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In recent years, a dramatic breakthrough in cancer treatment has arisen with the advent of immune-checkpoint inhibitor (ICI) therapy. However, these therapies are accompanied by multiple unique immune-related adverse effects that can present as an oncologic emergency to emergency department (ED). Here we describe the characteristics of cancer patients with no previous diagnosis of adrenal insufficiency who present to the emergency with low adrenocorticotropic hormone and cortisol levels following ICI therapy. Using data from a comprehensive cancer center, we conducted a retrospective cohort study of patients 18 years and older who received ICI between April 1 st, 2018, and December 31st, 2022, and presented to the ED with low ACTH and total cortisol levels. The billing database was used to exclude patients with prior diagnosis of adrenal insufficiency based on the ICD-10 codes. Demographics, clinical and cancerrelated data were collected from the institution's data warehouse. Descriptive statistics were used to analyze the data. A total of 101 cancer patients were identified based on the eligibility criteria, with a median age of 63 years (interquartile range= 58-72 years), who were mostly White race (83.2 %) and Not Hispanic or Latino ethnic group (86.1%). Melanoma, lung, renal and head and neck cancer were the most common cancer types for these patients. The median Charlson comorbidity index was 8 (interquartile range: 7–9). Most (98%) of the patients presented as level 2 or 3 on the emergency severity index. Almost all patients (94%) were admitted, of these, 26 patients (25.7%) were placed in the observation unit. Of the patients who got admitted, around 10% were placed in the intensive care unit during their hospital stay. The clinical use of ICI is continually broadening and certain ICI-induced toxicities including endocrinopathies requires immediate medical attention. We found that most patients presenting to the ED with low ACTH and cortisol levels with no previous diagnosis of adrenal insufficiency after ICI therapy require admission and close monitoring. Further studies are needed to better evaluate the incidence and outcomes of ICI-induced adrenal insufficiency among cancer patients after ICI therapy. [ABSTRACT FROM AUTHOR]

Background: The concurrence of ectopic adrenocorticotropic hormone (ACTH) syndrome (ectopic Cushing syndrome) and cancer is uncommon in the emergency department (ED) setting, but a constellation of nonspecific signs and symptoms can suggest the presence of Cushing syndrome.Case Report: A 65-year-old woman with diabetes visited the ED complaining of severe weight loss, generalized weakness, and hypokalemia. She was treated for hypokalemia and thrush. She was found to have a lung mass with a large pleural effusion. Upon discovery of the suspected malignancy, the patient was referred to the ED of a comprehensive cancer center, where she was diagnosed with ectopic Cushing syndrome and admitted to the hospital for further evaluation and treatment. WHY SHOULD THE EMERGENCY PHYSICIAN BE AWARE OF THIS?: The emergency physician should be able to recognize Cushing syndrome in cancer patients so that the paraneoplastic syndrome can be managed to avoid complications during cancer treatment. [ABSTRACT FROM AUTHOR]

Patients with a known cancer diagnosis are frequent visitors to general emergency departments (ED) Since MD Anderson Cancer Center is a dedicated oncologic hospital, new patients present with symptoms suspected to be attributable to a yet unconfirmed cancer diagnosis. The aim was to examine and characterize the oncologic ED presentation of new patients with a suspicion of cancer. Our institutional database was quired for all ED visits for subjects aged 18 and older with no prior cancer diagnosis (using tumor registry and billing database) between 11/1/2020 and 01/01/2022. Chart review was conducted to confirm the absence of previous cancer diagnosis in the identified subjects and to verify they received follow-up in our institution. Demographics, ED presentation and clinical data were collected. Descriptive statistics and Chi-Square test of independence were used to analyze, compare and report the presentation and the outcomes of final eligible patients. During the study period, of the 2727 subjects identified, 358 met the final eligibility criteria. The median age was 57 years (interquartile range: 45-66 years). The majority were male (51.1%), White or Caucasian race (57.0%) and not Hispanic or Latino ethnicity (74.0%). Almost all the patients (99.2%) were presented as emergent or urgent acuity level (i.e., Emergency Severity Index levels 2 or 3 respectively). The most frequent presenting complaint(s) were: Abnormal laboratory results (16.8%); Hypertension (9.8%); infection and/or suspected sepsis (7.5%); nausea/vomiting (7.3%); fatigue (7.0%); shortness of breath (6.7%) or headache (5.9%). Most of the patients were admitted either to the hospital (59.2%) or the observation unit (18.2%). Of the 212 admitted patients, 35 (16.5%) died within one year of the ED presentation, which was significantly (P=0.003) higher than the 5.5% one-year mortality rate for the patients who were discharged or placed in the observation unit. Most patients presenting to an oncologic emergency with unconfirmed suspicion of cancer require hospitalization. The admitted group have higher mortality for reasons that need further elucidation. Further research is also needed to understand why the fairly large segment that do not require hospitalization seek care in the ED setting. [ABSTRACT FROM AUTHOR]

Chimeric antigen receptor T cell infusion (CAR T) therapy revolutionized and led to a paradigm shift in the treatment of hematologic malignancies, but treatment- related toxicities including cytokine release syndrome and immune effector cell- associated neurotoxicity syndrome are of concern. In this study, we aimed to understand the timing and reasons for which patients present to the emergency department (ED) after CAR T therapy to better assist with early recognition and management of these toxicities. We conducted a retrospective observational study for patients who had undergone CAR T therapy in the past 6 months and visited the ED of our comprehensive cancer center between 04/01/2018 and 08/01/2022. We examined the timing of presentation after CAR T product infusion, patient characteristics, and outcomes of the ED visit. Survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. During the period studied, there were 276 ED visits by 168 unique patients. Most patients had diffuse large B-cell lymphoma (103/168; 61.3%), multiple myeloma (21/168; 12.5%), or mantle cell lymphoma (16/168; 9.5%). Almost all 276 visits required urgent (60.5%) or emergent (37.7%) care and 73.5% of visits led to admission to the hospital or observation unit. Fever was the most frequent presenting complaint, reported in 19.6% of the visits. The 30-day and 90-day mortality rates after the index ED visits were 17.0% and 32.2% respectively. Patients who had their first ED visit >14 days after CAR T product infusion had significantly worse overall survival (multivariable hazard ratio 3.27; 95% confidence interval 1.29–8.27; P=0.012) than patients who first visited the ED within 14 days of CAR T product infusion. Cancer patients who receive CAR T therapy frequently visit the ED and most are admitted and/or require urgent or emergent care. Early ED visits may indicate early systemic inflammatory response to CAR T therapy, with patients mainly presenting with constitutional symptoms such as fever and fatigue, and these early visits are associated with better overall survival. [ABSTRACT FROM AUTHOR]

Pain remains an undertreated complication of cancer and has been shown to affect patients' quality of life. Patients when presenting to an emergency department (ED) with pain have two routes to management: hospitalization or discharged for outpatient management. With the advent of observation units, there is now an opportunity to utilize hospital resources without an inpatient stay. In this study, we aimed to define the role of an EDOU in the management of cancer pain. We performed a retrospective observational study that included all patients aged 18 years and older who presented to our ED and were placed in the EDOU with uncontrolled cancer pain between 1 March 2019 and 29 February 2020. Patient characteristics were summarized using descriptive statistics and predictors of the disposition from the EDOU were identified with univariate and multivariate analyses. A total of 600 visits were eligible for analysis. The median age of the cohort was 59 years (interquartile range: IQR 48–68 years). Breast, lung, and colorectal cancer were the most common cancer types. The abdomen (29.0%), back (17.3%), and extremities (15.8%) were the most common locations of identified pain. Most patients were discharged home (61.8%), 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. Our data suggest that an EDOU appears to be an appropriate venue to care for a subsegment of patients presenting to an emergency department with cancer pain with low 72- hour ED revisits and 30-day mortality rates. Placing eligible cancer patients with pain in EDOU creates an optimal care environment than immediate admission or discharge for patients who require significant cancer pain management but may not require inpatient hospitalization for their therapy. [ABSTRACT FROM AUTHOR]