Hematology/Oncology & ID (Oct 2015)
Research: Glassberg et al. Provider practices & attitudes in SCD. Annals EM 2013
Review: McCurdy, Stanholtz. Oncologic Emergencies. Crit Care Med 2012
AIR Module: ID/Heme/Onc
Research: Glassberg et al. Provider practices & attitudes in SCD. Annals EM 2013
Review: McCurdy, Stanholtz. Oncologic Emergencies. Crit Care Med 2012
AIR Module: ID/Heme/Onc
19 comments
Glassberg et al.
1. What are some strengths of the study?
Addresses important issue in the care of patients with sickle cell disease. Shows how ethnicity of provider and patient can affect patient care. Pain control is a patient-centered outcome.
2. What are the limitations?
The survey did not ask providers if they were aware of the NHLBI expert panel recommendations or if they attempted to follow the recommendations. However, the article still made assumptions about penetration of the recommendations into the EM community.
3. What are the main outcomes of the study?
Provider attitudes toward patients with VOC. Provider self-reported analgesic practices.
4. Does reading this article change your practice? If so, how?
I will try harder to reach the NHLBI recommended goal of rapidly initiating “analgesic therapy within 30 minutes of triage or within 60 minutes of registration.” I think it will also be helpful to be aware of common provider biases and patient-physician dynamics when I treat patients with VOC.
That’s a great point about the limitation Andrew.
It’s hard to adhere to something you don’t know about.
For those guidelines, here’s the link”
https://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/quickguide.pdf
Page 14 is the section on VOC crises and pain control.
While the results of the Glassberg study is no surprise, take at another look at the methods section.
For a survey study, the authors devoted a huge amount of text in the methods section, demonstrating how difficult and arduous it can be to develop a valid survey that actually get researchers the answer they are asking. Don’t get bogged down by the statistical analysis. But definitely consult a survey expert next time you start a survey study. It’s easy to get way ahead of yourself and find out in the end that your survey isn’t valid.
McCurdy et al.
1. How has reading the article changed your practice?
Article provided a useful approach to diagnosing and managing these less commonly seen emergencies.
2. What information had you believed in previously that were debunked by reading this article?
Previously thought that SVC syndrome was almost exclusively a complication of malignancy. Now I know it is also associated with syphilis, histoplasmosis, pulmonary TB, and thrombotic events from implantable devices.
3. What new information did you learn from reading this article?
A lot. Postvoid residual is 90% sensitive and 95% specific for cauda equina syndrome. Bisphosphonates are first-line treatment for malignancy associated hypercalcemia. Recombinant urate oxidase (rasburicase) is a newer drug that helps normalize uric acid levels in TLS.
4. What are current areas of uncertainty on this topic that can be potential areas for research?
Use of steroids for acute management of SVC syndrome.
McCurdy et al.
Nice concise review of onc emergencies.
For those of you looking for neutropenic fever review, check out this month’s AIR module.
Specifically:
http://www.aliem.com/paucis-verbis-neutropenic-fever-in-cancer-patients/
Glassberg
1. The study had a high response rate. The study linked attitudes to self-reported practice. They used a validated attitude survey.
2. The adherence was self-reported rather than objectively measured.
3. Doctors with negative attitudes less likely to treat pain effectively. Pediatricians better at controlling pain. Doctors who see a high volume of SCD patients actually do worse job of caring for them. Sickle cell treatment centers don’t make better attitudes.
4. Be careful about developing biases.
Heme/Onc Emergencies
1. How has reading the article changed your practice?
It was a great refresher on the ONC emergencies we can see. Good reminder to get a Ca on patients with cancer and vague symptoms (comes on VBG but not on BMP or CMP, to the best of my knowledge).
2. What information had you believed in previously that were debunked by reading this article?
I did not think steroids did anything for malignant spinal cord compression. Now I know that high-dose steroids are evidence-based to improve ambulation, as long as there are no contraindications – DM, psych, etc.
3. What new information did you learn from reading this article?
I learned the 3 most common cancers to metastasize to bone are LBP – Lung, Breast, and Prostate.
In hypercalcemia a/w Malignancy – fluids only lowers the Ca to an acceptable rate 1/3 of the time so you likely will need to start bisphophonates.
4. What are current areas of uncertainty on this topic that can be potential areas for research?
Is continuous renal replacement more effective than intermittent therapy (CVVH vs. HD) in TLS. As an ED provider, I would like to see some cases re: these emergencies and time to treatment (i.e. does rapid initiation of bisphosphonates improve outcome in MAH).
McCurdy et al.
1. How has reading the article changed your practice?
Good review article with uptodate management guidelines
2. What information had you believed in previously that were debunked by reading this article?
I was not aware that there were two different regimens for steroid use in cord compression – in the setting of significant neuro deficits its a higher dose which is not something I have used before and will be a good question to ask NSGY/ortho next time around
3. What new information did you learn from reading this article?
I knew of the different issues mentioned but it was a good refresher. Did not know about newer methods for hyperuricemia and also stenting of SVC. I also did not realize how bad the mortality is for some of these complications and that it relates to how quickly we should act from the ED
4. What are current areas of uncertainty on this topic that can be potential areas for research?
Potentially using some of these new agents as prophlyaxis?
I would like to point out that the table for TLS mentions “hypercalcemia” but it should read “hypocalcemia”. Alex I think I deserve a bonus conference credit hour for that observation!
Good catch! Though it’s not as good as reading and answering questions for the other article. You do deserve a beer though! Remind me next time we are out.
McCurdy
1. Change practice: When encountering hypercalcemia of malignancy or otherwise, anticipate co-existing electrolyte abnormalities and make sure to treat and monitor all electrolytes with interventions such as large fluid boluses or
2. Debunked: Alkanizing urine in TLS is not recommended because of risk of inducing nephropathy.
3.New learned: I had associated TLS as causing renal damage, but I had not thought through how preexisting renal dysfunction predisposes to TLS, although that is not surprising.
4. Area for research:
What should be the clues that a pericardial effusion is the result of an undiagnosed malignancy? Also, how to manage TLS and MAH in patients with underlying CHF- fluids and diuretics or straight to dialysis?
Glassberg et al.
* What are some strengths of the study?
They achieved a high response rate and were able to focus on a very patient centered measure.
* What are the limitations?
They recognize their own biggest limitation, in that their study population might not be able to be generalized overall (ACEP attendees might not reflect most Emergency physicians). Another limitation, though, Grace touched on, is that people might not respond completely honestly, and the practice patterns found in the survey might not actually reflect what is really going on.
* What are the main outcomes of the study?
The main outcome they found is that people who see larger volumes of sickle cell patients are less adherent to the guidelines, as are people with negative attitudes towards these patients. One interesting thing they found out is that high scores on both the positive and negative attitudes scales were both associated with more frequent use of pain meds. Maybe these outliers on the negative side were more burned out and just adopted the practice of “giving them whatever they want”? Interesting to look into more.
* Does reading this article change your practice? If so, how?
The main way this would change my practice would be to be more aware of my own biases. It is easy to get frustrated with these patients, but important to be vigilant as well, because they can sometimes be very sick. Sticking to the regimented guidelines for treating them helps maintain some consistency, and helps to not miss the sick ones.
McCurdy et al.
* How has reading the article changed your practice?
This article serves as an excellent review that I could use as reference when encountering these patients on shift, and will consider some of the possible complications more often when seeing patients with cancer.
* What information had you believed in previously that were debunked by reading this article?
I thought previously that SVC syndrome was only really from compression from solid tumors, but learned that 40% of cases could be from thromboses from intravenous catheters or devices.
* What new information did you learn from reading this article?
I learned that pericardial effusions are often the first sign of malignancy. I learned the arrhythmias that are often caused by hypercalcemia (RBBB, Brugada, bradydysrhythmias), and that it can be seen in as high as 25% of cancer patients. I also learned that bladder dysfunction is extremely common in spinal cord compression and post-void residual volumes are actually an extremely useful tool.
* What are current areas of uncertainty on this topic that can be potential areas for research?
As people already said, the use of steroids in spinal cord compression seems like it could be studied more. But it would also be interesting to look at prognosis after decompression surgery, and if there could be other ways to improve survival rates.
McCurdy Onc Emergencies
Practice changing: making sure to think about ordering Ca, Uric Acid, Phos in Onc patients since these aren’t part of “standard” labs necessariliy
Debunked: none
New info: high dose steroids only if neuro abnormalities; that rasburicase even exists; up to 34% of cancer patients can have pericardial involvement: bust out that ultrasound!
Potential for research: prediction rule for pts more at risk for TLS
Glassberg et al.
1. What are some strengths of the study?
Fills an important research gap by actually connecting negative attitudes about patients with lower guideline adherence. Large sample size.
2. What are the limitations?
As others have mentioned, one of the biggest limitations in my mind is that this is simply self-reported data, which is an imperfect correlate to actual practice.
3. What are the main outcomes of the study?
Factors associated with negative attitudes included being in peds, being a non-black provider, and seeing lots of sickle cell patients in the ED. Negative attitudes were correlated with lower rates of redosing within 30 minutes. With the exception of the recommendations about using parenteral opioids and redosing, most of the NHLBI recs are not being followed.
4. Does reading this article change your practice? If so, how?
Makes me think about trying to use sub-Q instead of IM meds. Great reminder that the patients we see so frequently are not representative of the general sickle cell population and should not color our practice patterns. Also a good reminder that our residency/faculty demographics do not mirror those of the population we serve and that this can negatively impact the care that we are offering.
1. Change practice: Like a lot of people said, makes me think about getting a broader panel of lytes on cancer patients. Also makes me think more about prevalence of malignant pericardial effusions in these patients — something to watch for, especially since their chronic presentations are likely less impressive.
2. Debunked: I thought TLS was always related to treatment, didn’t realize it could happen spontaneously.
3. Learned: Didn’t know about the different steroid doses for MSSC, didn’t know that alkalinizing the urine wasn’t fashionable anymore, didn’t know that neuro sx in SVCS should make you think about brain mets rather than compression.
4. Area for research: I think there’s still a lot of space in clarifying the timeline for a lot of these interventions, i.e., which of these things really have to happen while the patient is still in the ED.
Oops, this is for the Onc Emergenciesa article.
Glassberg et al. – Sickle Cell
1. What are some strengths of the study?
Used 5 experts to evaluate the study before using it, which likely improved validity. Large sample size.
2. What are the limitations?
Dichotomized outcome measures miss nuances in practice, self-reported data, sampling @ ACEP more skewed towards MDs @ teaching institutions and/or self-motivated to participate in the study.
3. What are the main outcomes of the study?
Peds providers = more positive attitudes, used PCA 6x more than adult providers
as # of sickle cell patients per week goes up = negative perception also increases
Most do not choose sq over IM (interesting since we do a lot of IM in the adult ED)
4. Does reading this article change your practice? If so, how?
May use more SQ dosing in the ED. Good reminder to re-dose opioids q30 minutes. It is important to remember that these patients live with chronic pain everyday. They know their typical sickle cell pain vs. other, more severe, issues. This article is a good reminder to ask our patients about their symptoms and trust their answers.
https://www.nhlbi.nih.gov/files/docs/guidelines/sc_mngt.pdf – link to sickle cell guidelines if interested
More up to date JAMA article – http://jama.jamanetwork.com/article.aspx?articleid=1902235
Oncologic Emergencies
1. How has reading the article changed your practice?
More than anything, this article reinforces the association b/w certain pathology and its relationship with malignancy. The article does a great job describing the epidemiology underlying that relationship. As a result, I’ll more quickly jump to an onc ddx than I had previously. Overall, I think it was a great review article.
2. What information had you believed in previously that were debunked by reading this article?
I didn’t realize that TLS is primarily a/w aggressive hematologic malignancies. I had thought the epidemiology was similar with solid tumors.
3. What new information did you learn from reading this article?
Learned a lot! First, I learned that these diagnoses portend a very median survival – on the order of months (not years); MAH = 1 month, SVC = 6 months, etc. For each diagnosis, I learned: SVC – I found the epidemiology interesting (40% 2/2 intravenous devices), 75% of a/w malignancies are from the lung; malignant pericardial effusion: rate of fluid formation is more important than volume, exertional dyspnea is most common sxs; spinal cord compression: give high dose steroids in patients with abnormal neuro exam, otherwise give moderate dose; for hypercalcemia: 1/3 of ED hypercalcemia patients have malignancy; TLS: while all types of cancer tx can cause TLS, there is such a thing as spontaneous TLS (more often a/w rapidly proliferating tumors)
4. What are current areas of uncertainty on this topic that can be potential areas for research? Ultrasound for SVC dx? Maybe by using secondary venous structures (eg, brachiocephalic, IJ, etc.)
ED Provider practices/attitudes re: SCD
1. What are some strengths of the study?
Good participation. Largely based on recommendations coming from national guidelines. Takes into account important environmental factors. Participants included residents and other providers as opposed to just attendings.
2. What are the limitations?
Differential bias regarding population selection. Reporter bias. Study is cross-sectional and therefore weaker. Would have been nice to know admission outcomes. Would be nice to know if providers were aware of guidelines and to what extent.
3. What are the main outcomes of the study?
Pediatric providers have more positive attitudes and adults have more negative attitudes; negative attitude is a/w an increasing number of SCD patients treated per week; black providers had more positive attitudes compared to whites; sex, ethnicity, level of practice were variables not a/w differences in attitudes. High volume providers were less likely to redose meds in 30 minutes per guidelines.
4. Does reading this article change your practice? If so, how?
I don’t know if it changes my practice but it definitely makes me more aware of my own biases – which I hope can change my practice for the better. I think we’re lucky to have a very motivated SCD center with an ED partnership. I feel that this intervention and things like the conference we had earlier this year regarding attitudes/practices in treating SCD are very important to my training.