Greater Delay Research Articles

Factors influencing delay in cancer diagnosis: a qualitative study in Chile, Colombia and Ecuador

Abstract Background Although the greatest delays in cancer diagnosis in Latin America occur in the provider interval, little is known about related factors. This study, part of EquityCancer-LA, aims to analyse the factors influencing access to cancer diagnosis from key stakeholders’ perspective in healthcare networks of Chile, Colombia, and Ecuador. Methods A qualitative, descriptive-interpretative study was conducted in two networks per country in 2023, using semi-structured individual interviews (n = 114) with a criterion sample of primary care (PC) (n = 40) and secondary/tertiary hospitals (n = 44) health/administrative professionals, managers, and policy makers (n = 30). Thematic analysis was performed, segmented by country. Results The analysis revealed interacting factors that cause cumulative delays, with differences between countries. In all, participants identified networks structural characteristics (deficits in diagnostic resources; geographical accessibility), organizational factors (long waiting times, especially after referral), and limited knowledge of PC doctors, which all lead to delayed referral. In Chile and Colombia, barriers related to care rationing/prioritization policies hampered access to tests, and in Chile, increased delays for non-prioritized conditions. Barriers related to the health system organization also emerged: in Chile, problems related to private services subcontracting and the voucher system for using them; in Colombia, the management of care by insurers (authorizations; fragmented and short-term contracting of providers); and in Ecuador, health system underfunding. The barriers mostly affected the elderly, those with low socioeconomic status, limited social support networks, and rural areas residents. Conclusions The results reveal significant barriers in access to timely cancer diagnosis, which can and should be addressed with specific cancer diagnosis policies and general measures that strengthen public healthcare systems and networks. Key messages • Key health system factors influencing provider delays in cancer diagnosis are identified. • Evidence is provided for the design of policies to improve timely cancer diagnosis in studied countries.

Texting while driving is a visual problem influenced by phone viewing angle and working distance in young individuals

PurposeTo investigate the impact of smartphone viewing distance and angle on reaction times. DesignA prospective, self-controlled, single-center study. MethodsParticipants engaged in a driving simulation facing a large screen with a simulated brake pedal. They were tasked to stop the simulation once recognizing the deceleration of upcoming traffic. Tests were conducted without distraction and with a standardized distraction simulating texting while driving (TWD). Smartphone positions varied at distances of 30 cm and 60 cm, and at angles parallel to and 30° below the road plane. Reaction times were measured from the onset of simulated closure to detection. Stopping distances were extrapolated using data from the National Highway Traffic Safety Administration. ResultsNinety-four participants were included with a mean age of 24 ± 2.7 years. The control reaction time was 11.5 ± 4.1 s. Reaction times significantly decreased with smartphone placement at a closer distance of 30 cm parallel (17.0 ± 3.3 s) vs 60 cm parallel (15.4 ± 3.8 s), P < 0.001. A 30-degree downward placement at 30 cm (18.6 ± 4.0 s) and 60 cm (17.9 ± 3.6 s), further decreased reaction time compared to parallel phone positioning, P < 0.001. Extrapolating to stopping distances based on real-world data, smartphone distractions placed at 30 cm 30° below the dashboard had the greatest effect, resulting in a 3 times increase of stopping distance compared to the control, 1201 vs 394 ft respectively, P < 0.001. ConclusionTWD significantly delays reaction time in young participants. Both the distance and viewing angle of a smartphone significantly influences reaction times during driving simulations. The greatest delays are observed when the smartphone is positioned closer to the user and at a 30-degree angle which we hypothesize is due to vision blur from increased accommodation, loss of stereopsis, and fixation with the peripheral retina.

Abstract B048: Qualitative analysis of fieldnote and interview data for planning a food bank- based breast cancer screening intervention

Abstract Among individuals and communities with low-income, the experience of food insecurity is associated with greater delays in recommended mammography screening and late-stage breast cancer at diagnosis. Community-based interventions that address barriers to breast cancer screening in diverse communities of women with food insecurity can increase screening uptake, ultimately improving cancer health equity. In partnership with Sacramento Food Bank and Family Services (SFBFS), the largest non-profit provider of social services in Sacramento County, this study identified barriers and facilitators to implementing a breast cancer screening intervention in a food distribution setting, assessing the preliminary acceptability and logistical feasibility of the proposed intervention. Qualitative data about food bank distribution events and the clients served was collected over 24 weeks using participant observation with semi-structured fieldnotes and interviews, then analyzed via directed content analysis guided by the well-defined domains and determinants in the Consolidated Framework for Implementation Research (CFIR) and coded using Dedoose software. Fieldnotes were completed for 12 community food distribution events, and 20 stakeholder interviews were conducted with purposefully sampled food bank staff (N=10) and female clients (N=10) who regularly attend events. The results of this qualitative analysis identified barriers and facilitators to implementation in all CFIR domains, describing current workflows for food distribution events and existing health education efforts, capacity, client engagement logistics and modes of delivery, and resources available or needed to support implementation. Prominent CFIR determinants included characteristics of individuals, specifically the innovation recipients’ capability and motivation to receive a breast cancer screening intervention in this context. Participants often pointed out their awareness of important preventative behaviors such as nutrition while also acknowledging barriers such as time constraints, accessibility of breast cancer screening services, and culturally-specific health beliefs and practices. Determinants in the outer setting, inner setting, innovation characteristics, and process that relate to the overall theme of sustainability were identified as potential barriers including financing, the availability of resources, internal and external pressure to change, and the process of engaging with clients while they are at the food distribution event. Facilitators included buy-in from SFBFS leadership and staff, and the benefit of collaborating with reputable local partners. Intervention format should include tailored messaging that is culturally appropriate and empowers individuals to obtain recommended screening. Content of the intervention should provide interactive assistance that facilitates local support for screening eligibility and services. Overall, there was consensus that promoting breast cancer screening in the food distribution setting was beneficial and welcomed by all stakeholders. Citation Format: Charlotte L. Kerber, Julie HT Dang, Daniel J. Pasillas-Pablo, Jocelyn T. Canty, Laura Fejerman. Qualitative analysis of fieldnote and interview data for planning a food bank- based breast cancer screening intervention [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B048.

Development of an Electrochemical Biosensor for GFAP with Carbon-Based Substrate for Traumatic Brain Injury

This study concentrates on creating an electrochemical biosensor designed for the real-time identification and monitoring of biomarkers, specifically Glial Fibrillary Acidis Protein (GFAP). The intended applications involve the diagnosis and prognosis of Traumatic Brain Injury (TBI). TBIs pose a significant global health challenge, impacting millions each year, and existing diagnostic methods, such as neuroimaging, face constraints related to cost, radiation exposure and a greater delay in providing a diagnosis. The suggested biosensor exploits electrochemical techniques, offering benefits such as non-invasiveness and swift results. The primary objective is to advance wearable microelectrodes for TBI detection, with an emphasis on utilizing bodily fluids like sweat as practical samples. Moreover, the biosensor's versatility makes it well-suited for various environments, including extreme conditions.The objective of this research is to enhance the precision of TBI diagnosis and prognosis, thereby ultimately improving the efficacy of point-of-care treatment. Our methodology involves the utilization of the Capture Systematic Evolution of Ligands by Exponential Enrichment (Capture-SELEX) technique to create a highly specific aptamer designed for the detection of Glial Fibrillary Acidic Protein. The biosensor we are developing will feature electrodes modified with aptamers and a carbon-based substrate, enabling continuous real-time monitoring of the target substance. The primary objective of our biosensor is to identify GFAP, thereby reducing risks associated with exposure to radiation, and healthcare costs. To ensure the long-term stability of our biosensor, our design centers around a carbon-based substrate. Carbon-based nanomaterials have garnered significant attention in biosensor applications due to their diverse range of properties, encompassing chemical stability, biocompatibility, functionalization, and biodegradability.

2233 Incidence of inappropriate CPR in the emergency department—is ReSPECT making a difference?

Abstract Introduction A BMJ study suggested that 1 in 5 sick, older patients have a ‘do not resuscitate’ document and a large proportion only had this completed in the Emergency Department (ED) (1). Current ED pressures could cause greater delay in this discussion, resulting in inappropriate cardiopulmonary resuscitation (CPR). The ReSPECT form was established to bring consistency to the communication of patients wishes, including ‘do not attempt CPR’ (DNACPR) (2). This QUIP assessed the incidence of inappropriate CPR in two ED’s by investigating the proportion of CPR performed on those with a prior DNACPR or ReSPECT form. Method Data was collected retrospectively from cardiac arrests in two ED’s between the 1st of January 2023 and the 17th of November 2023. The three parameters assessed were the number patients undergoing CPR, number with prior DNACPR/ReSPECT forms, and how often CPR occurred within 30 minutes of patient arrival. Hospital A used ReSPECT forms, whereas Hospital B did not. Results Over the assessed period, CPR was performed on 21 patients at Hospital A. Of these, 19% had prior DNACPR/ReSPECT forms and 43% of CPR was within 30 minutes of patient arrival. 10 patients received CPR at Hospital B. Of these, 0 patients had prior DNACPR/ReSPECT forms and 40% of CPR occurred within 30 minutes of patient arrival. Conclusion Hospital A performed CPR on more patients with prior DNACPRs compared to hospital B. Occasionally, these DNACPRs were on the GP portal but were not easily accessible in the hospital setting due to the hospital’s paper-based notes system. Both sites performed CPR on a similar proportion of patients within 30 minutes of admission. This highlights the importance of prompt decisions, communication and the need for community discussion with documentation that is easily accessible across healthcare settings.

Patterns and Consequences of Delayed Self Care Among Rural Medical Providers.

The purpose of this study was to (a) examine personal healthcare practices of rural medical providers by issue type (e.g., physical health, social health, or mental health), (b) identify perceived consequences of taking time off and (c) determine whether greater delay in self-care was associated with perceived stress and burnout. Electronic surveys were sent to 805 medical providers (response rate = 17.8%, n = 143). The setting was a rural teaching hospital and affiliated community clinics. Participants included 143 rural medical providers. The survey included demographic information, perceived personal health risk, and questions about delaying health care, and perceived consequences of receiving health care. Medical providers delayed mental health care needs significantly more than physical health needs, t131 = 5.13, P < .01, d = .38. Respondents believed that there would be significantly more retaliation against them for taking time off for psychosocial issues, t124 = -3.80, P < .001, d = .25. There was a significant negative association between burnout and physical health self-care (r = -.24, P < .01), psychosocial self-care (r = -.20, P = .01), and mental health self-care (r = -.23, P < .01). Our study identified commonly reported consequences related to taking off work for care seeking behavior. Understanding perceived consequences can help guide health care organizations in dismantling these barriers. This study is limited by the generalizability of its sample.

The Effect of Insurance Type on Time to Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Critically Appraised Topic

Clinical Scenario: Delay in surgery for anterior cruciate ligament (ACL) injuries increases the risk of complications including secondary injuries. Previous research has shown individuals with public insurance have greater delays in care for a variety of health conditions. Clinical Question: In pediatric patients with ACL injuries, is the time from injury to surgery longer for patients with public insurance than patients with private insurance? Summary of Key Findings: Four studies met the inclusion criteria. All studies reported a greater wait time for surgery in pediatric patients with public insurance. Clinical Bottom Line: There is moderate evidence indicating that there is a delay in ACL surgery for pediatric patients with public insurance compared to those with private insurance. Strength of Recommendation: Grade B evidence exists that there is a delay in surgery for ACL injuries in pediatric patients with public insurance compared to those with private insurance.

Primary Angiitis of the CNS: Differences in the Profile Between Subtypes and Outcomes From an Indian Cohort.

Primary angiitis of the CNS (PACNS) is a rare disease that has significant morbidity and mortality. Subtypes of PACNS can have different presentations that could be missed with certain diagnostic modalities, further increasing diagnostic complexity. We sought to distinguish the subtypes of PACNS and describe their outcomes in an Indian cohort. Adult patients in this retrospective single-center cohort study were reviewed from the PACNS database between 2000 and 2019. Diagnosis was made as per Calabrese and Malleck criteria. Small and medium vessel vasculitis was defined, and their clinical and radiologic profile, treatment, and outcomes were compared. Functional outcomes were noted at 6-month, 1-year, and at last follow-up, while relapses were noted at last follow-up. A poor outcome was defined as modified Rankin Scale >2. Seventy-two patients fulfilled the inclusion criteria of whom 50 (69.4%) were male. The small vessel vasculitis subtype had a younger age at onset (30.5 vs 40.5 years, p = 0.014), presented less often as a stroke (22% vs 62%, p = 0.001), and had greater delay in diagnosis and treatment initiation (median of 620 days vs 118 days, p = 0.001) compared with medium vessel vasculitis subtype. Although no difference was noted at 6 months, the small vessel vasculitis group had poor outcomes at 1-year and last follow-up (57% vs 20%, p = 0.011 and 72% vs 34%, p = 0.005, respectively) and had more relapses at last follow-up (89% vs 30%, p < 0.001) when compared with the medium vessel vasculitis group. On analyzing the entire cohort, 50 of 72 (69%) and 37 of 53 (69.8%) patients had a good outcome at 6 months and 1 year, respectively. Relapse was noted in 35 of 72 (49%) at final follow-up. The choice of the treatment regimen did not predict outcomes or relapses. The small vessel vasculitis subtype of PACNS is a distinct entity that has diagnostic and treatment delays with poor long-term outcomes and more relapses. Recognizing the different subtypes of PACNS may help to expedite diagnosis and plan treatment.

A circadian-informed lighting intervention accelerates circadian adjustment to a night work schedule in a submarine lighting environment.

Night work has detrimental impacts on sleep and performance, primarily due to misalignment between sleep-wake schedules and underlying circadian rhythms. This study tested whether circadian-informed lighting accelerated circadian phase delay, and thus adjustment to night work, compared to blue-depleted standard lighting under simulated submariner work conditions. Nineteen healthy sleepers (12 males; mean±SD aged 29 ±10 y) participated in two separate 8-day visits approximately one month apart to receive, in random order, circadian-informed lighting (blue-enriched and dim, blue-depleted lighting at specific times) and standard lighting (dim, blue-depleted lighting). After an adaptation night (day 1), salivary dim light melatonin onset (DLMO) assessment was undertaken from 18:00-02:00 on days 2-3. During days 3-7, participants completed simulated night work from 00:00-08:00 and a sleep period from 10:00-19:00. Post-condition DLMO assessment occurred from 21:00-13:00 on days 7-8. Ingestible capsules continuously sampled temperature to estimate daily core body temperature minimum (Tmin) time. Tmin and DLMO circadian delays were compared between conditions using mixed effects models. There were significant condition-by-day interactions in Tmin and DLMO delays (both p<0.001). After four simulated night shifts, circadian-informed lighting produced a mean [95%CI] 4.3 [3.3 to 5.4] h greater delay in Tmin timing and a 4.2 [3 to 5.6] h greater delay in DLMO timing compared to standard lighting. Circadian-informed lighting accelerates adjustment to shiftwork in a simulated submariner work environment. Circadian lighting interventions warrant consideration in any dimly lit and blue-depleted work environments where circadian adjustment is relevant to help enhance human performance, safety, and health.

Health Disparities in the Neurosurgical Care of Patients with Trigeminal Neuralgia

IntroductionThere has been limited investigation into how social determinants of health (SDOH) impact treatment outcomes in patients with trigeminal neuralgia (TN). We aimed to investigate how SDOH may alter the course of clinical care for patients with TN. MethodsThe electronic medical record was queried for patients with a diagnosis of TN co-managed by neurosurgeons and other facial pain specialists at our medical center. Area Deprivation Index (ADI) served as a proxy for socioeconomic status. Multivariable linear regression models were performed using RStudio to assess the impact of social determinants on the time to neurosurgical referral and surgical intervention. Results229 patients (mean age 50 years, 74% female) were included. 135 (60%) patients underwent a neurosurgical procedure after referral, the most common being microvascular decompression (n=84, 62%) (Table 1). Most of the patients were white (76.3%) and insured by Medicare (51.8%), followed by private insurance (38.6%). Age and sex were significant predictors of time to neurosurgical referral after symptom onset, as older patients (p<0.01, Figure 3) and females (p=0.02) tended to have a greater delay between symptom onset and specialist referral. Race, socioeconomic status, and insurance status were not significantly associated with time-to-referral or time-to-treatment. DiscussionThis study found that older and female patients with TN had a longer time from symptom onset to specialist referral. Based on these data, there is no association between race, socioeconomic status, and insurance status with time-to-referral or time-to-treatment in patients with TN.

Imaging in malignant germ cell tumors involving the hypothalamo-neurohypophyseal axis: the evaluation of the posterior pituitary bright spot is essential

PurposeMalignant intracranial germ cell tumors (GCTs) are rare diseases in Western countries. They arise in midline structures and diagnosis is often delayed. We evaluated imaging characteristics and early tumor signs of suprasellar and bifocal GCT on MRI.MethodsPatients with the diagnosis of a germinoma or non-germinomatous GCT (NGGCT) who received non-contrast sagittal T1WI on MRI pre-therapy were included. Loss of the posterior pituitary bright spot (PPBS), the expansion and size of the tumor, and the expansion and infiltration of surrounding structures were evaluated. Group comparison for histologies and localizations was performed.ResultsA total of 102 GCT patients (median age at diagnosis 12.3 years, range 4.4–33.8; 57 males; 67 in suprasellar localization) were enrolled in the study. In the suprasellar cohort, NGGCTs (n = 20) were noticeably larger than germinomas (n = 47; p < .001). Each tumor showed involvement of the posterior lobe or pituitary stalk. A PPBS loss (total n = 98) was observed for each localization and entity in more than 90% and was related to diabetes insipidus. Osseous infiltration was observed exclusively in suprasellar GCT (significantly more frequent in NGGCT; p = .004). Time between the first MRI and therapy start was significantly longer in the suprasellar cohort (p = .005), with an even greater delay in germinoma compared to NGGCT (p = .002). The longest interval to treatment had circumscribed suprasellar germinomas (median 312 days).ConclusionA loss of the PPBS is a hint of tumor origin revealing small tumors in the neurohypophysis. Using this sign in children with diabetes insipidus avoids a delay in diagnosis.

Disparities in diagnosis and access to care in patients with young-onset rectal cancers in northeast Ohio.

e15521 Background: The rising incidence of young-onset colorectal cancers (YO-CRC) in individuals &lt; 50 years old is alarming. Despite the updated USPSTF recommended age for CRC screening ( &lt; 45) in 2021, disparities in receiving proper care for YO-CRC remained largely under addressed. We sought to identify modifiable disparities to be addressed with future interventions for patients with YO-rectal cancer (YO-RC). Methods: We analyzed a cohort of patients with newly diagnosed YO-RC from 2001 to 2023 at a large academic center in Northeast Ohio. Demographic data included sex, race, age, smoking status, and poverty index. A retrospective chart review was completed to assess diagnosis date and time from symptom onset to diagnosis. Access to guideline-concordant care was assessed via clinic visits with specialty providers in medical oncology, radiation oncology, colorectal surgery, genetics, and onco-fertility. Chi-square testing and Cox regression modeling was used for statistical analyses. Results: We identified 83 patients with YO-RC, 52% female (n = 43) and 48% male (n = 40), of which 76% were White (n = 63), 21% Black (n = 17), 2% Hispanic (n = 2), and 1% Asian (n = 1). Median age at diagnosis was 44 years (IQR[39-49]). Non-White (NW) patients had a greater delay from symptom onset to diagnosis compared to White (W) patients, with an average time of 6.9mo vs 1.3mo (p &lt; 0.00001). Colonoscopy completion rates after symptom onset for NW and W patients at 2-months was 11% vs 81% and 33% vs 98% at 4-months (p &lt; 0.0001, respectively). Rate of access to specialty care once diagnosed was not statistically significant for either groups, but there is a lower percentage of all YO-RC patients who accessed onco-fertility (13%, n = 11) or genetics services (46%, n = 38). The median 1-year overall survival was 50% for NW patients vs 85.7% for W patients, which was statically significant on univariate analysis (p = 0.04), but not on multivariate analysis. Conclusions: We found significant disparities for YO-RC from symptom onset to diagnosis with longer delays noted in NW patients. Such delays in diagnosis may lead to higher staging upon presentation and impact survival. Once a diagnosis was made, access to specialty oncology care rates was similar across groups. This study encourages further evaluation and consideration of socioeconomic factors and care access patterns to address disparities in diagnosis, access, and treatment of YO-CRC. [Table: see text]

The effect of unusual presentation on delayed diagnosis of prostate cancer: a case series

BackgroundEarly diagnosis of prostate cancer is key to achieving a cure and its proper management leads to a good prognosis. In Ghana a large percentage of patients present with advanced disease and unusual presentations in these patients result in greater delay in the diagnosis thus worsening the outcomes.Case presentationWe present three African males with advanced prostate cancer who had delayed diagnosis. The first patient, a 64 year old male presented with ascites of 2 years duration with weight loss and no lower urinary tract symptoms, the second, a 69 year old man with end stage renal failure of 6 months duration and was receiving dialysis, the third case, an 87 year old man was managed for pulmonary tuberculosis after he presented with chronic cough and lower urinary tract symptoms. All patients eventually had a prostate specific antigen done which were elevated. Further investigations including prostate biopsies, abdominopelvic CT scans for case 1, abdominopelvic ultrasound, prostate biopsies and blood urea and electrolytes for case 2, prostate biopsies, chest and lumbosacral showed a diagnosis of metastatic prostate carcinoma, and all patients were managed with androgen deprivation. The second patient received additional radiotherapy.ConclusionA lack of knowledge of prostate cancer symptoms including unusual symptoms, can result in delayed diagnosis especially in regions of the world where a large number of patients present with advanced disease.

Neurodevelopmental outcomes following possible serious bacterial infection in early infancy in Karachi, Pakistan: a prospective cohort study

BackgroundPakistan reports a significant burden of neonatal mortality, with infections as one of the major causes. We aim to assess the long-term impact of early infancy infections on neurodevelopmental outcomes during later childhood.MethodsWe conducted a prospective follow-up study of the cohort enrolled at the Karachi site of the Aetiology of Neonatal Infection in South Asia (ANISA) during 2019–2020. Children with a possible serious bacterial infection (based on the WHO IMCI algorithm) at early infancy were assessed for neurodevelopment at 6–9 years of age and compared with healthy controls. The Ten Questions (TQS) questionnaire, Strengths and Difficulties Questionnaire (SDQ), and Parent’s Evaluation of Developmental Stage Assessment Level (PEDS: DM-AL) neurodevelopmental assessment tools, were administered and scored by the research staff who were blinded to the child’s exposure status. Generalized Structural Equation Modelling (GSEM) was employed to verify relationships and associations among developmental milestones, anthropometry, and sociodemographic variables.ResultsA total of 398 children (241 cases and 157 controls) completed neurodevelopmental and growth assessments. Cases had a significantly higher rate of abnormal TQS scores (54.5% vs. 35.0%, p-value 0.001), greater delays in motor milestones (21.2% vs. 12.1%, p-value 0.02), lower fine motor skills (78.4 ± 1.4 vs. 83.2 ± 1.5, p-value 0.02). The receptive language skills were well-developed in both groups. According to the logistic regression model, exposure to infection during the first 59 days of life was associated with delayed TQS milestones (β = -0.6, 95% CI -1.2,-0.04), TQS hearing domain (β = -0.3, 95% CI: -1.2 to 0.7), PEDS: DM-AL fine motor domain (β = -1.3, 95% CI: -4.4 to 1.7), PEDS: DM-AL receptive language development (β = -1.1, 95% CI: -3.7 to 1.4) and child anthropometric measurements such as weight and height (β = -0.2, 95% CI: -0.4 to 0.01 and β = -0.2, 95% CI: -0.4 to -0.01, respectively). Early pSBI exposure was positively associated with PEDS: DM-AL self-help domain (β = 0.6, 95% CI: -1.2 to 2.4) and SDQ-P overall score (β = 0.02, 95% CI: -0.3 to 0.3).ConclusionChildren exposed to PSBI during early infancy have higher rates of abnormal development, motor delays, and lower fine motor skills during later childhood in Pakistan. Socioeconomic challenges and limited healthcare access contribute to these challenges, highlighting the need for long-term follow-ups with integrated neurodevelopment assessments.

E011 Magnetic resonance imaging in axial spondyloarthritis: usage, reporting times and scanning times - a service evaluation in a large tertiary centre

Abstract Background/Aims Rapid access to magnetic resonance imaging (MRI) of the spine and sacroiliac joints is essential for the timely diagnosis of axial spondyloarthritis (axSpA). A recent NASS/BRITSpA national FOI survey highlighted deteriorating waiting times to access MRI for the assessment of inflammatory back pain in the UK, with only 73% of Trusts reporting access within 8 weeks, compared to 90% in 2017. In addition, NHS England and the Royal College of Radiologists have recently published a target of 28 days for turn-around time (TAT) for a verified report to be provided after image acquisition in any circumstance. Aims: To evaluate the usage of MRI performed under the “inflammatory back pain protocol” at a large tertiary centre, including the time from MRI request to scan being performed, TAT for reporting and whether this has changed over time. Methods A service evaluation audit was conducted at Leeds Teaching Hospitals Trust (LTHT). MRIs of the spine and sacroiliac joints requested between December 2021 and May 2023 under the local “inflammatory back pain protocol” were identified by the radiology department. Data extracted from medical records included: indication for MRI request, time elapsed from request to scan, and from scan to verified report. Results A total of 668 MRI requests were identified. The commonest reason for MRI request was to aid the diagnosis of axSpA 75% (n = 501); followed by disease activity monitoring in established axSpA (16.7%, n = 111) and assessment of axial involvement in peripheral psoriatic arthritis, i.e. diagnosis of axPsA (8.5% n = 57 scans). The majority (92%) had a request to scan time of 8 weeks, with a TAT to report of 4 weeks (77%). However, a greater delay in TAT to verified report was seen from December 2022 to May 2023 with &amp;lt;45% of reports issued within 28 days, despite no change in scanning time. Causes identified were related to local workforce issues including delays in appointing new radiographers and radiology consultants. Conclusion The main reason for request of an MRI under the inflammatory back pain protocol at LTHT is to support making a diagnosis of axSpA. A significant number of patients were scanned for treatment monitoring and to diagnose axial psoriatic arthritis, although data on the utility of MRI for these indications are limited. Whilst nearly all patients were scanned within 2 months at all time periods, the TAT to report has significantly deteriorated since December 2022 in our region, due to workforce issues. Further understanding of the impact of workforce factors on service delivery in rheumatology is required. Disclosure J. Weddell: None. R. Shah: None. P. Robinson: None. A. Barr: None. C. Vandevelde: None. J. Freeston: None. D. McGonagle: None. H. Marzo-Ortega: None.

Actigraphic sleep patterns are associated with bone turnover and bone mineral density among university students.

Poorer sleep is associated with poorer bone health among older adults but the role of sleep in bone health during younger adulthood is understudied. In this observational study, the averages and variability in total sleep time (TST), sleep efficiency (SE), and sleep midpoint of university students were examined in relation to levels of bone turnover markers (BTMs) and bone mineral density (BMD) at the lumbar spine and femur. A sample of healthy, university students (N = 59, aged 18-25 years, 51.8% female, body mass index <30 kg/m2 ), wore a wrist actigraph for 7 days, completed a dual-energy X-ray absorptiometry scan, and underwent blood sampling to assess serum BTM concentrations of osteocalcin (OC) and N-terminal telopeptide of type 1 collagen. A sub-sample (n = 14) completed a one-year follow-up. Multiple regression models examined the associations between each sleep metric and bone health outcome at baseline and 1-year follow-up. At baseline, greater variability in sleep midpoint was cross-sectionally associated with greater OC (β = 0.21, p = 0.042). In the exploratory, follow-up sub-sample, lower average TST (β = -0.66, p = 0.013) and SE (β = -0.68, p = 0.01) at baseline were associated with greater increases in OC at follow-up. Greater delays in mean sleep midpoint over follow-up were significantly associated with decreases in lumbar spine BMD (β = -0.49, p = 0.03). In a sample of young adults, variable sleep schedules were associated with greater bone turnover suggesting the potential importance of regular sleep for optimising bone health into early adulthood.

Abstract 78: Mobile Stroke Units Address Disparities in Stroke Care as Demonstrated by Zip Code Level Socioeconomic Status

Introduction: Acute ischemic stroke (AIS) disproportionately affects minority populations with evidence showing black and Hispanic patients utilize traditional EMS less, have greater delay in arrival to the emergency department, are less likely to receive thrombolysis, and have lower odds for good functional outcomes. 1–3 Mobile Stroke Units (MSUs) bring diagnostic and treatment tools for AIS directly to patients, achieving faster thrombolytic administration and better outcomes. 4,5 Objective: This study compared demographic data and used Census data to characterize the socioeconomics of patient zip codes served and transported by our MSU based in Rochester, NY relative to patients that arrived at our institution via traditional EMS and private vehicle. Methods: Data was extracted from the 2018 American Community Survey (ACS), a 5-year a rolling survey of the US population. Zip code level socioeconomic status (zSES) was calculated based on 5 key factors by assigning percentile ranks to each across all US zip codes and combined to create one index variable measuring zSES. zSES, its factors, and demographics were compared amongst MSU and non-MSU patients. Results: 468 patients transported by our MSUs to our institution between October 2018 to January 2022 were compared to the 2,296 non-MSU patients for the same time-period. Patients transported by MSU lived in zip codes with significantly lower SES Index (0.482 versus 0.527, p=0.013). Component analysis showed that MSU patients came from zip codes with a higher percentage of households with single parents, higher percentage of individuals below the federal poverty line, higher percentage of unemployed individuals, and higher percentage of adults with less than a 12 th grade education. Per capita income did not differ. In addition, patients transported by our MSU’s were significantly more female, black, and Hispanic. Age did not differ. Conclusion: Mobile Stroke Units (MSU) help address disparities in stroke care, by bringing care to patients who live in zip codes that have significantly lower SES and are of historically marginalized communities, compared to patients transported by EMS and private vehicle.

Risk of long-term care admissions among Medicare beneficiaries treated with pimavanserin or quetiapine for Parkinson's disease psychosis in USA: a retrospective administrative claims database analysis.

Aim: Risk of long-term care (LTC) admission (LTCA) associated with atypical antipsychotic (AAP) use among patients with Parkinson's disease psychosis (PDP) is a major concern. However, no comparative studies have examined the differences in risk of LTC admissions between pimavanserin (PIM), the only FDA-approved AAP for PDP, and other off-label AAPs including quetiapine (QUE). Objective: To examine all-cause LTCA rates and risk among PDP patients treated with AAPs such as QUE or PIM. Methods: Analysis of Parts A, Band D claims (100% Medicare sample; 2013-2019) of Medicare beneficiaries with PDP that initiate ≥12-month continuous PIM or QUE monotherapy from 1 January 2014 to31 December 2018 (i.e., index date) without any AAP use in the 12-month pre-index period was conducted. Outcome assessments among 1:1 propensity score-matched (31 variables - age, sex, race, region and 27 Elixhauser comorbidities) beneficiaries on PIM versus QUE included risk of all-cause skilled nursing facility stays (SNF-stays), LTC-stays, and overall LTCA (i.e., SNF-stays or LTC-stays). All-cause LTCA rates and LTCA risk were compared using logistic regression and cox proportional hazards models, respectively, controlling for demographics, comorbidities and co-existing-dementia or insomnia. Results: Of the matched sample (n=842 for each group) from total sample (n=9652), overall all-cause LTCA and SNF-stay rates were 23.2 and 20.2% for PIM versus 33.8 and 31.4% for QUE, respectively (p<0.05, for each). Hazard ratio (95% CI) for risk of SNF-stay and overall LTCA was 0.78 (0.61, 0.98) and 0.80 (0.66, 0.97), respectively, for PIM versus QUE beneficiaries (p<0.05, for each). Conclusion: The 20% lower risk of LTCA (i.e., greater delay) with PIM versus QUE in this analysis may suggest that PIM should be started early for the treatment of PDP.

Home-spirometry exacerbation profiles in children with cystic fibrosis.

Pulmonary exacerbations (PEx) are strong predictors of respiratory disease progression in children with cystic fibrosis (CwCF) and may be associated with persistent decreased lung function after acute management. Telemonitoring devices can be used for early detection and monitoring of PEx, but its utility is debated. Which symptoms and telemonitoring spirometry characterics are related to outcome dynamics following initial PEx management? This retrospective study included CwCF followed at Bordeaux University Hospital, France. All severe PEx episodes treated with intravenous (IV) antibiotics (ATB) between 1 January 2017 and 31 December 2021 in CwCF using home telemonitoring were analyzed. Symptoms and home spirometry data were collected 45 days before and up to 60 days after each IV ATB course. We defined three response profiles based on terciles of baseline forced expiratory volume in 1 s (FEV1 ) recovery. A total of 346 IV ATB courses for PEx were administered to 65 CwCF during the study period. The drop in FEV1 became significant 8 days before IV ATB initiation. Forty-one percent of IV ATB courses failed to restore baseline FEV1 . The magnitude of FEV1 drop and a greater delay in the initiation of treatment correlated with a low response level. On the 14th day of the IV treatment, a FEV1 recovery less than 94% of baseline was associated with a nonresponder profile. Home spirometry may facilitate the early recognition of PEx to implement earlier interventions. This study also provides an outcome lung function threshold which identifies low responders to IV ATB.

Timeliness of Opioid Administration for Pain in the Emergency Department for Adults with Sickle Cell Disease

Background: Individuals with sickle cell disease (SCD) often require emergent care to manage debilitating pain. The American Society of Hematology recommends individuals seeking care for the treatment of acute pain should have their pain assessed and medication administered within one hour of their arrival at the emergency department (ED). Data regarding guideline timeliness of pain treatment in adults are not well understood. We therefore sought to determine the timeliness of care for pain treatment in the ED for adults with SCD and factors associated with timeliness of care. We hypothesized that those using public insurance will have greater delays in receipt of intravenous opioids for pain. Methods: We leveraged the Center for Disease Control's Sickle Cell Data Collection Program in Wisconsin to identify individuals with SCD who received care in the ED associated with the adult SCD comprehensive clinic between 2017-2020. Individuals were identified as having SCD if confirmed via the state newborn screening program or if they had 3 or more visits/claims with a diagnosis of SCD in a five-year time frame. ED treat and release visits with 1) any diagnosis of pain or vaso-occlusive crises, and 2) receipt of an intravenous opioid were considered painful crises. The timeliness of ED pain treatment was determined by calculating the time between placement in an ED room and receipt of first intravenous opioid. All analyses were conducted at the visit level. A multivariable generalized linear model was used to determine if age, sex or insurance status were associated with time to opioid administration. Results: There were 382 individuals with SCD who contributed to 3400 ED treat and release visits; 1755 were for painful crises. The mean age of individuals was 31.8 (SD = 9.5) years and the majority of the visits were by females (64%). The primary payers included Medicaid (63.9%), Medicare (25.6%), private (5.7%), and other (4.7%). The median time to administration of intravenous opioids after being roomed was 57 minutes (IQR: 39 - 86 minutes). Intravenous opioids were not administered within 60 minutes of being roomed for 43% of the ED visits. The multivariable model demonstrated that females (as compared to males; 72.6 vs 55.4 minutes), and those on Medicaid and Medicare (70.4 and 72.6 minutes respectively as compared to private insurance 46 minutes) had a significantly longer time to receipt of first intravenous opioid (Table 1). Conclusion: Our data show that intravenous opioids were not given within 60 minutes of being roomed for more than 40% of ED visits for pain at an adult care facility . These analyses do not include the time in waiting room prior to being roomed, thus the problem of timely care is worse than reflected by these results. Females and those on public insurance have significantly longer time to receipt of pain treatment. Immediate work is needed to identify steps to ensure that adults with SCD seeking emergent care for pain receive guideline-adherent pain treatment.