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Immune checkpoint inhibitors (ICIs) have significantly transformed cancer treatment, but their use is linked to immune-related adverse events (irAEs), including the rare ICI-associated myocarditis, myositis, and myasthenia gravis (MMM) overlap syndrome. This systematic review aims to highlight MMM's clinical implications in emergency departments. PubMed and Embase were searched using a specific search strategy. Reports were eligible for inclusion if all three conditions were present and associated with the use of an ICI. Data were extracted by independent reviewers using the Rayyan web application for systematic reviews. Descriptive statistics and qualitative synthesis were used to summarize demographic, clinical, and treatment data for the reported cases. Among 50 cases, predominantly associated with melanoma, lung cancer, and renal cancer, the in-hospital mortality rate was 38.0%. The most commonly presenting symptoms were ptosis (58%), dyspnea (48%), diplopia (42%), or myalgia (36%). The median time from ICI initiation to MMM presentation was 21 days (interquartile range: 15–28 days). Corticosteroids were the primary treatment for the irAEs. MMM, a rare but potentially fatal complication of ICI therapy, requires prompt recognition in emergency settings. Corticosteroids should be initiated if suspected, without waiting for confirmation. Multidisciplinary collaboration is vital for diagnosis and treatment planning. Research on MMM's link to specific cancers and ICIs is imperative for better risk assessment and interventions. [ABSTRACT FROM AUTHOR]

Simple Summary: Brain metastases (BMs), the most common type of cerebral tumor, are primarily associated with lung cancer, breast cancer, and melanoma. Patients typically present to the emergency department (ED) with insidious symptoms such as headaches, focal neurological deficits, seizures, and signs of increased intracranial pressure. Key symptomatic treatment in the ED includes corticosteroids to manage peritumoral edema, and carefully selected antiepileptic medications for tumor-related epileptic conditions. After stabilization, the treatment philosophy for BMs should prioritize effective yet minimally toxic options to maximize quality of life. Surgery is recommended for accessible BMs in patients with good performance status. Radiation therapy and systemic treatments, including chemotherapy, targeted therapy, and immunotherapy, are available options for managing disease progression. Given that over half of patients with BMs in the ED are admitted, a better understanding of avoidable hospitalizations is essential to differentiate those who can be safely discharged from those needing observation or hospitalization. Brain metastases (BMs) are the most prevalent type of cerebral tumor, significantly affecting survival. In adults, lung cancer, breast cancer, and melanoma are the primary cancers associated with BMs. Symptoms often result from brain compression, and patients may present to the emergency department (ED) with life-threatening conditions. The goal of treatment of BMs is to maximize survival and quality of life by choosing the least toxic therapy. Surgical resection followed by cavity radiation or definitive stereotactic radiosurgery remains the standard approach, depending on the patient's condition. Conversely, whole brain radiation therapy is becoming more limited to cases with multiple inoperable BMs and is less frequently used for postoperative control. BMs often signal advanced systemic disease, and patients usually present to the ED with poorly controlled symptoms, justifying hospitalization. Over half of patients with BMs in the ED are admitted, making effective ED-based management a challenge. This article reviews the epidemiology, clinical manifestations, and current treatment options of patients with BMs. Additionally, it provides an overview of ED management and highlights the challenges faced in this setting. An improved understanding of the reasons for potentially avoidable hospitalizations in cancer patients with BMs is needed and could help emergency physicians distinguish patients who can be safely discharged from those who require observation or hospitalization. [ABSTRACT FROM AUTHOR]

119 Background: Each year, approximately 33,000 new cancer patients seek treatment at our dedicated cancer hospital, with many placed in our observation unit, the Clinical Decision Unit (CDU). These patients often experience significant delays in receiving oncologic care after discharge resulting in distress for both patients and providers. Our goal is to reduce the two-week appointment time from CDU discharge to outpatient oncologic care by more 10% for those eligible to be seen at the hospital. Methods: In fiscal year 2023, we gathered data on patients admitted to and discharged from the CDU, focusing on new patients. A multidisciplinary team developed a fishbone diagram, process flowcharts, and an impact matrix. Interventions included automated referrals, discharge notifications, patient and provider education, discharge booklets, and oncology recommendations for urgent consults. A physician satisfaction survey was conducted pre- and post-intervention. Three months of post-intervention data (February-May 2024) were reviewed, measuring the baseline percentage of patients receiving an appointment within two weeks, one month or more after CDU discharge. Results: In 2023, 90 eligible patients new to the institution were discharged from the CDU. Of those, 3 (3%) had follow-up appointments within 2 weeks, and 39 (43%) had appointments after 30 days or no appointment at all. Post-intervention data showed that out of 15 new patients discharged between February and May 2024, 10 (66%) had follow up appointments within 2 weeks, 4 (27%) within 30 days, while 1 (7%) had not yet received an appointment. Conclusions: Streamlining the referral process through a central service, automating the requests, and educating both providers and patients can reduce the time to establish oncologic care through an observation unit. However, limitations remain for patients with out-of-network insurance or lack of insurance coverage. Further research is necessary to assess whether expediting follow up cancer care for new patients improves clinical outcomes and relieves associated stress as we suspect it does. Time interval for new patients to acquire oncology clinic appointments post discharge. Dates/Time Frame Eligible New Patients with Appointments Within 2 weeks Eligible New Patients with Appointments within 15 to 30 days Eligible New Patients with No Appointment or Appointment > 30 days* Baseline Data FY 2023 3% (3/90) 53% (48/90) 43% (39/90) Post-Intervention: 2/6/24 – 5/6/24 66%% (10/15) 27% (4/15) 7% (1/15) *Includes patients without follow up. [ABSTRACT FROM AUTHOR]

Background With increased use of antibiotics in high-risk patients, the investigation of new antibiotics to cover potentially resistant pathogens is warranted. In this prospective randomized trial, we compared ceftolozane/tazobactam (C/T), a new cephalosporin/β-lactamase inhibitor, to the standard of care (SOC) for the empiric treatment of neutropenia and fever in patients with hematological malignancies. Methods We enrolled 100 patients to receive intravenous (IV) C/T or SOC antibiotics (cefepime, piperacillin/tazobactam, or meropenem) in combination with gram-positive antibacterial agents. We evaluated responses at the end of IV therapy (EOIV), test of cure (TOC; days 21–28), and late follow-up (LFU; days 35–42). Results We analyzed 47 C/T patients and 50 SOC patients. C/T patients had a higher rate of favorable clinical response at EOIV (87% vs 72%). A 1-sided noninferiority analysis indicated that C/T was at least not inferior to the SOC for favorable clinical response at EOIV (P  = .002), TOC (P  = .004), and LFU (P  = .002). Superiority tests showed that C/T led to significantly lower rates of clinical failure at TOC (6% vs 30%; P  = .003) and LFU (9% vs 30%; P  = .008). C/T and SOC patients with documented infections had similar rates of favorable microbiological response. Serious adverse events leading to drug discontinuation (2% vs 0%; P  = .48) and overall mortality (6% vs 4%; P  = .67) were similar in both groups. Conclusions The empiric use of C/T in high-risk patients with hematological malignancies and febrile neutropenia is safe and associated with better clinical outcomes than SOC antimicrobial agents. Clinical Trials Registration NCT03485950. [ABSTRACT FROM AUTHOR]

Background Checkpoint inhibitor (CPI) immunotherapy has revolutionized cancer treatment. However, immune-related adverse events and the risk of infections are not well studied. To assess the infectious risk of CPIs, we evaluated the incidence of infections in lung cancer patients treated with CPIs plus conventional chemotherapy (CC) vs CC alone. Methods We performed a retrospective comparative study of patients with advanced non–small cell lung cancer who received CPIs combined with CC and those treated with CC alone at our institution during January 2016 to February 2019. We compared clinical characteristics, treatments, and outcomes including infection rate and mortality between the groups. Results We identified 123 patients for the CPI group and 147 patients for the control (CC) group. Eighteen patients (15%) in the CPI group and 33 patients (22%) in the control group developed infections (P  = .1). Pneumonia was the most common infection encountered in both groups. Urinary tract infection was higher in the CC group (40%) than in the CPI group (9%) (P  = .01). On multivariable analysis, chronic obstructive pulmonary disease (P  = .024), prior use of corticosteroids (P  = .021), and neutropenia (P  < .001) were independent risk factors for infection and severe infection requiring hospital admission. Chronic kidney disease (P  = .02), prior cancer treatment (P  = .023), and neutropenia (P  < .0001) were identified as independent risk factors for all-cause mortality. Conclusions Lung cancer patients treated with CPIs combined with CC have a comparable risk of infection to those treated with CC alone, although there is a trend towards fewer infections in those given CPIs, particularly when it comes to urinary tract infections. [ABSTRACT FROM AUTHOR]