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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]

Objective: The core content of emergency medicine (EM) residency training includes the management of oncologic emergencies; however, documented knowledge gaps continue to exist in this subtopic. This study represents a targeted needs assessment as indicated by Step 2 of Kern's curriculum design to determine the specific training gaps to be addressed within the oncologic EM curriculum. Methods: A multi‐institutional cross‐sectional survey of oncologists (surgical and medical) and emergency physicians (attendings and residents) was conducted during 2023 at five institutions. The voluntary survey consisted of general and specialty‐specific questions exploring gaps in oncologic emergency–specific training/education topics. Descriptive statistics reported responses as frequencies and percentages. Results: Of the 833 surveys sent across the five sites, 302 (36.3%) were accessed by link; of these, 271 (89.7%) surveys were completed. There were no differences in the responses between early and later respondents and no differences in the characteristics of respondents between sites. A vast majority of the oncologist and EM groups (91.2% and 83.0%, respectively) reported a belief that emergency physicians would benefit from additional oncologic emergency training. Our survey identified 16 important topics for inclusion in an oncologic EM curriculum, including five topics not present on the 2022 Model of Clinical Practice of Emergency Medicine. Conclusions: Based on this needs assessment, an oncologic EM curriculum should include the topics listed under oncologic emergencies in the 2022 Model of the Clinical Practice of Emergency Medicine along with our respondent‐identified topics of radiation therapy adverse effects, stem cell transplant complications, and the management of cancer‐specific postsurgical complications, pain, and common diseases in patients with cancer. [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]

With the widespread use of immune checkpoint inhibitors (ICIs) for cancer treatment, rare or uncommon immune-related adverse events (irAEs) are frequently being reported. As some of these irAEs can be severe or life-threatening with patients presenting to the emergency departments and acute care centers for care, understanding the presentation and management of these events is important. Here, a systematic review was conducted to examine the reported characteristics and management of myocarditis, myositis, and myasthenia gravis triad after ICI therapy. Following PRISMA guidelines, we conducted a systematic review that included studies written in English published in PubMed and Embase up to August 1st, 2023 that reported concurrent myocarditis, myositis, and myasthenia gravis in the setting of ICI. Data on presentation, patients' characteristics, management, and outcomes were collected. Qualitative synthesis and descriptive statistics were used to analyze and report the main results. A total number of 61 cases with the M triad were identified, of which the majority had melanoma or lung cancer (51%) with a median age of 71 years. Almost all the patients (92%) were treated with PD-1 inhibitors. The main frequent complaints were dyspnea (50.8%), ptosis (49.2%), and diplopia (36.1%). Corticosteroids and intravenous immunoglobulin were the main treatment modalities. Twenty-one (34.4%) patients died in the hospital. Concurrent M triad of myocarditis, myositis, and myasthenia gravis following ICI therapy is not uncommon and can present to the emergency department with a spectrum of complaints. As these concurrent irAEs are associated with high mortality rates, prompt recognition and thorough investigations by emergency department physicians are vital for effective management and early intervention. More research is needed to better identify risk factors that can be used as predictors to identify high-risk patients who may develop these events after ICI therapy, for which multidisciplinary collaboration and point-of-care testing in parallel with early recognition is necessary when evaluating these patients when they present to the emergency departments or acute care centers. [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]