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Visweshwar N, Rico JF, Killeen R, Manoharan A. Harnessing the Immune System: An Effective Way to Manage Diffuse Large B-Cell Lymphoma. J Hematol 2023; 12:145-160. [PMID: 37692863 PMCID: PMC10482611 DOI: 10.14740/jh1112] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/01/2023] [Indexed: 09/12/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a heterogenous hematological disorder with malignant potential controlled by immunological characteristics of the tumor microenvironment. Rapid breakthrough in the molecular pathways has made immunological approaches the main anchor in the management of DLBCL, with or without chemotherapeutic agents. Rituximab was the first monoclonal antibody approved for the treatment of DLBCL. Following rituximab that transformed the therapeutic landscape, other novel immunological agents including chimeric antigen T-cell therapy have reshaped the management of relapsed/refractory DLBCL. However, resistance and refractory state remain a challenge in the management of DLBCL. For this literature review, we screened articles from Medline, Embase, Cochrane databases and the European/North American guidelines from March 2010 through October 2022 for DLBCL. Here we discuss immunological agents that will significantly affect future treatment of this aggressive type of lymphoma.
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Affiliation(s)
- Nathan Visweshwar
- Department of Hematology, University of South Florida, Tampa, FL, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Robert Killeen
- Department of Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Arumugam Manoharan
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
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Visweshwar N, Rico JF, Ayala I, Jaglal M, Laber DA, Ammad-Ud-Din M, Sokol L, Sotomayor E, Manoharan A. Insights into the Impact of Hesitancy on Cancer Care and COVID-19. Cancers (Basel) 2023; 15:3115. [PMID: 37370725 DOI: 10.3390/cancers15123115] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/17/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
World Health Organization findings indicate that the COVID-19 pandemic adversely affected cancer diagnosis and management. The COVID-19 pandemic disrupted the optimal management of outpatient appointments, scheduled treatments, and hospitalizations for cancer patients because of hesitancy among patients and health-care providers. Travel restrictions and other factors likely affected medical, surgical, and radiation treatments during the COVID-19 pandemic. Cancer patients were more likely to be affected by severe illness and complications if they contracted COVID-19. A compromised immune system and comorbidities in cancer patients may have contributed to this increased risk. Hesitancy or reluctance to receive appropriate therapy or vaccination advice might have played a major role for cancer patients, resulting in health-care deficits. The purpose of this review is to evaluate the impact of COVID-19 on screening, entry into clinical trials, and hesitancy among patients and health-care professionals, limiting adjuvant and metastatic cancer treatment.
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Affiliation(s)
- Nathan Visweshwar
- Department of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Juan Felipe Rico
- Department of Pediatric Hematology, University of South Florida, Tampa, FL 33612, USA
| | - Irmel Ayala
- Department of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, USA
| | - Michael Jaglal
- Department of Satellite and Community Oncology and Hematology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Damian A Laber
- FACP Department of Satellite and Community Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | | | - Lubomir Sokol
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | | | - Arumugam Manoharan
- FRACP, FRCPA Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW 2217, Australia
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Bischof JJ, Elsaid MI, Bridges JFP, Rosko AE, Presley CJ, Abar B, Adler D, Bastani A, Baugh CW, Bernstein SL, Coyne CJ, Durham DD, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Yilmaz S, Caterino JM. Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study. J Geriatr Oncol 2022; 13:943-951. [PMID: 35718667 DOI: 10.1016/j.jgo.2022.06.003] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 04/05/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer. MATERIALS AND METHODS Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017. RESULTS Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics. DISCUSSION We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.
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Affiliation(s)
- Jason J Bischof
- Departments of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| | - John F P Bridges
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| | - Ashley E Rosko
- Department of Internal Medicine, Division of Hematology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital - Troy Campus, Troy, MI, USA.
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA.
| | - Danielle D Durham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA.
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine @ Dartmouth, Lebanon, NH, USA.
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Sule Yilmaz
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jeffrey M Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Cho S, Perry AM, Cheng AM, Wang C, Rico JF. Advances in Hemophilia A Management. Adv Pediatr 2022; 69:133-147. [PMID: 35985706 DOI: 10.1016/j.yapd.2022.03.009] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hemophilia A is an inherited insufficiency of Factor VIII (FVIII), one of the critical clotting factors. The gold standard for the management of moderate-to-severe hemophilia A is prophylaxis using regular replacement therapy with clotting factor concentrates. Compared with conventional treatment, extended half-life products reduce the burden of frequent factor replacement injections. Of note, up to 30% of patients with hemophilia A receiving prophylactic factor infusions develop "inhibitors," neutralizing anti-FVIII autoantibodies. Therapeutic options for patients with hemophilia A and inhibitors include the immune tolerance induction (ie, eradication of inhibitors) and the management of acute bleeds with bypassing agents and/or emicizumab. Emicizumab is a biphasic monoclonal antibody mimicking activated FVIII, approved for patients with hemophilia A with/without inhibitors. Gene therapy is an emerging therapy for hemophilia A, essentially curing patients with hemophilia A or transforming them to a milder phenotype by establishing continuous endogenous expression of FVIII after one-time treatment.
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Affiliation(s)
- Sukjoo Cho
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA
| | - Ashley M Perry
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA
| | - Anna M Cheng
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Carrie Wang
- University of South Florida Morsani College of Medicine, 560 Channelside Drive, Tampa, FL 33602, USA
| | - Juan Felipe Rico
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA.
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Yilmaz S, Grudzen CR, Durham DD, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Baugh CW, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Reyes-Gibby C, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Palliative Care Needs and Clinical Outcomes of Patients with Advanced Cancer in the Emergency Department. J Palliat Med 2022; 25:1115-1121. [PMID: 35559758 PMCID: PMC9467631 DOI: 10.1089/jpm.2021.0567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Older adults with cancer use the emergency department (ED) for acute concerns. Objectives: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. Design: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. Settings/Subjects: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. Measurements: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. Results: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0-7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0-3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2-10.4]). Conclusions: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.
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Affiliation(s)
- Sule Yilmaz
- Division of Supportive Care in Cancer, Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
- Address correspondence to: Sule Yilmaz, PhD, Division of Supportive Care in Cancer, Department of Surgery, University of Rochester Medical Center, 265 Crittenden Boulevard, Rochester, NY 14642, USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York, USA
| | - Danielle D. Durham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York, USA
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, New York, USA
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York, USA
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital—Troy Campus, Troy, Michigan, USA
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - Daniel J. Henning
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Troy E. Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Richard J. Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Charles R. Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Klotz AD, Caterino JM, Durham D, Felipe Rico J, Pallin DJ, Grudzen CR, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Lyman GH, Madsen TE, Reyes‐Gibby CC, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Jim Yeung S, Yilmaz S, Stutman R, Baugh CW. Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN. Acad Emerg Med 2021; 29:174-183. [PMID: 34811858 PMCID: PMC10359998 DOI: 10.1111/acem.14392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
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Affiliation(s)
- Adam D. Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Danielle Durham
- Department of Radiology School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Juan Felipe Rico
- Department of Pediatrics Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | - Beau Abar
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Aveh Bastani
- Department of Emergency Medicine William Beaumont Hospital Troy Michigan USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Jason J. Bischof
- Department of Emergency Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the Department of Medicine Hutchinson Institute for Cancer Outcomes Research University of Washington School of Medicine Seattle Washington USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City Utah USA
| | - Cielito C. Reyes‐Gibby
- Department of Emergency Medicine and Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Sai‐Ching Jim Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sule Yilmaz
- Department of Geriatric Oncology University of Rochester Medical center Rochester New York USA
| | - Robin Stutman
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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7
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Coyne CJ, Reyes-Gibby CC, Durham DD, Abar B, Adler D, Bastani A, Bernstein SL, Baugh CW, Bischof JJ, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN). Support Care Cancer 2021; 29:4543-4553. [PMID: 33483789 DOI: 10.1007/s00520-021-05987-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/04/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA.
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Danielle D Durham
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital - Troy Campus, Troy, MI, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, NY, USA
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Sciences University, Portland, OR, USA
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine and Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey M Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Alexandra L Howard
- Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Emily J Ankus
- University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA
| | - Juan Felipe Rico
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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Adler D, Abar B, Durham DD, Bastani A, Bernstein SL, Baugh CW, Bischof JJ, Coyne CJ, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer. J Emerg Med 2019; 57:354-361. [PMID: 31353265 DOI: 10.1016/j.jemermed.2019.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/25/2019] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Danielle D Durham
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital, Troy Campus, Troy, Michigan
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Matthew F Hudson
- Prisma Health-Upstate Cancer Institute, Greenville, South Carolina
| | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, Utah
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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10
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Caterino JM, Adler D, Durham DD, Yeung SCJ, Hudson MF, Bastani A, Bernstein SL, Baugh CW, Coyne CJ, Grudzen CR, Henning DJ, Klotz A, Madsen TE, Pallin DJ, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Venkat A, Wilson J, Thomas CR, Bischof JJ, Lyman GH. Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments. JAMA Netw Open 2019; 2:e190979. [PMID: 30901049 PMCID: PMC6583275 DOI: 10.1001/jamanetworkopen.2019.0979] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. OBJECTIVE To provide a benchmark description of patients who present to the ED with active cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. MAIN OUTCOMES AND MEASURES The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. RESULTS Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. CONCLUSIONS AND RELEVANCE This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.
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Affiliation(s)
- Jeffrey M. Caterino
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Danielle D. Durham
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Sai-Ching Jim Yeung
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew F. Hudson
- Greenville Health System Cancer Institute, Greenville, South Carolina
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital–Troy Campus, Troy, Michigan
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Troy E. Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Cielito C. Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa
| | - Richard J. Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa
| | - Charles R. Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Sciences University, Portland
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Department of Medicine, University of Washington School of Medicine, Seattle
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11
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Coyne CJ, Shatsky RA, Durham DD, Klotz A, Bastani A, Baugh C, Grudzen C, Henning D, Adler D, Wilson J, Rico JF, Pallin D, Yeung SCJ, Bernstein S, Caterino J, Madsen T, Ryan R, Kyriacou D, Venkat A, Reyes-Gibby CC. Cancer pain in the emergency department: A multicenter study of the Comprehensive Oncologic Emergencies Research Network. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.6541] [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)
| | | | | | - Adam Klotz
- Memorial Sloan Kettering Cancer Center, NY, NY
| | | | - Christopher Baugh
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA
| | | | | | | | | | | | - Daniel Pallin
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA
| | | | | | | | - Troy Madsen
- University of Utah School of Medicine, Salt Lake City, UT
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