Initial Delay Research Articles

A clinicoepidemiological study of serologically diagnosed acute febrile illness in a teaching hospital, Kolkata

ABSTRACT Introduction: Similar presenting manifestations in early phase and lack of awareness of aetiology of acute febrile illness (AFI) are major challenges in management of AFI. Material and Methods: This was a retrospective observational cross-sectional study conducted in the Department of Microbiology, NRS Medical College, from 1 July 2022 to 30 June 2023 in serologically diagnosed febrile patients attending the outpatient department or admitted. Clinical and epidemiological data and laboratory parameters were recorded in a pretested structured questionnaire study tool, and collected data were analysed on MS-Excel sheets with various charts and tables. Results: A total of 1711 serologically diagnosed febrile patients showed preponderance of dengue (38.3%), followed by leptospirosis (25%), scrub typhus (23.9%), malaria (12.6%), and enteric fever (1.92%). A majority of cases were male, less than 40 years of age, and from the rural population (73.2%), except in malaria (urban = 79.6%). The mean duration of fever was 9 days. Febrile cases were recorded maximum during the monsoon and postmonsoon periods (66.5%). The common manifestations are fever, headache (46.2%), pain abdomen (7.8%), nausea, and vomiting (9.4%). Thrombocytopenia with bleeding manifestation was higher in dengue (18%) cases. Mortality in dengue cases was recorded with multiorgan dysfunction syndrome (MODS). Scrub typhus cases showed seizure (8.3%) and altered sensorium (5%) due to fatal meningoencephalitis. Fatality in leptospirosis was mostly due to acute kidney injury (29.5%) and Weil’s disease (4.4%). Conclusion: Misdiagnosis or incorrect diagnosis and delay in initiation of appropriate treatment results in increased morbidity and mortality in AFI. Determination of epidemiological features and clinical manifestations of AFI along with timely correct diagnosis will benefit clinicians in proper treatment initiation, thereby reducing morbidity and mortality.

Relationship between self-reported challenges with social determinants of health and delayed time-to-treatment initiation for gynecologic malignancies.

90 Background: Delays in time to treatment initiation (TTI) for gynecologic malignancies have been associated with worse survival. Worsened outcomes and presentation with more advanced disease are more common for gynecologic cancer patients who come from socioeconomically disadvantaged populations and whose healthcare is negatively impacted by their social determinants of health (SDoH). There is a need to characterize the particular social determinants of health that are associated with delays in treatment initiation in patients with gynecologic malignancy, particularly in underserved urban populations. Methods: Retrospective cohort study at an urban community-based academic center. Participants were 257 patients with primary gynecologic malignancy either of the cervix, ovary, uterus, vulva/vagina or NOS diagnosed between January 2017 and August 2022, identified through the Montefiore Medical Center Cancer Registry. The primary exposure was TTI, defined as the duration between histopathological diagnosis and initial treatment. Univariate and multivariate logistic regression analyses were conducted to examine the association between delays in TTI and SDoH. Multivariate Cox proportional hazard regression was used to obtain hazard ratios and 95% confidence intervals associated with TTI. Results: Among 257 patients with gynecologic malignancy (median [IQR] age 63 [56-72] years), 205 patients were treated within 45 days of diagnosis, and 52 were treated at or after 45 days. Predictors of delayed TTI (defined as ≥45 days) included positive SDoH screening in univariate logistic regression (OR = 3.12, 95% CI 1.39-6.98, p = 0.0061) and in multivariate logistic regression (OR = 3.06, 95% CI 2.62-3.57, p<0.001) as well as increased age in multivariate logistic regression (OR = 1.02, 95% CI 1.02-1.03, p<0.001). Multivariate logistic regression showed that protective factors for delayed TTI were Non-Hispanic Black race/ethnicity (OR = 0.87, 95% CI 0.77-0.99, p = 0.0351), non-Hispanic white race/ethnicity (OR = 0.37, 95% CI 0.30-0.46, p<0.001), inpatient stay within 30 days of diagnosis (OR = 0.74, 95% CI 0.62-0.88, p=0.001) and AJCC clinically late stage (OR = 0.57, 95% CI 0.50-0.66, p<0.001). Conclusions: In patients with gynecologic malignancies, greater SDoH burden increases risk for delays in treatment ≥ 45 days from diagnosis. Non-Hispanic race/ethnicity, inpatient stay within 30 days of diagnosis and clinically late-stage diagnoses are protective factors for expedited treatment initiation. Identification of predictive and protective factors for treatment delay will help identify at-risk patients and facilitate earlier intervention in hospitals with underserved populations.

Planned Dental Extractions After Radiation Therapy.

Nonrestorable teeth are recommended to be extracted prior to radiation therapy (RT). Occasionally, preradiation extractions introduce unacceptable delays in treatment initiation. Planned dental extractions immediately postradiation presents an alternative strategy, though outcomes are uncertain. To evaluate the feasibility and safety of dental extractions immediately postradiation. A prospective cohort study including patients planned for curative-intent RT but unable or unwilling to proceed with 1 or more extractions recommended pretreatment was carried out. From January 2020 to September 2022, 58 patients were screened and 50 enrolled. The dental care was performed at a single academic department and the cancer care at regional centers. Analysis took place between September 22, 2023, and June 10, 2024. On completion of RT, patients were recommended to complete extractions as soon as feasible, and ideally within 4 months. The primary end point was the actuarial cumulative incidence of exposed alveolar bone noted by any practitioner at any time after extraction, calculated using Gray method with death as a competing risk. As a pilot study, no formal power calculation was performed; resources allowed for 50 evaluable patients. Among the 50 participants enrolled, RT was nonoperative for 32 patients (64%) and postoperative for 18 patients (36%). Intensity-modulated RT (IMRT) was delivered in all patients. Of the 50 patients, 20 (40%) declined dental extractions immediately postradiation and the remaining 30 (60%) underwent a median (range) of 8.5 (1-28) extractions at a median (range) of 64.5 (13-152) days after RT. The median (IQR) follow-up for survivors without exposed bone was 26 (17-35) months from the end of RT. The 2-year cumulative incidence of any exposed bone was 27% (95% CI, 14%-40%). The 2-year incidence of exposed bone for those who underwent dental extractions immediately postradiation was 40% (95% CI, 22%-58%) and 7% (95% CI, 0%-22%) for those who did not. Of the 13 who developed exposed bone: 4 resolved, 1 was lost to follow-up, and 8 were confirmed as osteoradionecrosis. This cohort study found that postradiation dental extractions incur considerable risk, even if performed within a 4-month window.

Factors associated with delays in receipt of neoadjuvant chemotherapy in patients with operable breast cancer.

126 Background: Delays in neoadjuvant chemotherapy initiation (NACTI) after breast cancer (BC) diagnosis have been associated with worse outcomes. We evaluated incidence and predictors of delays of NACTI among high clinical risk patients treated with NACT on a national level. Methods: We conducted a retrospective cohort study using the National Cancer Database. Eligibility included age ≥18 years, diagnosis of non-metastatic BC between 1/1/2010 – 12/31/2020, who were treated with NACT within 180 days of diagnosis. Patients who received neoadjuvant endocrine therapy were excluded. Time to chemotherapy (TTC) in days was recorded. Patients were categorized into sub-cohorts by receptor status and clinical stage: 1) Hormone Receptor positive/HER-2 negative (HR+/HER2-) and were lymph node (LN) LN+; 2) HER-2 positive (HER2+) cT2+ or LN+; and 3) triple negative BC (TNBC) cT2+ or LN+. Multivariable logistic regression, adjusted for demographic, socioeconomic and tumor characteristics, was used to identify characteristics associated with delays > 60 days from diagnosis to NACTI. Multiple imputation was used for missing data. Results: We identified 145,697 eligible patients, 74% were White, 18% were Black, 3.3% were Asian, and 4.6% were Other/Unknown. Across all racial categories, 9.2% were Hispanic. Median age at diagnosis was 52 years (range 18-90), median TTC was 32 days (range 0-180), and 10% had a delay > 60 days. There were 40,345 patients in the HR+/HER2- cohort, 56,868 in the HER2+ cohort, and 48,484 in the TNBC cohort; 12%, 9.0%, and 8.9% (p < 0.001) had a delay in NACTI, respectively. In multivariable analysis among the HR+/HER2- sub-cohort, characteristics associated with delays in NACTI included Black race (OR 1.71, 95%CI 1.57-1.86) and Hispanic ethnicity (OR 1.76, 95%CI 1.60-1.94) compared to White and non-Hispanic patients. Patients with Medicare, Medicaid, or who were uninsured were more likely to be delayed (OR 1.44 95%CI 1.30-1.58, 2.10, 95%CI 1.92-2.29, 2.28, 95%CI 1.99-2.61) compared to those with commercial insurance. Results were similar in the HER2+and TNBC cohorts, as seen (Table). Conclusions: Among patients with operable BC who received NACT, patients who were Black, Hispanic, had Medicaid or no insurance had as high as a twofold increase in odds of a delay in NACTI. Targeted interventions to address these racial and socioeconomic disparities are necessary to ensure equitable care. Multivariable logistic regression adjusted for demographic, socioeconomic, and tumor characteristics variables (n = 145,697). HR+/HER2-N= 40,345 HER2+N= 56,868 TNBCN= 48,484 OR 95%CI OR 95%CI OR 95%CI Black Race 1.71 1.57-1.86 1.89 1.74-2.04 1.90 1.76-2.06 Hispanic Ethnicity 1.76 1.60-1.94 2.18 2.00-2.36 2.00 1.80-2.21 Medicare 1.44 1.30-1.58 1.46 1.34-1.61 1.45 1.32-1.61 Medicaid 2.10 1.92-2.29 2.13 1.96-2.31 2.14 1.96-2.34 No Insurance 2.28 1.99-2.61 2.36 2.07-2.70 2.25 1.96-2.59

Delay in Time to Adjuvant Chemotherapy and its Impact on Oncological Outcomes in Patients Undergoing Optimal Cytoreductive Surgery for Advanced Ovarian Cancer: Analysis of 1480 Cases From the Indian HIPEC Registry.

The impact of delay in initiation of adjuvant chemotherapy following optimal CRS in different settings of treatment for advanced ovarian cancer needs to be studied with special reference to CRS HIPEC. The 1480 advanced EOC patients underwent optimal CRS, followed by adjuvant chemotheraphy, with or without intraperitoneal (IP) chemotherapy in Normothermic or Hyperthermic form. Interval between the day of surgery and start of adjuvant chemotherapy and its impact on outcome was analyzed. CRS, CRS with IP or HIPEC was done in 400, 480, and 600 patients respectively. Median interval of starting adjuvant chemotherapy was 32 days CRS group, 34 days CRS + IP group and 41 days CRS + HIPEC group. Delay in chemotherapy impacted on recurrence free survival (RFS) in CRS + IV group (36 vs. 17 months: p = 0.02) and some impact in CRS + IP group (38 vs. 28 months; P 0.78) and no impact on CRS + HIPEC group (35 vs. 32 months; p = 0.17). Delay in starting adjuvant chemotherapy adversely affects RFS in patients undergoing optimal CRS alone. However, the delay didn't have an impact in the CRS + HIPEC group. Well-designed clinical studies are required to evaluate the impact of single dose of HIPEC.

Socioeconomic Disparities in Diagnosis-to-Treatment Time Among Patients Diagnosed With Breast Cancer in Saudi Arabia: A Cross-Sectional Study in a Tertiary Care Center.

Introduction Despite Saudi Arabia's' free healthcare system, breast cancer (BC) has a major impact on affected individuals. Previous studies have shown that socioeconomic variables could contribute to inequities in receiving treatment. Although early detection and treatment are essential, delays are frequently influenced by either insurance status or other socioeconomic variables. Assessing characteristics that influence the duration of BC treatment for Saudi women will aid in improving health equity and lowering system costs. Methods This was a cross-sectional study that included all female patients who were diagnosed with BC between 2016 and 2023 at a tertiary care center. All patients were contacted by phone calls to fill out a questionnaire. Results A total of 113 females were included; the mean age at the time of diagnosis with BC was 48.88±10.97 years, and the majority were Saudis (58.4%). Additionally, the median duration for treatment initiation was 28 (15.50-45.50) days from the date of diagnosis. Factors influencing the time for initiating the treatment included nationality, as non-Saudis took longer to receive their treatment (27.00 (13.00-39.25) days vs. 30.00 (18.00-59.00) days, p = 0.176). Moreover, patients living further from the hospital demonstrated a delay in receiving treatment compared to those living near the hospital. However, the relation was not statistically significant. Conclusion Our study investigated the demographic disparities among BC patients. Our results showed that some variables contributed to a delay in treatment initiation, including nationality and distance from the hospital, which suggest further areas for investigation. We recommend further studies be conducted with a larger sample size to improve accessibility and reduce treatment delays for BC patients.

Anticoagulation strategies in patients with coexisting traumatic intracranial hematomas and cerebral venous sinus thrombosis: an observational cohort study

PurposePost-traumatic cerebral venous sinus thrombosis (ptCVT) is a rare but serious complication of traumatic brain injury (TBI). Managing ptCVT is challenging due to the concurrent risk of traumatic intracranial hematoma (ICH) expansion. Limited data exists on the safety and efficacy of anticoagulation therapy (ACT) in these cases.MethodsThis single-center observational cohort study included adult TBI patients with concurrent ICH and ptCVT. Low-molecular-weight heparin (LMWH) or heparin infusion was used to treat all ptCVTs based on institutional protocols. The outcomes of interest were hemorrhagic and thrombotic complications.ResultsOut of 1,039 TBI-patients admitted between 2006 and 2020, 32 met the inclusion criteria. The median time from injury to ptCVT diagnosis was 24 h. ACT was initiated at a median of 9 h after ptCVT diagnosis. Patients were administered either heparin infusion (n = 8) or LMWH at dosages ranging from 28 to 72% of the therapeutic level (n = 24). There were no hemorrhagic complications, even in patients receiving LMWH at ≥ 50% of the therapeutic dose. Thrombotic complications occurred in 3 patients (9.4%) – two cases of thrombus progression and one venous infarct. The patients who developed thrombotic complications differed from those who did not by having a 17-h delay in ACT initiation after diagnosis or by receiving an initial LMWH dose at 28% of the therapeutic level.ConclusionLMWH at approximately 50% of the therapeutic level was effective for managing ptCVT associated with TBI in our retrospective dataset, with no risk of hematoma expansion. Prospective trials are warranted to confirm these results.

Evaluating the Effects of Decentralized District-Based Treatment of Drug-Resistant Tuberculosis in Pakistan: An Alternative Model of Care

Background: Pakistan faces a high burden of drug-resistant tuberculosis (DR-TB), with traditional centralized care resulting in delays and poor treatment outcomes. Decentralizing care to district-level hospitals offers a potentially more effective alternative.Objective: This study aimed to evaluate the impact of decentralized DR-TB care on treatment initiation time, patient follow-up, and treatment outcomes.Methods: A descriptive post-intervention study was conducted at a decentralized DR-TB clinic in Sheikhupura, Punjab, between June 2021 and December 2022. Data from 100 patients were retrospectively collected from hospital records and diagnostic labs, including demographic information, treatment compliance, smear and culture conversion rates, and adverse drug reactions. SPSS 25 was used for statistical analysis, including descriptive statistics.Results: The average time from diagnosis to treatment initiation was 14.9 days. Smear conversion by the sixth month was 99%, while culture conversion was 98%. The treatment success rate was 70%, with a 7% loss to follow-up, 2% treatment failure, and 15% mortality.Conclusion: Decentralized DR-TB care significantly reduced delays in treatment initiation and improved patient outcomes. This model is feasible for national implementation with potential to enhance DR-TB management in Pakistan.

Early Addition of Selexipag to Double Therapy for Pulmonary Arterial Hypertension

A subgroup analysis of a randomized clinical trial established the efficacy of selexipag plus background therapy (monotherapy or double oral therapy [DOT]) vs placebo plus background therapy and found that the addition of selexipag within 6 months had an added benefit. However, the timing of selexipag addition to DOT and the incremental benefit in clinical practice is not well studied. To compare triple oral therapy (TOT) consisting of selexipag, endothelin receptor antagonist (ERA), and phosphodiesterase type 5 inhibitor (PDE5i) vs DOT consisting of ERA and PDE5i. This comparative effectiveness study was conducted using data from the US Komodo claims database to emulate a randomized trial. Patients aged 18 years or older with pulmonary arterial hypertension (PAH) treated with ERA plus PDE5i with records from July 2015 through June 2022 were duplicated to TOT and DOT and artificially censored when observed treatment deviated from assigned treatment. Hypothetical randomization was emulated using inverse probability of treatment weighting, and the study accounted for censoring-induced selection bias using inverse probability of censoring weighting. A pooled logistic model estimated the per-protocol difference between treatment groups. Data were analyzed from November 2022 through July 2023. TOT (addition of selexipag within 3, 6, and 12 months of initiating DOT) vs DOT. Adjusted risk of all-cause hospitalization, PAH-related hospitalization, and PAH-related disease progression over a 2-year follow-up. A total of 2966 patients with PAH (mean [SD] age, 54.3 [14.0] years; 2125 female [71.6%]) met eligibility criteria. Adding selexipag within 6 months of ongoing DOT was associated with a reduction in risk for all-cause hospitalization (adjusted hazard ratio [aHR], 0.82; 95% CI, 0.72-0.94), PAH-related hospitalization (aHR, 0.81; 95% CI, 0.70-0.95), and PAH-related progression (aHR, 0.82; 95% CI, 0.70-0.95) vs DOT alone. There were no associations if selexipag was initiated within 12 months for all-cause hospitalization, PAH-related hospitalization, or PAH-related disease progression. The association remained with a greater decrease in risk for disease progression vs DOT for selexipag initiation within 3 months (aHR, 0.74; 95% CI, 0.61-0.90). This study found that early selexipag addition to ERA plus PDE5i was associated with a reduction in risk of hospitalization and disease progression. These findings suggest that delays in selexipag initiation likely contribute to suboptimal patient and health system outcomes.

Abstract C135: The heterogenous impact of healthcare access factors throughout the breast cancer care continuum

Abstract Background: Delays in breast cancer diagnosis and treatment lead to worse survival and quality of life decrements. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (diagnosis, treatment initiation, treatment duration, and genomic testing). Methods: The Carolina Breast Cancer Study Phase 3 (CBCS3) is a population-based cohort (n=2998, 50% Black) with invasive breast cancer diagnoses (2008-2013). We used latent class analysis (LCA) to group participants based on patterns of factors within 3 separate domains: “socio-economic status (SES)”, “care barriers”, and “care use.” These classes were evaluated in association with delayed diagnosis (approximated with stage 3 or 4 at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment – by treatment modality), and receipt of OncotypeDx genomic testing (evaluated among patients with early stage, ER+, HER2- disease). Associations were evaluated using adjusted linear-risk regression to estimate relative frequency differences (RFDs) with 95% confidence intervals (CIs). Results: Overall, 18% of CBCS participants had late stage/delayed diagnosis, 35% had delayed treatment initiation, 48% had prolonged treatment duration, and 62% did not receive OncotypeDx. Black women had greater frequency of each unfavorable care outcome compared to non-Black women, including diagnostic delay (22% vs 15%, RFD= 6.9, 4.1-9.6), treatment initiation delay (39% vs 31%, RFD=7.9, 4.5-11.3), prolonged treatment (50% vs 46%, RFD= 4.3, 0.5-8.2), and OncotypeDx non-receipt (69% vs 57%, RFD= 12.2, 7.3-16.7). We identified 3 latent classes for SES (“high SES”, “moderate SES,” and “low SES”) 2 classes for care barriers (“few barriers”, “more barriers”), and 5 classes for care use (“short travel/high preventive care”, “short travel/low preventive care,” “medium travel,” “variable travel,” and “high travel”). Low-SES and more barriers to care were associated with greater frequency of delayed diagnosis (RFDadj = 5.5, 2.4-8.5; RFDadj =6.7, 2.8-10.7, respectively) and prolonged treatment (RFDadj = 9.7, 4.8-14.6; RFDadj = 7.3, 2.4-12.2, respectively). Variable travel (short time to diagnosis but long time to surgery) was associated with delayed treatment in the entire study population (RFDadj = 10.7, 2.7-18.8) compared to the short travel, high use referent group. The high travel group (representing long travel to both diagnosis and surgery) was associated with delayed treatment only among Black women relative to the same referent group (RFDadj = 10.0, -3.3-23.2). Conclusions: Black patients face more frequent delays throughout the care continuum, likely stemming from different types of access barriers at key junctures. Improving breast cancer care access will require intervention on multiple aspects of SES and healthcare access. Citation Format: Matthew R. Dunn, Didong Li, Marc A Emerson, Caroline A. Thompson, Hazel B Nichols, Sarah C Van Alsten, Mya L. Roberson, Lisa A. Carey, Terry Hyslop, Jennifer Elston Lafata, Melissa A. Troester. The heterogenous impact of healthcare access factors throughout the breast cancer care continuum [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 C135.

Abstract C135: The heterogenous impact of healthcare access factors throughout the breast cancer care continuum

Abstract Background: Delays in breast cancer diagnosis and treatment lead to worse survival and quality of life decrements. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (diagnosis, treatment initiation, treatment duration, and genomic testing). Methods: The Carolina Breast Cancer Study Phase 3 (CBCS3) is a population-based cohort (n=2998, 50% Black) with invasive breast cancer diagnoses (2008-2013). We used latent class analysis (LCA) to group participants based on patterns of factors within 3 separate domains: “socio-economic status (SES)”, “care barriers”, and “care use.” These classes were evaluated in association with delayed diagnosis (approximated with stage 3 or 4 at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment – by treatment modality), and receipt of OncotypeDx genomic testing (evaluated among patients with early stage, ER+, HER2- disease). Associations were evaluated using adjusted linear-risk regression to estimate relative frequency differences (RFDs) with 95% confidence intervals (CIs). Results: Overall, 18% of CBCS participants had late stage/delayed diagnosis, 35% had delayed treatment initiation, 48% had prolonged treatment duration, and 62% did not receive OncotypeDx. Black women had greater frequency of each unfavorable care outcome compared to non-Black women, including diagnostic delay (22% vs 15%, RFD= 6.9, 4.1-9.6), treatment initiation delay (39% vs 31%, RFD=7.9, 4.5-11.3), prolonged treatment (50% vs 46%, RFD= 4.3, 0.5-8.2), and OncotypeDx non-receipt (69% vs 57%, RFD= 12.2, 7.3-16.7). We identified 3 latent classes for SES (“high SES”, “moderate SES,” and “low SES”) 2 classes for care barriers (“few barriers”, “more barriers”), and 5 classes for care use (“short travel/high preventive care”, “short travel/low preventive care,” “medium travel,” “variable travel,” and “high travel”). Low-SES and more barriers to care were associated with greater frequency of delayed diagnosis (RFDadj = 5.5, 2.4-8.5; RFDadj =6.7, 2.8-10.7, respectively) and prolonged treatment (RFDadj = 9.7, 4.8-14.6; RFDadj = 7.3, 2.4-12.2, respectively). Variable travel (short time to diagnosis but long time to surgery) was associated with delayed treatment in the entire study population (RFDadj = 10.7, 2.7-18.8) compared to the short travel, high use referent group. The high travel group (representing long travel to both diagnosis and surgery) was associated with delayed treatment only among Black women relative to the same referent group (RFDadj = 10.0, -3.3-23.2). Conclusions: Black patients face more frequent delays throughout the care continuum, likely stemming from different types of access barriers at key junctures. Improving breast cancer care access will require intervention on multiple aspects of SES and healthcare access. Citation Format: Matthew R. Dunn, Didong Li, Marc A Emerson, Caroline A. Thompson, Hazel B Nichols, Sarah C Van Alsten, Mya L. Roberson, Lisa A. Carey, Terry Hyslop, Jennifer Elston Lafata, Melissa A. Troester. The heterogenous impact of healthcare access factors throughout the breast cancer care continuum [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 C135.

Opioid Use and Outcomes in Patients Hospitalized With Acute Severe Ulcerative Colitis.

Opioid use has not been shown to improve hospitalized inflammatory bowel disease patient pain scores and may prolong the length of stay (LOS). Additional clinical implications of opioid use, particularly high amounts, in the hospital setting have not yet been explored. We sought to determine how high opioid use impacts clinical outcomes in acute severe ulcerative colitis (ASUC). In this single-center study, we identified all patients hospitalized with ASUC who received intravenous corticosteroids from July 1, 2014 to December 31, 2021. Clinical outcomes including opioid exposure, cumulative intravenous corticosteroid dose, biologic rescue therapy initiation date, colectomy rate, opioid prescription at discharge, LOS, and hospitalization cost were collected. High opioid use was defined as ≥40 oral morphine equivalents (OMEs) per day. A univariable logistic regression was performed to evaluate the association of high opioid use with ASUC outcomes. 185 eligible hospitalizations for ASUC were evaluated. 75 patients (41%) received opioids during hospitalization, and 20 patients (11%) received ≥40 OMEs/day. High opioid use was associated with a median 3-day delay in biologic rescue therapy initiation when compared with low/no opioid use (P = .02). 70% of patients with high opioid use received an opioid prescription at discharge compared with 10% of those with low/no use (P < .001). Opioid use was not associated with LOS, duration of corticosteroid therapy, colectomy rate, or hospitalization cost. Among ASUC hospitalizations, high opioid use was associated with delayed biologic rescue therapy initiation and higher rates of opioid prescriptions at discharge.

Medication management and electrocardiogram screening in children with attention deficit hyperactivity disorder.

To quantify the proportion of referrals sent to Crumlin Cardiology Department for cardiac screening prior to commencement or modifying attention deficit hyperactivity disorder medication and assess the number detected with a clinically significant abnormality. A prospective audit was performed over a 6-month period, from November 2021 to April 2022 inclusive. Referrals sent via outpatient department triage letters, electrocardiogram dept. email, and walk-in electrocardiogram service were screened for those pertaining to commencing or modifying medication for children with attention deficit hyperactivity disorder. Each referral was coded against National Institute for Health and Care Excellence guidelines to determine the degree of clinical details given. Reported abnormalities, recommended management, and correspondence were recorded. Ninety-one referrals were received during the 6-month audit period. More than half lacked a clinical indication for referral (53/91, 58.2%), with fewer than one third (26/91, 28.5%) meeting National Institute for Health and Care Excellence criteria for referral for cardiology. Eighty (80/91) referrals had clinical outcomes available for review (missing outpatient department information and age outside of service range accounted for eleven referrals with unavailable clinical outcomes). Of the eighty clinically reviewed referrals, seventy-two (72/80, 90%) were reported as normal with no cardiology follow up required. Eight referrals (8/80, 10%) were reviewed in the Cardiology Outpatient Department prior to commencement or modifying attention deficit hyperactivity disorder medication. Of these, only one (1/80 1%) had a clinically significant abnormality which was a potential contraindication to attention deficit hyperactivity disorder medication use, and this referral was appropriate as per National Institute for Health and Care Excellence guidelines. Routine screening prior to attention deficit hyperactivity disorder medication prescription in the absence of clinical indications (as per National Institute for Health and Care Excellence) contributed to delays in medication initiation among young people with attention deficit hyperactivity disorder. Unnecessary referrals have resource implications for cardiology clinical team. Improved adherence to National Institute for Health and Care Excellence guidelines would provide benefits for patients and clinicians.

Focal therapy for oligometastatic and oligoprogressive renal cell carcinoma: a narrative review.

Metastatic renal cell carcinoma (RCC) can present with oligometastatic disease and/or develop oligoprogression following systemic therapy. Cytoreductive and focal metastasis-directed therapy options include resection, stereotactic ablative radiation and thermal ablation. Aggressive focal therapy may allow delay in initiation of or modification to systemic therapy and improve clinical outcomes. In this narrative review we synthesize current practice guidelines and prospective data on focal therapy management options and highlight future research. Patient selection and the choice of focal treatment techniques are controversial due to limited and heterogeneous data and patients may benefit from multidisciplinary evaluation. Prospective comparative trials with clearly defined inclusion criteria and relevant end points are needed to clarify the risks and benefits of different approaches.

Evaluation of a Quality Measure for Multiple Sclerosis Care: Disease-Modifying Therapy Initiation at the University of North Carolina's Outpatient Neurology Clinic.

Multiple sclerosis (MS) is a neurological condition leading to significant disability and challenges to quality of life. To slow progression and reduce relapses, it is critical to rapidly initiate disease-modifying therapy (DMT) after diagnosis. Patient demographics may play a role in timely DMT initiation. Financial barriers may also result in delays in DMT access. This retrospective, single-center, cross-sectional study included patients seen at a neurology clinic at a large academic medical center for an initial evaluation of MS between January 1, 2022, and June 30, 2022. As an indicator of the quality of care, the primary study outcome was whether patients were offered DMT initiation on their first clinic visit. Secondary outcomes evaluated the time to DMT initiation, including differences in care based on demographic factors and financial coverage. Of the 49 eligible individuals studied, 45 (91.8%) were offered DMT at their initial MS visit. Descriptive statistics appeared to demonstrate that demographic factors did not impact whether DMT was offered. However, the majority of patients experienced access barriers relating to prior authorization requirements (80.0%) and/or the need for co-pay assistance (52.0%). DMT was appropriately offered to a majority of patients at their initial MS visit, regardless of demographic considerations. No offer of DMT and delays in initiation were primarily due to the need for imaging and specialty referrals, as well as financial barriers. Medication assistance teams may play a crucial role in limiting delays and financial hurdles associated with insurance coverage and co-pay assistance.

A practical approach to febrile cancer patients: Diagnostic stewardship in Oncology units

Introduction Cancer and cytotoxic chemotherapy used for its treatment predispose to severe and often fatal infections. Prompt diagnosis and timely antibiotic therapy are crucial, with delays in therapy initiation having high mortality. Complete blood count (CBC) is an inexpensive, standardized, and preliminary investigation for the management and follow-up of cancer patients with diagnostic and prognostic value. Method We studied the types of infections associated with various cancers treated with chemotherapy, their etiologies and susceptibility patterns, and the hematological profile of these patients as predictors of infection. Results A total of 21 patients (12 solid and 9 hematological malignancies) presented with 31 febrile episodes. White Blood cell count (2079 cells/cu. mm), percentage of neutrophils (52.9%), absolute neutrophil (137.5 cells/cu. mm), and platelet count (1,77,507 cells/cu. mm) were significantly lower in the 11 patients with febrile neutropenia. The absolute lymphocyte count (412.7 cells/cu. mm) was reduced with a strikingly low Neutrophil-to-lymphocyte ratio (NLR) (6.07) in patients with neutropenia. Laboratory and radiological evidence were present in 14/15 episodes of hematological malignancies (p-0.218) whereas unexplained clinical sepsis was common in solid malignancies (p-0.0202). The majority of documented infections were bacterial, caused by gram-negative bacilli, often showing multi-drug resistance. Infectious etiologies were identified in 71.4% of the patients with febrile neutropenia for &gt;5days. Bacterial infections developed within 2 days of neutropenia, whereas viral and fungal infections manifested in prolonged neutropenia. Multi-site infections and higher mortality rates were observed in patients with febrile neutropenia. (p&lt;0.04) Conclusion Febrile neutropenia is a common complication among patients receiving chemotherapy for cancer, with an increased risk of morbidity and mortality. Early, rapid, and accurate diagnosis is key to prompt intervention. Hematological parameters such as Total Leukocyte count, platelet count, NLR, and Platelet-to-lymphocyte ratio are promising biomarkers in conjunction with morphological changes in neutrophils, thus proving that CBC and peripheral smears are simple, easily available, cost-effective, and highly dependable screening tools, especially in resource-poor settings.

Complications and implications of Caesarean delivery: Facts and perceptions

Background/objectivesCaesarean delivery (CD), though considered a life-saving surgical procedure, poses a public health problem and puts mothers and babies at higher risk of post-delivery complications. The present study aims to explore the post-delivery maternal complications among CD and normal vaginal delivery (NVD) mothers in India. MethodsThe present study is a PAN-India study conducted across various Indian states, considering a significant increase in CD rates. Data was collected from face-to-face interviews of 1407 recently delivered mothers during January–March 2023. ResultsThe findings indicate that 22 % of CD mothers reported post-delivery complications compared to 15 % of NVD mothers. Notable complications among CD mothers include body/abdominal pain (12.9 %), infection/pain in the suture area (6.2 %), and high blood pressure (1.1 %). Conversely, higher proportion of NVD mothers reported pelvic pain (3.3 %). Further, a greater proportion of NVD (22 %) and CD (28 %) mothers reported pain in the pelvic area and infection/pain in the suture area, respectively. Socio-economic and demographic factors such as age, education, and residence significantly influenced the incidence of self-reported maternal complications. Mothers aged 25 and above, with at least ten years of education, and those residing in urban areas reported higher complications. Additionally, CD mothers also experienced longer hospital stays, higher costs, and delays in breastfeeding initiation. ConclusionThe study underscores the necessity for targeted healthcare interventions to mitigate the specific risks associated with CDs and improve maternal outcomes through appropriate policy formation to address the rising trend of CDs and their implications on maternal health.

Predictors of Morbidity and Mortality of Gastrointestinal Perforation in Children

Background: Gastrointestinal perforation is a common surgical problem in paediatric surgical ward in our country. It carries a high morbidity and mortality in children. The predictors of postoperative morbidity and mortality are still not well established. Objectives: The objective of this study was to identify the predictors of morbidity and mortality following surgery for gastrointestinal perforation in children. Methods: This was a single centre cross sectional type of descriptive observational study carried out in the Department of Paediatric Surgery, Mymensingh Medical College Hospital with 16-month duration from 1st January, 2017 to April 30, 2018, in children aged from 2-12 years. Predictors related to postoperative morbidity and mortality were investigated. Results: A total of 40 patients were selected for this study with mean age of 8.92±2.61 years. Male: female was 1.5:1. Analysis indicated that factors associated with postoperative morbidity and mortality were low BMI, poor nutritional status, low serum total protein and albumin, delay in seeking treatment and contaminated peritoneal collection. Appendicular perforation was the highest number perforation in 23(57.5%) patients. Ileal perforation was the second highest number 8(20%). Appendectomy was the highest surgical procedure 21(52.5%), followed by resection-anastomosis and wound excision &amp; repair 3(7.5%) each. Serum total protein and albumin were below normal limit among 15(37.5%) and 35(87.5%) patients respectively. 13(32.5%) patients received treatment 72 hours after onset of symptom and 18(45%) patients undergone operation within 24-48 hours of admission. Postoperative complications developed in 30 patients. Among them SSI were in 20(66.66%), SIRS in 9(30%) and leakage of repair in 1(3.33%) patient. Mortality rate was 5%. Conclusion: Poor nutritional status, low total serum protein and albumin, delay in initiation of treatment, and contaminated peritoneal fluid are the predictors of morbidity and mortality of gastrointestinal perforation in children.

Evaluation of Proper Treatment Delivery and Time of Initiation of Treatment After Hospitalization by Nursing Staff in Kuwait Teaching Hospital Peshawar

Background: Medication errors are a pressing public health concern, leading to adverse outcomes and substantial healthcare costs. This study examines the incidence of drug administration errors, emphasizing the critical importance of timely treatment initiation. Delays in treatment pose significant risks to patient safety, highlighting the need for improved medication delivery protocols and enhanced patient care practices in hospitals. Methods: A prospective cross-sectional study in a Kuwait teaching hospital's paediatrics unit, involving 120 participants, utilized non-probability convenient sampling. Data collection from patient files and attendants utilized a specially designed form. Data was collected by observing one patient for 24 hours. Participants were instructed to retain medication vials. Permission was obtained from the department head, and oral informed consent was secured. No personal identifiers were recorded. Interventions included workshops and performance evaluations, leading to observed improvement. Data analysis was conducted using SPSS version 22. Results: Baseline data showed variations in dose administration across departments, with notable discrepancies in proper drug administration alignment with prescriptions. Treatment initiation delays were significant, and patient satisfaction was moderate. Post-intervention, improvements were observed in dose administration, although treatment initiation delays persisted. However, patient satisfaction notably increased following interventions. Conclusion: Our study highlighted several critical issues in medication administration, such as delays in treatment initiation, improper dose administration, and missed doses. Implementing training sessions and workshops for nursing staff will ensure the best practices and they can manage their responsibilities more effectively.

Treatment delays for cancer patients in Sub-Saharan Africa: South Africa as a microcosm.

Delays in initiating cancer treatment time to treatment initiation (TTI) can negatively impact patient outcomes. This study aimed to quantify the association between TTI and survival in breast, cervical and prostate cancer patients at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa, as a microcosm of Sub-Saharan Africa (SSA). We analyzed electronic medical records of patients diagnosed with breast, cervical or prostate cancer at IALCH between 2010 and 2020. Median TTI was calculated for different treatment modalities. To assess the link between treatment delay and mortality, we employed a Cox proportional hazards model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), treating breast cancer and patients over 40 as competing events. Additionally, Kruskal-Wallis one-way analysis and linear regression were used to compare TTI across racial groups. The study included patients with breast (44%), cervical (44%) and prostate cancer (12%). Mean age at diagnosis was 62.6, 56.6 and 73.0 years, respectively. Breast cancer patients experienced the longest delays for mastectomy (median 18.4 weeks), followed by prostate cancer patients waiting for radiotherapy (median 16.6 weeks). Significantly longer TTI for radiotherapy was observed in patients younger than 40 with cervical (HR = 2.30, 95% CI: 2.16-2.44, p < 0.001) or prostate cancer (HR = 1.42, 95% CI: 1.03-1.95, p = 0.033) compared to older breast cancer patients. Similar trends were seen for younger patients with cervical cancer receiving chemotherapy. Notably, all racial groups exhibited substantial delays in initiating treatment for all three cancers (breast p < 0.001, prostate p = 0.004 and cervical cancer p < 0.001). This study identified significant delays in treatment initiation (TTI) for breast, prostate and cervical cancer patients at Inkosi Albert Luthuli Central Hospital (IALCH) in South Africa. These delays were concerning, particularly for younger patients and individuals across all racial backgrounds. Delays in treatment initiation have been linked to increased mortality risk in other studies, highlighting the urgency of addressing this issue. Furthermore, this study serves as a valuable model for future research throughout SSA to collectively address the challenges of treatment delays and improve cancer care for the region.