Jessica Zuleta, MD, FHM

Clinical question: Does emergency department management of patients with febrile neutropenia (FN) follow current guidelines?

Background: Chemotherapy-related FN is an oncologic emergency frequently leading to hospitalization and intravenous antibiotics. Familiarity with FN guidelines allows risk stratification for inpatient versus outpatient therapy.

Study design: Single-center, retrospective, cohort study.

Setting: Large, urban, tertiary-care academic hospital.

Synopsis: Of 173 patient visits, 25% were risk stratified as eligible for outpatient treatment and 75% as inpatient care. All patient care was assessed for guideline concordance at the time of ED disposition and therapy.

Primary outcome analysis demonstrated management was guideline discordant in 98% of low-risk patients versus 7% of high-risk patients. Secondary 30-day clinical outcomes showed high-risk patients were more likely to have positive blood cultures (54%), sepsis-induced hypotension (9.3%), and death (5.4%). Seventeen percent of all patients who received IV antibiotics were prescribed vancomycin without guideline support.

Bottom line: Low-risk FN patients in the ED received more aggressive treatment than recommended. Further research is needed to strategize means of better aligning FN management with standards of care.

Citation: Baugh CW, Wang TJ, Caterino JM, et al. ED management of patients with febrile neutropenia: guideline concordant or overly aggressive [published online ahead of print Sept. 9, 2016]? Acad Emerg Med. doi: 10.1111/acem.13079.

Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does emergency department management of patients with febrile neutropenia (FN) follow current guidelines?

Background: Chemotherapy-related FN is an oncologic emergency frequently leading to hospitalization and intravenous antibiotics. Familiarity with FN guidelines allows risk stratification for inpatient versus outpatient therapy.

Study design: Single-center, retrospective, cohort study.

Setting: Large, urban, tertiary-care academic hospital.

Synopsis: Of 173 patient visits, 25% were risk stratified as eligible for outpatient treatment and 75% as inpatient care. All patient care was assessed for guideline concordance at the time of ED disposition and therapy.

Primary outcome analysis demonstrated management was guideline discordant in 98% of low-risk patients versus 7% of high-risk patients. Secondary 30-day clinical outcomes showed high-risk patients were more likely to have positive blood cultures (54%), sepsis-induced hypotension (9.3%), and death (5.4%). Seventeen percent of all patients who received IV antibiotics were prescribed vancomycin without guideline support.

Bottom line: Low-risk FN patients in the ED received more aggressive treatment than recommended. Further research is needed to strategize means of better aligning FN management with standards of care.

Citation: Baugh CW, Wang TJ, Caterino JM, et al. ED management of patients with febrile neutropenia: guideline concordant or overly aggressive [published online ahead of print Sept. 9, 2016]? Acad Emerg Med. doi: 10.1111/acem.13079.

Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does emergency department management of patients with febrile neutropenia (FN) follow current guidelines?

Background: Chemotherapy-related FN is an oncologic emergency frequently leading to hospitalization and intravenous antibiotics. Familiarity with FN guidelines allows risk stratification for inpatient versus outpatient therapy.

Study design: Single-center, retrospective, cohort study.

Setting: Large, urban, tertiary-care academic hospital.

Synopsis: Of 173 patient visits, 25% were risk stratified as eligible for outpatient treatment and 75% as inpatient care. All patient care was assessed for guideline concordance at the time of ED disposition and therapy.

Primary outcome analysis demonstrated management was guideline discordant in 98% of low-risk patients versus 7% of high-risk patients. Secondary 30-day clinical outcomes showed high-risk patients were more likely to have positive blood cultures (54%), sepsis-induced hypotension (9.3%), and death (5.4%). Seventeen percent of all patients who received IV antibiotics were prescribed vancomycin without guideline support.

Bottom line: Low-risk FN patients in the ED received more aggressive treatment than recommended. Further research is needed to strategize means of better aligning FN management with standards of care.

Citation: Baugh CW, Wang TJ, Caterino JM, et al. ED management of patients with febrile neutropenia: guideline concordant or overly aggressive [published online ahead of print Sept. 9, 2016]? Acad Emerg Med. doi: 10.1111/acem.13079.

Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does therapeutic anticoagulation of isolated calf deep vein thrombosis (DVT) decrease risk for proximal DVT or PE?

Background: Optimal management of isolated calf DVT lacks consensus.

Study design: Single-center, retrospective, cohort study.

Setting: Large academic hospital.

Nevertheless, 9.2% of control patients and 3.3% of exposure patients developed a proximal DVT or PE. The anticoagulation group was associated with lower likelihood of proximal DVT or PE (risk ratio 0.36; 95% CI, 0.15-0.84) but an increased risk of bleeding (8.6%), compared with the nonexposure group (2.2%). Sensitivity analysis did not alter the observed association.

Bottom line: Therapeutic anticoagulation for isolated calf DVT may be warranted to decrease the risk for proximal DVT or PE but with an increased risk of bleeding. Randomized trials are needed to clarify the risk versus benefit.

Citation: Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. doi: 10.1001/jamasurg.2016.1770.


Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does therapeutic anticoagulation of isolated calf deep vein thrombosis (DVT) decrease risk for proximal DVT or PE?

Background: Optimal management of isolated calf DVT lacks consensus.

Study design: Single-center, retrospective, cohort study.

Setting: Large academic hospital.

Nevertheless, 9.2% of control patients and 3.3% of exposure patients developed a proximal DVT or PE. The anticoagulation group was associated with lower likelihood of proximal DVT or PE (risk ratio 0.36; 95% CI, 0.15-0.84) but an increased risk of bleeding (8.6%), compared with the nonexposure group (2.2%). Sensitivity analysis did not alter the observed association.

Bottom line: Therapeutic anticoagulation for isolated calf DVT may be warranted to decrease the risk for proximal DVT or PE but with an increased risk of bleeding. Randomized trials are needed to clarify the risk versus benefit.

Citation: Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. doi: 10.1001/jamasurg.2016.1770.


Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does therapeutic anticoagulation of isolated calf deep vein thrombosis (DVT) decrease risk for proximal DVT or PE?

Background: Optimal management of isolated calf DVT lacks consensus.

Study design: Single-center, retrospective, cohort study.

Setting: Large academic hospital.

Nevertheless, 9.2% of control patients and 3.3% of exposure patients developed a proximal DVT or PE. The anticoagulation group was associated with lower likelihood of proximal DVT or PE (risk ratio 0.36; 95% CI, 0.15-0.84) but an increased risk of bleeding (8.6%), compared with the nonexposure group (2.2%). Sensitivity analysis did not alter the observed association.

Bottom line: Therapeutic anticoagulation for isolated calf DVT may be warranted to decrease the risk for proximal DVT or PE but with an increased risk of bleeding. Randomized trials are needed to clarify the risk versus benefit.

Citation: Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. doi: 10.1001/jamasurg.2016.1770.


Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.