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Krishnamani PP, Qdaisat A, Wattana MK, Lipe DN, Sandoval M, Elsayem A, Cruz Carreras MT, Yeung SCJ, Chaftari PS. Characteristics and Outcomes of Patients with Cancer Pain Placed in an Emergency Department Observation Unit. Cancers (Basel) 2022; 14:cancers14235871. [PMID: 36497353 PMCID: PMC9738053 DOI: 10.3390/cancers14235871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Pavitra Parimala Krishnamani
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Monica Kathleen Wattana
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demis N. Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- IQVIA Biotech, Morrisville, NC 27560, USA
| | - Marcelo Sandoval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ahmed Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria Teresa Cruz Carreras
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Patrick S. Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence:
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Elsayem AF, Warneke CL, Reyes-Gibby CC, Buffardi LJ, Sadaf H, Chaftari PS, Brock PA, Page VD, Viets-Upchurch J, Lipe D, Alagappan K. "Triple Threat" Conditions Predict Mortality Among Patients With Advanced Cancer Who Present to the Emergency Department. J Emerg Med 2022; 63:355-362. [DOI: 10.1016/j.jemermed.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/19/2022] [Accepted: 05/09/2022] [Indexed: 11/12/2022]
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Qdaisat A, Wu W, Lin JZ, Al Soud R, Yang Z, Hu Z, Gao S, Wu CC, Liu X, Silvestre J, Hita AG, Viets-Upchurch J, Al Adwan S, Al Haj Qasem N, Cruz Carreras MT, Jacobson KL, Chaftari PS, Abdel-Razeq H, Reyes-Gibby CC, Jim Yeung SC. Clinical and Cancer-Related Predictors for Venous Thromboembolism in Cancer Patients Presenting to the Emergency Department. J Emerg Med 2020; 58:932-941. [PMID: 32376060 DOI: 10.1016/j.jemermed.2020.03.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/02/2020] [Accepted: 03/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The accurate detection of cancer-associated venous thromboembolism (VTE) can avoid unnecessary diagnostic imaging or laboratory tests. OBJECTIVE We sought to determine clinical and cancer-related risk factors of VTE that can be used as predictors for oncology patients presenting to the emergency department (ED) with suspected VTE. METHODS We retrospectively analyzed all consecutive patients who presented with suspicion of VTE to The University of Texas MD Anderson Cancer Center ED between January 1, 2009, and January 1, 2013. Logistic regression models were used to identify risk factors that were associated with VTE. The ability of these factors to predict VTE was externally validated using a second cohort of patients who presented to King Hussein Cancer Center ED between January 1, 2009, and January 1, 2016. RESULTS Cancer-related covariates associated with the occurrence of VTE were high-risk cancer type (odds ratio [OR] 3.64 [95% confidence interval {CI} 2.37-5.60], p < 0.001), presentation within 6 months of the cancer diagnosis (OR 1.92 [95% CI 1.62-2.28], p < 0.001), active cancer (OR 1.35 [95% CI 1.10-1.65], p = 0.003), advanced stage (OR 1.40 [95% CI 1.01-1.94], p = 0.044), and the presence of brain metastasis (OR 1.73 [95% CI 1.32-2.27], p < 0.001). When combined, these factors along with other clinical factors showed high prediction performance for VTE in the external validation cohort. CONCLUSIONS Cancer risk group, presentation within 6 months of cancer diagnosis, active and advanced cancer, and the presence of brain metastases along with other related clinical factors can be used to predict VTE in patients with cancer presenting to the ED.
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Affiliation(s)
- Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Weixin Wu
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Oncology, Zhong Shan Hospital, Xiamen Medical University, Xiamen, People's Republic of China
| | - Jun-Zhong Lin
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Rawan Al Soud
- Department of Emergency Medicine, King Hussein Cancer Center, Amman, Jordan; Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Zhi Yang
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Intensive Care, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Zhihuang Hu
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Shujun Gao
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Center of Diagnosis and Treatment of Cervical Disease, Obstetrics and Gynecology Hospital of Fudan University, Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, People's Republic of China
| | - Carol C Wu
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiangdong Liu
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Laboratory Medicine, Qilu Hospital, Qilu Medical University, Jinan, Shandong, People's Republic of China
| | - Julio Silvestre
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - A Guido Hita
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jayne Viets-Upchurch
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Saif Al Adwan
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Nafi' Al Haj Qasem
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Maria T Cruz Carreras
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kalen L Jacobson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patrick S Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas
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El Majzoub I, Qdaisat A, Chaftari PS, Yeung SCJ, Sawaya RD, Jizzini M, Carreras MTC, Abunafeesa H, Elsayem AF. Association of emergency department admission and early inpatient palliative care consultation with hospital mortality in a comprehensive cancer center. Support Care Cancer 2018; 27:2649-2655. [DOI: 10.1007/s00520-018-4554-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 11/13/2018] [Indexed: 01/10/2023]
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Maamari J, Yeung SCJ, Chaftari PS. Diabetic ketoacidosis induced by a single dose of pembrolizumab. Am J Emerg Med 2018; 37:376.e1-376.e2. [PMID: 30361152 DOI: 10.1016/j.ajem.2018.10.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 10/18/2018] [Indexed: 12/13/2022] Open
Abstract
Immune checkpoint inhibitors are a new class of anticancer drugs recently approved by the US Food and Drug Administration (FDA) for the treatment of various malignancies. Pembrolizumab is an immune checkpoint inhibitor that targets the programmed cell death protein-1 (PD-1) receptor and blocks its interaction with programmed cell death ligand-1 (PD-L1) and programmed cell death ligand-2 (PD-L2). Pembrolizumab was first approved by the FDA in 2014 for the treatment of advanced melanoma and is currently approved for use in non-small cell lung cancer and several other neoplasms. Immune checkpoint inhibitors such as pembrolizumab have been reported to induce immune-mediated side effects, including type 1 diabetes mellitus in very rare cases (0.1% in clinical trials). Here, we report the case of a woman with no known history of diabetes who presented to our emergency department in a state of diabetic ketoacidosis within 3 weeks of receiving only a single dose of pembrolizumab therapy, and without any previous exposure to immunotherapy. This case of abrupt adult-onset type 1 diabetes mellitus is an example of the undesirable side effects that can emerge after only a brief exposure to an immune checkpoint inhibitor. Close monitoring of patients receiving immune checkpoint inhibitors is warranted for the early diagnosis and management of imminent and potentially life-threatening complications.
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Affiliation(s)
- Julian Maamari
- School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick S Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Elsayem AF, Merriman KW, Gonzalez CE, Yeung SCJ, Chaftari PS, Reyes-Gibby C, Todd KH. Presenting Symptoms in the Emergency Department as Predictors of Intensive Care Unit Admissions and Hospital Mortality in a Comprehensive Cancer Center. J Oncol Pract 2016; 12:e554-63. [PMID: 27072570 DOI: 10.1200/jop.2015.009019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The identification of patients at high risk for poor outcomes may allow for earlier palliative care and prevent futile interventions. We examined the association of presenting symptoms on risk of intensive care unit (ICU) admission and hospital death among patients with cancer admitted through an emergency department (ED). METHODS We queried MD Anderson Cancer Center databases for all patients who visited the ED in 2010. Presenting symptoms, ICU admissions, and hospital deaths were reviewed; patient data analyzed; and risk factors for ICU admission and hospital mortality identified. RESULTS The main presenting symptoms were pain, fever, and respiratory distress. Of the patients with cancer who visited the ED, 5,362 (58%) were admitted to the hospital at least once (range, 1 to 13 admissions), 697 (13%) were admitted to the ICU at least once, and 587 (11%) died during hospitalization (31% of 233 patients with hematologic malignancies and 27% of 354 patients with solid tumors died in the ICU; P < .001). In multivariable logistic regression, presenting symptoms of respiratory distress or altered mental status; lung cancer, leukemia, or lymphoma; and nonwhite race were independent predictors of hospital death. Patients who died had a longer median length of hospital stay than patients discharged alive (14 v 6 days for hematologic malignancies and 7 v 5 days for solid tumors; P < .001). CONCLUSION Patients with cancer admitted through an ED experience high ICU admission and hospital mortality rates. Patients with advanced cancer and respiratory distress or altered mental status may benefit from palliative care that avoids unnecessary interventions.
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Affiliation(s)
- Ahmed F Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly W Merriman
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carmen E Gonzalez
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Patrick S Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Knox H Todd
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Elsayem AF, Silvestre J, Merriman KW, Chaftari PS, Gonzalez CE, Yeung SCJ. Outcome of cancer patients admitted through the emergency department (ED) of a comprehensive cancer center: A call for ED-based palliative care. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.31_suppl.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
194 Background: The National Cancer Policy Forum advocated for improving quality of end life care, and reducing cost for cancer patients. Identifying those at high risk for Intensive Care Unit (ICU) admission, and hospital death may allow earlier palliative care and avoid futile interventions. The purpose of this study is to examine risk factors for ICU admission, and hospital death among cancer patients admitted through the emergency department (ED). Methods: We queried MD Anderson Cancer Center databases for all patients who visited our ED in 2010. ICU admission and hospital deaths of these patients were reviewed, and individual patients’ data were analyzed. Results: In 2010, 16,038 ED visits were made by 9,246 unique cancer patients. Of these patients, 5,362 (58%) were admitted to the hospital at least once (range 1-13 admits). Of all patients admitted through the ED, 697 (13%) were admitted at least once to ICU. Of all patients admitted, 11% died during hospitalization; of those, 29% died in ICU. Among patients who died in ICU, 73/233 (31.3%) had hematologic malignancies and 96/354 (27.1%) had solid tumors (P<0.001). Patients admitted to ICU had median lengths of hospital stay (MLOS) of 13 days for hematologic and 8 days for solid tumors (P<0.001; using means); patients without ICU admission had MLOS of 6 and 5 days, respectively (P<0.001). In a multivariate logistic regression model for predicting in-hospital mortality, we found that ED presenting symptoms of respiratory distress or altered mental status; primary tumor of lung cancer, leukemia, unknown primary, or lymphoma; and nonwhite ethnicities were independent predictors of death. Insignificant factors included age, gender, residence, fever and pain. Conclusions: Cancer patients admitted through the ED experience high ICU admission rate, and hospital mortality. Lung and certain other cancers; race; and symptoms of respiratory distress and altered mental status were associated with increased risk of in-hospital death. Patients with these risk factors may benefit from efforts to improve palliative care and prevent futile interventions.
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Affiliation(s)
| | - Julio Silvestre
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Elsayem AF, Merriman KW, Gonzalez CE, Yeung SCJ, Chaftari PS, Henderson JD, Todd KH. Intensive care unit admissions and in-hospital mortality in patients admitted through the emergency department of a comprehensive cancer center. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.9562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Knox H. Todd
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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