Initial Delay Research Articles

Implementation of stroke protocol: Insights from a tertiary care facility in urban India

Abstract Background: Stroke is the second leading cause of death globally and ranks third for combined death and disability. Over the past two decades, there has been a significant rise in stroke incidence, mortality, and morbidity, with low- and middle-income countries being disproportionately affected. The effectiveness of thrombolytic therapy for acute ischemic stroke has led centers specializing in acute stroke care to develop protocols for rapid identification and triage of stroke patients. It is recommended that various stakeholders be educated on recognizing and managing stroke early and implement stroke protocols to improve coordination between different departments. Materials and Methods: The study was conducted in the emergency department of a tertiary care center in urban India from September 2021 to September 2022. We aimed to determine the average door-to-imaging (DTI) and door-to-needle (DTN) times for patients presenting with acute ischemic stroke. Additionally, we examined the factors contributing to delays in DTN time management of acute ischemic stroke at our center. Results: During the one-year study period, 131 patients with acute stroke presented to our center. One patient was under 18 years old, 10 patients arrived more than 4.5 h after symptom onset, and 2 patients had contraindications for thrombolysis. Consequently, 118 patients were included in the study. The average DTI time was 23 min, and the average DTN time was 58 min. Of these, 106 patients (89.8%) had a DTN time of less than 60 min. The most common cause of treatment initiation delay was obtaining consent (n = 7; 58.3%), followed by an unreliable time of symptom onset (n = 3; 25%) and delays due to resuscitation (n = 2; 16.6%). Conclusion: Acute stroke is a time-sensitive emergency where early thrombolysis can significantly reduce both morbidity and mortality. However, due to a lack of awareness and accessible resources, many patients often arrive outside the treatment window. Despite these limitations, a substantial number of patients do reach the hospital in time. Implementing a stroke protocol and utilizing innovative methods to reduce time can ensure these patients benefit from the global “standard of care” treatment for stroke.

Late Preterm Newborns: Breastfeeding and Complementary Feeding Practices.

The aim of this study is to identify factors associated with successful breastfeeding in late preterm infants (LPIs) and explore the initiation of complementary feeding; Methods: Prospective cohort study was conducted of infants born at 34+0 to 36+6 weeks gestational age in the Hospital of the Lithuanian University of Health Sciences Kaunas Clinics during 2020-2021. Families were followed up until the infants reached 12 months of age. Average breastfeeding initial time, average breastfeeding duration time, prevalence of exclusive breastfeeding and average solid-food feeding initiation time were examined. The correlations among factors that might affect breastfeeding rates were calculated using the chi-square test (p < 0.05); Results: In our study with 222 eligible participants, we observed a statistically significant delay in breastfeeding initiation only in the 34+0+6 gestational age group (p < 0.001). At discharge, the 36+0+6 group exhibited a significantly higher exclusive breastfeeding rate (p < 0.001). Over the first year, breastfeeding rates varied, with no correlation found between duration of exclusive breastfeeding and gestational age. Initial solid-food feeding times were similar across groups, and all infants were introduced to vegetables first; Conclusions: Vaginal delivery, skin-to-skin contact after birth, early rooming-in, and breastfeeding within 2 h after birth statistically significantly causes earlier breastfeeding initiation and longer duration of breastfeeding in LPIs. All infants began solid-food feeding at an average age of 5 months, with vegetables being the primary food choice.

Impact of the Coronavirus Disease 2019 pandemic on neoadjuvant chemotherapy use in patients diagnosed with epithelial type ovarian cancer.

The Coronavirus Disease 2019 (COVID-19) pandemic posed critical challenges in providing care to ovarian cancer (OC) patients, including delays in OC diagnosis and treatment initiation. To accommodate for delays in OC surgery, the Society of Gynecologic Oncology (SGO) recommended preferential use of neoadjuvant chemotherapy during the pandemic. The purpose of this study was to assess the association of the COVID-19 pandemic with neoadjuvant chemotherapy use in patients diagnosed with OC. This retrospective cohort study included patients diagnosed with stage II-IV ovarian cancer of epithelial subtype between 01/01/2017-06/30/2021 at Kaiser Permanente Southern California (KPSC), a large integrated healthcare system in the United States. Ovarian cancer patients diagnosed between 2017-2020 were identified from KPSC's Surveillance, Epidemiology, and End Results (SEER)-affiliated cancer registry. Patients diagnosed in 2021 were identified from the electronic medical records (EMR) using ICD-10 diagnosis codes, followed by medical chart review to validate diagnosis and extract information on histology and stage at diagnosis. March 4, 2020 was used as the cut-off to define pre-pandemic and pandemic periods. Patients diagnosed with COVID-19 between OC diagnosis and treatment completion were excluded. Data on neoadjuvant chemotherapy use were extracted from the cancer registry and EMR, supplemented by chart review. Modified Poisson regression was used to evaluate the association of the pandemic with neoadjuvant chemotherapy use. Of 566 OC patients, 160 (28.3%) were diagnosed in the pandemic period. Patients diagnosed in the pandemic period were slightly younger (mean age 62.7 vs 64.9 years, p=0.07) and had a higher burden of Charlson comorbidities (p=0.05) than patients diagnosed in pre-pandemic period. No differences in time to treatment initiation were observed by pandemic periods. Neoadjuvant chemotherapy use was documented in 58.7% patients during the pandemic period compared to 47.3% in pre-pandemic period (p=0.01). After adjusting for covariates, patients diagnosed in the pandemic period were 29% more likely to receive neoadjuvant chemotherapy than patients diagnosed in pre-pandemic period [RR(95%CI): 1.29(1.12-1.49)]. Ovarian cancer patients diagnosed in the COVID-19 pandemic were more likely to receive neoadjuvant chemotherapy than patients diagnosed before the pandemic. Future research on patient outcomes and trends in the post-pandemic period are warranted.

Abstract 4793: Effects of treatment delays on lung cancer survival

Abstract Background: Previous studies have established a link between treatment initiation delays and reduced overall survival in individuals diagnosed with lung cancer. These delays are often influenced by diagnostic complexities, logistical hurdles, and patient-related factors. However, the association between treatment delays and survival outcomes has yet to be extensively investigated using data from a large national cohort. This study aims to fill this research gap and provide unique insights into the relationship between treatment delays and lung cancer survival by utilizing data from a substantial national cohort. Methods: The study population consisted of 3,723 lung cancer patients participating in the NCI PLCO Cancer Screening Trial. Cox Proportional Hazards (PH) Regression analyses examined the time between cancer diagnosis and treatment initiation using several measures including intervals from tumor doubling/stage progression time models by Spratt et al. (1964) and Detterbeck et al. (2008). Analyses controlled for patient and clinical characteristics including age, sex, race/ethnicity, smoking status, histopathologic type, cancer stage, and treatment modality. Data analysis was conducted using Microsoft Excel, STATA, and IBM SPSS software. Results: PH Regression analyses demonstrated a clear association between longer time intervals from diagnosis to treatment initiation and increased risk of mortality. Patients with time intervals exceeding 20 days exhibited a hazard ratio (HR) for mortality of 1.21 (p &amp;lt; 0.001, 95% confidence interval [CI] 1.1158-1.3176). The Spratt tumor progression model, considering intervals exceeding 88 days, revealed a HR of 1.22 (p = 0.03, 95% CI 1.0146-1.4885). On the other hand, the Detterbeck model, which considered intervals exceeding 118 days, did not show a statistically significant association with increased mortality risk. Furthermore, PH analysis identified cigarette smoking status, marital status, and tumor grade as significant predictors of mortality risk. Conclusions: Data from a large national cohort study indicate that delays in lung cancer treatment initiation have detrimental impacts on survival. Treatment initiation shortly after diagnosis had the most significant differential impact on mortality risk. Timely initiation of treatment is of utmost importance and should be prioritized in lung cancer care. By addressing factors contributing to treatment delays, it is likely possible to improve the survival rates of patients with lung cancer. Citation Format: Percy Guzman Montero, Sharon Segura Cordero. Effects of treatment delays on lung cancer survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4793.

Abstract 2237: Determinants of time to cancer treatment initiation at a comprehensive cancer center

Abstract Background: Delays in treatment initiation adversely impact cancer mortality and survival. To inform potential enhancements and targets for our existing oncology patient navigation program, we examined characteristics associated with timely treatment initiation among patients at a tertiary comprehensive cancer center that serves four diverse counties in Southern California. Methods: We performed a retrospective analysis of patients newly diagnosed with non-hematological cancers between January 2020 and June 2023. Using electronic medical record data, we used a multivariable Cox proportional model to examine the association between patient demographic and clinical characteristics and time to treatment initiation (time between first encounter and start of definitive treatment) within a clinical benchmark of 3 months. A hazard ratio (HR)&amp;gt;1 indicates shorter (faster) time to treatment initiation while a HR&amp;lt;1 indicates a longer (slower) time. Results: Our sample included 9,148 patients, who were predominantly &amp;lt;65 years (57%), female (61%), married or with a partner (64%), and retired or unemployed (56%); 50% were non-White. In multivariable analyses, patient’s age, primary language, employment status, cancer diagnosis type, and first treatment type were significant determinants of time to treatment initiation. Faster treatment initiation was observed among patients ages &amp;gt;=75 vs &amp;lt;65 years (HR=1.36, 95% CI 1.23 - 1.52). Among the primary languages spoken in our sample (Spanish, Chinese, Korean, Vietnamese, among others), patients who spoke Armenian vs English also had shorter time to treatment (HR=1.64, 95% CI 1.32 - 2.04). By contrast, longer time to treatment initiation was associated with patients who were retired or disabled vs employed full-time (HR=0.85, 95% CI 0.78 - 0.94, and HR=0.70, 95% CI 0.59 - 0.83, respectively) and underwent radiation or oral chemotherapy vs chemo-infusion (HR=0.65, 95% CI 0.57 - 0.74, and HR=0.82, 95% CI 0.76 - 0.89, respectively). With the exception of melanoma, all diagnoses had a longer time to treatment compared with neuro-oncology. In our multivariable model, sex, marital status, race and ethnicity, and receipt of at least one navigation encounter were not significant determinants. Conclusions: In our study, which overlapped the early stages of the COVID-19 pandemic, findings highlight opportunities to enhance navigation delivery, especially for certain subpopulations, diagnoses, and treatment types with complex scheduling and coordination needs. Future research will explore navigation intensity and other process and clinical outcomes modifiable through navigation. Citation Format: Narissa J. Nonzee, Marianne Razavi, William Dale, Lauren Cai, Annette Mercurio, Lorena Gaytan, Deborah Lefkowitz, Chrissy Kim, Terry Hernandez, Steven Morales, Danilo Duque, Ana I. Tergas. Determinants of time to cancer treatment initiation at a comprehensive cancer center [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2237.

Initiation of belimumab with higher daily prednisolone is effective for rapid glucocorticoid reduction: A 96-week retrospective study.

For appropriate glucocorticoid (GC) reduction, we investigated the optimal strategy including baseline factors that could reduce GC more than 50% with 96weeks of belimumab. This is a retrospective cohort study of Kakogawa Central City hospital from 2019 to 2023. We identified SLE patients who were receiving 200mg of belimumab weekly by subcutaneous injection for 96 weeks. The background at baseline, trends in clinical indicators, and factors involved in GC reduction were statistically analyzed. Finally, univariate and multivariate logistic analyses were carried out to identify baseline factors associated ≥50% GC reduction at 96weeks. Forty-seven patients were enrolled, with a median daily prednisolone of 5mg. Almost 90% of them received concomitant immunosuppressants and/or hydroxychloroquine. Serological indices, daily GC dose, and SLEDAI-2K scores showed significant improvement in 96weeks. At baseline, a significant negative correlation has been shown between the daily dose of GC and the duration from onset or last flare, as well as C4 levels. At 96weeks, GC reduction rate and SLEDAI-2K scores were negatively correlated with duration from onset or last flare to initiation of belimumab. Mycophenolate mofetil use was significantly frequent in patients with lupus nephritis (LN), which also correlated with the frequency of past flares. In addition, LN presence was associated with higher SLEDAI-2K scores at 96weeks, and baseline SLEDAI-2K ≥10 was associated with significantly higher GC dose at 96weeks. Univariate analysis of the factor contributing to achieving ≥50% GC reduction at 96weeks has pointed shorter disease duration and higher daily GC dose at baseline as significant variables. Finally, we performed a multivariate analysis by combining above two items with age, which extracted the higher daily GC dose at baseline as a significant variable (OR (95% CI) 1.25 (1.00 to 1.56), p = .047). Our study showed that a delay in belimumab initiation led to higher SLEDAI-2K score and difficulty in achieving a 50% GC reduction at 96weeks. Since GC-related adverse events increase with long-term administration of GC though with small daily doses, we proposed here that belimumab should be started in combination with higher daily prednisolone.

Delays to treatment initiation and emergence of drug resistance among new adult tuberculosis patients in Tigray, Northern Ethiopia.

Introduction. Studies in Ethiopia have indicated that tuberculosis (TB) patient's elapsed a long time before initiating treatment.Gap Statement. However, there is very limited evidence on the association of treatment initiation delay with drug resistance.Research Aim. To investigate the association of delayed treatment initiation with drug resistance among newly diagnosed TB patients in Tigray, Ethiopia.Methods. We conducted a follow-up study from October 2018 to June 2020 by recruiting 875 pulmonary tuberculosis (PTB) patients from 21 randomly selected health facilities. Delays to initiate treatment and drug resistance were collected using a standardized questionnaire and standard laboratory investigation. The association of delay to initiate treatment with acquired drug resistance was modelled using penalized maximum-likelihood (PML) regression models. Data were analysed using stata software version 15. Statistical significance was reported whenever the P-value was less than 0.05.Result. The median total delay to treatment initiation was 62 days with an inter-quartile range of 16-221 days. A unit change in time to initiate treatment reduced the risk of acquired drug resistance by 3 %. Being smear-positive at the end of treatment and after 2 months of treatment initiation were significantly associated with a higher risk of acquired drug resistance. Whereas, having a mild clinical condition was associated with a lower risk of drug resistance.Conclusion. Time to treatment initiation delay is associated with an increased risk of the emergence of drug resistance. Efforts targeted towards reducing the negative effects of PTB should focus on reducing the length of delay to initiate treatment.

Delays in Cervical Cancer Treatment Initiation for Patients Living With or Without HIV in Botswana: An Observational Cohort Analysis (2015-2019)

PURPOSEPresent delays in treatment initiation of chemoradiation or radiation alone for patients with advanced stage cervical cancer in Botswana. METHODSWomen with locally advanced cervical cancer (stages IB2-IVB) were prospectively enrolled in an observational cohort study in 2015-2019. We evaluated delays at 30, 60, 90, 120, 150, and 180 or greater days between the date of diagnosis and treatment initiation. Factors associated with overall survival (OS) were modeled with multivariable Cox proportional hazards regression (aHR). Associations between delays in cervical cancer treatment initiation were evaluated via univariable logistic regression. RESULTSAmong the 556 patients included (median age = 47.9 years), 386 (69.4%) were women living with HIV with a median CD4 count of 448.0 cells/μL (IQR, 283.0-647.5 cells/μL) at diagnosis. Most patients had stages II (38.1%) and III (34.5%) cervical cancer. Early-stage patients experienced longer delays in treatment initiation compared to late-stage patients (p=0.033). Early-stage patients with delays ≥90 days and pathology diagnosis between 2016-2019 (aHR 0.34, p<0.001) versus <90 days decreased the risk of mortality, while those with delays ≥90 days and pathology diagnosis before 2016 (aHR 5.67, p=0.022) versus <90 days increased the risk the mortality. Late-stage patients with delays ≥120 days and pathology diagnosis between 2018-2019 (aHR 1.98, p=0.025) versus <120 days increased the risk the mortality. Early-stage patients with pathology diagnosis between 2016-2019 (OR 2.32, p=0.043) versus before 2016 were more likely to experience delays ≥90 days and late-stage patients who traveled >100 km to the treatment facility (OR 2.83, p<0.001) versus <100 km were more likely to experience delays ≥120 days. CONCLUSIONSDelays in care are common in Botswana, particularly for those living farther from the treatment clinic and at advanced stages. This paper is among the first to show an association between treatment delays and worsened OS at advanced stages of cervical cancer, highlighting the need for interventions to help patients receive timely care in global settings.

Pathways to care and barriers in treatment among patients with Dissociative disorders

IntroductionDissociative disorder patients often present with sudden and embarrassing symptoms, and it is difficult for the patient and care giver to understand initially, recognize the need for help and reach for appropriate treatment timely. This can result in high risk of engaging in dangerous behaviors such as self-harm and suicidal acts, impaired global functioning, and poor quality of life. Knowledge about the types of barriers which are there in treatment seeking, can help in planning strategies for their removal and to facilitate the treatment process. MethodsCross-sectional study among patients (n=133) with Dissociative disorders which were recruited from January 2023 to June 2023 in a tertiary care hospital. Pathways to care and barriers in treatment for Dissociative disorders were assessed by interviewing patients using semi-structured proforma. The Dissociative Experience Scale and World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)) were used to assess disease severity and impact of illness on various domains of life respectively. Group comparison was made to assess differences in social- clinical profile of patients choosing different modalities of treatment. Results133 patients of Dissociative disorders with mean age 29.6±9.2, showed their first-choice of help seeking from general practitioner/ neurologist (40.6%), traditional faith healers (35.3%), psychiatrist (18.1%) and 5.2% preferred alternative treatments. This trend changed with 2nd and 3rd contact of help seeking with greater preference for psychiatrist in their 2nd (n=45, 33.8%) and 3rd (n=69, 51.8%) contact. The median duration of untreated illness was 56 weeks (IQR 24–182 weeks). Social-clinical profile of patients varied with their choice of treatment, having lower education level (P = 0.013), longer duration of untreated illness (p=0.003), more severity of symptoms (p=0.032) and greater disability scores(p=0.002) in patients whose first treatment choice was traditional faith healers. More than 70% patients faced availability barriers, stigma, unawareness about mental illness and influence of others in treatment of choice as barriers in initiating and continuing treatment. ConclusionPatients with Dissociative disorders seek treatment from a multitude of healthcare providers including traditional faith healers, general physicians, and alternative medicine practitioners before reaching psychiatrist and undergoes various barriers in treatment. There is need to implement necessary measures for sensitization and awareness about Dissociative disorders to prevent prolonged and undue delays in initiation of appropriate management.

Questionnaire Survey to Identify the Medical Departments That Patients With Possible Head and Neck Cancer (HNC) Symptoms Tend to Choose.

In the treatment of head and neck cancer (HNC), any delay in omit initiation worsens the overall prognosis. Thus, the early start of HNC treatment is crucial. Unfortunately, treatment delays persist in clinical practice. There are several possible reasons for this. One reason is that patients with HNC do not visit an ear, nose, and throat (ENT) doctor. This is because non-ENT doctors (e.g., general practitioners {GPs}) lack expertise in HNC and therefore may unrecognize it. Therefore, guiding patients with suspected HNC symptoms to an otorhinolaryngologist, an HNC specialist, is necessary. To determine the departments that patients with potential HNC symptoms tend to select, we administered a questionnaire survey to 140 participants. Fewer than 60% of respondents indicated they would consult an otorhinolaryngologist even when recognizing symptoms suggestive of HNC. Notably, a significantly low percentage of respondents mentioned they would consult an otorhinolaryngologist for neck masses. Public awareness of HNC symptoms, especially the association between a neck mass and HNC, is limited. The lack of understanding by the general public regarding the relationship between neck masses and HNC is a challenge to prompt initiation of treatment.

Benefits of Some Phytochemical Compounds in Experimental Sepsis Models: A Therapeutic Perspective.

Sepsis represents a major contributor to mortality among critically ill patients, imposing a substantial economic strain on health-care systems. The uncontrolled inflammatory response during sepsis development, often leading to multiorgan failure and death, remains a challenge despite advances in antibiotics and supportive care. Factors such as antibiotic resistance, noninfectious causes, and delays in treatment initiation contribute to the complexity of managing sepsis. This review explores alternative treatment strategies focusing on the ameliorative efects of widely consumed phytochemicals and their cellular and molecular mechanisms in various in vitro and in vivo sepsis models. Preemptive administration of phytochemicals before sepsis onset appears efective, emphasizing their potential as adjunct or complementary therapeutic agents for critically ill sepsis patients. As a consequence, phytochemicals can be included in treatment regimens to enhance overall efectiveness and expedite the healing process.

Visual perceptual processing is unaffected by cognitive fatigue

Cognitive fatigue (CF) can lead to an increase in the latency of simple reaction time, although the processes involved in this delay are unknown. One potential explanation is that a longer time may be required for sensory processing of relevant stimuli. To investigate this possibility, the current study used a visual inspection time task to measure perceptual processing speed before and after a CF (math and memory) or non-fatiguing (documentary film) intervention. Subjective fatigue and simple reaction time significantly increased following the CF, but not the non-fatiguing intervention, confirming that CF was induced. Conversely, there was no effect of CF on inspection time task performance. It was therefore concluded that the speed of perceptual processing is not significantly impacted by CF, and thus is unlikely to underlie CF-related reaction time increases. Instead, increases in simple reaction time latency in CF may be due to delays in response preparation or initiation.

Experience with cascade screening: A comprehensive family pedigree analysis of two index patients with Fabry disease.

The wide range of clinical symptoms observed in patients with Fabry disease (FD) often leads to delays in diagnosis and initiation of treatment. Delayed initiation of therapy may result in end-organ damage, such as chronic renal failure, hypertrophic cardiomyopathy, and stroke. Although some tools are available to identify undiagnosed patients, new comprehensive screening methods are needed. In this study, the outcomes of the cascade screening applied to three index cases with FD from 2 familes were investigated. In the pedigree analysis, 280 individuals were included; out of them, 131 individuals underwent genetic testing and cascade screening for FD. During the screening program, a total of 45 individuals were diagnosed, with a diagnostic ratio of 1:15. The average age at diagnosis for all individuals was 30.9 ± 17.7 years, and %25 were pediatric cases (mean age 9.5 ± 5.9 years). Thirty affected relatives were diagnosed from thetwo index cases in Family 1 and 15 individuals were diagnosedfrom one index case in Family 2. There were 13 consanguineous marriages observed among 2 pedigres, in two both spouses were affected, leading to two homozygous affected daughters in one couple. In regions where there is a high prevalence of consanguineous marriages, implementing the cascade screening approach to identify all individuals at risk can be beneficial for patients with FD, specifically women and children.

The Every Woman Study (EWS) in Kenya: Identifying challenges and opportunities to improve survival and quality of life for women with ovarian cancer

Background: Ovarian cancer is the second most common cause of death among gynecological cancerpatients in Kenya, and the number of cases is predicted to rise from 1,130 to 2,600 per year by 2040. However, there is very limited diagnostic and treatment capacity. This study aims to establish the first-ever patient experience evidence base of women with ovarian cancer in Kenya and identify challenges and opportunities to improve survival and quality of life.Methods: This was a prospective cross-sectional observational study in which all eligible womenattending Moi Teaching and Referral and Aga Khan Hospitals with a diagnosis of ovarian cancer withinthe previous five years were recruited.Results: Of 104 eligible women with a median age of 51 years, epithelial ovarian cancers were the mostcommon (70%), particularly high-grade serous carcinoma (46%). Most respondents (66%) had advanceddisease. Approximately 24% had to travel for five hours or more to access care. The mean average timefrom experiencing symptoms to diagnosis was 7.4 months. Almost half had never heard of ovariancancer. Approximately 81% reported that their finances had been affected largely by the diagnosis, with55% of these women reporting that their household income had dropped below what they needed tosurvive.Conclusion: The inaccessibility of quality cancer care in Kenya leads to delays in diagnosis andtreatment initiation. Innovative awareness strategies, health provider education, and cost mitigation areneeded to ensure that women can seek help promptly to reduce morbidity and mortality.

Pneumocystis jirovecii pneumonia: a case report

Introduction and importancePneumocystis jirovecii (PJP) pneumonia is a serious life-threatening condition in immunocompromised individuals and is often associated with human immunodeficiency virus (HIV) + patients. We describe a case of PJP pneumonia which provided a diagnostic challenge in a patient who presented with no known risk factors leading to a delay in initiation of appropriate antibiotic therapy.Case presentationA 71-year-old previously healthy white/Caucasian male presented with subacute hypoxic respiratory failure due to multifocal pneumonia with diffuse bilateral ground glass opacities with consolidations despite prior treatment with antibiotics and steroids. He was admitted and started on intravenous broad-spectrum antibiotics but continued to deteriorate, eventually requiring intubation and transfer to the ICU. Bronchoscopy revealed PJP and treatment was initiated, but the patient developed refractory shock and multiorgan failure, and ultimately died. It was later discovered that he was HIV-1 positive.Clinical discussionPJP, as a potential cause of his presentation, was not considered given that our patient lacked any overt risk factors for PJP pneumonia. He continued to worsen despite broad spectrum antibiotic therapy and hence bronchoscopy was pursued. His clinical profile, in hindsight, was suspicious for PJP pneumonia and early PJP-directed antibiotic therapy may have prevented a fatal outcome, as in this case. There was an element of cognitive bias across multiple providers which may have contributed to the delay in treatment despite his rapid clinical decline while on conventional pneumonia treatment protocol. His diagnosis was later evident when his BAL-DFA grew PJP in addition to his low levels of CD4 and CD8 cells. He was found to be HIV-1 positive five days after his death; there was a delay in this diagnosis since all positive HIV tests from the hospital are reported as ‘pending’ until the presumptive positive sample goes to the Connecticut Department of Public Health State laboratory for the confirmatory test. PJP-targeted therapies were initiated later in our patient’s hospital course when the infection had progressed to refractory septic shock with multiorgan failure and eventual death.ConclusionPJP pneumonia is a fatal disease if not recognized early in the course of illness, and the patient usually undergoes multiple antibiotic regimens before they are diagnosed and receive appropriate clinical care. The gold standard of diagnostic testing for PJP is by obtaining bronchial washings through a flexible bronchoscopy and the turnaround time for such results may take a few days to result. A significant proportion of patients may not have any overt risk factors of immunosuppression and early empiric treatment for PJP may be clinically appropriate as the delay in diagnosis may be associated with significant morbidity and mortality risk.

Patient-Perceived Impact of the COVID-19 Pandemic on Medication Adherence and Access to Care for Long-Term Diseases: A Cross-Sectional Online Survey

The COVID-19 pandemic has been associated with lifestyle changes, reduced access to care and potential impacts on medication self-management. Our main objectives are to evaluate the impact of the pandemic on patient adherence and access to care and long-term medications and determine its association with sociodemographic and clinical factors. This study is part of the Specchio-COVID-19 longitudinal cohort study in Geneva, Switzerland, conducted through an online questionnaire. Among the 982 participants (median age: 56; 61% female), 827 took long-term medications. There were 76 reported changes in medication dosages, of which 24 (31%) were without a physician’s recommendation, and 51 delays in initiation or premature medication interruptions, of which 24 (47%) were without a physician’s recommendation. Only 1% (9/827) of participants faced medication access issues. Participants taking a respiratory medication had a four-times greater odds of reporting more regular medication (OR = 4.27; CI 95%: 2.11–8.63) intake, whereas each year increase in age was significantly associated with 6% fewer relative risks of discontinuation (OR = 0.94; CI 95%: 0.91–0.97) and 3% fewer relative risks of changes in medication dosage (OR = 0.97; CI 95%: 0.95–1.00). Despite the limited impact of the pandemic on adherence and access to medications, our results emphasize the need for understanding patient challenges when self-managing their long-term medication, notably during public health crises.

Rheological and Flexural Strength Characteristics of Cement Mixtures through the Synergistic Effects of Graphene Oxide and PVA Fibers.

This study investigates the synergistic effects of incorporating graphene oxide (GO) and polyvinyl alcohol (PVA) fibers into cement paste mixtures, aiming to modify their rheological properties and flexural behaviors with resistance to crack formation. The relationship between static yield stress and critical shear strain was examined in ten cement paste mixtures with varying concentrations of 6 mm and 12 mm PVA fibers and 0.05% GO. Additionally, viscosity analyses were performed. For the specimens fabricated from these mixtures, flexural strength tests were conducted using the Digital Image Correlation (DIC) technique for precise strain analysis under load history. The results indicated a significant increase in static yield stress, viscosity, and critical shear strain due to the combined addition of GO and PVA fibers, more so than when added individually. Notably, in PVA fiber-reinforced cement mixtures, the integration of GO increased the crack initiation load by up to 23% and enhanced pre-crack strain by 30 to 50%, demonstrating a notable delay in crack initiation and a reduction in crack propagation. Microstructural analyses using Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectroscopy (EDS) revealed a concentrated presence of GO around and on the PVA fibers. This promotes increased C-S-H gel formation, resulting in a denser microstructure. Additionally, GO effectively interacts with PVA fibers, enhancing the adherence of hydration products at their interface.

Tuberculosis-related knowledge, practices, perceived stigma and discrimination among patients with tuberculosis: a cross-sectional study in Jordan

Background Tuberculosis knowledge, practices, and perceived stigma and discrimination among patients with tuberculosis are key factors for the management of the disease. Objectives The objectives of the study were to assess knowledge, practices, perceived stigma and discrimination, perceived family and health workers support, perceived level of satisfaction with healthcare services, delay in diagnosis/treatment and reasons for delay among patients with tuberculosis in Jordan. Methods A cross-sectional study was conducted among patients who were under treatment for tuberculosis in Jordan in 2021. Results This study included a total of 452 patients with tuberculosis. About 91.4% of patients had low to moderate overall tuberculosis-related knowledge score and 8.6% had high knowledge score. Almost two-thirds of patients (67.5%) had perceived a low level of stigma, 61 (13.5%) perceived a moderate level of stigma, and 86 (19.0%) perceived a high level of stigma. The majority (84.5%) of patients with tuberculosis thought that there was a delay in diagnosis and/or treatment of tuberculosis. Conclusion Our study showed gaps in tuberculosis knowledge and practices, high perceived stigma and discrimination, and perceived delay in diagnosis and treatment initiation,. Efforts within the national tuberculosis control program should be made to increase public awareness about the symptoms of tuberculosis and the importance of seeking early care.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States.

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment. Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS). There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively. Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Abstract WP45: A Collaborative Approach to Improving Inpatient Stroke Code Time Target Metrics

Much effort and education has been placed on pre-hospital and emergency departments to recognize signs and symptoms of acute stroke and time metrics such as door-to-CT, door-to-needle, and door-to-device. For admitted patients with acute onset of stroke symptoms, our data analysis identified a gap in the timeliness of stroke code activation upon symptoms discovery and subsequent delays in CT initiation and treatment. We evaluated our current process and implemented action plans to enhance the current inpatient stroke code process through focused education and training of staff to improve their recognition of acute stroke, timely activation of stroke code and improved CT initiation and treatment times. In 2021, several cardiology pilot units were selected and neuroscience nurse specialists conducted staff education which focused on recognition of stroke signs and symptoms, code activation criteria and response time targets. A resource binder and checklist were created to guide staff in putting together pertinent elements for communication and documentation. Data was collected on stroke code response times and individual feedback was provided. The group meets quarterly to evaluate progress, discuss opportunities for improvement and highlight best practices and outcomes. The checklist was a useful tool in reminding staff of pertinent information to communicate to the stroke team although form completion is not consistent. In 2021-2022, 54% of stroke codes were called within 10 minutes of symptoms discovery. CTH initiation time within 25 minutes of symptoms discovery was achieved in 16.2% of patients. Data analysis showed an opportunity to improve documentation of symptoms discovery time which were missing in 13.8% of cases. This collaborative approach with the pilot units has increased awareness and focus to the inpatient stroke code process. Opportunities exist to improve time target achievements in CTH initiation, treatment, and documentation of symptoms discovery time. Communication between the stroke team and the patient’s primary team has been identified as an essential factor for continued improvement along with on-going staff education.