among their reasons for ED attendance and a high need for hospitalization and case fatality. Malignancy and general health status played a major role in the patient outcomes. This study suggests that the emergency care of cancer patients may be complex. Thus, studies to assess the impact of a dedicated oncology curriculum for ED physicians are warranted.

Taking care of our own: A narrative review of cancer care services-led models of care providing emergent care to patients with cancer

PURPOSE

To synthesise available evidence on cancer care services-led models of care in the acute care setting that aim to reduce emergency presentations and/or hospital admissions for patients with cancer.

METHODS

A narrative review of studies describing models of care for patients with cancer and emergent healthcare needs was undertaken. Four databases were searched using keywords to identify primary research or quality improvement articles published between January 2005-June 2017.

RESULTS

After a systematic search, 22 studies were included in the review. The methodological quality of the included studies was poor when assessed using the Mixed Methods Appraisal Tool. Most studies were retrospective and set in a single centre. The overarching outcomes associated with the most commonly described models of care (telephone advice services and/or unplanned care and assessment units) were improved coordination of care/continuity of care, prompt access to specialist care, reduced utilisation of emergency departments, fewer hospital admissions and reduced cost. At the time of this review, evaluation of Nurse Practitioner-led services and acute oncology services had been limited.

CONCLUSIONS

Findings indicate several models of care reduce emergency presentations and/or hospitalisations for those living with cancer and improve patient outcomes. What remains unclear is which underlying mechanisms reduce emergency presentations and/or hospitalisations for patients with cancer and whether successful models of care are uniquely suited to specific contexts of care or applicable across different healthcare settings. More research is needed to assist healthcare services to develop and evaluate models of care to address the emergent needs of people with cancer.

Disaggregating Hispanic American Cancer Mortality Burden by Detailed Ethnicity

BACKGROUND

Hispanics are the largest minority population in the United States (18%). They represent a heterogeneous and growing population. Cancer is the leading cause of death among Hispanics, yet few studies have described cancer mortality burden by specific Hispanic group nationwide.

METHODS

Cancer-related deaths from U.S. death certificates for the years 2003-2012 were analyzed for decedents identifying as Mexican, Puerto Rican, Cuban, and Central or South American. We calculated descriptive statistics, including potential years of lives lost (PYLL), age-adjusted rates, standardized mortality ratios, and fitted JoinPoint regression models, to evaluate annual trends by Hispanic group, using non-Hispanic Whites (NHW) as the reference population.

RESULTS

We identified 287,218 cancer-related deaths among Hispanics and 4,570,559 among NHWs. Mortality trends were heterogeneous across Hispanic groups. Female NHWs and male Puerto Ricans had the greatest rates of adjusted PYLL per 1,000 (NHWs, 19.6; Puerto Ricans, 16.5). Liver cancer was ranked among the top 5 cancer-related deaths for every Hispanic group, but not for NHWs. Stomach cancer mortality was twice as high for most Hispanic groups when compared with NHWs and especially high for Mexicans [male standardized mortality ratio (SMR), 2.07; 95% confidence interval (CI), 2.01-2.13; female SMR, 2.62; 95% CI, 2.53-2.71].

CONCLUSIONS

We observed marked heterogeneity in cancer mortality across Hispanic groups. Several cancers affect Hispanics disproportionately compared with NHWs. Screening programs in Hispanics should be considered for stomach and liver cancer.

IMPACT

Disaggregated analysis of Hispanics is needed to fully understand cancer burden among the diverse Hispanic population and is critical for cancer prevention and control efforts.

National characteristics of Emergency Department visits by patients with cancer in the United States

PURPOSE

The Emergency Department (ED) is an important venue for the care of patients with cancer. We sought to describe the national characteristics of ED visits by patients with cancer in the United States.

METHODS

We performed an analysis of 2012-2014 ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). We included adult (age≥18years) ED patients, stratified by history of cancer. Using the NHAMCS survey design and weighting variables, we estimated the annual number of adult ED visits by patients with cancer. We compared demographics, clinical characteristics, ED resource utilization, and disposition of cancer vs. non-cancer patients.

RESULTS

There were an estimated 104,836,398 annual ED visits. Patients with cancer accounted for an estimated 3,879,665 (95% CI: 3,416,435-4,342,895) annual ED visits. Compared with other ED patients, those with cancer were older (mean 64.8 vs. 45.4years), more likely to arrive by Emergency Medical Services (28.0 vs. 16.9%), and experienced longer lengths of ED stay (mean 4.9 vs. 3.8h). Over 65% of ED patients with cancer underwent radiologic imaging. Patients with cancer almost twice as likely to undergo CT scanning; four times more likely to present with sepsis; twice as likely to present with thrombosis, and three times more likely to be admitted to the hospital than non-cancer patients.

CONCLUSIONS

Patients with cancer comprise nearly 4 million ED visits annually. The findings highlight the important role of the ED in cancer care and need for addressing acute care conditions in patients with cancer.

Emergency department use by recently diagnosed cancer patients in California

BACKGROUND

Improving the quality of cancer care and reducing preventable health system use are goals of increasing importance to health practitioners and policy makers. Emergency department (ED) visits are often cited as a source of preventable health system use, however, few studies have described the incidence of ED use by recently diagnosed cancer patients in population-based samples, and no study has addressed the full spectrum of cancer types.

OBJECTIVE

To describe ED use by recently diagnosed cancer patients.

METHODS

California Office of Statewide Health Planning and Development data and the California Cancer Registry were used to describe ED use in the year after a cancer diagnosis (2009-2010). The incidence of ED use was tabulated by cancer type. Logistic regression and recycled predictions were used to examine ED use adjusting for confounding factors.

RESULTS

Most ED visits (68%) occurred within 180 days of diagnosis. The incidence of ED use for all cancer types examined was 17% within 30 days, 35% within 180 days and 44% within 365 days of diagnosis. ED use varied by cancer type (5%-39% within 30 days of diagnosis; 14% -62% within 180 days; and 22%-69% within 365 days). Patterns of ED use by cancer type remained similar after accounting for demographic and socioeconomic factors.

LIMITATIONS

Those common to administrative and registry datasets. Specifically, we were unable to account for ED visits in relation to cancer treatment dates and comorbid conditions.

CONCLUSIONS

Cancer patients use EDs at higher rates than previously reported, with considerable variability by cancer type. Future research should examine reasons for ED visits by cancer type and identify predictors of ED use, including treatment and comorbid conditions.

Retrospective study of unplanned hospital admission for metastatic cancer patients visiting the emergency department

PURPOSE

The purpose of the study was to identify factors that predict unplanned admission for metastatic cancer patients visiting the emergency department (ED).

METHODS

Patients visiting the ED of a general hospital from April 2012 to March 2013 were investigated retrospectively. Data including demographics, vital signs, and laboratory measurements were collected from a chart review for each patient. Factors related to emergency admission were identified by univariate and multivariate analyses.

RESULTS

A total of 15,716 individuals visiting the ED during the study period included 1244 (7.9%) patients with cancer. Among the 491 cancer patients with metastasis, univariate analysis revealed that emergency admission was significantly associated with an age of ≥76 years; an altered mental status; fever (≥38 °C); a blood oxygen saturation of <90%; a white blood cell (WBC) count of ≤2000 or ≥10,000/μL; hypoalbuminemia (≤2.5 g/dL); and elevated levels of aspartate aminotransferase (≥100 IU/L), blood urea nitrogen (≥25 mg/dL), and C-reactive protein (CRP, ≥10 mg/dL). Multivariate analysis identified age, an altered mental status, hypoxemia, an abnormal WBC count, and elevated CRP as putative independent predictive factors for emergency admission. The number of these five factors present was also correlated with 30-day mortality (c-statistic = 0.72).

CONCLUSIONS

Age, unconsciousness, hypoxemia, an abnormal WBC count, and elevated CRP were found to be associated with emergency admission and 30-day mortality for metastatic cancer patients. Prospective validation of a predictive scoring system based on these findings is warranted.

Symptom-related emergency department visits and hospital admissions during ambulatory cancer treatment

BACKGROUND

People with cancer experience symptoms related to the disease and treatments. Symptom distress has a negative impact on quality of life (QoL). Attending to symptoms and side effects of treatment promotes safe and effective delivery of therapies and may prevent or reduce emergency department visits (EDVs) and unplanned hospital admissions (HAs). There is limited evidence examining symptom-related EDVs or HAs (sx-EDV/HAs) and interventions in ambulatory oncology patients.

OBJECTIVE

To examine factors associated with sx-EDV/HAs in ambulatory oncology patients receiving chemotherapy and/or radiation.

METHODS

This secondary analysis used data from a randomized controlled trial of ambulatory oncology patients (n = 663) who received the web-based Electronic Self-Report Assessment – Cancer intervention (symptom self-monitoring, tailored education, and communication coaching) or usual care with symptom self-monitoring alone. Group differences were described by summary statistics and compared by t test. Factors associated with the odds of at least 1 sx-EDV/HA were modeled using logistic regression.

RESULTS

98 patients had a total of 171 sx-EDV/HAs with no difference between groups. Higher odds of at least 1 sx-EDV/HA were associated with socioeconomic and clinical factors. The multivariable model indicated that work status, education level, treatment modality, and on-treatment Symptom Distress Scale-15 scores were signifcantly associated with having at least 1 sx-EDV/HA.

LIMITATIONS

This is a secondary analysis not sized to determine cause and effect. The results have limited generalizability.

CONCLUSION

Most patients did not experience a sx-EDV/HA. Demographic and clinical factors predicted a sx-EDV/HA.

Abdominal Pain in the Immunocompromised Patient-Human Immunodeficiency Virus, Transplant, Cancer

Patients with human immunodeficiency virus, those who are posttransplant, and those undergoing chemotherapy are populations who are immunocompromised and present to the emergency department with abdominal pain related to their disease processes, opportunistic infections, and complications of treatment. Emergency department practitioners must maintain vigilance, as the physical examination is often unreliable in these patients. Cross-sectional imaging and early treatment of symptoms with aggressive resuscitation is often required.

Patterns of analgesic adherence predict health care utilization among outpatients with cancer pain

BACKGROUND

Studies in chronic noncancer pain settings have found that opioid use increases health care utilization. Despite the key role of analgesics, specifically opioids, in the setting of cancer pain, there is no literature to our knowledge about the relationship between adherence to prescribed around-the-clock (ATC) analgesics and acute health care utilization (hospitalization) among patients with cancer pain.

PURPOSE

To identify adherence patterns over time for cancer patients taking ATC analgesics for pain, cluster these patterns into adherence types, combine the types into an adherence risk factor for hospitalization, identify other risk factors for hospitalization, and identify risk factors for inconsistent analgesic adherence.

MATERIALS AND METHODS

Data from a 3-month prospective observational study of patients diagnosed with solid tumors or multiple myeloma, having cancer-related pain, and having at least one prescription of oral ATC analgesics were collected. Adherence data were collected electronically using the medication event-monitoring system. Analyses were conducted using adaptive modeling methods based on heuristic search through alternative models controlled by likelihood cross-validation scores.

RESULTS

Six adherence types were identified and combined into the risk factor for hospitalization of inconsistent versus consistent adherence over time. Twenty other individually significant risk factors for hospitalization were identified, but inconsistent analgesic adherence was the strongest of these predictors (ie, generating the largest likelihood cross-validation score). These risk factors were adaptively combined into a model for hospitalization based on six pairwise interaction risk factors with exceptional discrimination (ie, area under the receiver-operating-characteristic curve of 0.91). Patients had from zero to five of these risk factors, with an odds ratio of 5.44 (95% confidence interval 3.09-9.58) for hospitalization, with a unit increase in the number of such risk factors.

CONCLUSION

Inconsistent adherence to prescribed ATC analgesics, specifically the interaction of strong opioids and inconsistent adherence, is a strong risk factor for hospitalization among cancer outpatients with pain.

Early postoperative emergency department presentation predicts poor long-term outcomes in patients surgically treated for meningioma

Previous authors have identified a number of factors that predict morbidity, mortality, and recurrence in patients undergoing resection of a meningioma. We sought to study a novel potential prognostic indicator: early postoperative visit to the emergency department (ED). We conducted a retrospective cohort study on 239 patients who underwent a meningioma resection at our institution between 2001 and 2013 with over 3 months of follow-up postoperatively. All postoperative entries in the medical record were reviewed to identify any ED visit with a neurologic or wound-related complaint within a 90 day postoperative period. The relationships between ED presentation, tumor grade, and extent of surgical resection with future risk of operative recurrence and mortality were analyzed using Fisher's exact test. Variables associated with increased risks of mortality or operative recurrence in a univariate analysis were then included in the multivariate logistic regression model. Patients with a postoperative ED visit were found to be significantly more likely to die during the follow-up period (23.0% versus 4.85%, p<0.0001) or develop an eventual operative recurrence (12.2% versus 3.0%, p=0.0131). Postoperative ED presentation was found to be associated with a higher risk of mortality and operative recurrence independent of pathological tumor grade (p<0.0001 and p=0.0102, respectively). Presentation to the ED is associated with significantly higher rates of future operative recurrence and mortality in patients with recent meningioma resections. This poor prognostic relationship is independent of tumor pathological grade. Increased vigilance and follow-up may be warranted in such patients.

Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia

PURPOSE

People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer.

METHODS

This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients.

RESULTS

ED (529,377) presentations occurred over the 36 months, of which 2.4% (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33%, p < 0.001), with twice the rate of hospital admission (90 vs 46%, p < 0.001), longer inpatient length of stay (5.6 vs 2.8 days, p < 0.001) and had higher inpatient mortality (7.9 vs 1.0%, p < 0.001). Acuity and arriving by ambulance were significant predictors of hospital admission, with cancer-related attendances having ten times the odds of admission compared to other attendances (OR = 10.4, 95% CI 9.8-11.1).

CONCLUSIONS

ED presentations by people with cancer represent a more urgent, complex caseload frequently requiring hospital admission when compared to other presentations, suggesting that for optimal cancer care, close collaboration and integration of oncology, palliative care and emergency medicine providers are needed to improve pathways of care.

Mortality in emergency surgical oncology

PURPOSE

Cancer patients can experience problems related to their disease or treatment. This study evaluated reasons for presentation at the emergency room (ER) and outcome of surgical oncology patients.

METHODS

A retrospective chart review for all surgical oncology patients who presented at the ER of the UMCG for surgical consultation between October 1, 2012, and March 31, 2013.

RESULTS

A total of 200 cancer patients visited the ER for surgical consultation: 53.5 % with complications of (previous) cancer treatment, 25.5 % with symptoms caused by malignant disease, and 21.0 % with symptoms not related to cancer or cancer treatment. The 30-day mortality rate for patients with progressive disease was 25.5 %, and overall mortality rate was 62.8 %. The most frequent reason for ER presentation was intestinal obstruction (26.5 %), of which 41.5 % was malignant. Most cancer patients (59.5 %) did not undergo surgery during follow-up. The 30-day mortality for these patients was 14.3 % and overall mortality was 37.8 %. Most patients who died within the first 30 days after ER presentation had not undergone any surgery after presentation (89.5 %).

CONCLUSIONS

There is great variation in mortality rates for cancer patients presenting at the ER for surgical consultation. The mortality in this study was greatest for patients with progressive disease (30-day mortality 25.5 % and overall mortality 62.8 %), and the majority of patients who died within 30 days (89.5 %) had not undergone surgery after ER presentation. Surgery should only be performed in the acute setting when essential and when the expected outcome is favorable for the patient.

How has acute oncology improved care for patients?

A United Kingdom-wide appreciation of the systemic failings of emergency cancer care led to the creation of a new subspecialty, acute oncology. It was meant to bridge the gap between admitting teams, oncology, and palliative care, providing support to manage the symptoms of cancer, the side effects of cancer treatment, and people presenting with cancer of unknown primary origin. This article identifies the reasons for the creation of acute oncology and explores various models for this aspect of cancer care worldwide. With health care budgets static and demand increasing, the article also identifies ways in which acute oncology can contribute to an efficient and caring health system.

Surgical emergencies in oncology

An oncologic emergency is defined as an acute, potentially life threatening condition in a cancer patient that has developed as a result of the malignant disease or its treatment. Many oncologic emergencies are signs of advanced, end-stage malignant disease. Oncologic emergencies can be divided into medical or surgical. The literature was reviewed to construct a summary of potential surgical emergencies in oncology that any surgeon can be confronted with in daily practice, and to offer insight into the current approach for these wide ranged emergencies. Cancer patients can experience symptoms of obstruction of different structures and various causes. Obstruction of the gastrointestinal tract is the most frequent condition seen in surgical practice. Further surgical emergencies include infections due to immune deficiency, perforation of the gastrointestinal tract, bleeding events, and pathological fractures. For the institution of the appropriate treatment for any emergency, it is important to determine the underlying cause, since emergencies can be either benign or malignant of origin. Some emergencies are well managed with conservative or non-invasive treatment, whereas others require emergency surgery. The patient's performance status, cancer stage and prognosis, type and severity of the emergency, and the patient's wishes regarding invasiveness of treatment are essential during the decision making process for optimal management.

Attributes of cancer patients admitted to the emergency department in one year

BACKGROUND

Cancer patients frequently visit the emergency department (ED) with various symptoms of cancer. The purpose of this study was to determine the clinical characteristics and 1-year survival rate of cancer patients in the ED of a university hospital.

METHODS

We conducted a retrospective review of 408 cancer patients who visited the ED between January 2011 and December 2011. Patient information on demographics, chief complaints, findings, and survival was gathered from the hospital registry and corresponding health administration.

RESULTS

The study included 240 (58.8%) males and 168 (41.2%) females with a median age of 57.9 years (range 19-87). Regarding cancer staging, 266 patients (65.3%) had metastatic disease and 142 (34.7%) had local and loco-regional disease. The hospitalization rate was 59.6%. The most common symptoms were shortness of breath (23.2%), pain (17.8%), fever (14.2%), and nausea/vomiting (14.4%). The most common cancer sites were the lung (32.5%), gastrointestinal system (25.4%), and breast (9.3%). The initial evaluation determined progressive disease (42.4%), chemotherapy effects (20.7%), infections (17.2%), radiotherapy effects (4.7%), extravasation (1.8%), anemia (1.4%), and unknown (11.3%). During follow up, 191 (46.8%) patients died after admission to the ED. The 1-year overall survival of all patients was 7.3 months.

CONCLUSIONS

Symptom management in cancer patients is a complex multifaceted concern for the emergency physician. Because of the increasing prevalence of cancer patients, emergency physicians should develop consensus algorithms in collaboration with the relevant disciplines to manage the commonly encountered problems.

Severe cardiotoxicity associated with ixabepilone use in metastatic breast cancer

OBJECTIVE

To report a case of cardiogenic shock and fulminant heart failure associated with a single dose of ixabepilone.

CASE SUMMARY

A 32-year-old woman presented to the emergency department (ED) with abdominal pain and difficulty breathing within 1 hour after receiving a partial dose of ixabepilone (26 mg/m(2)) at an oncologist's office. She had breast cancer, with metastases to the bone and liver and evidence of early liver failure. While in the ED, she developed acute respiratory failure requiring intubation. Bedside ultrasound imaging showed free abdominal fluid. Computed tomography (CT) scans showed evidence of right-sided heart failure and abdominal fluid consistent with ascites but no evidence of pulmonary embolism. After the CT scan, the patient experienced pulseless electrical activity cardiac arrest. All attempts at resuscitation were unsuccessful.

DISCUSSION

Ixabepilone is a novel drug for treatment of advanced breast cancer. The most commonly reported adverse effects are peripheral neuropathies and hematologic issues such as neutropenia. To our knowledge, this is the first detailed report of a severe adverse cardiac event associated with ixabepilone use. Many other chemotherapeutic agents have cardiotoxic effects. An objective causality assessment, using the Naranjo probability scale, revealed that an adverse drug event was probable.

CONCLUSIONS

Clinicians should maintain broad differential diagnoses that include adverse reactions to drugs relatively new to the market. Ixabepilone may have cardiotoxic effects that necessitate further study, particularly when the drug is administered after cardiotoxic chemotherapy.

Emergency department visits for symptoms experienced by oncology patients: a systematic review

PURPOSE

The aim of this review was to explore the range and prevalence of cancer treatment or disease-related symptoms in the emergency department and their associated outcomes.

METHODS

A systematic review examined studies cited in Medline, Embase, PsycINFO, and CINAHL published from 1980 to July 2011. Eligible studies measured emergency department visits for symptom assessment in adult oncology patients. Two reviewers independently screened citations and double data extraction was used. Descriptive analysis was conducted.

RESULTS

Of 1,298 citations, six prospective and 12 retrospective descriptive studies were included. Of these, eight focused on multiple symptoms and 10 targeted specific symptoms. The studies were published between 1995 and 2011, conducted in seven countries, and had a median sample size of 143 (range 9-27,644). Of the 28 symptoms reported, the most common were febrile neutropenia, infection, pain, fever, and dyspnea. Definitions provided for individual symptoms were inconsistent. Of 16 studies reporting admission rates, emergency visits resulted in hospital admissions 58 % (median) of the time in multi-symptom studies (range 31 % to 100 %) and 100 % (median) of the time in targeted symptoms studies (range 39 % to 100 %). Of 11 studies reporting mortality rates, 13 % (median) of emergency visits captured in multi-symptom studies (range 1 % to 56 %) and 20 % (median) of visits in targeted symptoms studies (range 4 % to 67 %) resulted in death.

CONCLUSIONS

Individuals with cancer present to emergency departments with a myriad of symptoms. Over half of emergency department visits resulted in hospital admissions. Few symptoms were defined adequately to compare data across studies, thereby revealing an important gap in cancer symptom reporting.

Is Weekend Radiation Therapy Always Justified?

BACKGROUND

Patients presenting with an oncology emergency should be assessed and treated promptly to address symptoms, preserve function, and maintain quality of life. In some circumstances, this requires treatment of patients on weekends. The primary objective of this study was to review the delivery of urgent radiotherapy (RT) at our institution to determine the proportion of courses with a documented indication for which weekend RT could be justified based on comparison with published literature.

METHODS

Patients undergoing RT on weekends (January 2009-July 2009) were reviewed retrospectively for demographics, disease site, functional status, and documented reason for after-hours treatment. Data were obtained from both the electronic and paper medical records and input into an Excel spreadsheet after being anonymized. Summary statistics were calculated. A literature search was conducted to supplement the Alberta Health Services Palliative Radiotherapy clinical practice guidelines, which included review of relevant publications from the Standards and Guidelines Evidence database.

RESULTS

A total of 108 patients (73 males, 35 females) received RT to 132 sites over this period, primarily on both Saturday and Sunday (87.8%). Of these, 37.9% had a lung primary, 97.0% were treated with palliative intent, and 46.2% received spine RT. On average, 18.9 weekend treatment courses took place each month (range, 2-12). 67.1% had a planned anteroposterior field arrangement, and the dose-fractionation schedule was 2000 cGy in five fractions in the majority (68.9%). Based on the reason documented for emergency RT, 72.1% of all after-hours treatments could be justified by comparison to published literature.

CONCLUSIONS

Given resource and technical considerations, delivery of RT during weekends requires specific clinical justification. Presently at our center, decision to institute after-hours RT is at the discretion of the treating radiation oncologist. The majority of indications for weekend treatment of these patients could be justified based on published evidence.

Abdominal pain in special populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.

Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic syndrome

Neurologic symptoms commonly occur in oncology patients, and in some cases they may be the presenting symptom of malignancy. Cancer-related neurologic syndromes are rarely pathognomonic and must be differentiated from other benign or serious conditions. This article reviews common neuro-oncologic syndromes that may lead to urgent evaluation in the emergency department, including cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic neurologic syndromes.

Cancer emergencies: the acute abdomen

The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.

A review of the role of emergency nurses in management of chemotherapy-related complications

AIMS AND OBJECTIVES

To examine the role of emergency nurses in caring for patients who receive chemotherapy in ambulatory oncology settings. Reasons for emergency department presentations are examined, specific sources of clinical risk for patients receiving chemotherapy who require emergency care are discussed and cost implications of emergency department presentations related to chemotherapy are analysed.

BACKGROUND

Given the increased administration of chemotherapy in ambulatory settings, emergency nurses play an important role in the management of patients undergoing adjuvant chemotherapy. Emergency departments are the major entry point for acute inpatient hospital care of complications arising from chemotherapy.

DESIGN

Systematic review.

RESULTS

Chemotherapy-related emergency department presentations have considerable clinical and cost implications for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications and reduction in preventable emergency department presentations has significant implications for improving cancer patients' quality of life and reducing the cost of cancer care.

CONCLUSIONS

Nurses are well placed to play a pivotal role in chemotherapy management and lead interventions such as a specialist oncology nursing roles that provide information and support to guide patients through their chemotherapy cycles. These interventions may prevent emergency department presentations for patients receiving chemotherapy in ambulatory settings.

RELEVANCE TO CLINICAL PRACTICE

Patients receiving chemotherapy require access to specialised care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach both within and across nursing specialities may improve care for patients receiving chemotherapy and increase effective use of healthcare resources.

Cancer pain as the presenting problem in emergency departments: incidence and related factors

GOALS OF WORK

Since emergency departments (ED) are designed to manage people with urgent and life-threatening conditions, cancer patients presenting with pain may not receive the appropriate care in the ED. The purpose of this study was to identify the incidence and factors related to ED visits by cancer patients with pain complaints.

MATERIALS AND METHODS

Medical charts selected by stratified random sampling were retrospectively reviewed to obtain information about ED visits by cancer patients during a 1-year period. The sample included 1,179 ED visits by 1,026 cancer patients.

MAIN RESULTS

Pain was the most common reason for ED visits by cancer patients. The incidence of ED visits for pain as a presenting problem was 27.8%. The 72-h ED return-visit rate was 8.2% for cancer patients who visited the ED with pain complaints. Patients with gastrointestinal and genitourinary cancers were more likely to visit the ED for pain. Patients who had received radiation therapy were less likely to visit the ED for pain.

CONCLUSION

Effective cancer pain management programs need to be developed and tested to reduce ED visits by cancer patients with pain. More research is needed to explore why cancer patients with pain visit the ED.

Semiology, proteomics, and the early detection of symptomatic cancer

"Diagnostic delay," the duration of symptoms or the symptom to diagnosis interval (SDI), are highly complex variables that reflect the behavior of the patient and the attending physician, tumor biology and host-tumor interactions, the functioning of the health care system, and sociocultural norms. In addition to tumor stage, other variables mediate the relationship between duration of symptoms and survival; clinical and epidemiologic procedures to measure them must be improved. Largely at odds with clinical and common wisdom, decades of research have shown that often SDI is not associated with tumor stage and/or with survival from cancer. It would be relevant to increase evidence in support of the notion that, for each type of tumor, there is a positive relationship between the length of the presymptomatic and the symptomatic phases. SDI could then be used to classify tumors according to their likelihood of being detected early when still asymptomatic. Also, tumors could be classified according to the ratio of the median SDI to the median survival (SDI to survival ratio, SSR), which may estimate the relative likelihood for clinical lead-time bias. If adhering to rigorous methodologic standards, proteomic analyses of early-stage cancers might provide new insights into changes that occur in early phases of tumorigenesis. More real examples are needed of uses of pathologic and genomic data to study mechanisms through which SDI influences-or fails to influence-prognosis. The degree of correlation between proteomic patterns and classic semiology constitutes an area of interest in itself; their respective correlations with cancer prognosis should be assessed in properly designed epidemiologic studies.

Thalomid (Thalidomide) capsules: a review of the first 18 months of spontaneous postmarketing adverse event surveillance, including off-label prescribing

The sedative/hypnotic thalidomide was withdrawn from the worldwide market nearly 40 years ago, because of its teratogenic and neurotoxic effects. Thalidomide was later found to very effectively suppress erythema nodosum leprosum (ENL). The US Food and Drug Administration (FDA) has approved Thalomid (thalidomide) capsules for the acute treatment of the cutaneous manifestations of moderate to severe ENL. Thalidomide is currently under investigation for the treatment of a wide variety of diseases, including conditions thought to have an inflammatory or immune basis, malignancies and complications of infection with HIV. Interest in the potential anti-inflammatory, immunomodulatory and anti- angiogenic effects of thalidomide has resulted in off-label use of prescription thalidomide. During the first 18 months of spontaneous postmarketing adverse event surveillance for Thalomid, 1210 spontaneous postmarketing adverse event reports were received for patients treated with prescription thalidomide for all therapeutic indications, including off-label use. The most common adverse events spontaneously reported would have been expected on the basis of the current Thalomid labelling/product information. The current labelling/product information reflects what was known about the risks associated with thalidomide therapy in limited patient populations at the time of the approval of Thalomid. With the postmarketing use of thalidomide in populations other than patients with ENL, it becomes increasingly important to identify patient groups that may be particularly susceptible to specific adverse drug effects and to identify conditions under which specific adverse events may be more likely to occur. Oncology patients may represent a patient population with increased susceptibility to thalidomide-associated adverse effects, including thromboembolic events. Consideration of the spontaneous postmarketing safety surveillance data may help to identify and characterise factors associated with increased risk in this and other patient groups. Serious unexpected adverse events reported with sufficient frequency to signal previously undetected product-event associations for which there may potentially be plausible evidence to suggest a causal relationship have included seizures and Stevens-Johnson syndrome. The potential effects of thalidomide on wound healing are also being closely monitored. Premarketing human clinical trials of drug products are inherently limited in their ability to detect adverse events. Broader postmarketing experience with thalidomide in more varied patient populations and more experience in the setting of long term thalidomide use will increase our ability to detect rare adverse events and to identify signals that may need to be evaluated in more controlled settings.

Fever in the immunocompromised host

A broad classification of immune defects provides a framework for the approach to fever in the immunocompromised host. Practical, historical, and physical examination findings are reviewed, and common clinical scenarios are highlighted. A general initial work-up and treatment plan are outlined.

Neurologic emergencies in cancer patients

Neurologic emergencies are common among cancer patients and their incidence is increasing as patients live longer as a result of improved antineoplastic therapy. This article reviews acute neurologic complications in cancer patients. Among those complications reviewed are brain metastases, epidural spinal cord compression, leptomeningeal metastases, cerebrovascular disorders, complications of antineoplastic therapy, and paraneoplastic syndromes.

Emergency admission for cancer: a matter of survival?

The objective of this study was to compare the pre-hospital health care process, clinical characteristics at admission and survival of patients with a digestive tract cancer first admitted to hospital either electively or via the emergency department. The study involved cross-sectional analysis of information elicited through personal interview and prospective follow-up. The setting was a 450-bed public teaching hospital primarily serving a low-income area of Barcelona, Catalonia, Spain. Two hundred and forty-eight symptomatic patients were studied, who had cancer of the oesophagus (n = 31), stomach (n = 70), colon (n = 82) and rectum (n = 65). The main outcome measures were stage, type and intention of treatment and time elapsed from admission to surgery; the relative risk of death was calculated using Cox's regression. There were 161 (65%) patients admitted via the emergency department and 87 (35%) electively. The type of physician seen at the first pre-hospital visit had more often been a general practitioner in the emergency than in the elective group (89% vs 75%, P < 0.01). Emergency patients had seen a lower number of physicians from symptom onset until admission, but two-thirds had made repeated visits to a primary care physician. Emergency patients were less likely to have a localized tumour and a diagnosis of cancer at admission, and surgery as the initial treatment. Median survival was 30 months for elective patients and 8 months for emergency patients (P < 0.001), and the relative risk of death (RR) was 1.83 (95% confidence interval, CI, 1.32-2.54). After adjustment for strong prognostic factors, emergency patients continued to experience a significant excess risk (RR = 1.58; CI 1.10-2.27). In conclusion, in digestive tract cancers, admission to hospital via the emergency department is a clinically important marker of a poorer prognosis. Emergency departments can only partly counterbalance deficiencies in the effectiveness of and integration among the different levels of the health system.