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Initial presentation of lung cancer in the emergency department: a descriptive analysis.

ABSTRACT: BACKGROUND:Guidelines aimed at improving care for lung cancer, the leading cause of cancer-related death in Canada and worldwide, require accurate knowledge of the diagnostic setting or pathway. We sought to determine how often lung cancer is initially diagnosed through the emergency department. METHODS:We performed a descriptive study that included all cases of primary lung cancer diagnosed in residents of Nova Scotia in 2014. Cancer registry data included diagnostic data and date of death to Aug. 31, 2016. We reviewed linked hospital records, including laboratory and imaging results, to identify the first positive diagnostic study and the route of presentation (emergency department v. other). We evaluated time from diagnosis to death as a function of presentation route using Kaplan-Meier curves and Cox regression (hazard rate ratios [HRRs]). RESULTS:Sufficient data were available for 946 of 951 cases identified, of which 336 (35.5%) were diagnosed through the emergency department. Cases diagnosed via the emergency department were more likely to be at an advanced stage (stage IV, 59.5% v. 43.4%), with patients experiencing shorter survival (1-yr survival, 28.4% v. 49.5%), including stage-specific survival. Mortality for cases diagnosed in the emergency department was 54% higher than for the non-emergency department group after adjusting for age and stage (HRR 1.54, 95% confidence interval 1.32-1.81). Few patients (7.1%, n = 24) who presented to the emergency department reported having no family physician. INTERPRETATION:The emergency department is a common route of presentation for lung cancer and is associated with advanced stage at diagnosis and reduced survival time. Strategies are needed to encourage pre-emergent diagnosis and to ensure that emergency providers are supported in the initial care of patients with lung cancer.

SUBMITTER: Suhail A

PROVIDER: S-EPMC6404960 | biostudies-literature | 2019 Jan-Mar

REPOSITORIES: biostudies-literature

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Initial presentation of lung cancer in the emergency department: a descriptive analysis.

Suhail Aamir A Crocker Candice E CE Das Bijon B Payne Jennifer I JI Manos Daria D

CMAJ open 20190101 1

<h4>Background</h4>Guidelines aimed at improving care for lung cancer, the leading cause of cancer-related death in Canada and worldwide, require accurate knowledge of the diagnostic setting or pathway. We sought to determine how often lung cancer is initially diagnosed through the emergency department.<h4>Methods</h4>We performed a descriptive study that included all cases of primary lung cancer diagnosed in residents of Nova Scotia in 2014. Cancer registry data included diagnostic data and dat ...[more]

PMID: 30808631

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Project description:ObjectivesMost children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine.MethodsRetrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.ResultsTwenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.ConclusionsEmergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Project description:Importance:Emergency departments (EDs) have the potential to play a pivotal role in suicide risk detection and prevention, yet little is known about the profile of risk of suicide after ED visits in the United States. Objectives:To examine 1-year incidence of suicide and other mortality among ED patients who presented with nonfatal deliberate self-harm, suicidal ideation, or any other chief concern, and to examine sociodemographic and clinical factors associated with suicide mortality risk. Design, Setting, and Participants:This retrospective cohort study included statewide, all-payer, longitudinally linked ED patient records and mortality data from all California residents who presented to a California-licensed ED at least 1 time from January 1, 2009, to December 31, 2011, with deliberate self-harm, suicidal ideation but not self-harm, or neither (a 5% random sample). Age-, sex-, and race/ethnicity-adjusted standardized mortality ratios (SMRs) for suicide and other manners or causes of death were determined for each patient group using statewide mortality data. Data were analyzed from January 10 to July 18, 2019. Main Outcomes and Measures:Suicide and other manners or causes of death were ascertained using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Suicide rate and all mortality rates were measured per 100?000 person-years. Results:Among 648?646 individuals (mean [SD] age, 43.8 [20.6] years; 350?687 [54.1%] women) who visited an ED in California from 2009 to 2011, the rates of suicide deaths per 100?000 person-years in the year after index ED presentation were 693.4 deaths among 83?507 individuals presenting with deliberate self-harm (SMR, 56.8; 95% CI, 52.1-61.4), 384.5 deaths among 67?379 individuals presenting with suicidal ideation but not self-harm (SMR, 31.4; 95% CI, 27.5-35.2), and 23.4 deaths among 497?760 reference patients (SMR, 1.9; 95% CI, 1.6-2.3). Compared with the demographically matched general population, the rates of nonsuicide external-cause mortality were also increased among patients with self-harm (SMR, 14.2; 95% CI, 12.9-15.5), patients with suicidal ideation (SMR, 11.8; 95% CI, 10.6-13.0), and reference patients (SMR, 2.2; 95% CI, 2.0-2.3). In all 3 groups, the rates of suicide mortality per 100?000 person-years were higher among men (deliberate self-harm: 1011.1 deaths; suicidal ideation: 539.8 deaths; reference: 36.6 deaths), people 65 years or older (deliberate self-harm: 1919.5 deaths; suicidal ideation: 691.2 deaths; reference: 28.6 deaths), and non-Hispanic white patients (deliberate self-harm: 914.1 deaths; suicidal ideation: 511.6 deaths; reference: 33.8 deaths) than among their respective referent groups. Other sociodemographic factors and clinical diagnoses were associated with striking differences in suicide rates, but these patterns were heterogeneous across patient groups. Conclusions and Relevance:These findings suggest that ED patients with deliberate self-harm or suicidal ideation are associated with substantially increased risk of suicide and other mortality during the year after ED presentation. The process of planning for ED discharge may present opportunities to help ensure safe transitions to continuing outpatient mental health care and to consider broader risk for unintentional injury and other causes of premature mortality.

Project description:Study objectiveOpioid abuse and overdose constitute an ongoing health emergency. Many presume opioids have little potential for iatrogenic addiction when used as directed, particularly in short courses, as is typical of the emergency department (ED) setting. We preliminarily explore the possibility that initial exposure to opioids by EDs could be related to subsequent opioid misuse.MethodsThis cross-sectional study surveyed a convenience sample of patients reporting heroin or nonmedical opioid use at an urban, academic ED. We estimated the proportion whose initial exposure to opioids was a legitimate medical prescription and the proportion of those prescriptions that came from an ED. Secondary measurements included the proportion of patients receiving nonopioid substances before initial opioid exposure, the source of opioids between initial exposure and onset of regular nonmedical use, and time from initial prescription to opioid use disorder.ResultsOf 59 subjects, 35 (59%; 95% confidence interval [CI] 47% to 71%) reported they were first exposed to opioids by a legitimate medical prescription, and for 10 of 35 (29%; 95% CI 16% to 45%), the prescription came from an ED. Most medically exposed subjects (28/35; 80%; 95% CI 65% to 91%) reported nonopioid substance use or treatment for nonopioid substance use disorders preceding the initial opioid exposure. Emergency providers were a source of opioids between exposure and onset of regular nonmedical use in 11 of 35 cases (31%; 95% CI 18% to 48%). Thirty-one of the 35 medically exposed subjects reported the time of onset of nonmedical use; median time from exposure to onset of nonmedical use was 6 months for use to get high (N=25; interquartile range [IQR] 2 to 36), 12 months for regular use to get high (N=24; IQR 2 to 36), 18 months for use to avoid withdrawal (N=26; IQR 2 to 38), and 24 months for regular use to avoid withdrawal (N=27; IQR 2 to 48). Eleven subjects (36%; 95% CI 21% to 53%) began nonmedical use within 2 months, and 9 of 11 (82%; 95% CI 53% to 96%) reported nonopioid substance use or treatment for alcohol abuse before initial opioid exposure.ConclusionAlthough short-term opioid administration by emergency providers is unlikely to cause addiction by itself, ED opioid prescriptions may contribute to the development of addiction in some patients. There is an urgent need for further research to estimate long-term risks of short-course opioid therapy so that the risk of iatrogenic addiction can be appropriately balanced with the benefit of analgesia.

Project description:ImportanceThe emergency department (ED) is used to manage cancer-related complications among the 15.5 million people living with cancer in the United States. However, ED utilization patterns by the population of US adults with cancer have not been previously evaluated or described in published literature.ObjectiveTo estimate the proportion of US ED visits made by adults with a cancer diagnosis, understand the clinical presentation of adult patients with cancer in the ED, and examine factors related to inpatient admission within this population.Design, setting, and participantsNationally representative data comprised of 7 survey cycles (January 2006-December 2012) from the Nationwide Emergency Department Sample were analyzed. Identification of adult (age ?18 years) cancer-related visits was based on Clinical Classifications Software diagnoses documented during the ED visit. Weighted frequencies and proportions of ED visits among adult patients with cancer by demographic, geographic, and clinical characteristics were calculated. Weighted multivariable logistic regression was used to examine the associations between inpatient admission and key demographic and clinical variables for adult cancer-related ED visits.Main outcomes and measuresAdult cancer-related ED utilization patterns; identification of primary reason for ED visit; patient-related factors associated with inpatient admission from the ED.ResultsAmong an estimated 696 million weighted adult ED visits from January 2006 to December 2012, 29.5 million (4.2%) were made by a patient with a cancer diagnosis. The most common cancers associated with an ED visit were breast, prostate, and lung cancer, and most common primary reasons for visit were pneumonia (4.5%), nonspecific chest pain (3.7%), and urinary tract infection (3.2%). Adult cancer-related ED visits resulted in inpatient admissions more frequently (59.7%) than non-cancer-related visits (16.3%) (P?<?.001). Septicemia (odds ratio [OR], 91.2; 95% CI, 81.2-102.3) and intestinal obstruction (OR, 10.94; 95% CI, 10.6-11.4) were associated with the highest odds of inpatient admission.Conclusions and relevanceConsistent with national prevalence statistics among adults, breast, prostate, and lung cancer were the most common cancer diagnoses presenting to the ED. Pneumonia was the most common reason for adult cancer-related ED visits with an associated high inpatient admission rate. This analysis highlights cancer-specific ED clinical presentations and the opportunity to inform patient and system-directed prevention and management strategies.

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Initial presentation of lung cancer in the emergency department: a descriptive analysis.

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Initial presentation of lung cancer in the emergency department: a descriptive analysis.

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