Significant Differences In Time Interval Research Articles

Understanding breast cancer patient pathways and their impact on survival in Mexico

BackgroundUnderstanding patient pathways from discovery of breast symptoms to treatment start can aid in identifying ways to improve access to timely cancer care. This study aimed to describe the patient pathways experienced by uninsured women from detection to treatment initiation for breast cancer in Mexico City and estimate the potential impact of earlier treatment on patient survival. MethodsWe used process mining, a data analytics technique, to create maps of the patient pathways. We then compared the waiting times and pathways between patients who initially consulted a private service versus those who sought care at a public health service. Finally, we conducted scenario modelling to estimate the impact of early diagnosis and treatment on patient survival. ResultsOur study revealed a common pathway followed by breast cancer patients treated at the two largest public cancer centres in Mexico City. However, patients who initially sought care in private clinics experienced shorter mean wait times for their first medical consultation (66 vs 88 days), and diagnostic confirmation of cancer (57 vs 71 days) compared to those who initially utilized public clinics. Our scenario modelling indicated that improving early diagnosis to achieve at least 60% of patients starting treatment at early stages could increase mean patient survival by up to two years. ConclusionOur study highlights the potential of process mining to inform healthcare policy for improvement of breast cancer care in Mexico. Also, our findings indicate that reducing diagnostic and treatment intervals for breast cancer patients could result in substantially better patient outcomes. Policy summaryThis study revealed significant differences in time intervals along the pathways of women with breast cancer according to the type of health service first consulted by the patients: whether public primary care clinics or private doctors. Policies directed to reduce these inequities in access to timely cancer care are desperately needed to reduce socioeconomic disparities in breast cancer survival.

397 Impact of COVID-19 on Theatre Utility

IntroductionCovid-19 has significantly impacted the environment in which surgeons operate. Level-2 PPE is worn in our orthopaedic theatres, with increased time taken for simple tasks due to claustrophobia, excessive heat, and difficulties in communication due to masks, including donning and doffing. We sought to determine the impact of Covid-19 on theatre utility.Method8week period during Covid-19 was reviewed for semi-elective orthopaedic surgery. Pre-Covid-19 case controls for age, procedure and ASA were identified. Electronic database was used to determine total time in theatre complex, time taken for anaesthesia, total procedure time, and time taken for patient to leave the theatre.Results27patients undergoing semi-elective surgery during Covid-19 pandemic and 27-matched controls from before pandemic were identified. No statistically significant difference in procedural or anaesthetic time. Significant difference in time interval between cases (14minutes pre-Covid-19 v 58minutes during Covid-19; p < 0.05). Mean theatre start times are 51minutes later during Covid-19.ConclusionsProcedural times of surgery have not significantly increased, however the time between cases has increased; resulting in a decrease in overall theatre complex utility and direct impact on future costing.

Time Intervals Under the Lens at Sweden's First Diagnostic Center for Primary Care Patients With Nonspecific Symptoms of Cancer. A Comparison With Matched Control Patients.

IntroductionFast-track referral pathways for patients with nonspecific, serious symptoms have been implemented in several countries. Our objective was to analyze time intervals in the diagnostic routes of patients diagnosed with cancer at Sweden’s first Diagnostic Center (DC) for nonspecific symptoms and compare with time intervals of matched control patients.MethodsAdult patients with nonspecific symptoms that could not be explained by an initial investigation in primary care were eligible for referral to the DC. Patients diagnosed with cancer were matched with patients at another hospital within the same healthcare organization. We aimed for two control patients per DC-patient and matched on tumor type, age and sex. Five time intervals were compared: 1) patient interval (first symptom—primary care contact), 2) primary care interval (first visit—referral to the DC/secondary care), 3) diagnostic interval (first visit—cancer diagnosis), 4) information interval (cancer diagnosis—patient informed) and 5) treatment interval (cancer diagnosis—treatment start). Comparisons between groups and matched cohort analyses were made.ResultsSixty-four patients (22.1%) were diagnosed with cancer at the DC, of which eight were not matchable. Forty-two patients were matched with two controls and 14 were matched with one control. There were no significant differences in patient-, primary care-, or diagnostic intervals between the groups. The information interval was shorter at the DC compared to the control group (difference between matched pairs 7 days, p = 0.001) and the treatment interval was also shorter at the DC with significant differences in the matched analysis (difference between matched pairs 13 days, p = 0.049). The findings remained the same in four sensitivity analyses, made to compensate for differences between the groups.ConclusionsUp to diagnosis, we could not detect significant differences in time intervals between the DC and the control group. However, the shorter information and treatment intervals at the DC should be advantageous for these patients who will get timely access to treatment or palliative care. Due to limitations regarding comparability between the groups, the results must be interpreted with caution and further research is warranted.Trial registration ClinicalTrials.gov-ID: NCT01709539. Registration-date: October 18, 2012.

REFERRAL PATTERN OF INTERVENTIONAL PULMONOLOGY PROCEDURES AT A QUATERNARY MEDICAL CENTER

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Interventional pulmonology (IP) focuses on management of malignant and benign airways and pleural diseases. Access to this specialized care is increasing nationwide, though is largely limited to academic medical centers. We hypothesized a patient’s referral (and subsequent advanced therapies) may be delayed due to access to care, socioeconomic factors, and lack of awareness or understanding of IP’s role in patient care. METHODS: We performed a retrospective analysis of patients who underwent advanced IP procedures in the Operating Room (OR) at our medical center from 7/1/2015 to 12/31/2018 after IRB approval. Procedures included rigid and flexible bronchoscopies for tumor debulking, stent placement, and tissue diagnosis. We obtained demographic data including age, sex, race, primary location of oncologic care, and date of death. We analyzed the distance from patient’s residence to our medical center, reason for referral, and advanced procedures performed. We calculated time intervals, including time to IP referral; to first IP evaluation; to procedure; to IP follow-up; and death. We used a cut-off distance of 51 miles from medical center to identify patients residing “near” versus “far”. Two-tailed Student’s t-test with alpha 0.05 was used for comparison. RESULTS: A total of 277 procedures were performed by IP practitioners on 227 patients during the study period. Forty five percent, (45.4%, 103/227) were female, with an average age of 60.8±11.2 years. The median distance of patient residences were 51 miles from our medical center. Eighty-two percent (188/227) had cancer; 30.3% (57/188) of these malignancies were diagnosed during the IP procedure. Patients residing near our medical center had significantly shorter interval from imaging to IP referral (11.3±18.8 days vs. 17.4±26.6 days, p=0.046). There were no statistically significant differences in days from referral to initial evaluation by IP (p=0.84) or from IP evaluation to time of procedure (p=0.66) between “near” and “far” patients. There was no significant difference in time interval from procedure to first clinic follow-up between the two groups (p=0.14). CONCLUSIONS: Patients residing more than 51 miles from our medical center were associated with an average delay of 6 days for IP referral for necessary intervention when compared to those living within 51 miles. There were no subsequent delays from the date of referral to IP evaluation, nor from date of IP evaluation to IP procedure performed. CLINICAL IMPLICATIONS: IP intervention is delayed for those living away from a quaternary medical center. Appropriate education of referring physicians, community access to IP physicians, and direct communication by telemedicine may be helpful to improve the delay. DISCLOSURES: no disclosure on file for Shaheen Islam; No relevant relationships by Divyesh Mehta, source=Web Response no disclosure on file for Shailesh Pinto; No relevant relationships by Alberto Revelo, source=Web Response No relevant relationships by Virgil Secasanu, source=Web Response No relevant relationships by Harsh Shah, source=Web Response

Anaphylaxis diagnosis and management in the Emergency Department of a tertiary hospital in the Philippines.

BackgroundIn the Emergency Department (ED), diagnosis and management of anaphylaxis are challenging with at least 50% of anaphylaxis episodes misdiagnosed when the diagnostic criteria of current guidelines are not used.ObjectiveObjective of our study was to assess anaphylaxis diagnosis and management in patients presenting to the ED.MethodsRetrospective chart review conducted on patients presenting to The Medical City Hospital ED, the Philippines from 2013–2015 was done. Cases were identified based on International Statistical Classification of Diseases, 10th revision coding for either anaphylaxis or other allergic related diagnosis. Cases fitting the definition of anaphylaxis as identified by the National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network (NIAID/FAAN) were included. Data collected included demographics, signs and symptoms, triggers and management.ResultsA total of 105 cases were evaluated. Incidence of anaphylaxis for the 3-year study period was 0.03%. Of the 105 cases, 35 (33%) were diagnosed as “urticaria” or “hypersensitivity reaction” despite fulfilling the NIAID/FAAN anaphylaxis criteria. There was a significant difference in epinephrine administration between those given the diagnosis of anaphylaxis versus misdiagnosed cases (61 [87%] vs. 12 [34%], χ2 = 30.77, p < 0.01); and a significant difference in time interval from arrival at the ED to epinephrine administration, with those diagnosed as anaphylaxis (48%) receiving epinephrine within 10 minutes, versus ≥ 60 minutes for most of the misdiagnosed group (χ2 = 52.97, p < 0.01).ConclusionDespite current guidelines, anaphylaxis is still misdiagnosed in the ED. Having an ED diagnosis of anaphylaxis significantly increases the likelihood of epinephrine administration, and at a shorter time interval.

Progression of deep infiltrating rectosigmoid endometriotic nodules.

What is the risk of progression of deep endometriotic nodules infiltrating the rectosigmoid? There is a risk of progression of deep endometriotic nodules infiltrating the rectosigmoid, particularly in menstruating women. Currently, there is a lack of acceptance in the literature on the probability that deeply infiltrating rectosigmoid endometriotic nodules progress in size. We conducted a monocentric case-control study between September 2016 and March 2018 at Rouen University Hospital. We enrolled 43 patients who were referred to our tertiary referral centre with deep endometriosis infiltrating the rectosigmoid, who had undergone two MRI examinations at least 12months apart and had not undergone surgical treatment of rectosigmoid endometriosis during this interval. MRI images were reinterpreted by a senior radiologist with experience and expertise in endometriosis, who measured the length and thickness of deep infiltrating colorectal lesions. Intra- and inter-observer reliability were tested on 30 randomly selected cases. We defined 'progression' of a nodule as an increase of ≥20% in length or in thickness and 'regression' of a lesion as a decrease of ≥20% in length or in thickness between two MRIs. Any nodule for which the variation in length and thickness was <20% was considered as 'stable'. Patients were divided into three groups based on evidence of progression, regression or stability of deep endometriotic nodules between their two MRI examinations. The total length of any period of amenorrhoea between the two MRI examinations, due to pregnancy, breastfeeding or hormonal treatment, was recorded. The total proportion of the time between MRIs where amenorrhoea occurred was compared between groups. Eighty-six patients underwent at least two MRIs for deep endometriosis infiltrating the sigmoid or rectum between September 2016 and March 2018. Of these, we excluded 10 patients with an interval of <12months between MRIs, 10 patients who underwent surgery between MRIs, 17 patients for whom at least 1 MRI was considered to be of poor quality and 6 patients for whom no deep colorectal lesion was found on repeat review of either MRI. This resulted in a total of 43 patients eligible for enrolment in the final analysis. Mean time (SD) between MRIs was 38.3 (22.1) months. About 60.5% of patients demonstrated stability of their colorectal lesions between the two MRIs, 27.9% of patients met the criteria for 'progression' of lesions and 11.6% met the criteria for 'regression' of lesions. There was no significant difference in time interval between MRIs for the three groups (P = 0.76). Median duration of amenorrhoea was significantly lower in women with progression of lesions (7.5months) when compared to those with stability of lesions (8.5months) or regression of lesions (21months) (P < 0.001). Median duration of amenorrhoea (expressed as percentage of total time between two MRIs) was also found to be significantly lower in the group demonstrating progression (15.1%) when compared to the group demonstrating stability (19.2%) and the group demonstrating regression (94.1%; P = 0.006). Progression of rectosigmoid nodules was observed in 34% of patients without continuous amenorrhoea, in 39% who had never had amenorrhoea and in no patients with continuous amenorrhoea. Due to a lack of universally accepted criteria for defining the progression or regression of deep endometriotic nodules on MRI, the values used in our study may be disputed. Due to the retrospective design of the study, there may be heterogeneity of interval between MRIs, MRI techniques used, reason for amenorrhoea and duration of amenorrhoea. The mean inter-MRI interval was of short duration and varied between patients. Our findings are reported for only deep endometriosis infiltrating the rectosigmoid and cannot be extrapolated, without caution, to nodules of other locations. Patients with deeply infiltrating rectosigmoid endometriotic nodules, for which surgical management has not been performed, should undergo surveillance to allow detection of growth of nodules, particularly when continuous amenorrhoea has not been achieved. This recommendation is of importance to young patients with rectosigmoid nodules who wish to conceive, in whom first line ART is planned. There is a very low risk of progression of deep endometriotic nodules infiltrating the rectosigmoid in women with amenorrhoea induced by medical therapy, lactation or pregnancy. No funding was received for this study. The authors declare no competing interests related to this study.

Amaurosis fugax - delay between symptoms and surgery by specialty.

PurposeTo describe the time course of management of patients with amaurosis fugax and analyze differences in management by different specialties.MethodsPatients diagnosed with amaurosis fugax and subjected to carotid ultrasound in 2004–2010 at the Sahlgrenska University Hospital, Gothenburg, Sweden (n=302) were included in this retrospective cohort study, and data were collected from medical records.ResultsThe prevalence of significant carotid stenosis was 18.9%, and 14.2% were subjected to carotid endarterectomy. A trend of longer delay for surgery was noted for patients first consulting a general practitioner (P=0.069) as compared to hospital-based specialties. For 46.3% of the patients, an ophthalmologist was their first medical contact. No significant difference in time interval to endarterectomy was seen between ophthalmologists and neurologists/internists. Only 31.8% of the patients with significant carotid stenosis had carotid endarterectomy within 2 weeks from the debut of symptoms, and this proportion was smaller for patients residing outside the Gothenburg city area (P=0.038).ConclusionInitially consulting an ophthalmologist does not delay the time to ultrasound or carotid endarterectomy. The overall time from symptoms to surgery is longer than recommended for a majority of the patients, especially for patients from rural areas and for patients initially consulting a general practitioner.

세치제내 SLS함유에 따른 타액과 세균변화

이 연구는 세치제 내 함유되어 있는 SLS의 함유여부에 따라 구강 내 타액과 세균수의 변화정도를 비교분석하여 향후 보다 양질의 세치제 개발을 위한 기초자료를 제공하고자 하였다. SLS의 함유량을 2.2%와 0.0%의 세치제를 제조하여 각각 30명으로 구성된 두 집단의 실험대상자에게 4주간 사용하게 하고 실험 전 후의 타액과 구강 내 세균 수의 변화 차이를 보았다. 연구결과 SLS의 배합여부는 타액, 세균수의 변화에 현저한 차이를 보이지 않았다. 또한 SLS 배합여부는 타액량과 구강 내 세균수의 관련성이 없는 결과를 보였다. 하지만 실험대상자들이 사용한 세치제에 대한 만족도 조사에서는 SLS가 함유되지 않은 그룹 보다 SLS가 함유된 그룹에서 만족도가 현저하게 높은 것으로 나타났다. 만일 SLS가 선호감 때문에 이용되고 있다면 SLS의 적정 함유량에 대한 구체적 개선방안을 모색하여 할 것이다. Dentifrices comtaining SLS of 2.2% and 0.0% were applied to 60 subjects for 4 weeks in this study. Dentifrice is used for salivary and oral bacteria amount change according to its SLS contents in toothpaste. The results were as follows. Anaysis of LSL contents befor and after the after experiment in salivary and bacterial count oral cavity didn't show significant difference in time interval. There was no correlation between salivary flow rate and bacterial count in the oral cavity according to content of SLS. Dentifrice of 2.2% content satisfied the subjects much more than that of 0.0% content(p<0.001).

Non-invasive diagnosis of acute rejection in kidney transplants with delayed graft function

Delayed graft function (DGF) often occurs in kidney transplants from deceased donors. We wanted to provide studies giving more accurate non-invasive tests for acute rejection (AR). Using real-time PCR, we examined the expression of cytolytic molecules such as perforin, granzyme B, and fas-ligand along with serpin proteinase inhibitor-9. We also measured the expression of FOXP3, a characteristic gene of T-regulatory cells known to be involved in AR. These studies were conducted on peripheral blood monocytes, urinary cells, and 48 surveillance kidney biopsies taken from a total of 35 patients with DGF. Of these patients, 20 had a histopathological diagnosis of AR, whereas other 28 had characteristics of acute tubular necrosis (ATN). Expression of cytolytic and apoptotic-associated genes in the biopsy tissue, peripheral blood leukocytes, and urinary cells was significantly higher in patients with AR than that in patients with ATN. Diagnostic parameters associated with FOXP3 gene expression were most accurate in peripheral blood leukocytes and urine cells with sensitivity, specificity, positive and negative predictive values, and accuracy between 94 and 100%. Our study shows that quantification of selected genes in peripheral blood leukocytes and urinary cells from renal transplant patients with DGF may provide a useful and accurate non-invasive diagnosis of AR.

The effect of fentanyl pretreatment on myoclonus during induction of anesthesia with etomidate in elderly patients

Background: Etomidate is frequently used as an induction agent in the elderly patients. This study was done to determine whether etomidate-based induction can provide hemodynamic stability and fentanyl decreases the incidence of myoclonus. Methods: Eighty ASA II or III patients older than 65 years were randomly allocated to four groups. Group 1 (n = 20) received etomidate 0.2 mg/kg after normal saline 3 ml, Group 2 (n = 20) received etomidate 0.25 mg/kg after normal saline 3 ml, Group 3 (n = 20) received fentanyl 2 ug/kg before the administration of etomidate 0.2 mg/kg, Group 4 (n = 20) received fentanyl 2 ug/kg before the administration of etomidate 0.25 mg/kg. The time interval from etomidate infusion to loss of eyelash reflex, to decrease bispectral index (BIS) 50, to intubation were recorded. We measured hemodynamic change, the BIS index, the incidence, duration and grade of myoclonus. Results: There were no significant differences in time interval, mean arterial pressure (MAP), BIS index between groups. MAP and HR were increased after intubation in all groups. The incidence of myoclonus were 25%, 30%, 0%, 15% respectively. There were no significant differences in incidence and duration of myoclonus between 4 groups, but group 3 had reduced incidence compared with group 1. Conclusions: Loss of consciousness and hemodynamic changes during induction with 0.2 mg/kg and 0.25 mg/kg of etomidate were appropriate. Pretreatment with fentanyl and small dose of etomidate decrease the incidence of myoclonus.

Does standardized mega-code training improve the quality of pre-hospital advanced cardiac life support (ACLS)?

The aim of our prospective study was to evaluate the effects of a standardized mega-code and arrhythmia training upon process elements of quality of pre-hospital advanced cardiac life support provided by a physician-staffed mobile intensive care unit. In 145 cases of adult cardiac arrest due to cardiac aetiology, time intervals from arrival of the mobile intensive care unit at the patient's side until first ECG diagnosis, first defibrillation, endotracheal intubation, and first epinephrine administration were measured with on-line tape recording, prior to, and following a standardized 8-h arrhythmia and mega-code training. Following the training, patients with asystole or pulseless electrical activity were intubated 1.1 min earlier ( P = 0.03), and received epinephrine 1.3 min earlier ( P = 0.01) than prior to the training. There were no significant differences in time intervals concerning management of ventricular fibrillation or tachycardia. Neither admission nor discharge rates differed significantly before and after the training. Thus, practical training including rhythm analysis and mega-code sessions improved the performance of our mobile intensive care unit in cases of asystole and pulseless electrical activity, and, hence, process elements of quality.